IS-BAO Internal Audit Manual - IBAC · IS-BAO Internal Audit Manual International Business Aviation Council (IBAC) Suite 16.33, 999 University Street Montreal, Quebec, H3C 5J9, Canada

IS-BAO Internal Audit Manual

International Business Aviation Council (IBAC) Suite 16.33, 999 University Street

Montreal, Quebec, H3C 5J9, Canada Tel 1-514-954-6198 Fax: 1-514-954-6161

www.ibac.org

IS-BAO Internal Audit Manual

Copyright © International Business Aviation Council (IBAC)

All rights reserved

No part of this document may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without the prior permission of IBAC. Operators who have purchased the IS-BAO are granted permission to reproduce this document in whole or in part, for use in their internal audit program.

IS-BAO Internal Audit Manual International Business Aviation Council (IBAC)

January 1, 2014 page - © IBAC All rights reserved

i

RECORD OF AMENDMENTS

Number Date Date Entered Entered By

1 January 1, 2005 Included Included






7 January 1, 2011 included included



10 January 1, 2014 included Included



ii

Page intentionally left in blank



iii

LIST OF EFFECTIVE PAGES

Page No. Amendment No. Effective Date

Page No. Amendment No. Effective Date

I thru viii January 1, 2014 1 thru 90 January 1, 2014



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v

FOREWORD

This Manual is prepared by the International Business Aviation Council (IBAC) and is issued under the authority of the IS-BAO Standards Board. The Internal Audit Manual has been developed for the assistance of operators who have implemented, or are in the process of implementing, the IS-BAO - an International Standards for Business Aircraft Operations. It is designed to provide the operator with a systematic approach to assessing their conformity with the provisions of the IS-BAO. It should be of use to operators in determining their preparedness for an IS-BAO registration audit and for the development of a process for ongoing assessment of the appropriateness and effectiveness of the safety management activities. The audit procedures were developed in recognition of proven industrial management auditing concepts. The procedures will ensure that audits are completed consistently and in accordance with a systematic, objective and proven process.



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vii

TABLE OF CONTENTS

Record of Amendments .............................................................................................................. i

List of Effective Pages ................................................................................................................ ii

Foreword .................................................................................................................................... v

Table of Contents ...................................................................................................................... vi

1.0 Purpose ........................................................................................................................ 1 1.1 Purpose Statement ...................................................................................................... 1 1.2 Structure of the Manual ................................................................................................ 1 1.3 Definitions and Audit Terminology ............................................................................... 1

2.0 IS-BAO – an International Standard for Business Aircraft Operations ........................ 3 2.1 Background .................................................................................................................. 3 2.2 IS-BAO Standards Board ............................................................................................. 3 2.3 Keeping the IS-BAO Current ........................................................................................ 3

3.0 IS-BAO Internal Audits ................................................................................................. 4 3.1 Internal Audit Programs ............................................................................................... 5 3.2 Audit Objectives and Scope ......................................................................................... 5 3.3 Audit Principles ............................................................................................................ 6

4.0 Audit Procedures .......................................................................................................... 9 4.1 The Audit Standard ...................................................................................................... 9 4.2 Audit Opening Meeting................................................................................................. 9 4.3 Audit Protocols ........................................................................................................... 10 4.4 Using the Audit Protocols ........................................................................................... 10 4.5 Conducting the Audit .................................................................................................. 10 4.6 Determining if an Audit is Successful ......................................................................... 11 4.7 Judgement and Decision Making ............................................................................... 11 4.8 Closing Meeting ......................................................................................................... 12

5.0 Evaluating the Operator’s SMS .................................................................................. 13 5.1 What is a Safety Management System (SMS)? ........................................................ 13 5.2 Measuring Safety Performance ................................................................................. 13 5.3 Stages in the Development of a Safety Management System .................................. 14 5.4 Determining the Objectives of the Evaluation ............................................................ 14 5.5 Preparations to Evaluate the SMS ............................................................................. 15 5.6 Scoping the Evaluation .............................................................................................. 16 5.7 Measuring Soundness, Appropriateness and Effectiveness ..................................... 16

6.0 Preparing Audit Findings ............................................................................................ 21

7.0 Audit Reports ............................................................................................................. 27

8.0 Audit Forms ................................................................................................................ 29

Appendix A - Auditing Aircraft Management Companies ........................................................ 89



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1.0 PURPOSE

1.1 Purpose Statement The Internal Audit Manual provides guidance operators for the conduct of internal audits pursuant

to the IS-BAO standards established by the IS-BAO Standards Board.

1.2 Structure of the Manual The IS-BAO Internal Audit Manual consists primarily of standards and protocols for the conduct of

IS-BAO audits. Explanatory and guidance material is included where considered necessary for clarity and guidance.

1.3 Definitions and Audit Terminology The following definitions and explanatory material apply to the IS-BAO auditing processes.

Adequate: fulfilling minimal requirements; satisfactory; acceptable; sufficient.

Assessment: an appraisal of procedures or operations based largely on experience and professional judgement.

Audit: a systematic and objective review of an operator’s operations and maintenance framework to verify conformity with IS-BAO standards, and good aviation safety practices.

Audit activities: those activities and procedures by which information is obtained to verify the audited operator is in conformity with applicable IS-BAO provisions. Such activities may include, but are not limited to, interviews, observations, inspections and the review of files and documents.

Audit conclusion: the outcome of the audit provided by the auditor after consideration of the audit objectives and all audit findings.

Audit finding: a problem or cause-and-effect statement, and is accompanied by specific examples of the observed condition. These are significant issues requiring the operator's immediate attention. Findings may relate to one or more non-conformities but should be sufficiently significant to require urgent action.

Audit leader: an individual accredited by the accredited auditing organization responsible for the planning and conduct of an audit, including the production of an audit report.

Audit report: a standardised means of reporting the audit findings to operators.

Closing meeting: a meeting at the end of the audit, the purpose of which is to brief the client on the audit findings.

Compliance: a product or activity that meets required characteristics and was performed in accordance with the required processes and system requirements. The output of one or more processes and the controls under which the processes occurred.

Conformity: meets required characteristics. The fulfilment of a requirement in the IS-BAO.

Convening manager:

The flight department manager or other responsible manager, who convenes the internal audit.

Evaluation (SMS): a systematic assessment of the appropriateness and effectiveness of an operator’s efforts to manage the safety of the operation.

Hazard: the condition or circumstance that can lead to physical injury or damage.

Inspection: the basic activity of an audit, involving examination of the specific characteristics of the operator’s systems, procedures, processes and documents.



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Non-conformity: the non-fulfilment of a requirement specified in the IS-BAO.

Major non-conformity:

a non-conformity that in itself constitutes a significant risk to the safety of the operation.

Note: A significant risk to safety is any risk identified as moderate or high via the methodologies described in ICAO Doc 9859, Safety Management Manual.

Minor non-conformity:

a non-conformity that does not constitute a significant risk to safety. It may be an isolated instance of non-conformity, a lack, or error in documentation of a process or procedure that was correctly executed, or a similar instance.

Objective evidence: information, which can be proved to be true, based on facts obtained through observation, measurement, test or other means.

Objectivity: freedom of bias engendered by the illogic of emotion or prejudice.

Operator: A person, organization or enterprise engaged in or offering to engage in an aircraft operation.

Procedure: a series of steps followed in a methodical manner to complete an activity – what shall be done and by whom, when, where, and how it shall be completed; what materials, equipment, and documentation shall be used, and how it shall be controlled.

Process: a system of activities that uses resources to transform inputs into outputs.

Product: the end result of a procedure or process.

Protocol: a document, which organizes audit procedures into a general sequence of audit steps and describes the steps in terms of specified standards or practices to be verified.

Quality assurance: that part of the overall management of the IS-BAO audit program that focuses on providing confidence that quality requirements of the program are being fulfilled.

Random sample: sample drawn in such a manner that every possible item has an equal chance to be selected.

Remedial Action Plan:

a plan to resolve a non-conformity that describes the actions that will be taken and the time frame for completing them.

Risk: the consequence of a hazard, measured in terms of severity and likelihood.

Safety: the state in which the risk of harm or damage is limited to an acceptable level as low as is reasonably practical.

Sampling: the inspection of a representative portion of a particular characteristic to produce a statistically meaningful assessment of the whole.

Satellite/Additional Operating Base

an airport or heliport other than the operator/ management company’s main base at which one or more aircraft and personnel are based and managed by the operator/management company.

Standard: established criteria used as a basis for measuring an operator’s level of conformity.

Verification: the independent review, inspection, examination, measurement, testing, checking, observation, and monitoring to establish and document that products, processes, practices, services and documents conform to specified standards. This includes evaluating the effectiveness of management systems.

Working papers: all documents required by the auditor or audit team to plan and implement the audit.



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2.0 IS-BAO – AN INTERNATIONAL STANDARD FOR BUSINESS AIRCRAFT OPERATIONS

2.1 Background 2.1.1 After a two and one half year development program the IS-BAO - an International Standards for

Business Aircraft Operations was launched in May 2002. It has been widely accepted and is becoming the “Gold Standard” for business aviation flight departments. Flight departments who have been involved in implementing the IS-BAO or have already implemented it have expressed an interest in having an internal audit manual available. At their October 2003 meeting, the IS-BAO Standards Board agreed to produce and publish such a document.

2.1.2 In 2010 and 2011 IBAC worked with the Helicopter Association International (HAI), the British

Helicopter Association (BHA) and the European Helicopter Association (EHA) to adapt the IS-BAO to include helicopter operations. Pursuant to the agreement under which this project was undertaken, the HAI developed a set of helicopter mission specific standards (HMSS), to augment the IS-BAO. Operators who have implemented the IS-BAO can undergo an IS-BAO audit and become registered as being in conformance with the IS-BAO. They then can undergo an audit relative to their specific mission and also become registered as being in conformance with those standards.

2.2 IS-BAO Standards Board 2.2.1 The IS-BAO Standards Board has been delegated responsibility by the IBAC Governing Board for

the maintenance of the IS-BAO standards and for overseeing the auditing process.

2.2.2 The Standards Board consists of members nominated by the IBAC Members associations and the IS-BAO partner helicopter industry associations. At least three members must be aircraft operators, one must be involved in the helicopter industry and one must have aircraft maintenance expertise.

2.2.3 The Standards Board meets at least once per year to consider proposed changes to the IS-BAO,

the Audit Procedures Manual (for auditors) and the Internal Audit Manual. Professional standards services are provided by the IBAC Secretariat through the IS-BAO Program Director who will assemble and provide an analysis of recommendations for change.

2.3 Keeping the IS-BAO Current Proposals for change to the IS-BAO can come from many sources. In essence, all

recommendations will be assessed by the IBAC Director, IS-BAO Program and any proposals that will enhance the efficiency or effectiveness of the IS-BAO, will be submitted to the Standards Board for consideration.



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3.0 IS-BAO INTERNAL AUDITS

3.1 Internal Audit Programs 3.1.1 An internal audit program is not a specified requirement of the IS-BAO. However, operators may

desire to conduct internal audits to determine their preparedness for an IS-BAO registration audit or as a means to assess the appropriateness and effectiveness of their safety management activities on an ongoing basis. An internal audit program can be an effective element of the continuous improvement through ongoing safety management activities that is a key aspect of the IS-BAO. Operators may wish to develop an annual internal audit plan to manage their internal audit program. Such a plan could be composed of a series of audits, each of which would address one or more elements of the IS-BAO standards. An example of an annual audit plan is presented in Figure 3.1. It is recommended that personnel involved in doing internal audits have basic auditor training. One such source is ISO 9000:2000 internal audit training that is provided by many ISO 9000:2000 registrars. Some registrars offer internal auditor training on-line. Civil aviation authorities or the operator’s IS-BAO auditor may also be a source of auditor training.

3.1.2 Operators should carefully consider how they are going to conduct their internal audit. A first

principle is that the auditor, or audit team leader, should not have any management responsibilities for the area being audited. In the case where more than one person is involved in the audit it is logical to have team members from the area being audited who would act as subject matter experts, but if possible the team leader should be from outside of the work unit being audited. In small organizations the manager would probably task a staff member with no managerial responsibility to conduct the audit. Other options may be to draw auditors or audit team leaders from the parent company or from another operator on a reciprocal basis.

3.1.3 While the manager of the operation should retain responsibility for the internal audit program the

responsibility to act as convening manager for organizing and administering it can be assigned to a member of the organization. If this is the case the accountabilities of the convening manager should be clearly identified.

3.2 Audit Objectives and Scope The objectives and scope of an internal audit should be clearly established prior to

commencement of the audit. The objectives may be:

a. to determine that the operator is in conformity with the IS-BAO standards;

b. to observe and assess the organization’s adherence to the recommended practices contained in the IS-BAO;

c. to assist the organization identify any safety deficiencies; and

d. to assess the appropriateness and effectiveness of the organization’s safety management activities.

The scope of the audit will be dependant upon the audit objectives. If the objective is to determine the organization’s conformity with the IS-BAO standards and assess adherence to the recommended practices, the scope should include audit of all of the elements of the protocol contained in Chapter 8. However, should the audit be part of the organization’s ongoing audit program, the objective may be to focus on the safety management activities or to assess only a portion of the elements of the IS-BAO standards. In that case the scope should be modified accordingly. The manager of the operation or other manager, who convenes the internal audit, should carefully consider the audit objectives and scope and ensure that the audit team leader and members fully understand them.



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3.3 Audit Principles 3.3.1 In conducting an internal audit the audit team should follow the following audit principles:

a. Transparency and disclosure;

b. Timeliness;

c. Systematic, consistent and objective;

d. Fairness; and

e. Quality. 3.3.2 Transparency and disclosure

The philosophy of “no secrets” is very important during the audit and in the reporting process. By openly discussing concerns or apparent shortcoming, as soon as they are identified, the auditor will provide the convening manager with the opportunity to provide additional information or in some cases take immediate action to resolve the issue. Audit results including all identified non-conformities and findings, will be provided to the convening manager at the end of the audit through a verbal debriefing and subsequent provision of a written report. The written report must be consistent with the verbal debriefing.

3.3.3 Timeliness

The audit report will be produced and provided by the auditor to the convening manager on a timely basis.

3.3.4 Systematic, consistent and objective

Audits will be conducted in a systematic, consistent and objective manner. There should be no variation in the scope, depth and quality of the audits from that which was agreed between the auditor and/or audit team and the convening manager. However, it must be recognized that the depth of investigation may have to be modified during the course of the audit in order that the auditor can accurately identify the cause(s) of non-conformities.

3.3.5 Fairness

Audits should to be conducted in a manner such that operator personnel involved in the audit are given every opportunity to monitor, comment and respond. As previously noted such opportunities should be provided as soon as a non-conformity is identified or suspected.

3.3.6 Quality

Audits will be conducted in recognition of quality audit concepts including the use of auditors who are trained to carry out the task. The four fundamental rules for auditing should be applied:

a. Audits provide information for decisions.

b. Auditors are qualified to perform their tasks.

c. Measurements are taken against defined requirements.

d. Conclusions are based on facts.



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Figure 3.1 Internal Audit Plan Example

SOME COMPANY IS-BAO INTERNAL AUDIT PLAN - 2014

IS-BAO Element Auditor(s) Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

3. SMS HG, CC, EG IA AC IA AC

4. Organization & Personnel HG, CC IA AC

5. Training & Proficiency CC, FP IA AC

6. Flight Operations CC, FP IA AC

7. Ops in Intn’l Airspace CC, FP IA AC

8. Aircraft Equipment EG, CC IA AC

9. Aircraft Maintenance EG HG IA AC

10. Ops Manual CC, FP IA AC

11. Emerg Response Plan CC, FP IA AC

12. Environmental Mgt. HG IA AC

13. OSH HG IA AC

14. TDG HG IA AC

15. Security HG IA AC

IS-BAO Audit Audit

Legend IA - Internal Audit

AC – Audit Complete



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4.0 AUDIT PROCEDURES

4.1 The Audit Standard 4.1.1 The basic standard to which the audit should be conducted is the IS-BAO. However, the IS-BAO

provides considerable latitude for the operator to develop programs and procedures that are suited to the size and complexity of the individual operation and to publish them in company manuals and directives. While a small operation, such as one aircraft and less than five people, still must meet the standards specified in the IS-BAO they would be expected to use much more rudimentary programs, systems and procedures than a large operation. In conducting the audit the auditor must not only determine if these programs and procedures are in conformity with the requirements of the IS-BAO that are applicable to the category of aircraft operated (aeroplanes or helicopters), but that they are appropriate to the size and complexity of the operation and that it is being conducted in conformity with the company manuals and directives as they relate to IS-BAO requirements.

4.1.2 The operator’s safety management system (SMS) is the cornerstone of the IS-BAO. Hence, it is

a key item of the audit. An evaluation of the operator’s SMS will include the related standards that are an integral part of their SMS. These related standards include:

organization structure,

duties and responsibility of personnel,

training and proficiency programs,

flight operations procedures and processes,

standard operating procedures,

maintenance control system, etc.

In a registration audit all of these components of the operator’s SMS will be audited to the level required to determine that it is appropriate and effective. For initial audits and other Stage One audits, as well as the SMS evaluation the auditor must complete all of the remaining Audit Protocols contained in chapter 8. When using the audit protocols in chapter 8 it must be understood that they only paraphrase the standards, and as such, the standards in the IS-BAO must be considered when conducting the audit.

4.1.3 When conducting Stage Two or Stage Three audits the evaluation of the effectiveness of the SMS will involve in-depth examination of the systems, procedures and processes related to the standards that are an integral part of their SMS, such as those noted in Section 4.2.2, a thru f, to ensure they are appropriate and effective in managing safety risks and that they meet the related IS-BAO requirements. In that case the detailed protocol for chapter 3 (SMS) will be the primary audit document and the results of the SMS evaluation should be fully documented in that protocol. It will be supplemented by the detailed protocols for chapters 4 thru 15. The auditor will determine whether the detailed protocols for each chapter (4 thru 15) will be audited in-depth or checked for basic conformance. Although sampling is allowable at the discretion of the auditor, at least 50% of the protocols for each chapter (4 thru 15) must be assessed to substantiate that the operator is in conformity with the requirements of the IS-BAO.

4.1.4 For internal audits the convening manager will determine the objective and scope of the audit. Therefore, the internal auditor or audit team will conduct the audit and apply the appropriate standards accordingly.

4.2 Audit Opening Meeting The auditor or audit team leader should arrange for an Audit Opening Meeting with the convening

manager and involved operator personnel. The agenda for the meeting should include:

a. Introductions if the audit team are not known to all of the operator personnel involved;



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b. Objective and scope of the audit;

c. Schedule for the audit, including those to be interviewed; and

d. Overview of the Audit Protocols (checklists) that will be used.

4.3 Audit Protocols The Audit Protocols (checklists) have been prepared to guide the auditor through the process of

assessing whether or not the organization is in conformity with the standards specified in the IS-BAO. However, for internal audits it may be advisable for the convening manager of the audit team to develop their own checklist that pertain to their individual operation and issues that are to be addressed. In any event, auditors should complete the parts of any protocol or checklist used and review them with the convening manager as part of the Audit Closing Meeting.

4.4 Using the Audit Protocols 4.4.1 The Detailed IS-BAO Audit Protocol in section 8.2 follows the structure of the IS-BAO. This

protocol is used to do an in-depth assessment of one or more IS-BAO element. When this protocol is used the auditor should determine and indicate whether the operator is in conformity or not, with each of the referenced requirements. If that requirement is not applicable to the operator check N/A. The IS-BAO contains some standards and recommended practices that apply to all operators and others that apply only to either fixed wing operators or rotary wing operators. Some of the requirements refer specifically to aeroplanes or helicopters and as well the aeroplane specific requirements have an “A” suffix to the element of item number and the helicopter specific items have an “H” suffix. Also, some of the general provisions would not be applicable where the operator does not engage in that activity. Therefore, auditors must ensure that the audit report accurately reflects the type and nature of the operations conducted and the operator’s conformance with the appropriate IS-BAO requirements.

4.4.2 If an item was not audited, the auditor should leave the three columns blank and note in the

Remarks column the reason why it was not audited. The right hand column is used to record remarks related to the effectiveness of the operator’s programs, systems and procedures and objective evidence of any non-conformities. Comments relating to recommended practices, good aviation safety practices or activities that are especially well done may also be recorded. These are items that can add value for the operator. At this point it is not necessary to determine whether there are minor or major non-conformities. That can be done when all instances of non-conformity and the related objective evidence have been analysed and, if appropriate, Findings are made. In such cases and Audit Finding Forms would then be prepared. See Chapter 6 - Preparing Audit Findings.

4.4.3 When a detailed protocol (8.2) item includes sub-elements, the auditor shall indicate their

assessment of each of these sub-elements with a “Y, N, or NA” adjacent to each item, with appropriate references and remarks associated with the same.

4.5 Conducting the Audit 4.5.1 An IS-BAO audit should be conducted as a systems audit. A system is a group of processes all

working together to achieve a common goal. As such, the audit will examine the operator’s safety management system, programs, procedures, and processes and assess how they are integrated to ensure conformity with the IS-BAO and effectively manage the safety of the operation. Therefore, the audit will be conducted at a higher level than a process or product audit. The audit will be conducted by collecting objective evidence through observations, interviews and examination of documents. This evidence will then be compared with the requirements of the IS-BAO and analyzed. If there are shortcomings, that information will be used to develop observations or statements of non-conformity and if necessary, findings which identify the root cause(s) of the problems. It must be remembered that non-conformities and findings must describe the problem, not the symptoms of the problem.



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Figure 4.1 General Model for Auditing

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4.5.2 While gathering objective evidence the auditor should ensure that they interview a variety of

operator personnel as well as management personnel. This will help to determine the level of knowledge and understanding for key IS-BAO program elements throughout the organization and to form a complete picture of the organization and its activities

4.5.3 While this process will facilitate an effective audit for a variety of types of operations Appendix A

presents some considerations for the audit of aircraft management companies which may be involved in commercial and non-commercial operations or non-commercial managed aircraft operations.

4.6 Determining if an Audit is Successful 4.6.1 As the IS-BAO is based on industry best practices and many of the standards are performance

based, that is they identify “what” must be achieved not “how” it is to be done, a considerable amount of judgement must be used in determining if an audit is successful. In general terms, the audit is considered successful if the operator is in conformity with the standards contained in the IS-BAO in that there are no major non-conformities.

4.6.2 A minor non-conformity would be one that does not constitute a significant risk to safety. It may

be an isolated instance of non-conformity, a lack, or error in documentation of a process or procedure that was correctly executed, or a similar instance. A major non-conformity is when there is a pattern of instances of minor non-conformities or a non-conformity with a standard specified in the IS-BAO that in its self constitutes a significant risk to the safety of the operation.

4.6.3 As previously mentioned it is important that instances of apparent non-conformity be discussed

with the operator as soon as they are noted. This will provide the client with an opportunity to provide additional information or in some cases, to undertake action to resolve the non-conformity prior to completion of the audit.

4.7 Judgement and Decision Making 4.7.1 As the IS-BAO provides considerable latitude for the operator to develop programmes and

procedures that are suited to the individual operation and to publish them in manuals and directives, a high degree of judgement by the auditor is required when determining Non-

1 Dennis R. Arter, Quality Audits for Improved Performance (3rd ed. Milwaukee: Quality Press, 2003) p. 5.



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conformity. As the cornerstone of the IS-BAO is the operator’s safety management system, it should be key in making that decision. There would be a major non-conformity if there is clear evidence that:

a. the operator has not correctly identified the safety-risks associated with the operation; or

b. effective mitigation has not been developed and applied for a safety-risk assessed in the Operator Safety-Risk Profile as “Medium” or higher.

4.7.2 After that point, the key consideration is the effectiveness of the process or procedure that the

operator has developed and applied to mitigate the safety-risks inherent in the operation. Consideration of the “company culture” and the “hazard identification and tracking system” may be of assistance in making determinations. The company culture should be to effectively involve all operator personnel in the organization’s safety management system. The hazard identification and tracking system should actively involve all operator personnel, and management should analyse observations, develop and implement appropriate solutions and track their effectiveness. If there is clear evidence that these two key components of the operator safety management system are in place, considerable latitude in application of IS-BAO standards is appropriate. Chapter 5 provides more information on evaluation of the operator’s SMS and taking into consideration the stage of development that it is at.

4.7.3 Of course, it is a given that the process and procedures used by the operator must be in

conformity with the civil aviation rules of the State of Registry and for commercial operations the State of the Operator.

4.8 Closing Meeting

4. 8.1 A Closing Meeting should be conducted at the conclusion of the audit. 4.8.2 The purpose of the Closing Meeting is to communicate to the convening manager and other

appropriate personnel, the results of the audit and to do so immediately after completion of the audit activities.

4.8.3 The Closing Meeting should consist of a discussion of the audit findings, observations and

results. The Closing Meeting should be organized in accordance with the audit protocols used covering each module in turn.

4.8.4 The format and major headings for the Closing Meeting should be as follows:

a. objective and scope of the audit;

b. summary of the audit procedures, (including a list of those interviewed); and

c. audit findings and observations.



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5.0 EVALUATING THE OPERATOR’S SMS

5.1 What is a Safety Management System (SMS)?

5.1.1 A Safety Management System (SMS) is a process to explicitly identify, manage and measure the

safety risks that inevitably occur in all aviation operations. It is the cornerstone of the

performance based IS-BAO and it includes the key elements of the IS-BAO standards such as:

organization structure,

duties and responsibility of personnel,

training and proficiency programs,

flight operations procedures and processes,

standard operating procedures,

maintenance control system, etc.

Therefore, it must be kept in mind when discussing the operator’s SMS that these key elements are an integral part of it.

5.1.2 The IS-BAO has been designed so operators can customize their safety management activities to

suit the size and nature of their operation and their specific operating conditions. The operator’s

safety-risk profile or the methods each organization uses to identify and manage safety-risks are

particularly important when the auditor is planning and conducting the evaluation, and when

determining the relative significance of findings. This chapter of the Internal Audit Manual has

been developed to assist auditors in dealing with the range of differences that may result from the

application of these performance based standards in a broad range of specific situations.

5.2 Measuring Safety Performance

5.2.1 The goal of the SMS evaluation is to determine whether the operator is managing the safety-risks

of the operation to a level as low as reasonably practical. This is done by assessing the

soundness, appropriateness and effectiveness of the operator’s safety management activities.

Figure 1.1 refers.

Figure 5.1 Measures that Determine Optimal Performance

5.2.2 Although auditors will explicitly evaluate the SMS, they will, at the same time, gauge and

comment on aspects of the operator’s safety culture. An operator’s safety performance is the

sum of the achievements of its formal SMS and the attitudes and values that influence the

behaviour of everyone in the company. The guidelines for evaluating the effectiveness of an

SMS, described in section 5.8, assess indicators of safety culture.



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5.3 Stages in the Development of a Safety Management System

The implementation and operation of an SMS takes time, even for mature aviation organizations. Therefore, the auditor must determine a reasonable level of performance that can be expected when evaluating the SMS. Figure 5.2 illustrates the different stages of an SMS and guidelines are provided in section 5.4 for determining the stage of development of the operator’s SMS.

Figure 5.2

2Stages of Maturing of an SMS

5.4 Determining the Objectives of the Evaluation

5.4.1 As noted earlier, the maturity of a Safety Management System will vary from operator to operator,

and within the same operation over time. The auditor must take this into account before

conducting an evaluation. It is counter-productive to measure an SMS that is just being

implemented in the same way as one that has been in operation for years. What is as “low as

reasonably practical” will differ from one operator to another and evolve with the maturity of the

operator’s SMS. Yet evaluation processes must be fair, and findings consistently derived.

Therefore, an auditor’s first step before each evaluation is to determine, with the operator, the

objective of that evaluation.

5.4.2 The stages of SMS development described below are illustrated in Figure 5.2.

5.4.3 Stage One – The SMS is Documented, Approved, Resourced and Being Implemented

A Stage One Evaluation is conducted:

a. For initial applicants for IS-BAO registration;

b. For a renewal audit if considerable weaknesses were identified in the previous evaluation; or

c. As a benchmark audit in situations such as after a change in management or after significant

organizational change.

The objectives of a Stage One Evaluation are to confirm that:

a. The necessary SMS infrastructure is in-place; and

b. Past and planned safety management activities are appropriately targeted.

Consequently, the evaluation focuses mainly on assessing the soundness and appropriateness of

the SMS. Auditors should plan approximately 75% of their activities to be spent measuring the

soundness of the SMS, and approximately 25% for assessing appropriateness. Guidance is

provided in section 5.8.1.

2 Adapted from B. Frohlich, “Performance Measurement of Safety Management Systems” in Safety Performance

Measurement, edited by J. van Steen, European Process Centre, Institute of Chemical Engineers, Rugby, UK, 1996.



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5.4.4 Stage Two – SMS Functioning, Results Being Measured

A Stage Two Evaluation is conducted of an operator that has successfully completed either a

Stage One or Stage Two Evaluation.

The objectives of a Stage Two Evaluation are to confirm that:

a. Safety management activities are appropriately targeted; and

b. Safety-risks are being effectively managed.

Consequently, a Stage Two renewal audit focuses on assessing the appropriateness and

effectiveness of the SMS, and only samples indicators of SMS soundness.

Auditors should plan approximately 30% of their activities to measure soundness, and

concentrate their attentions on areas that were previously weak or on areas that are particularly

important (e.g. safety profile, reporting program, hazard tracking process). They should plan to

focus the remaining 70% of their activities on assessing appropriateness and effectiveness.

The proportion may favour appropriateness for companies still implementing their SMS (e.g. 50%

appropriateness and 20% effectiveness) and effectiveness for more mature SMS (e.g. 20%

appropriateness and 50% effectiveness). Guidance is contained in section 5.8.2.

5.4.5 Stage Three – SMS Sustained and Supported by an Ongoing Improvement Process

A Stage Three Evaluation is conducted during an evaluation of an operator that has successfully

completed at least one renewal audit. The objectives of a Stage Three Evaluation are to confirm

that:

a. Safety management activities are fully integrated into the operator’s business; and

b. A positive safety culture is being sustained.

Consequently, a Stage Three Evaluation primarily assesses the effectiveness of the SMS, and

only samples indicators of SMS soundness and appropriateness. Auditors should plan to spend

approximately 75% of their activities measuring effectiveness, and only assess soundness and

appropriateness where necessary to understand the causes of potential deficiencies identified in

effectiveness. Guidance is included in section 5.8.3.

5.5 Preparations to Evaluate the SMS

The convening manager and the auditor should work together to ensure that the objective and

scope adequately consider the stage of maturity of the operator’s SMS before the

commencement of the audit.



16

SUMMARY

Determine the objectives of the Safety Management System evaluation

Stage One Initial applicants

Renewal audit (previously weak performance)

As requested or required

Stage Two Most renewal audits

Stage Three Renewal (exceptional performance)

Sample indicators of soundness, appropriateness and effectiveness in proportion to

the stage of development of the SMS

Note: Structure the evaluation to reflect the agreement made with the operator.

5.6 Scoping the Evaluation

5.6.1 As noted earlier, safety performance is best if the SMS is sound, safety activities are appropriate,

and the actions of executives, managers and staff consistently and effectively reduce safety-risks

to a level as low as reasonably practical. For this reason, the SMS evaluation framework is

designed to measure indicators of soundness, appropriateness and effectiveness.

5.6.2 Because operations vary in size and complexity, the aircraft flown, the airspace and airports

used, the geographic and meteorological conditions encountered, and the experience and skills

of the managers and staff employed; optimal safety management varies from operator to

operator. The auditor’s evaluation must consistently and fairly measure the safety performance

of each operator, despite the differences.

5.7 Measuring Soundness, Appropriateness and Effectiveness

5.7.1 Soundness is measured to determine whether the operator has the necessary foundation for

proactive safety management. It is also the first general diagnosis of the operator’s safety health,

and therefore its safety culture. Most of the indicators of soundness can generally be found by

reviewing formal documents, files and procedures. The information can be subsequently verified

by interviews or observations. When assessing soundness, the auditor seeks to answer the

question:

“Is the infrastructure in place to reduce safety-risks to a level as low as reasonably

practical?”

5.7.2 Appropriateness is measured to determine if safety activity is targeted to consistently manage

the operator’s safety risks. An SMS may be soundly managed, but it may not be appropriately

targeted. This may happen when the operator’s SMS has not been well conceived, developed, or

implemented, or in situations where there has been significant organizational or operational

change. The indicators of appropriateness are generally found by reviewing documents, files,

and procedures; by conducting interviews with managers and operational staff; and by observing

the operation first-hand. When assessing appropriateness, the auditor seeks to answer the

question:

“Are safety activities purposefully and appropriately targeted to reduce safety risks to a

level as low as reasonably practical?”



17

5.7.3 Effectiveness is measured to determine if the desired results are being achieved.

Circumstances embedded in human, operational, and organizational factors will conspire to

impede safety performance, even in companies with a well-managed, well-targeted SMS. The

indicators of effectiveness are generally found when conducting interviews, or when observing

the operation (after which the observations are validated by follow-up interviews, or by examining

files or documents). When assessing effectiveness, the auditor seeks to answer the question:

“Is everybody effectively engaged in, and capable of, reducing safety risks to a level as

low as reasonably practical?”

5.8 Conducting the Evaluation

The evaluation is conducted by assessing each of the SMS requirements specified in the IS-BAO

for soundness, appropriateness, and effectiveness utilizing the Chapter 3 of the Detailed ISBAO

Audit Protocols in section 8.2 of this APM.

Auditors should customize their evaluation to suit the operation being examined. For example a

small operation with one or two people would be expected to have a basic SMS, while the SMS of

a large operation would be expected to be much more intricate.

5.8.1 SMS Stage One Evaluation

The aim of the Stage One evaluation is to confirm that the SMS is documented, approved,

resourced and being implemented. The auditor examines indicators of the soundness of the SMS

foundation, and of the appropriateness of the operator’s safety management activities.

The SMS is considered sound if the operator has the required components of an SMS in place

based on the ICAO framework of 4 components and 12 elements. The auditor determines the

level of detail required to evaluate soundness. Section 6.3 contains guidelines for determining the

relative importance of the deficiencies that might be identified.

Appropriateness is assessed for all 12 elements of the SMS. Although effectiveness is not

required to be assessed for a stage 1 evaluation, the auditor may do so if the SMS maturity

allows and if it provides value to the operator.

5.8.2 SMS Stage Two Evaluation

The aim of a Stage Two evaluation is to confirm that:

the SMS is functioning,

results are being measured,

safety management activities are appropriately targeted, and

safety-risks are being effectively managed.

The auditor should concentrate on assessing the appropriateness and effectiveness of the operator’s safety management activities utilizing the detailed protocols. Although the auditor is expected to validate soundness for renewal audits, an in-depth evaluation of soundness is only required for those areas that have changed since the previous evaluation, or which warrant re-examination. For example, if there has been a significant change in any of the following areas, a more in-depth examination of the related SMS elements, to include soundness, would be appropriate:

Structure of the organization

Roles of key managers

Staffing levels



18

Aircraft type

Routes, or

Missions.

In cases where there has not been significant change since the previous evaluation, the auditor

may wish to examine, in more depth, the components that were either weak in the previous

assessment, or which are key to effective safety performance.

5.8.3 SMS Stage Three Evaluation

The aim of a Stage Three evaluation is to confirm that:

SMS is sustained and supported by an on-going improvement process,

A positive safety culture is sustained, and

Safety management activities are fully integrated into the operator’s business.

A Stage Three operator is expected to have the following characteristics:

a. Widespread employee commitment to and involvement with improving safety performance,

including visible leadership by top management;

b. A sustained desire for good safety performance as a goal in itself, not just as an issue of

regulatory compliance;

c. Consistently, with interest, seeks the causes of deficiencies, rather than the allocation of

blame;

d. Effective communication of safety information within and outside the organization, including

safety performance trends;

e. A deeply held commitment to the benefits of continuous evaluation and improvement;

f. Managerial awareness of the issues that adversely impact the operator’s safety culture;

g. Primary goals that include safety, that do not focus only on cost or financial targets, and that,

with other goals, are actively and proactively measured;

h. Adequate allocation of financial and other resources for safety management;

i. Initiatives to learn from the safety performance of external organizations; and

j. Safety performance measures that include those of effectiveness of activities of processes,

rather than just the results of these activities.

The on-going improvement process should include regular evaluation of safety management activities in relation to stated SMS objectives plus the evaluation of the effectiveness of risk controls. It also should include a formal process to identify the causes of sub-standard performance of the SMS, determine the implications of sub-standard performance of the SMS in operations, and eliminate or mitigate such causes. For Stage Three evaluations, auditors are encouraged to conduct an in-depth evaluation of effectiveness utilizing the detailed protocols along with the following performance indicator examples. The possible methods by which the information can be obtained are provided in brackets with the following abbreviations employed: doc. – manuals, formal documents, procedures, files, etc; int. – interviews with managers, staff or stakeholders; obs. – on-site or in-flight observations; exp. – the experience of the auditor.

Stage 3 SMS Performance Indicators

1. Safety Policy and Objectives

a. Are comments on the efficacy of the safety policy and related policies actively solicited



19

from all stakeholders, managers and staff? (doc., int., obs., exp.)

b. Are the policy/policies periodically and thoroughly reviewed and when appropriate,

revised? (doc., int., obs., exp.)

c. Is top management fully aware of the human and organizational factors that endanger the

operation and do they continuously make decisions mindful of those factors? (doc., int.,

obs., exp.)

d. Does management drive the SMS process and vigorously seek excellence? (int.)

e. Are responsibilities for safety and contributing to the SMS effectiveness fully imbedded

throughout all levels of the organization? (doc., int.)

f. Do the appraisals of personnel at all levels include related SMS targets (activities and

results) and is exemplary behaviour rewarded? (doc., int.)

g. Are safety management activities being continually monitored, evaluated and improved

when opportunities are identified? (doc., int.)

h. Have managers and staff clearly demonstrated that they are capable of performing their

roles to proactively manage safety? (obs., exp.

i. Is there evidence of the documentation evolving as the other elements of the SMS

matured? (doc., int.)

2. Safety Risk Management

a. Are the policies and procedures to mitigate safety-risks periodically reviewed for

applicability and effectiveness and modified when found wanting. (int., obs., doc.)

b. Does the mitigation account for predictable human, operational and organizational

limitations? (int., obs., exp.)

c. Are risk assessment and management fully integrated into all operations and

maintenance activities? (int., obs., doc.)

d. Is the information indicating the need to change respected and valued? (doc., int., obs.)

e. Are long and short-term plans to improve safety performance driven by multi-level

analyses of the safety-risk management database and integrated with business planning.

(int., obs., doc.)

f. Is there solid evidence that managers and staff are fully engage in and committed to,

enhancing safety performance? (int., obs., doc., exp.)

g. Is their consistent feedback that has been effective in ensuring the participation of

managers and employees? (doc. int., obs.)

h. Is the information used not only to enhance day-to-day safety, but also to improve long-

term safety management? (doc., int.)

i. Are the results of safety management activities evident in the operations manual and its

amendments? (obs., doc., int.)

j. Are there effective processes to ensure that any amendments to the Operations Manual

that result from safety management activities are made in a timely manner? (obs., doc.,

int.)

k. Are employees highly motivated to report occurrences and does the environment exist

where they are fully prepared to make such reports when it involves admitting that they

made mistakes? (int.)

l. Are occurrences analyzed and the lessons learned integrated into the appropriate

programs and procedures? (doc., int.)

3. Safety Assurance



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a. Is the effectiveness of safety management activities periodically evaluated and modified

to improve the organization’s safety performance. (doc., int.)

b. Is there effective use of tools such as internal safety surveys? (doc., int.)

c. Is there an effective ongoing program to evaluate safety performance? (doc., int., obs.,

exp.)

d. Is the information obtained used to enhance appropriate programs and procedures?

(doc., int., obs., exp.)

4. Safety Promotion

a. Is there an established effective process to ensure that the results of SMS activities are

fully integrated into the appropriate training programs? (int., doc.)

b. Are employees highly motivated to report apparent safety deficiencies and fully confident

that there will not be retribution? (int.)

c. Are there well established processes to expeditiously evaluate safety information and

integrate it into safety management activities? (doc., int. obs., exp)

5.9 Reserved



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6.0 PREPARING AUDIT FINDINGS

6.1 Introduction Findings are significant issues which require urgent action by the operator's to correct. Findings may relate to one or more non-conformities but should be sufficiently serious to require urgent action. As previously noted, a minor non-conformity would be one that does not constitute a significant risk to safety. It may be an isolated instance of non-conformity, a lack, or error in documentation of a process or procedure that was correctly executed, or a similar instance. A major non-conformity is when there is a pattern of instances of minor non-conformity or a non-conformity that in itself constitutes a significant risk to the safety of the operation.

Non-Conformity (NC) Condition Consequence

Minor

Single NC Low risk to safety Finding or “ACTION REQUIRED” statement in protocols

Multiple related NCs Increased risk to safety

Finding

Major Significant risk to safety

Finding

Figure 6.1. Non-Conformity/Finding Matrix

6.2 Making Findings

6.2.1 Findings must be significant issues that need the operator’s attention. They must relate to

standards specified in the IS-BAO, must be substantiated by factual information and in most

cases should be validated by objective evidence of different forms or sources of information (for

instance, corroborating information from: different documents; documents and observations; or

documents, interviews and observations). Findings of an IS-BAO audit must address the degree

to which safety risks are being managed to a level “as low as reasonably practical” (i.e. the

objective of all evaluations of SMS). As such, the findings should always relate to management

of the safety-risks, not to the operational indicators of deficient safety management.

Consequently, the findings are developed after the components of the SMS and related elements

have been assessed (as described in chapter 5). Auditors must take the information from their

assessments, and use logic and experience to determine the cause(s) of the problem. It is these

cause(s) that make up the findings. It is important that the auditor address the disease not the

symptoms of the disease.

6.2.2 Several examples are provided below:

a. A Safety-Risk Profile that failed to identify a number of key hazards might lead to

observations by the auditor of inappropriate operational procedures and training. By seeking

the cause(s), the auditor’s finding might target the procedures used to conduct the Hazard

Analysis, rather than the profile, the operational procedures or the training.

b. An auditor might identify that plans to revise self-dispatch procedures had been slipping for

some time. Further inquiry or other observations might lead to a finding regarding an

absence of resources to modify the procedures, and possibly an absence of managerial

oversight of this slippage.

c. An auditor might observe a number of maintenance related issues. By reviewing the

Maintenance Control System and interviewing personnel, deficiencies in the Maintenance

Control System, or related procedures, training or managerial oversight might be identified as

the causes of these issues.



22

6.2.3 It is therefore important that indications of non-conformity and the related objective

evidence collected in the course of the audit be carefully analysed to determine the

cause(s) of the problem. When the cause has been identified it should be presented as a

Finding with the non-conformities and other objective evidence, used as supporting material.

If it is determined that one or more minor non-conformities are simply slips, lapses or omissions

that can easily be corrected and there is no significant underlying problem, rather than making a

Finding the non-conformity should be noted in the Analysis of Non-conformities section of the

Audit Protocol along with the comment, “ACTION REQUIRED”. “Full Conformity” should not be

selected on the Audit Report Form if there are any instances of non-conformities, regardless of

how they are documented, i.e. on the Finding forms or in Analysis of Non-conformities block. 6.2.4 A major non-conformity, by definition, will be sufficiently critical that a Finding must be made.

However, the same degree of analysis must be undertaken to identify the cause(s) of the problem.

6.2.5 Findings are to be recorded on the Audit Finding Form that is contained in section 8.3. 6.2.6 It should be noted that a finding cannot be based on non-conformity with a Recommended

Practice contained in the IS-BAO, but that fact can be used in conjunction with other non-conformity information to substantiate a conclusion.

Figure 6.2. Process for Documenting Non-Conformities

6.3 Determining Criticality

Auditors must be able to consistently determine the criticality of their findings so operators can

plan appropriate remedial action. Criticality is determined by judging the scope of the finding (i.e.

by determining whether the consequence is far reaching), and by assessing its impact on the

safety of the operation. The measure differs from an Initial and a Renewal audit.

6.3.1 IS-BAO Audit with a Stage One SMS Evaluation



23

An IS-BAO audit that is conducted of an operator where their SMS is at a first stage of

development and implementation will focus on the degree to which the SMS and other IS-BAO

requirements are documented, approved, resourced and is being implemented, so that safety

risks are reduced to a level as low as reasonably practical. Therefore, critical findings would be

those that indicated deficiencies in documentation, resources and implementation, and

particularly those that could seriously impede a sound SMS, or could lead to unsafe operational

practices. Examples of critical deficiencies in the SMS structure might include:

a. A deficient document management system;

b. An absence of planning or coordinated activity to implement the programs, procedures or

SMS; and

c. An absence of resources (time, money, skills) to implement or operate the programs,

procedures or SMS

Examples of deficiencies that could lead to unsafe practices might include:

a. A poorly constructed hazard identification and risk management process or Safety-Risk

Profile;

b. Poorly developed or implemented mitigation (programs, procedures and manuals) from a

sound Safety-Risk Profile; and

c. Weak management oversight.

Generally, the findings of a Stage One Evaluation are important because deficiencies identified

have the potential to be broad in scope and far-reaching in consequence. Weaknesses in the

foundation of the operators programs, procedures, manuals or SMS suggest:

a. The operator will be unable to proactively and consistently manage and measure its safety

performance; and

b. There may be a lack of understanding, or a lack of commitment to appropriate and effective

safety management. 6.3.2 IS-BAO Audit with a Stage Two SMS Evaluation

An IS-BAO audit that is conducted of an operator where their SMS as at the second stage of development and implementation will focus on the degree to which the operators systems and procedures, including SMS, are functioning and the results are being measured so that systems and procedures can be improved when required and safety-risks can be continuously reduced to a level as low as reasonably practical. Therefore, critical deficiencies would be those that indicate:

a. There are inconsistencies in adherence to operational, maintenance or safety management

procedures, including during periods of change; and

b. Feedback from hazard reports, safety committees, audits or risk assessments is either not

being obtained, or not being employed to update operator programs, procedures and the risk

profile, or to improve the related mitigation (e.g. procedures, training, equipment, etc.). The auditor must take this information and determine the cause(s) before making the finding(s). Deficiencies may indicate a need to make findings on a lack of understanding of human or organizational factors; a lack of understanding of, or commitment to, proactive safety management; or conflicting resource requirements, amongst others.

6.3.3 IS-BAO Audit with a Stage Three SMS Evaluation

An IS-BAO audit that is conducted of an operator where their SMS as at the third stage of development and implementation will focus on determining whether the SMS is sustained and supported by an ongoing improvement process. This ongoing improvement process should be evident in the operator programs, procedures, manuals and SMS processes and procedures so that safety risks are continuously reduced to a level as low as reasonably practical.



24

Figure 6.3. Example Protocol Entries for Non-Conformities

6.13 Fatigue Management

6.13.1 Does the operator have a fatigue management programme that ensures that all personnel (including maintenance, pilots, cabin crew, other crew) involved in the operation do not carry out their duties when they are fatigued and that includes: a. fatigue management guiding

principles,

N

b. appropriate training and

education regarding preventive

and operational fatigue

countermeasures;

N

c. flight and duty time limitations,

and

Y OM 6.4

d. an evaluation process that assess

the effectiveness of the fatigue

management system?

N

6.13.2 If deviations from the flight and duty time limitations are permitted, does the system include: a. A risk assessment process,

N OM 6.5 Describes the procedure to conduct a risk assessment. However, it has not been utilized.

b. The identification of the

management person authorized

to approve the deviation, and

Y OM 6.6

c. A record of the deviation, risk

assessment and mitigation?

N Although deviations are recorded, risk assessments and mitigation strategies are not completed.

6.13.3 Do deviations require the expressed approval of all personnel involved?

Y OM 6.7

Comments/Observations/Recommendations

The fatigue management system (FMS) described in the OM states that personnel can continue beyond the normal duty limits by one hour only with the authorization of the Director of Operations and as long as all affected personnel concur. Although this is a good safety control feature, risk assessments and mitigation will provide a better means to reduce risks to as low as reasonably practicable. Records show that 6 extensions have been granted in the past 12 months. The FMS does not consider factors which are highlighted in the ISBAO guidance material such as: 1) Window of Circadian Low, 2) Maximum Flight Time, 3) Time Zone changes, 4) Standby duty, 5) Chronic fatigue, 6) Adequate crew rest facilities, 7) Adequate time off to ensure proper rest. It is recommended that the operator review the ISBAO guidance material in the IG and implement the appropriate measures.

Analysis of Non-Conformities/Findings 6.13.1a,b,d 6.13.2 a,c

The FMS lacks: 1) Guiding principles on fatigue management, 2) appropriate education and training program, and 3) an evaluation process. Pilot and maintenance tech interviews revealed that this situation occurs rarely and that the Director does discuss risks when they decide to extend. Although deviations from duty limits are allowed, the documented risk assessment procedure has not been utilized for these instances. Therefore, documentation of the deviations lacks the risk assessment and associated mitigation.



25

Figure 6.4. Example Finding Form

Shape Up Aviation NUMBER __1_ OF __2_

OPERATOR NAME NON-CONFORMITY CATEGORY 123 LOOP ROAD

ADDRESS MINOR MAJOR X

Anytown, NH 77777

IS-BAO ELEMENT & REF. # SMS TRAINING 3.2.4A

OPERATORS MANUAL OR PROCEDURE AND REFERENCE OM Chapter 2.7

DETAILS OF FINDING [CAUSE/EFFECT/CRITICALITY IAW SECTIONS 6.2 & 6.3] The Accountable Executive, SM and Management have not received adequate SMS training, which has resulted in the operator being unaware of several SMS requirements including the following: - Proactive and Predictive methods of safety data collection - Evaluation of mitigation strategies/establishment of performance indicators and targets, and - System to review applicable regulations, standards, approvals, and exemptions and ensure compliance with them. Criticality – This issue affects the entire organization's ability to control safety risks to a level as low as reasonably practical. The risk associated with this finding is significant (medium to high) as latent conditions are able to continue without detection due to the lack of proactive detection methods. OBJECTIVE EVIDENCE

- Lack of proactive and predictive safety data (doc., int.)

- No evidence of mitigation review and/or evaluation (doc., int.)

- Performance indicators and targets not established (doc, int.)

- No systematic method to review regulations, standards, and approvals (doc., int.)

I.M. Auditor 4/17/2014

Auditor’s Name Signature Date

OPERATOR REMEDIAL ACTION PLAN (INCLUDING ESTIMATED DATE OF PLAN COMPLETION) Accountable Executive, SM, Director, Operations Manager, and Maintenance Manager will receive formal industry-recognized SMS training. The following procedures will be documented and implemented: (1) Proactive and predictive methods of data capturing, (2) Evaluation of mitigation strategies, (3) Compliance monitoring. A policy letter will be developed to address these new procedures and sent to all personnel. All personnel will be trained on the new procedures. The Director of Aviation will be responsible for ensuring the completion of this plan no later than July 1, 2014.

Jackie N. Charge 4/17/2014 Manager of the Operation Signature Date

Remedial Action Plan Acceptable X Not Acceptable

I.M. Auditor 4/17/2014 Auditor’s Name Signature Date

AUDITOR COMMENTS AND FOLLOW-UP – FOR MAJOR NON-CONFORMITY COMMENTS: REMEDIAL ACTION PLAN SUCCESSFULLY IMPLEMENTED.

Follow-up Review Acceptable X Not Acceptable

I.M. Auditor 6/15/2014


IS-BAO Audit Procedures Manual International Business Aviation Council (IBAC)


26




27

7.0 AUDIT REPORTS

7.1 Report Standards 7.1.1 Audit reports are a consistent and objective reflection of the results of the audit and are to adhere

to the reporting principles established in this Manual. 7.1.2 The purpose of the audit report is to:

a. provide information to the operator regarding the status of implementation of IS-BAO standards, safety-related guidance material and good aviation safety practices;

b. demonstrate the need to initiate corrective actions if registration is to be granted pursuant to the IS-BAO standards;

c. provide information to the operator for use in development of remedial action plans; and

d. provide the IBAC Secretariat with a report of the audit if the operator is applying for registration.

7.1.3 Key principles in the development of the audit reports are:

a. there must be consistency in findings between the Closing Meeting and Audit Report;

b. the audit conclusions must be substantiated with references and relate to the audit requirements and objectives;

c. the findings must clearly identify the problem and its cause(s) and communicate the full extent of the problem;

d. findings based on minor non-conformities must have an accepted corrective action plan,

e. findings based on major-nonconformities must be rectified prior to submission of the audit report to IBAC,

f. accepted aviation terminology and acronyms should be used, non-standard acronyms and jargon should be avoided; and

g. criticism of individuals or positions should be avoided. 7.1.4 Operator conformance with the IS-BAO standards is recorded in the audit protocol; however this

does not inform the operator, audit review group or subsequent auditors about the level of conformity and the maturity of the operator’s systems, programs and procedures. The spaces provided for remarks and observations within the protocols should be used for this purpose. The auditor shall provide a comment or reason for any protocol element indicated as “NA”.

7.1.5 While broad, general observations help to better understand the operation, comments regarding

specific elements of the protocol will provide the operator with reinforcement on those done well and serve as insights to improve areas requiring emphasis. Specific comments also provide audit reviewers with valuable insights into the operator's program and how the standards are being applied. Qualitative comments/observations about levels of implementation, program acceptance and understanding by operator personnel, especially for the SMS, are helpful for all concerned. Training, standardization levels, corporate culture and record keeping are also areas of interest.

7.2 Determining Audit Results 7.2.1 As explained in section 4.9 an audit is considered successful if the operator is in conformity with

the standards contained in the IS-BAO in that there is no major non-conformity. When considering most of the IS-BAO requirements this will be very straightforward, however, when determining if there are any minor or major non-conformities related to the operator’s SMS, it is important to carefully consider the stage of development and implementation that it is at. In general terms, for an initial IS-BAO audit where the SMS is in the first stage of development and implementation, the auditor will assess the findings and conclude the evaluation by determining whether the operator’s SMS is:



28

a. documented and approved;

b. resourced; and

c. being implemented.

In the case of an IS-BAO renewal audit, the auditor will determine whether the SMS:

a. is functioning; and

b. the results are being measured and employed.

In both cases, the conclusion will be based on whether the safety-risks are being reduced to a level as low as reasonably practical, in light of the relative maturity of the operator’s SMS. A positive determination in each of the criteria is the indicator of a successful evaluation. Findings indicating deficiencies will become the basis for the operator’s action plan, and will be one of the starting points for the next evaluation.

7.2.2 If an auditor finds that one or more of the above-listed criteria have not been met, then the auditor

will conclude that the operator’s safety performance is unsatisfactory. Such a conclusion must

be supported with a major non-conformity finding that explicitly identifies the risk to safety. In

doing so the critical deficiencies (as described in 6.3.1 and 6.3.2, respectively) must be

highlighted to explain the auditor’s conclusion, so that the operator can develop an action plan

that will lead to rectification of the deficiency and a successful audit.

7.3 Audit Report Contents 7.3.1 A copy of the IS-BAO Audit Report Form is provided in section 8.1. A copy of all IS-BAO Audit

Finding Forms and the other completed Audit Protocols that were used in the audit should be attached to the Audit Report Form.



29

8.0 AUDIT FORMS

8.1 Audit Report Form AUDIT DATE NO. OF DAYS ON SITE

OPERATOR NAME & ADDRESS Telephone

e-mail

OPERATOR CONTACT NAME & POSITION

IBAC member association from which the operator purchased their copy of the IS-BAO:

Is it the current edition? Yes No

AUDIT SCOPE Full System Partial

SMS STAGE One Two Three

If partial, elements covered: `

Auditor / Audit Team Leader

Contact Information

Members

Email and Telephone

Audit Results and IS-BAO Registration Recommendation

Full Conformity Minor Non-conformity Major Non-conformity

Stage 1 SMS is documented, approved, resourced, and being implemented.

Stage 2 SMS is functioning and results are being measured; Safety risks are effectively managed;

Safety management activities are appropriately targeted.

Stage 3 Stage 2 performance, plus SMS is sustained and supported by an on-going

improvement process; Safety management activities are fully integrated into the operator’s business; and a positive safety culture is being sustained.

IS-BAO Auditor Signature / Date Operator Representative Signature / Date



30

Summary of Audit Including Overall Assessment of the Appropriateness and Effectiveness of the Operator’s SMS and Other Management System Controls

Type of Operations Conducted

Non-commercial Commercial Aircraft management services

(Comply with APM Appendix C)

Other please specify

Total Number of Aircraft Operated

Total Number of Personnel

Total Number of Fixed-Wing

Total Number of Rotor-Wing

Types of Aircraft Operated

Home Operating Base

Additional Operating Bases

List of Persons Interviewed and Position or Job Title

(Interview a representative sample of line and management personnel)

Additional Comments

IS-BAO Audit Protocols International Business Aviation Council (IBAC)

ref. Requirement Conform

N/A References / Comments/ Evidence of Non-Conformities Y N


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8.2 Detailed Audit Protocols

3 Safety Management System

3.2 Safety Management System Requirements

3.2.1 Safety Policy and Objectives

3.2.1a Management Commitment and Responsibility

SOUND: Is there a safety policy that:

Reflects management’s

commitment to safety?

Includes a clear statement about

providing necessary resources?

Includes safety reporting

procedures?

Is signed and dated by the

Accountable Executive (AE)?

Is communicated, with visible

endorsement, throughout the

organization?

Indicates which types of behaviours

that are unacceptable?

Includes the conditions under which

exemption from disciplinary action

would be applicable?

Is periodically reviewed to ensure it remains relevant and appropriate to the organization?

APPROPRIATE

Is the safety policy relevant to the

scope and complexity of the

organization’s operations?

Is everyone aware of the safety

policy?

EFFECTIVE

Is the safety policy reinforced by

day-to-day decisions?

Is everyone committed to

enhancing safety performance?

Is there visible evidence of

management demonstrating by

example?

3.2.1.b Safety Accountabilities SOUND: Does the SMS documentation identify the AE and the safety responsibilities, accountabilities and authorities of all personnel, to include a definition of the levels of management with authority to make decisions regarding safety risk tolerability?





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APPROPRIATE

Do the AE’s terms of reference

indicate his/her ultimate

responsibility for the SMS?

Are there clear lines of safety

accountabilities throughout the

organisation?

EFFECTIVE

Are the resources available to

manage risks effectively?

Does everyone know their role in

the SMS and participate

accordingly?

3.2.1c Appointment of Key Safety Personnel SOUND: Does the SMS documentation include an appointment of a safety manager?

APPROPRIATE

Is the safety manager properly trained?

EFFECTIVE

Are the results of safety management activities formally recorded and analysed?

3.2.1d Coordination of ERP SOUND: Does the SMS documentation include an ERP that is properly coordinated with the emergency response plans of those organizations it must interface with during the provision of its services?

APPROPRIATE

Is there a procedure for periodic review of the ERP to ensure its continuing relevance and effectiveness?

EFFECTIVE

Is the ERP regularly tested and updated including coordination with other organisations as appropriate?

3.2.1e SMS Documentation SOUND: Does the SMS documentation include:

A plan that defines the

organization‘s approach to meet the

safety objectives;

Safety policy and objectives;





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SMS requirements;

SMS processes and procedures;

Accountabilities, responsibilities

and authorities for processes and

procedures; and

SMS outputs?

APPROPRIATE

Is the SMS documentation readily available to ALL personnel?

EFFECTIVE

Is there evidence that the SMS

documentation is regularly

reviewed and updated?

Does the documentation provide

evidence that safety objectives are

being met?

3.2.2 Safety Risk Management

3.2.2a Hazard Identification SOUND: Is there a formal process to ensure hazards are identified using the following methods:

Reactive?

Proactive?

Predictive?

APPROPRIATE

Is there a reporting system to

capture errors, hazards and near

misses that is simple to use and

accessible to all personnel?

Is there a procedure to review

hazards/risks from external

reports?

EFFECTIVE

Are hazards, errors, near misses,

and audit findings being identified

and reported throughout the

organization?

Are employees confident they can

report apparent safety deficiencies

without retribution?

Are both internal and external

information used to update the

safety risk profile?

Is there a procedure for periodic

review of existing risk analysis

records?

3.2.2b Risk Assessment and Mitigation





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SOUND: Is there a formal process for to manage safety risks that includes:

Analysis?

Assessment?

Control?

APPROPRIATE

Does the AE and management

team have visibility of medium and

high risks and their controls?

Do training programs highlight

safety critical issues identified in the

safety risk profile?

Does the Ops Manual contain

mitigation described in the safety

risk profile?

EFFECTIVE

Does the organisation use its risk

management results to develop

best practices?

Is the information indicating the

need to change respected, valued,

validated, and used?

Is there consistent feedback to

encourage the future participation

of managers and employees?

Is the Operations Manual

consistently employed by

operational managers and staff?

Does mitigation take into account

Human Factors and Organizational

Factors?

3.2.3 Safety Assurance

3.2.3 a Safety performance monitoring and measurement

SOUND: Is there a process and/or procedure to:

Validate the effectiveness of the

safety risk controls?

To established safety performance

indicators and targets?

APPROPRIATE

Has the organisation developed a

series of safety performance

indicators that are appropriate to

the type of operation?

Are safety indicators and targets

specific, measurable, agreed to,

relevant and time-based?





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Is the information from occurrences

analyzed and where appropriate,

used to upgrade policies and

procedures?

Are priorities regularly reviewed,

reassessed and, if required,

reassigned to address safety

issues?

EFFECTIVE

Are safety targets being achieved?

Is there a means to measure and

monitor trends and take appropriate

action when necessary?

Have the controls for the safety

risks been evaluated?

Are the results from internal audits

used to measure safety

performance?

3.2.3 b Management of Change SOUND: Is there a process to identify and manage organizational changes that may affect safety?

APPROPRIATE

Are stakeholders involved in the

change management process?

Are there procedures for managing

the revisions of documents,

manuals, and checklists?

Are changes to critical documents

communicated throughout the

organization?

EFFECTIVE

Does the organisation use the SMS

to proactively assess all major

changes to the organisation and its

operations?

Do staff members always use up-

to-date documents, manuals,

checklists, and/or procedures?

3.2.3 c Continuous Improvement SOUND: Is there a process or procedure to ensure continuous improvement of the SMS?

APPROPRIATE

Is there an internal

audit/assessment process and a

follow-up procedure to address





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audit findings?

EFFECTIVE

Is there evidence of improvements

to policies, procedures, and/or

processes based on internal audit

findings?

3.2.4 Safety Promotion

3.2.4 a Training and Education

SOUND: Has the organization developed and maintained safety training programmes that ensure that personnel are competent to perform their SMS duties?

APPROPRIATE

Does training include human and

organisational factors with the

intent of reducing human error?

Does technical training (i.e. pilot,

maintenance, dispatch/scheduling,

etc.) reinforce SMS principles (i.e.

human factors, organizational

factors, risk assessments, risk

management, etc.)?

EFFECTIVE

Is there evidence that all personnel

involved in SMS operations have

undergone appropriate SMS

training?

Are executives, managers, and

staff capable of performing their

roles to proactively manage safety?

3.2.4 b Safety Communication SOUND: Has the organization developed and maintained a formal means of safety communication?

APPROPRIATE

Are significant events and investigation outcomes from internal and external sources communicated to all personnel?

EFFECTIVE

Is there evidence that all personnel are aware of the SMS, safety critical information, and their role in respect of aviation safety?

3.3 Compliance Monitoring

3.3.1 Has the operator established and maintained a system for identifying applicable regulations, standards, approvals, exemptions and





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demonstrated compliance with them?

3.4 Flight Data Analysis

3.4.1 Has the organization established a flight data analysis programme (Recommended Practice)

Comments, Observations, and Recommendations

Analysis of Non-Conformities/Findings





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Element 4 Organization and Personnel Requirements

4.1 Organization and Personnel

4.1.1

Does the operator have an organization structure that clearly defines qualifications, duties, authorities & accountabilities of the:

a. Manager of the operation;

b. Person responsible for managing the flying operations; and

c. A person responsible for aircraft maintenance?

4.1.2 Where the organization has more than one operating base, has the organization structure addressed the exercise of management of the above responsibilities at all locations?

4.2 Aircraft Crew Member Duties and Responsibilities

4.2.1 Does the operator have a procedure to ensure that the minimum number of flight crew as specified in the aircraft flight manual or other document associated with the C of A, and the minimum numbers of cabin crew members, as required by State of Registry regulations, are assigned?

4.2.2 Does the operator have procedure for designation of a pilot-in-command and other aircraft crew positions?

4.2.3

Have the duties and responsibilities of the PIC been specified and do they meet section 4.2.3 of the IS-BAO?

4.2.4 Have the duties and responsibilities of the SIC, if required, been specified?

4.2.5 Have the duties and responsibilities of the cabin crew and other crew members assigned on-board duties specified?





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4.3 Crew Member Qualifications

4.3.1 a. Are there procedures to ensure that all flight crew members: i) hold the licence, medical

certificate and ratings (including radiotelephony licence unless it is included in the pilot licence) required by national regulations,

ii) meets all recency requirements of the national regulations,

iii) meets the licence, medical and rating requirements specified in ICAO Annex 1 when operations are conducted outside of the national airspace of the State of issue of the flight crew licence,

iv) has fulfilled the requirements of the operator's ground and flight training programme referred to in sections 5.1, 5.2, 5.3 and 5.4,

v) have successfully completed the proficiency requirements specified in section 5.5 for that type of aircraft, and

vi) can demonstrate the capability to speak and understand the language used for aeronautical radiotelephony communications as specified in ICAO Annex 1.

b. Are there procedures to ensure that each cabin crew member has fulfilled the requirements of the national regulations and the operator's ground and flight training programme referred to in sections 5.1, 5.2 and 5.3, and recommended in section 5.4?

c. Are there procedures to ensure that each crew member or task specialist, other than a flight crew member or a cabin crew member, has fulfilled the requirements of the operator's ground and flight training programme referred to in section 5.1?

4.3.2.A Where it is the operator’s practice to fly two crew aeroplanes from the left





40

seat, has the operator established right seat landing and take-off recency and training requirements? (Recommended Practice)

4.3.2.H Where it is the operator’s practice to fly two crew helicopters from the right seat, has the operator established left seat landing and take-off recency and training requirements? (Recommended Practice)

4.4 Maintenance Personnel Qualifications

4.4.1 Do the maintenance personnel hold the licences and ratings required by the State of the Operator or State of Registry of the aircraft?

4.5 Other Personnel

4.5.1 Are duties, authorities and responsibilities for other personnel involved in the operation described within the operations manual?

4.6 Use of Psychoactive Substances

4.6.1 Is there a policy to ensure that personnel do not undertake safety related duties while under the influence of any psychoactive substance which might render them unable to safely and properly exercise their licence privileges or carry out their safety related duties?

(Recommended Practice)

4.6.2 Do policies also address any problematic use of substances? (Recommended Practice)

4.7 Mobile Phones & PEDs

Do policies provide guidance on the use of mobile phones and PED for all personnel, including critical phases of flight and ground operations, operating vehicles, and maintenance work? (Recommended Practice)


Is there a program to assess and manage the inherent risks associated fatigue for ALL personnel and does it include all the elements as described in Section 6.13? (Recommended Practice)






41






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Element 5 Training and Proficiency

5.1 Training Programs

5.1.1 Does the operator have a training programme that ensures that personnel are trained and competent to perform their assigned duties?

5.1.2 Is the training program included or referenced, in the company operations manual?

5.1.3

a. Flight Crew Members:

Does the ground and flight training programme include:

(i). Initial and annual aircraft type and systems training including emergency and abnormal procedures related to the aircraft category and type?

(ii) Initial and every two years thereafter: A. Emergency Procedures

Training? (See Section 5.3.1)

B. Aircraft Surface Contamination Training?

C. Dangerous Goods Training?

(iii) Upgrade training program?

(iv) Periodic first aid training for operators that do not use cabin crew (Recommended Practice)

b. Cabin Crew Members:

(i) Does the initial and annual training include:

A. Aircraft Type Training?

1. Safety Procedures Training (see Section 5.3.2)

(ii) Initial and every two years thereafter:

A. Emergency procedures training (see Section 5.3.1)

B. First aid training;

C. Aircraft surface contamination training, and

D. Dangerous goods training?

c. Is there an initial and recurrent training program for other crew members: (i.e. loadmasters, stewards, HEMS medical teams, observers, etc.)?

d. Is there an initial and recurrent training for schedulers or dispatchers?





43

e. Does the organization’s training program include all the elements required to ensure a safe operation?

5.1.4 Does the operator prohibit simulated emergency or abnormal situations in flight with passengers on board?

5.1.5 Does the operator use flight simulators for training? (Recommended Practice)

5.1.6 Maintenance Personnel Training a. Has the operator established a

training programme that ensures that the organization’s maintenance personnel have the competencies appropriate to the level of maintenance performed?

b. Is the training course outline referenced in the company operations manual?

c. Does the training programme include both initial and recurrent training appropriate to the aircraft group, type or system and the related procedures for which a maintenance release is to be signed?

d. Does the training programme include other subjects [See Section 5.1.6d items (i) – (ix)]?


e. Do persons who hold maintenance release authority undertake recurrent training at least every 2 years on aircraft for which they exercise that authority? (Recommended Practice)

5.2 Crew Resource Management/Human Factors Training

5.2.1 Have aircraft crew members received CRM training?

5.2.2 Have ALL personnel received CRM or Human Factors training and do recurrent training programs include instruction in these subjects? (Recommended Practice)





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5.3 Emergency and Safety Procedures Training

5.3.1 Are there initial and recurrent Emergency Procedures training programs per Standard 5.3.1 and have all aircraft crew members received their training for:

a. fire in the air and ground,

b. use of fire extinguishers,

c. operation/use of emergency exits

d. passenger preparation for emergency landing and/or ditching,

e. emergency evacuation procedures,

f. donning and inflation of life preservers (if equipped),

g. removal from stowage, deployment, inflation and boarding of life rafts (when equipped);

h. pilot incapacitation

i. unlawful interference, bomb threat, other security procedures,

j. MEDEVAC or ill or injured passenger transportation in emergency situations, and

k. passenger health emergencies?

5.3.1.1 Is there a programme to provide emergency procedures training to passengers that fly frequently? (Recommended Practice)

5.3.2 Are there initial and recurrent Safety Procedures training programmes for all cabin crew members?

5.3.3H Is helicopter underwater escape training (HUET) provided to personnel involved in over water helicopter operations in hostile environmental conditions?

(Recommended Practice helicopter operators)

5.4 High Altitude Training

5.4.1 Have flight crew members received high altitude training for aircraft operated above 10,000 feet?

5.4.2 Is pertinent aircraft type specific high altitude training conducted? (Recommended Practice)

5.5 Proficiency Certification

5.5.1 Is there a process to ensure that all





45

aircraft crew members meet national proficiency requirements?

Is there a process to ensure that all crew member training courses meet the training objectives required by the national civil aviation authority?

5.5.2

Has the proficiency of flight crew members been certified at the conclusion of initial type training and on a recurrent basis as required by the national civil aviation authority?

5.6 Training and Qualification Records

5.6.1

Does the operator have a system to record licensing, training and qualifications information for each person who is required to receive training and does it meet the IS-BAO requirements?

5.6.2 Are records retained for the required period?







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Element 6 Flight Operations

6.1 Standard Operation Procedures

6.1.1 a. Does the operator have a SOP for each aircraft operated with two or more crew members?

b. Does the operator have a SOP for single pilot aircraft? (Recommended Practice)

6.1.2 Has the operator ensured that all crew members are trained in use of the SOP and that it is used?

6.1.3 Is a copy of the SOP issued to each aircraft crewmember?

6.1.4 Is a copy of the SOP carried onboard the aircraft when it is operated more that 25 nm from home base?

6.2 Flight Planning and Pre-Flight Requirements

6.2.1.1 Does the operator have a requirement and procedures for the PIC to be familiar with the available information appropriate for the flight and to ensure that the facilities and services are adequate for the safe operation of the aircraft?

6.2.1.2

Does the operator have a requirement and procedures for the PIC to: a. be familiar with all available

meteorological information, and

b. plan an alternative course of action for the eventuality that the flight cannot be completed because of weather conditions?

6.2.2 Does the operator have procedures for VFR flight operations?

6.2.3

a. Does the operator have a procedure to ensure that a flight shall not be commenced unless the available information indicates that conditions, at the aerodrome or heliport , of intended landing or at least one destination alternate will, at the estimated time of arrival, be at or above the aerodrome or heliport, operating minima?

b. Does the operator have a procedure to ensure that a take-off alternate aerodrome/heliport is selected and specified in the flight plan if the weather conditions at the aerodrome/heliport of departure are at or below the





47

applicable operating minima or it would not be possible to return to the point of departure for other reasons?

c. Is there a procedure to ensure that the weather conditions for the departure alternate, at the estimated time of use, will be at or above the applicable operating minima for that operation?

6.2.4 Does the operator have a procedure to ensure that at least one destination alternate aerodrome or heliport, shall be selected and specified in the flight plan, with the following exceptions: a. The approach at the destination

can be flown under VMC

d. The destination is isolated and no alternate is available (See IS-BAO 6.2.4b)

6.2.5A Does the operator have policies and procedures to ensure that in-flight fuel checks are performed? Do they include: a. Minimum fuel reserves defined, to

include flights with a destination alternate?

b. One final reserve fuel value for each aeroplane type figured and published? (Recommended Practice)

c. The PIC continually ensuring that the amount of usable fuel remaining on board is not less than the fuel required to proceed to an aerodrome where a safe landing can be made with the planned final reserve fuel remaining upon landing?

d. Guidance for declaring MINIMUM FUEL?

e. Guidance for declaring a fuel emergency? (See IS-BAO 6.2.5A for details)

6.2.5H

Does the operator have a procedure to ensure that a helicopter carries sufficient fuel and oil to safely complete the flight and land with adequate reserves? (See IS-BAO 6.2.5.H for more detail)

6.2.6 Does the operator have a procedure to ensure that a flight is not commenced unless a sufficient quantity of stored breathing oxygen is carried to supply all crew members and passengers in accordance with





48

the national regulations of the State of Registry?

6.2.7A Has the operator developed operational and maintenance procedures for extended diversion time operations (EDTO)? EDTO are described in ICAO Annex 6 Part 1, Section 4.7. (Recommended Practice)

6.2.8 Does the operator have requirements that meet the aircraft performance standards of this section?

6.2.9 Does the operator have requirements that meet the standards prescribed for refuelling with passengers on board, if permitted?

6.2.10 Does the operator have procedures to ensure that an aircraft does not take off or attempt to take off, that has frost, ice, or snow adhering to any critical surface?

6.3 Operational Control

6.3.1 Does the operator’s operations manual contain an operational control system that at least consists of a pilot self-dispatch system that: a. identifies the person responsible

for release of the flight;

b. specifies flight planning requirements; and

c. specifies when the pilot must advise the operator of the aircraft’s departure and arrival and the associated procedures?

6.3.2 Does the operational control system include procedures for ensuring that: a. all operating requirements

specified in the COM have been met;

b. the aircraft is operated within weight/mass and balance limits;

c. the names of persons on board the aircraft are recorded or otherwise know by the operator; and

d. SAR authorities are notified on a timely basis should an aircraft be overdue?

6.3.3 Does the operational control system also include procedures for ensuring that the pilot-in-command has access to appropriate information concerning the search and rescue services in the area over which the aircraft will be





49

flown? (Recommended Practice)

6.4 Weather Minima

6.4.1 Does the operator have procedures to ensure the weather minima used for IFR departures and approaches are those specified in the instrument approach procedures approved for use by the operator?

6.4.2 a. Does the operator have procedures in their operations manual for the determination of take-off minima from runways or heliports where no take-off minima are specified?

b. Does it include a risk analysis?

6.4.3 Does the operator have a policy not to use operating minima lower than those which may be established for that aerodrome or heliport by the State in which it is located, except with the specific approval of that State?

6.4.4 Does the operator have a policy not to continue towards the aerodrome or heliport of intended landing unless the latest available meteorological information indicates that conditions at that aerodrome or heliport, or at least one destination alternate aerodrome or heliport, will, at the estimated time of arrival, be at or above the specified aerodrome operating minima?

6.4.5 a. Are there procedures to restrict continuing an approach beyond the outer marker for precision approach or below 1000 feet above the aerodrome for a non-precision approach if the reported visibility is less than the specified minima?

b. Are there procedures for the flight crew if the visibility is reported less than specified minima after passing the outer marker for precision approaches or below 1000 feet above the aerodrome for non-precision approaches?

c. If the State of Registry and State of Operation allows deviations to the above, is there a policy to ensure that the aircrew do not continue an approach-to-land beyond a point at which the limits





50

of the aerodrome or heliport operating minima would be infringed?

d. If deviations are allowed, are there procedures to ensure the flight crew files a safety occurrence report to include the details of the event and the outcome?

6.4.6 Reserved

6.4.7 Does the operator have a policy and procedures for operating in known or expected icing conditions appropriate to the aircraft icing certification and equipment?

6.4.8H Do the operators of helicopters have VFR weather limits for both day and night operations that take into account the nature of the operations being conducted and the operating environment?

6.5 All Weather Operations

6.5.1 Does the operator have procedures that prohibit conducting an instrument approach or departures below standard Category I weather minima unless all equipment, training and operating requirements and regulatory requirements have been met?

6.5.2 If the operator has authority to conduct CAT II & III ops are:

a. there approved Category II or III operating procedures in the company operations manual,

b. the flight crew trained and certified to conduct Category II or III instrument approaches,

c. the aircraft equipped and approved for Category II or III operations?

6.6 CNS Requirements

6.6.1 Is there a process to ensure that prior to operations in airspace where special CNS requirements exist such as Performance Based Navigation (PBN) Specifications, Minimum Navigation Performance Specification (MNPS), Reduced Vertical Separation Minimums (RVSM), Controller Pilot Data Link





51

Communication (CPDLC), or Automatic Dependent Surveillance (ADS) B/C:

a. the aircraft and operator has been authorized by the State of Registry and, if required, the State of Operations;

b. the aircraft meets the aircraft system, airworthiness, continuing airworthiness (including maintenance personnel training) and operational requirements for the operations concerned; and

c. continuing RVSM height monitoring requirements have been met.

6.6.2 a. Are there procedures to ensure that Flight crews engaged in operations in airspace where special CNS requirements apply (i.e. PBN, RVSM, MNPS, CPDLC, ADS) are authorized by an appropriate manager?

b. Are there procedures to ensure that each flight crew member authorized to conduct operations under this section complete training in the subject areas as required by the specific State authorizations and as necessary to ensure competency in operations in such airspace?

c. Are such authorizations included in the pilot training records?

6.7 Aircraft Operating Requirements

6.7.1 Does the operator have a process for identifying and complying with all aircraft operating rules that the operator is subject to, as required by the civil aviation authority of the State of Registry and the States in whose airspace the operations are being conducted?

6.8 Noise Certification

6.8.1 Is there documentary proof from the State of Registry attesting noise certification of the aircraft, carried on board the aircraft when such a document has been issued?

6.8.2 Does the operator have procedures to ensure that aircraft adhere to





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published noise abatement procedures consistent with safety?

6.9 Aircraft Airworthiness

6.9 Does the operator have procedures to ensure that aircraft are maintained and operated in accordance with their C of A and the provisions of the company maintenance program? (Also see 9 Aircraft Maintenance)

6.10 Use of Oxygen

6.10.1 Does the operator have a procedures to ensure that when an aircraft is operated at cabin-pressure-altitudes above 10,000 ft. (700 hPa) but not exceeding 13,000 ft. (620 hPa) each crew member shall wear an oxygen mask and use supplemental oxygen for any part of the flight at those cabin pressure altitudes that is more than 30 minutes in duration?

6.10.2 Where an aircraft is operated at cabin-pressure-altitudes above 13,000 ft. (620 hPa) does each person on board the aircraft wear an oxygen mask and use supplemental oxygen for the duration of the flight at those altitudes?

6.10.3 Does the pilot at the flight controls of an aircraft use an oxygen mask if the aircraft is not equipped with quick-donning oxygen masks, and it is operated at or above FL 250?

6.10.4 Does the operator have procedures for the pilot at the controls to use an oxygen mask when the aircraft is operated above FL 410, or if one pilot leaves the flight deck for any reason above FL 350?

Recommended Practice

6.11 Passenger Safety Briefing

6.11.1 Does the operator have procedures as applicable for the type of operation, to ensure that passenger safety briefings are given for normal operations? (See ISBAO for details)

6.11.2 Are there procedures to modify briefings as appropriate for frequent passengers or mission needs?

6.11.3 Are there procedures to provide individual briefings for special circumstances, i.e. passenger limitations?

6.11.4 Are there procedures to ensure that,





53

in the event of an emergency, where circumstances permit, all passengers are given an emergency briefing covering the following items:

a. safety belts or safety/shoulder harnesses;

b. seat backs, seats and tables

c. carry-on baggage

d. passenger safety briefing cards

e. brace position (when to assume, how long to remain) and considerations for side facing seats

f. evacuation procedures

g. if applicable, life preservers; flotation devices and life rafts; and

h. if applicable, evacuation procedures for an occupant of a child restraint system?

6.11.5 Are there aircraft specific passenger safety briefing cards in all aircraft that at least cover:

a. the location and operation of emergency exits;

b. the location and use of the passenger oxygen system (when installed);

c. the location of life jackets and life rafts(when on board); and

d. the location of emergency equipment as required by State of Registry?

6.12 Use of Checklists

6.12.1 Is there a checklist for each type of aircraft operated that covers normal, abnormal and emergency operations and is it available to crew members?

Is the checklist consistent with the aircraft flight manual and any SOP?

Does it have a date of issue that reflects this consistency?

6.12.2 Does the operator have procedures to ensure that every crew member follows the checklist in the performance of their assigned duties?


6.13.1 Does the operator have a fatigue management programme that ensures that all personnel (including maintenance, pilots, cabin crew, other crew) involved in the operation do not





54

carry out their duties when they are fatigued and that includes:

a. fatigue management guiding principles,

b. appropriate training and education regarding preventive and operational fatigue countermeasures;

c. flight and duty time limitations, and

d. an evaluation process that assess the effectiveness of the fatigue management system?

6.13.2 If deviations from the flight and duty time limitations are permitted, does the system include:

a. a risk assessment process,

b. the identification of the management person authorized to approve the deviation, and

c. a record of the deviation, risk assessment and mitigation?

6.13.3 Do deviations require the expressed approval of all personnel involved?

6.13.4 Are deviations from the limits contained in IS-BAO Implementation Guide supported by a comprehensive risk assessment process? (Recommended Practice)

6.14 Travel Health Issues

6.14 If the operator conducts international operations have they developed procedures for assessment of health risks at out of country destinations and for handling of passengers and crew should they be exposed to infectious disease or significant health risks? (Recommended Practice)

6.15 Seating Requirements

6.15.1

Are there procedures to ensure flight crew member seating requirements are met? (See ISBAO for details)

6.15.2 Are there procedures to ensure cabin crew member seating requirements are met? (See ISBAO for details)

6.15.3 Are there procedures to ensure passenger seating requirements are met? (See ISBAO)

6.16 Cabin Baggage

6.16 Does the operator specify procedures to ensure that all baggage carried onto an aircraft and taken into the passenger cabin is adequately and





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securely stowed?

6.17 Microphones and Headsets

6.17 Does the operator have procedures to ensure that flight crew members of:

a. large or turbojet aeroplanes on the flight deck required to communicate through boom microphones below the transition level/altitude,

b. helicopters use headsets and communicate through a boom microphone at all times?

6.18A Personnel Qualified to Taxi Aeroplane

6.18A Is there a procedure to ensure that an aeroplane is not taxied on the movement area of an aerodrome unless the person at the controls is an appropriately qualified pilot or:

a. has been duly authorized by the operator;

b. is fully competent to taxi the aeroplane;

c. is qualified to use the radio if radio communications are required; and

d. has received instruction from a competent person in respect of aerodrome layout, and where appropriate, information on routes, signs, marking, lights, ATC signals and instructions, phraseology and procedures, and is able to conform to the operational standards required for safe aeroplane movement at the aerodrome.

6.19H Helicopter Rotor Turning Under Power

6.19H Is there a procedure to ensure that the helicopter rotor shall not be turned under power for the purpose of flight without a qualified pilot at the controls?

6.20 Maintenance Check Flights

6.20 Are there procedures to effectively manage the risks associated with Maintenance Check Flights? (Recommended Practice)

6.21 Piloting Competency in Key Safety Areas

6.21 (Recommended Practice) Are there procedures and training requirements to ensure each pilot maintains competency in key safety areas such as: a) Manual Flying Skills

b) Stabilized Approaches





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c) Runway Excursion Prevention

d) Automation Management

e) Upset Recovery







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Element 7 Operations in International Airspace

7.1 Sovereign and International Airspace

7.1 a. Are there procedures to ensure that when operating in the sovereign airspace of a State other than the State of Registry, the flight crew identify and apply the most restrictive requirements regarding the State of Registry and the State where the operations are being conducted?

b. Are there procedures to ensure that the rules in force relating to flight and manoeuvre of aircraft when operating outside the airspace of any sovereign state, i.e. oceanic or high seas, are in accordance with ICAO Annex 2, Rules of the Air”?

7.2 Compliance

7.2.1

Has the operator maintained a process to ensure that flight crews are familiar with and comply with the requirements, rules, regulations and procedures in international and the various sovereign airspaces in which they operate?

7.2.2 Does the operator have procedures for discharging responsibility for disembarking passengers and crew members from the time they leave the aircraft until they are accepted for examination for entry into a State?

7.3 International Airspace Operations Qualifications

7.3.1

a. Is there a process to ensure that flight crew members engaged in international operations are authorized by the chief pilot?

b. Is there a process to ensure that each flight crew member completes training in the subject areas as required by the specific authorizations and as necessary to ensure competency in operations in such airspace?

c. Is there a procedure to ensure such authorizations are included in the pilot training records?

7.3.2 Does the training programme ensure that crews understand the relationship between State of Registry/Operator operating rules and procedures and the ICAO Rules of the Air when operating in international airspace?





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7.4 Reserved

7.5 Standard Operating Procedures

7.5.1

For operations in international airspace involving performance based navigation:

a. Does the operator have standard operating procedures for international airspace operations?

b. Are flight crews trained in use of the international operations SOP?

c. Are copies of the SOP carried on board the aircraft?

7.6 International Publications Library

7.6 Do the flight crews have access to publications relevant to flight in international airspace? (Recommended Practice)







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Element 8 Aircraft Equipment Requirements

8.1 General Requirements

8.1.1

Are the operator’s aircraft equipped in accordance with the requirements set out in ICAO Annex 6, Part II or Part III as applicable, for VFR, IFR and night operations?

(See section 8.10 – 8.14 of this element)

8.1.2 Is all required aircraft equipment approved or do they otherwise meet the technical specifications prescribed by the State of Registry?

8.2.A Instruments and Associated Equipment - Aeroplanes

8.2.1A

Are all aeroplanes equipped with the instruments and associated equipment for VFR operations?

(See IS-BAO for details)

8.2.2A Are all aeroplanes equipped with the instruments and associated equipment for IFR operations?


8.2.3A Are all aeroplanes equipped with the instruments and associated equipment for Night operations?


8.2.4A Are all aeroplanes equipped with proper emergency power supply? (See IS-BAO for details)

8.2.H Instruments and Associated Equipment - Helicopters

8.2.1H

Are all helicopters equipped with the instruments and associated equipment for VFR operations?


8.2.2H Are all helicopters equipped with the instruments and associated equipment for Night or IMC operations?


8.2.3H Are all helicopters equipped with the instruments and associated equipment for IFR operations?


8.2.4H Are all helicopters equipped with the adequate interior lighting?


8.2.5H Are all helicopters equipped with a trainable landing light?






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8.3 Operational Information and Documents

8.3.1 Is the following documentation or information available on the flight deck:

a. pertinent aeronautical charts;

b. pertinent enroute, terminal area, and instrument approach procedure charts;

c. aircraft performance data;

d. aircraft checklists;

e. the operator’s operations manual;

f. SOP manual (where established)

g. the aircraft flight manual;

h. the aircraft minimum equipment list (MEL) if aircraft is being operated in accordance with a MEL;

i. aircraft C of A or other flight authority and C of R;

j. aircraft radio licence;

k. insurance certificate;

l. documentation required for the area of operation;

m. interception procedures; and

n. for international commercial air transport operations, a certified true copy of the air operator certificate?

8.4 Seats, Safety Belts and Shoulder Harnesses

8.4.1 Except as provided in 8.4.2.H below, are all aircraft equipped with:

a. a seat for each occupant of the aircraft, except for infants under an age specified by the State of Registry;

b. a safety belt, having a metal-to-metal latching device, for each passenger (other than infants);

c. a shoulder harness for each flight crew member and any other person occupying a flight deck seat or a sideways facing seat; and

d. a shoulder harness for each flight attendant seat that is not a regular passenger seat?

8.4.2.H For helicopter operations where in-flight transfer of personnel or door-open operations is required and approved, involving operations without a crew seat, is a secure safety





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harness fitted and used?

8.5 Emergency Equipment - General

8.5.1 Are all aircraft equipped with at least:

a. first aid kit;

b. fire extinguishers for use in the crew, passenger and cargo compartments; and

c. a crash axe (aircraft with a seating capacity of more than 19 passengers only, if installed IAW State of Registry requirements).

8.5.2 For pressurized aeroplanes is there portable breathing equipment suitable for use when combating fires on board the aircraft? (Recommended Practice)

8.5.3 Are there placards that identify the location of aircraft emergency equipment? (Recommended Practice)

8.5.4 Are aircraft equipped with means of ensuring that the following information and instructions are conveyed to passengers: a. when seat belts are to be fastened;

b. when and how oxygen equipment is to be used if the carriage of oxygen is required;

c. restrictions on smoking;

d. location and use of life jackets or equivalent individual flotation devices where their carriage is required;

e. location of emergency equipment; and

f. location and method of opening emergency exits?

8.5.5 a. Does the operator have available for immediate communication to rescue coordination centres, lists containing information on the emergency and survival equipment carried on board the aeroplane?

b. Does the information include the number, colour and type of life rafts and pyrotechnics, details of emergency medical supplies, water supplies and the type and frequencies of the emergency portable radio equipment?

8.6.A Flight Over Water - Aeroplanes

8.6.1 If aeroplanes are operated on





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extended flights over water are they equipped with a life preserver or flotation device for each occupant of the aircraft?

8.6.2 Does the operator of aeroplanes have a process to determine survival risks involved in extended flights over water and based on the risk assessment ensure the aircraft is equipped with:

a. Life rafts available in sufficient numbers to carry all persons on board carried in the aeroplane?

b. Are these life rafts provided with distress signalling devices and life-saving equipment, including a means of sustaining life, appropriate to the area of operation?

8.6.H Flights Over Water - Helicopters

8.6.1 Are helicopters fitted with a permanent, or rapidly deployable, means of flotation so as to ensure a safe ditching when engaged in any overwater operations where it is likely that a forced ditching manoeuvre would be executed in the case of a power-plant failure?

8.6.2 Are helicopters operating in accordance with 8.6.1 equipped with:

a. lifejackets with illumination for each person on board,

b. life rafts in sufficient number to carry all persons on board the helicopter,

c. with the life raft equipment providing means of sustaining life as appropriate to the operations being undertaken,

d. pyrotechnical distress signals equipment?

8.6.3 Does the operator have procedures for helicopter occupants to wear ether survival suits or life jackets when offshore operations are being conducted?

Does the operator have procedures for survival suits to be worn by all occupants when the sea temperature is less than 10°C or when the estimated rescue time exceeds the calculated survival time, except when temperature conditions on the flight deck make the wearing of survival suits a hazard?





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8.6.5 Does the operator have a procedure to ensure that life jackets are available to all on-board when helicopters are taking off or landing over water and there is a risk of ditching?

8.6.6 Are the life rafts required in 8.6.2.b deployable by remote control?


8.6.7 If the life rafts referred to above are not deployable by remote control and have a mass of 40 kg or more is there a means of mechanical assist deployment?

8.7 Flights Over Remote Land Areas

8.7 If aircraft are operated across land areas which have been designated as areas in which search and rescue would be especially difficult, are they equipped with signalling devices and life-saving equipment (including means of sustaining life) as is appropriate to the area overflown?

8.8 High Altitude Flights – Oxygen Requirements

8.8.1.A Are aeroplanes that are intended to be operated at high altitudes equipped with sufficient oxygen storage and dispensing apparatus capable of storing and dispensing the oxygen supplies required under section 6.2.6?

8.8.1.H Do helicopters when intended to be operated at altitudes where the use of oxygen has been prescribed, carry equipment for storing and dispensing the oxygen supplies required in 6.2.6?

8.9 Icing Protection and Weather Detection Equipment

8.9.1 Has the operator ensured that only aircraft that are certified and equipped to cope with such conditions are operated into known or forecast icing conditions?

8.9.2.A Are pressurized aeroplanes equipped with operative weather detection equipment, when appropriate?

8.9.2.H Are helicopters which are involved in passenger carrying operations at night or under IFR in areas where thunderstorms may be expected, equipped with weather-detecting equipment capable of detecting





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thunderstorms?


8.10.A ELT - Aeroplanes

8.10.1 Are the operator’s aeroplanes equipped with ELTs except as provided in 8.10.2, with at least one ELT of any type?

8.10.2 Are all aeroplanes for which the individual Certificate of Airworthiness was first issued after 1 July 2008 shall be equipped with at least one automatic ELT?

8.10.3 It is recommended that all aircraft carry an automatic ELT.


8.10.4 Are ELTs carried to satisfy the requirements of 8.10.1 and 8.10.2 capable of operation on both 406 MHz and 121.5 MHz simultaneously in accordance with the relevant provisions of Annex 10, Volume III?

8.10.H ELT - Helicopters

8.10.1 Are the operator’s helicopters equipped with at least one automatic ELT?

8.10.2 Are all helicopters operating over water in accordance with 8.6.1 a. or b. equipped with at least one ELT(S) in a raft or life jacket?

8.10.3 Are ELTs carried to satisfy the requirements of 8.10.1 and 8.10.2 capable of operation on both 406 MHz and 121.5 MHz simultaneously in accordance with the relevant provisions of Annex 10, Volume III?

8.11.A GPWS - Aeroplanes

8.11.1 Are the operator’s aeroplanes with a maximum certificated take-off mass in excess of 5 700 kg or authorized to carry more than nine passengers equipped with a ground proximity warning system which has a forward-looking terrain avoidance function?

8.11.2 Does the ground proximity warning system provide automatic timely and distinctive warning to the flight crew when the aeroplane is in potentially hazardous proximity to the earth‘s surface?

8.11.3

Does the ground proximity warning system provide, as a minimum, warnings of at least the following circumstances:

a. Excessive descent rate;





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b. Excessive altitude loss after take-off or go-around; and

c. Unsafe terrain clearance?

8.11.4 a. Does the operator have a process to ensure that the data base for the GPWS is current?

b. Are the pilots trained in use of the system?

8.11.H GPWS - Helicopters

8.11.1

For helicopters that are equipped with a GPWS, does the GPWS provide:

a. i. Automatic, timely and distinctive

warning to the flight crew when the aircraft is in potentially hazardous proximity to the earth‘s surface, and

2. As a minimum, warnings of at least the following circumstances: A. Excessive descent rate,

B. Excessive altitude loss after take-off or go-around, and

C. Unsafe terrain clearance?

b. Does the operator have a process to ensure that the data base for the GPWS is current?

c. Are the pilots trained in use of the system?

8.12 ACAS II (TCAS II)

8.12.1 Are all turbine-engined aeroplanes of a maximum certificated take-off mass in excess of 15 000 kg or authorized to carry more than 30 passengers, for which the individual airworthiness certificate is first issued after 1 January 2007, equipped with an ACAS II?

8.12.2 Are aircraft as described above but with and individual C of A first issued after 1 Jan 2005 equipped with an ACASII? (Recommended Practice)

8.12.3 Are all turbine-engined aeroplanes of a maximum certificated take-off mass in excess of 5 700 kg, or authorized to carry more than 19 passengers, for which the individual airworthiness certificate is first issued after 1 January 2008, equipped with an ACAS II? (Recommended Practice)

8.13 Transponder and Altitude Reporting System

8.13.1.A

Are all aeroplanes equipped with a pressure altitude reporting transponder?

(Exception - VFR only operations that have been exempted by the





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appropriate civil aviation authorities)

8.13.1.H Are all helicopters equipped with a pressure altitude reporting transponder, unless exempted by the appropriate civil aviation authorities?

8.14.A FDR and CVR - Aeroplanes

8.14.1A

Are aeroplanes equipped with FDR and /or CVR (See IS-BAO for details)

TO Mass>27000kg – Type I FDR

8.14.2A TO Mass>5700kg – Type IA FDR

8.14.3A TO Mass>5700kg – Type II FDR


8.14.4A TO Mass>27000kg - CVR

8.14.5A TO Mass>5700kg – CVR


8.14.6A Are there procedures to ensure that, in the event an aeroplane becomes involved in an accident or incident, the all related flight recorder records, and if necessary the associated flight recorders are preserved, and their retention in safe custody pending their disposition as determined in accordance with ICAO Annex 13?

8.14.7A Are there procedures to ensure that Flight data and cockpit voice recorders are not switched off during flight time?

8.14.8A Does the operator have procedures on the post-flight protection and use of flight and cockpit voice recorder data?

8.14.H FDR and CVR - Helicopters

8.14.1H

Are helicopters equipped with FDR and /or CVR equipped as required? (See IS-BAO for details) TO Mass>7000kg-Type IV FDR

8.14.2H TO Mass>3180kg – Type IVA FDR

8.14.3H TO Mass>3180kg – Type V FDR


8.14.4H TO Mass>7000kg - CVR

8.14.5H TO Mass>3180kg – CVR


8.14.6H Are there procedures to ensure that, in the event a helicopter becomes involved in an accident or incident, the all related flight recorder records, and if necessary the associated flight recorders are preserved, and their retention in safe custody pending their disposition as determined in





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accordance with ICAO Annex 13?

8.14.7H Are there procedures to ensure that Flight data and cockpit voice recorders are not switched off during flight time?

8.14.8H Does the operator have procedures on the post-flight protection and use of flight and cockpit voice recorder data?

8.15 MEL

8.15.1 Where a master minimum equipment list (MMEL) is established for the type(s) or aircraft used, has the operator devised a MEL approved by the State of Registry?

8.15.2

Are flight crews and maintenance personnel trained in its use?

Is a copy of the MEL carried on board the aircraft?

8.16 Comm and Nav Equipment

8.16.1

Are all aircraft equipped with radio communication equipment to permit the pilot to conduct two-way communications on the appropriate aeronautical frequencies?

8.16.2 Are all aircraft equipped with sufficient radio navigation equipment to receive radio signals from the transmitting facilities to be used and to permit the aircraft to navigate in the event of the failure of one navigation unit?

8.16.3 Does the operator have procedures to ensure that electronic data bases are compatible with the intended function of the equipment and are current?

8.16.4.A Are large and turbojet aircraft equipped with boom mikes at all flight crew stations?

8.16.5.H Are helicopters equipped with headset with boom microphone and a transmit button on the flight controls for each required pilot and crew member at his working station?







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Element 9 Aircraft Maintenance Requirements

9.1 Maintenance Control System

9.1.1

Does the operator, other than one to which 9.1.2 applies, have a maintenance control system that is appropriate to the type and number of aircraft operated and the manner in which the maintenance is conducted?

9.1.2 Does an operator to which the EASA rules apply have a continuing airworthiness management system that meets the requirements of (EC) No 2042/2003 Annex I (Part-M) as amended?

The remainder of Element 9.1 applies only to those operators to which section 9.1.1 applies.

Note 1: It is the owner's/lessee's/operator's (as applicable) responsibility to take all appropriate actions to ensure adequate oversight of the contracted CAMO for the continued airworthiness of its aircraft/fleet. See IG 9.1.2 for more information.

Note 2: The CAMO oversight process should be integrated into the compliance monitoring system required by IS-BAO 3.3.1.

9.1.3 Does the operator have a written description of its maintenance control system in the company operations manual or maintenance manual?

9.1.4

Does the maintenance control system documentation contain at least the following information:

a. Where maintenance functions have been assigned:

i. The position or title of the person to whom functions have been assigned?

ii. A description of the functions and scope of work that have been assigned to each position, person or organization?

iii. Where necessary for clarity, a chart depicting the distribution of functions and lines of authority (if not depicted in the organizational chart)?

b. For elementary work or preventive maintenance and aircraft servicing:

i. Identification of those standards or maintenance data (aircraft manufacturer’s, CAA’s or other) to be used?

ii. The procedures to confirm that regulatory information and technical data appropriate to the work performed are used;

iii. Details of the methods used to





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record the maintenance, elementary work/preventive maintenance or servicing performed, and to ensure that any defects are recorded in the aircraft technical record;

c. Has the operator identified a maintenance schedule/ programme authorized by the State of Registry?

d. Is there a detailed description of the procedure used to ensure that any maintenance tasks required by the maintenance schedule/ programme, an airworthiness directive, or any task required for the rectification of a defect is completed within the time constraints specified in national regulations?

e. Is there a description of the assessment programme for aircraft Service Bulletins and Airworthiness Directives and the associated documentation?

f. Are there procedures to ensure that only parts and materials that meet regulatory requirements and manufacturer’s specifications are used in the performance of maintenance, elementary work/preventive maintenance or servicing, including any details respecting part-pooling arrangements that have been entered into?

g. Are there procedures to ensure that properly calibrated tools are used in the performance of maintenance, elementary work/preventive maintenance or servicing?

h. Is there a description of the maintenance training and required competencies of the maintenance staff?

i. Is there a procedure for maintaining personnel and training records?

j. Is there a procedure to ensure that the Basic Empty Weight (BEW) of an aircraft is maintained, current and properly documented?

k. Is there a process to obtain a Special Flight Permit or Special





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Flight Authorization?

l. Are there procedures for a tool control programme designed to ensure tools, supplies, and test equipment are accounted for following maintenance performed on an aircraft?

m. Is there a description of the fatigue management system? (See section 6.13 for requirements)

n. Are there procedures to manage the risks associated with maintenance personnel working alone?

9.1.5 Does the operator have procedures to provide a copy of the relevant manual or maintenance manual section that details the maintenance control system, or relevant portions thereof, to each person or organization who performs or certifies work?

9.1.6 In the part of its manual that describes its maintenance control system, does the operator include defect recording and rectification control procedures for:

a. Recording aircraft defects?

b. Ensuring that defects are rectified in accordance with regulatory requirements and manufacturer’s specifications?

c. Detecting defects that recur and identifying those defects as recurring defects?

d. Scheduling, within the permitted period of deferral, the rectification of defects whose repair has been deferred?

9.1.7a Are there procedures that ensure the aircraft are:

i. Maintained in an airworthy condition,

ii. Appropriately equipped, configured and maintained for the intended use, and

iii. Maintained in accordance with the authorized maintenance program;

9.1.7b Are there procedures to ensure that all MEL requirements are met?

9.1.7c Are there procedures to ensure adherence to State of Registry regulations and standards?

9.1.7d Are there procedures to ensure a maintenance release has been





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completed following maintenance?

9.1.8 If there have been any deviations from the procedures in the maintenance control system do they conform to national regulations and are substantiated by a risk analysis?

9.1.9

Does the operator have a procedure that ensures that the following records are kept on each aircraft for appropriate periods:

The records in 9.1.9.a. to 9.1.9.e., shall be kept for a minimum period of 90 days after the unit to which they refer has been permanently withdrawn from service and the records in 9.1.9.f. for a minimum period of one year after the signing of the maintenance release.

State of Registry requirements for record retention may vary and must be respected.

a. Total time in service for the aircraft and life-limited components?

b. Current status of compliance with applicable mandatory continuing airworthiness information, including life limited components?

c. Appropriate details of modifications and repairs to the aircraft?

d. Time in service since last overhaul of the aircraft or its components subject to a mandatory overhaul life?

e. Current status of the aircraft’s compliance with the maintenance programme?

f. Detailed maintenance records to show that all requirements for the signing of a maintenance release have been met?

9.1.10 Does the operator have a procedure to ensure that continuing airworthiness information resulting from maintenance and operational experience is transmitted to the State of Registry as required?

9.1.11 For an operator of turbojet-engined aeroplanes OR those with a maximum take-off mass > 5700 kg OR any aircraft engaged in commercial operations, does the maintenance program:

a. Observe Human Factors principles according to the State of Registry’s guidance material?

b. Include, if applicable, a continuing structural integrity programme?

c. Include, when applicable and approved by the State of Registry, condition monitoring and reliability programme descriptions for aircraft systems, components and power plants?

9.2 Maintenance Agreements





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9.2.1 Does the operator have a system that ensures that no person or organization performs maintenance on operator aircraft unless the person is an employee of the operator or has been authorized to perform the work under the terms of a written maintenance agreement or other form of authorization specified in the company operations manual or maintenance manual?

9.2.2 Has the operator included provisions in the company operations manual for flight crew to obtain maintenance services when away from home base?

9.2.3 Does the operator include provisions in maintenance agreements to ensure that maintenance personnel do not carry out maintenance work when they are fatigued?


9.3 Person Responsible for Maintenance

9.3.1a Has the operator appointed a person to be responsible for its maintenance control system?

9.3.1b Is that person authorized to remove aircraft from operation where the removal is justified because of non-compliance with the requirements of national regulations or because of a threat to the safety of the aircraft, persons or property?

9.3.2 Has the operator provided the person who is responsible for the maintenance control system with the staff, facilities and other resources necessary to ensure that the maintenance is conducted in accordance with the civil aviation authority requirements and meets the safety management goals of the operator?

9.4 Maintenance Personnel Recency

9.4.1 Does the operator have a process to ensure that persons who hold maintenance release authority have had at least six months experience in the preceding 24 months?






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Element 10 Company Operations Manual

10.1 Does the operator provide each person concerned with an operations manual containing all the instructions and information necessary for personnel to perform their duties?

Is the manual amended or revised as necessary to ensure that the information contained in it is kept up to date?

Are all amendments or revisions issued to all personnel that are required to use the manual?

10.2

Does the manual (or set of manuals) contain at least the following (non-commercial ops only)

a. Table of contents?

b. Amendment control page and list of effective pages?

(Unless the entire document is re-issued with each amendment and the document has an effective date on it)

c. Duties, responsibilities and succession of management and operating personnel?

d. Safety management system?

e. Operational control system?

f. MEL procedures (if applicable)?

g. Normal flight operations?

h. SOPs (may be a separate manual for each aircraft type)?

i. Weather Limitations?

j. Fatigue Management System for both operations and maintenance personnel?

k. Emergency equipment and operating procedures?

l. Accident/Incident consideration?

m. Personnel qualifications and training?

n. Record Keeping?

o. Maintenance Control System?

p. Security Procedures?

q. Performance operating limitations?

r. use/protection or FDR/CVR records, if installed?

s. Handling of dangerous goods?





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10.3 Does the company operations manual contain a description of the process to allow deviations (if deviations are allowed) from the provisions contained in it and specify the person who may approve such deviations?

Do deviations identify the associated conditions under which they are permitted or required?

Are deviations based on a risk assessment process?

10.4 Is the design of the company operations manual and all associated manuals based on good Human Factors principles? (Recommended Practice)







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Element 11 Emergency Response Plan

11.1 Does the operator have a plan detailing the procedures to be followed in the event of an accident, incident or other emergency that is appropriate for the operation?

11.2

Does the emergency response plan address in-flight incidents involving injuries or serious medical problems suffered by passengers or crew?

11.3 Does the emergency response plan address accidents and incidents not involving aircraft flight operations?

11.4 Does the emergency response plan include at least:

11.4a Procedures for the flight crew or organization to notify the appropriate authorities in the State in which the accident occurred, and to seek medical assistance, as required?

11.4b Procedures for the flight operator personnel to notify organization officials of the accident, incident or event?

11.4c Procedures for the operator to notify State agencies of the accident, as may be required by law?

11.4d Procedures for notification of next of kin?

11.4e On-site procedures to be taken by the flight and cabin crew to assist passengers, prepare visual distress signals (if in a remote area), and preserve the integrity of the accident site?

11.4f Procedures for dealing with questions from and providing assistance to the families of passengers and crew members?

11.4g Procedures for dealing with questions from the media?

11.4h Procedures for participating or co-operating with State agencies and police authorities who may be investigating the accident?

11.4i Considerations for dealing with the impacts and effects of the accident on the organization’s operations and on employees? (i.e. trauma counselling services and other crises intervention support for persons involved or affected by the event)





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11.5 Is training and testing on the emergency response plan conducted?







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Element 12 Environmental Management

12.1 Does the operator have a process for ensuring compliance with national and local environmental laws and requirements related to:

12.1a Noise abatement procedures, consistent with safety including airport curfews?

12.1b Ground operations, including aircraft fuelling and de/anti-icing procedures?

12.1c Spill containment of toxic and flammable materials and chemicals including disposal of collected materials?

12.1d The disposal of waste materials?

12.1e The disposal of international garbage?

12.1f The construction and operation of the operator’s hangars and other facilities including fuel storage facilities?

12.1g Operations subject to emissions charges, fees, or purchase of credits related to Market Based Measures regulations?

12.2 Does the operator have procedures to make flight crews aware of local environmental rules and procedures at destination and en-route airports? (Recommended Practice)







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Element 13 Occupational Health and Safety

13.1 Does the operator have a process for identifying and complying with all national and local occupational health and safety laws and requirements related to:

13.1a Development and implementation of workplace safety programs?

13.1b Compliance with fire safety, first aid and sanitary requirements?

13.1c Provision of safety and protective clothing, devices and equipment, particularly fall protection for aircraft maintenance personnel?

13.1d Provision of safety information and training to employees?

13.1e Ensuring that machinery, tools and equipment, including lifting equipment, meets safety standards?

13.1f Ensuring that hazardous materials are controlled and that employees have information and training in their handling and storage?

13.2 Does the operator have procedures to ensure that all company personnel and passengers accessing the aviation environment are made aware of OHS requirements and adhere to the operator’s associated procedures?

13.3 Does the operator have procedures to manage the safety risks relating to any person who works alone? (Recommended Practice)







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Element 14 Transportation of Dangerous Goods

14.1.1 Has the operator ensured that dangerous good are not transported except where authorized and in accordance with ICAO Technical Instructions for the Safe Transport of Dangerous Goods or the IATA Dangerous Goods Regulations?

14.1.2 Has the operator taken steps to advise passengers as to what constitutes dangerous goods, and whether and how those goods can be carried on aircraft?

14.1.3 Does the operator train aircraft crewmembers on these procedures at least every two years?

The remainder of this section is not required if the operator does not have Transportation of Dangerous Goods authority.

14.2.1 Has the operator met all State regulatory requirements for the transportation of dangerous goods?

14.2.2

Has the operator ensured that all dangerous goods are:

a. Classified?

b. Packed?

c. Labelled and Marked?

d. Loaded?

e. Stowed?

f. Accompanied by documentation?

g. Transported in accordance with the provisions of the ICAO Technical Instructions for the Safe Transport of Dangerous Goods or the IATA Dangerous Goods Regulations and the rules of the State of the operator?

14.2.3 Has the operator taken steps to ensure that all personnel involved in the transportation of dangerous goods are trained and certified in accordance with the ICAO or IATA requirements and those of the State of the operator?

14.2.4 Does the operator have a system to advise their shipping department of what constitutes dangerous goods, and whether and how those goods can be carried on aircraft?

Have aircraft crew members received training on these procedures in the last two years?





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14.2.5 Has the operator taken steps to ensure that dangerous goods are not accepted from third parties for transportation unless the shipper has complied with all relevant ICAO or IATA provisions and the rules of the State of the operator?

14.2.6 Has the operator taken steps to ensure that the PIC of their aircraft is informed of what dangerous goods are being carried on board the aircraft, as early as practicable before the departure of the aircraft?

14.2.7

Does the operator have a process to ensure that if an aircraft carrying dangerous goods is involved in an accident or serious incident, information on the dangerous goods on board is provided to emergency personal, the authorities of the State in which the accident occurred and the State of the operator without delay?

14.2.8 Does the operator have a process to ensure that if an aircraft carrying dangerous goods is involved in an incident, information on the dangerous goods on board is provided to emergency personal and the authorities of the State in which the accident occurred if such information is requested?







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Element 15 Security

15.1 Has the operator established, and maintained a security programme that is proportional to the threat against the operator, its personnel, aircraft and facilities?

15.2

Where a security programme has been established does it include:

a. Threat assessment process?

b. Preventive measures designed to deter and prevent the commission of unlawful acts?

c. Responsive measures to be taken when an unlawful act has been committed against the operator?

d. Appropriate training and testing of personnel involved?




Item Conform

N/A Remarks and Objective Evidence of Non-conformities Y N


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Element 16 In-Flight Inspection

An In-Flight inspection is not a required part of an IS-BAO audit. However, should it be agreed with the operator that an In-Flight inspection should be conducted the following protocol may be used.

The objective of an In-Flight inspection is to assess the compliance of aircraft crew members with the provisions of the company operations manual, SOPs and relevant operator directives, as well as with safe operating procedures.

Flight Operations

1. Flight Preparation

a. Weather Briefing

b. NOTAMs

c. Other Flight Planning Info

d. Flight & Duty Time

2. Flight Planning

a. Route Analysis

b. Fuel Consumption

c. Alternates

d. Weights and Performance

3. Weight & Balance

4. Aircraft Servicing & Ramp

a. Fuelling Procedures

b. Load Security

c. Ground Handling

d. Aircraft Parking

5. Pre-Flight

a. External Inspection

b. Cabin & Flight Deck

c. Emergency Drills

6. Passenger Safety Briefing

7. Pre-Start

8. Start & After Start

9. Taxi & Take-off

10. Radio Procedures & ATC


Item Conform



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11. Departure Procedures

a. Engine handling

b. ATC Procedures

c. Noise Abatement

d. Lookout

e. Checks

f. Radio Procedures

12. Climb Procedures

13. Cruise Procedures

a. En-route Comm

b. Navigation

c. Flight Management

14. Approach Procedures

a. Planning

b. Descent

c. Final Approach

d. Landing & Taxiing

15. Shutdown

16. Flight Log, Aircraft Log & Defect Recording

17. Passenger Deplaning

18. Crew Resource Management

19. Crew Discipline


Item Conform



86

Aircraft

1. Manuals & Related Documents

2. MEL

3. C of A & C of R and AOC, if required

4. Aircraft Log

5. Maintenance Release

6. Aircraft Equipment

7. Emergency Equipment

8. Passenger Safety Briefing Card



IS-BAO Audit Finding Form


87

8.3 IS-BAO Audit Finding Form

NUMBER ___ OF ___

OPERATOR NAME NON-CONFORMITY CATEGORY

ADDRESS MINOR MAJOR

IS-BAO ELEMENT & REF. #

OPERATORS MANUAL OR PROCEDURE AND REFERENCE

DETAILS OF FINDING [SHOW CAUSE/EFFECT/CRITICALITY IAW APM SECTIONS 6.2 & 6.3]

OBJECTIVE EVIDENCE


OPERATOR REMEDIAL ACTION PLAN (INCLUDING ESTIMATED DATE OF PLAN COMPLETION)

Manager of the Operation Signature Date

Remedial Action Plan Acceptable Not Acceptable


AUDITOR COMMENTS AND FOLLOW-UP – FOR MAJOR NON-CONFORMITY

Comments

Follow-up Review Acceptable Not Acceptable


IS-BAO Audit Finding Form


88

ADDITIONAL OBJECTIVE EVIDENCE OR DETAILS


89

APPENDIX A - AUDITING AIRCRAFT MANAGEMENT COMPANIES

Management Company Audits IS-BAO registration has been available to and used by a number of aircraft management companies over the life of the program. However, the addition of larger companies offering aircraft management services for non-commercial operations has introduced elements that must be considered during the audit. Among them are:

Company size – Management companies comprising a large number of operators providing both private and commercial operations are becoming more common. Taken together these operations may encompass scores or even hundreds of aircraft/personnel.

Multiple bases – Few management companies provide services to clients at a single base, with the norm being from two to sometimes more than 20 bases.

Changing constituency – Clients enter into or terminate management contracts at will, creating a constantly changing workforce and aircraft roster.

Mission diversity – Clients inevitably desire different frequency, type and levels of service. While the structure of IS-BAO is designed to accommodate the aircraft management company concept the variables mentioned above must be considered when conducting an audit. These are not changes to the methodology set forth in the IS-BAO Audit Procedures Manual, but points of emphasis to be addressed when conducting a management company audit: Management company central operations

Has the company established a management structure, oversight methodology and procedures that will accommodate the needs of all of their clients?

Are the required accountabilities and responsibilities inclusive of all client operations clearly stated within the company operations manual, SMS and emergency response plan?

Is there an effective internal evaluation program to ensure that all IS-BAO policies, standards and procedures are being performed adequately by all personnel?

Management Contract

Does the management contract clearly define the roles and accountabilities of each party and require compliance with stated procedures and provisions?

SMS

How is the SMS managed at the management company and within each of the client locations?

How is the SMS integrated between the management company and its clients? Accommodating new clients

When a new client is received, what provisions are made to ensure that any new personnel are aware of the IS-BAO related systems, process and procedures? This will include indoctrination, training and verification of required knowledge.

Multiple bases

Are there methods for monitoring performance and conformance of all operating bases?

How does the management company ensure that all operations are in compliance with applicable State of registry regulations and in conformance with IS-BAO standards and procedures?

Are actions taken to rectify deficiencies noted during the internal evaluation process and conduct post implementation reviews?

Sampling

Personnel at a minimum of 10% of the management company clients should be interviewed to ensure adequate knowledge of and conformance with IS-BAO standards.


90

If multiple bases are involved, these interviews should be conducted at the main base and no less than one satellite base.

Management companies with clients at more than 4 satellites should have interviews performed with clients at following number of bases:

o 4-8 satellites – 2 bases;

o more than 8 satellites -- 3 bases. Audit Report

The audit report for a management company providing comprehensive services should:

Clearly indicate the size and scope of operations and level of services provided.

Comment on all of the features listed in the above bulleted statements.