Purpose of Continuous Improvement in Safety Assurance Pillar
Continuous Improvement in FAA Part 5 compliance (Part 5.75) is simply a requirement for correcting “deficiencies identified in the assessments conducted under [the Safety Performance Assessment] process.” (Part 5.75 documentation)
The continuous improvement element is triggered when safety performance is found to be unacceptable, and the problem is due to the company’s compliance/safety policy or risk controls. Corrective actions are used to correct the deficiencies in the applicable compliance/safety policy.
The continuous improvement element is the final step in the Safety Assurance process. At this point:
- Risk has already been analyzed;
- Risk has already been assessed;
- The problem(s) has been identified; and
- The only action needed is to develop corrective actions.
Generally, corrective actions are facilitated by subject matter experts, such as department heads, and reviewed/overseen by safety mangers and/or safety committees.
What is a Corrective Action
A corrective action is an action used to correct any undesirable element of safety performance. Most commonly, corrective actions are called CPAs. You may also see them called CAPAs (corrective action preventative action) or RCAs (recommended corrective action), though CPA is the most recognized globally in the aviation industry.
Corrective actions fix safety issues by making changes that bring an adverse element of the program into an acceptable level of safety (ALoS) or as low as reasonably possible (ALARP).
Corrective actions differ from:
- Preventative actions, which are used to include a new element into the SMS in order to reduce the likelihood of undesirable things (which may not have happened yet); and
- Detective actions, which are used to include new elements into the SMS in order to identify emerging undesirable elements.
Corrective actions are generally considered as a part of reactive risk management activities. Having effective corrective action implementation strategies is absolutely essential to the development and success of the Safety Assurance Pillar of aviation SMS programs.
Example Scenario for Continuous Improvement
Here is an example safety concern that would culminate in the Safety Assurance continuous improvement action:
- A safety incident is reported and safety mangers are notified (Data Acquisition);
- A preliminary investigation is performed (Analysis of Data)
- A risk assessment is performed (Safety Performance Assessment);
- Based on the assessment and investigation, the responsible manager determines that deficiencies in company policy and control measures contributed to the safety issue; and
- Based on these findings, he/she will issue corrective action(s) to employees in order to correct the problem(s) (Continuous Improvement).
As shown above, corrective actions are triggered by some kind of safety event or discovery. Corrective actions are extremely important for SMS programs, as safety programs first and foremost needs to be able to quickly and efficiently fix problems.
Continuous Improvement Corrective Action Types
Corrective actions can be anything from training, to safety policy update, to new control measures. They can address individual people or the bureaucracy of the safety management system. Corrections of individuals are usually things like:
- Attending remedial aviation SMS training;
- Update safety policy to correct specific human behavior; or
- Probation, performance reviews, etc. (usually in more serious circumstances).
Corrections of the SMS bureaucracy are usually:
- Updating a dated safety policy or procedure;
- Replacing a malfunctioning/old piece of equipment, sign, etc.; or
- Fixing an area of non-compliance in the program.
EDIT: As one commenter pointed out, any changes to the System using corrective actions would then require that the changes are processed through the Safety Risk Management Process.
Final Thought: Indications of Continuous Improvement Compliance
Establishing whether or not you are compliant with the FAA’s continuous improvement element is as simple as assessing whether or not:
- You have documented the process for creating corrective actions, which may be physically documented in something like a Word document, or inherently documented in the process of aviation safety management software.;
- You have evidence of creating corrective actions in response to safety performance deficiencies, including justification of why those corrective actions were created;
- You have evidence that corrective actions are delivered to relevant employees, and that the actions are carried out to completion; and
- You have documented evidence for reviewing the effectiveness of the control measures.
For a full overview of FAA compliance, you will find these resources valuable: