Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697637127428.pdf (Bahamas)
THE BAHAMAS CIVIL AVIATION DEPARTMENT ADVISORY CIRCULAR AC-01-005 GUIDELINES FOR VOLUNTARY SELF DISCLOSURE SECTION 1 POLICY & GENERAL INFORMATION 1.1 PURPOSE A.

This Advisory Circular (AC) provides a method for regulated entities (see definition) to voluntarily self disclose apparent violations of the Civil Aviation Safety Regulations (CASR).
The processing of self-disclosures will be treated in a more benign nature than those situations where the Flight Standards Inspec- torate discovers or determines that a violation of the CASR requirements has occurred.

B.

Regulated entities are encouraged, but not required, to develop internal evaluation programs that continually monitor company policies and procedures and ensure that the highest level of safety and security compliance is maintained.
C. They may voluntarily disclose apparent violations of CASR covered by this program in accordance with the procedures in this AC even though a safety management system or other type of internal evaluation program has not been established.

1.2 APPLICABILITY A.

This AC is for use by entities licensed or certificated or otherwise regulated by the FSI.

B.
B.

The procedures and practices outlined in this AC can be applied to the maintenance, flight operations, anti-drug and alcohol misuse prevention programs, and other functions of the regulated entity's organization.

C. The procedures and practices outlined in this AC can not be applied to those persons who are required to report mechanical failures, malfunctions and defects under the CASRs and do not make those reports in the time frame required by the regulation.
D. With respect to foreign airlines, apparent violations of FSI regulations requiring compliance with their FSI-approved security program only are covered by this program.

1.3 STATUS OF THIS AC This AC is an original issuance.

1.4 BACKGROUND A.

Penalties under the FSI's enforcement program are means to promote compliance with the FSI's regulations, not an end in themselves.
Advisory Circulars are intended to priovide advice and guidance to illustrate a means, but not necessarily the only means, of complying with the Regulations, or to explain certain regulatory requirements by providing informative, interpretative and explanatory material.

 Where an AC is referred to in a ‘Note’ below the regulation, the AC remains as guidance material, ACs should always be read in conjunction with the referenced regulations.
Issue Date: 31 December 2008 2 AC-01-005: VOLUNTARY SELF DISCLOSURE B. C. In addition to the deterrence achieved by the appropriate 'use of civil penalties, the public interest is also served by positive incentives to promote and achieve compliance.

Indeed, the FSI believes that aviation safety is well served by incentives for regulated entities to identify and correct their own instances of noncompliance and to invest more resources in efforts to preclude their recurrence.
D. The FSI's policy of forgoing civil penalty actions when one of these entities detects violations, promptly discloses the violations to the FSI, and takes prompt corrective action to ensure that the same or similar violations do not recur is designed to encourage compliance with the FSI's regulations, foster safe operating practices, and promote the development of internal evaluation programs.

1.5 RELATED REGULATIONS CASR 1.020 1.6 RELATED PUBLICATIONS None provided.
1.7 DEFINITIONS The following key terms and phrases are defined to ensure a standard interpretation and understanding of the FSI's voluntary disclosure policy— 1.7.1 EVIDENCE This list of definitions is applicable in the con- text of this manual only.

Words may be found in other publications with a different defini- tion.

A.
A.

For the purpose of voluntary disclosure, evidence generally should be in the form of written documentation or reports that support a regulated entity’s analysis of the disclosed apparent violation and the resulting elements of the proposed comprehensive fix.

B.

Evidence generally comes from the following four elements— 1) Documents or manuals reviewed.

2) Equipment examined.

3) Activities observed.

4) Interview data.


1.7.2 COMPREHENSIVE FIX A comprehensive fix is an action, or actions, proposed by a certificated organization and accepted by the principal inspector to preclude recurrence of the apparent violation that has been voluntarily disclosed under this program.

1) When appropriate, a regulated entity may work with an airport consortium on a comprehensive fix.
2) A schedule of the dates and events But, regardless of the working arrangements, the appropriate regulated entity will remain responsible for implementation of the compre- hensive fix.

encompassed by the comprehensive fix must be established and included in a letter of correction.

1.7.3 SATISFACTORY FIX A satisfactory fix is a comprehensive fix in which all corrective measures have been completed on schedule and are satisfactory to the FSI.
Issue Date: 31 December 2008 AC-01-005: VOLUNTARY SELF DISCLOSURE 3 1.7.4 PRINCIPAL INSPECTOR Under the voluntary disclosure program, principal inspector refers to the designated FSI official responsible for oversight of the area of noncompliance involved in the disclosure.

1.7.5 REGULATED ENTITY An organization that is certificated, licensed or authorized by the FSI to conduct activities in aviation.

SECTION 2 VOLUNTARY DISCLOSURE POLICY A.


The FSI believes that the open sharing of apparent violations and a cooperative as well as an advisory approach to solving problems will enhance and promote aviation safety.

B.

Regulated entities will receive a letter of correction in lieu of civil penalty action for covered instances of noncompliance that are voluntarily disclosed to the FSI in accordance with the procedures set forth in this AC.
Once the letter of correction is issued, the case will be considered closed unless the agreed-upon comprehensive fix is not satis- factorily completed by the appropriate entity.

C. In evaluating whether an apparent violation is covered by this policy, the FSI will ensure that the following five conditions are met— 1) The regulated entity has notified the FSI of the apparent violation immediately after detecting it and before the agency has learned of it by other means.
2) The apparent violation was inadvertent.

3) The apparent violation does not indicate a lack, or reasonable question, of qualification of the regulated entities.

4) Immediate action, satisfactory to the FSI, was taken upon discovery to terminate the conduct that resulted in the apparent violation.

5) The regulated entity has developed or is developing a comprehensive fix and schedule of implementation satisfactory to the FSI.
The comprehensive fix includes a follow-up self-audit to ensure that the action taken correc.ts the noncompliance.

 This self-audit is in addition to any audits conducted by the FSI.

D. Ordinarily, the FSI will not forgo legal enforcement action if the regulated entity informs the FSI of the apparent violation during, or in anticipation of, an FSI investigation/inspection or in association with an accident or incident.
E. The procedures to be followed when applying the voluntary disclosure policy are further described in the following paragraphs.

SECTION 3 NOTIFICATION TO THE FSI OF AN APPARENT VIOLATION A.

The voluntary disclosure policy applies only when notification of an apparent violation is made to the FSI by the regulated entity immediately after the apparent violation has been discovered by that regulated entity, and before the FSI learns of the apparent violation by some other means.
The FSI believes that it is important for the initial notification to be within 24 hours of the discovery of the apparent violation.

B.

The form of notification may be oral, a written hard copy, or a written electronic copy.

Issue Date: 31 December 2008 4 AC-01-005: VOLUNTARY SELF DISCLOSURE 3.1 NOTIFICATION BY THE REGULATED ENTITY A.

When a regulated entity notifies the FSI of an apparent violation, contact must be made with, or directed to, the appropriate principal inspector.

B.
B.

The regulated entity should not delay notification for any reason, and should address, to the maximum extent possible, the following items with the principal inspector— 1) A brief description of the apparent violation, including an estimate of the duration of time that it remained undetected, as well as how and when it was discovered.

2) Verification that noncompliance ceased after it was identified.
3) A brief description of the immediate action taken after the apparent violation was identified, the immediate action taken to terminate the conduct that resulted in the apparent violation, and the person responsible for taking the immediate action.

4) Verification that an evaluation is underway to determine if there are any systemic problems and a description of the corrective steps necessary to prevent the apparent violation from recurring.
5) Identification of the person responsible for preparing the comprehensive fix.

6) Acknowledgment that a detailed written report will be provided to the principal inspector within 10 working days.

3.2 DISCLOSURE TO THE FSI IN THE CONTEXT OF AIRPORT CONSORTIA A.

Normally when the FSI becomes aware of an apparent violation by a regulated entity before that entity notifies the FSI of its apparent violation, the Voluntary Disclosure policy will not apply.
1) Several airports, however, have created consortia to conduct airport security vulnerability assessments.

 Membership in each consortium is voluntary and usually includes airline and airport regulated entities as well as an FSI representative.

 Consortium membership also may include persons and entities that do not hold certificates, including, but not limited to, law enforcement personnel, screening company representatives, and airport tenants.
2) The purpose of an airport consortium is to conduct formal airport vulnerability assessments in order to identify actual or potential security weaknesses, and to openly discuss assessment findings with a view toward collaborating on security improvements.

3) Airport consortia also are encouraged to engage in informal ongoing assessments of airport vulnerabilities.
4) During consortium assessment activities, an apparent violation by a regulated entity may be discovered by someone other than the regulated entity and brought forward for discussion by the consortium members.

5) Because an FSI representative is a member of the consortium, the FSI may become aware of an apparent violation during this discussion, at the same time, or before, the regulated entity, becomes aware of the apparent violation.

B.
Notwithstanding the requirement that an appropriate regulated entity notify the FSI of its apparent violation before the agency has learned of it by other means, if the FSI— 1) Initially becomes aware of the entity's apparent security violation before or at the same time the responsible entity does, because of information disclosed by a person or entity other than the regulated entity during an airport consortium activity or meeting, or Issue Date: 31 December 2008 AC-01-005: VOLUNTARY SELF DISCLOSURE 5 2) Becomes aware of an apparent security violation at the same time the responsible regulated entity does during consortia assessments that involve both FSI personnel and a regulated entity, the apparent violation will be covered by this policy provided the other elements of Section 2 are met.
Such disclosure will be deemed notification to the FSI of the apparent violation, instead of the initial notification outlined in paragraph 3.1.

C. The appropriate FSI principal inspector will send a written acknowledgment of the notification to the pertinent regulated entity and open an enforcement investigative report (EIR) in accordance with procedures outlined in this circular.
1) The regulated entity will have 10 work days from the date of the written acknowledgment of the apparent violation to follow up with a written report to the principal inspector in accordance with the guidance in this circular.

2) If the regulated entity does not agree that there has been a violation, or otherwise fails to provide information identified in this circular, the FSI thereafter will proceed with its investigation and initiate enforcement action, if appropriate, against the entity.
D. Except when the FSI becomes aware of an apparent violation, at the same time the regulated entity does during consortia assessments that involve both FSI personnel, and the regulated entity, or, at the same time or before the regulated entity does because of information disclosed by another entity during a consortium activity or meeting, a regulated entity self-reporting an apparent violation must follow the procedures outlined in this circular.

3.3 FSI RESPONSE TO VOLUNTARY DISCLOSURE NOTIFICATION A.
The principal inspector responds with a written acknowledgment of the entity's initial notification.

B.

This acknowledgment includes the request for a written report, and is sent in lieu of a letter of investigation provided the written report is completed in accordance with the voluntary disclosure reporting procedures set forth in this AC.
C. The principal inspector will open an enforcement investigative report that will be closed out with a letter of correction, following satisfactory development of a comprehensive fix and schedule of implementation agreed upon by the FSI and the entity.

3.4 CONTENTS OF VOLUNTARY DISCLOSURE NOTIFICATION A.

The written report should be provided to the principal inspector by the entity within 10 working days after the initial notification was made.
A sample format for this report is provided in the appendix to this AC.

B.

In summary, the written report should include the following information— 1) A list of the specific FSI regulations that may have been violated.

2) A description of the apparent violation, including the duration of time it remained undetected, as well as how and when it was detected.
3) A description of the immediate action taken to terminate the conduct that resulted in the apparent violation, including when it was taken, and who was responsible for taking the action.

4) An explanation that shows the apparent violation was inadvertent.

5) Evidence that demonstrates the seriousness of the apparent violation and the regulated entity's analysis of that evidence.
Issue Date: 31 December 2008 6 AC-01-005: VOLUNTARY SELF DISCLOSURE 6) Identification of the company official responsible for monitoring the implementation and completion of the comprehensive fix.
7) A detailed description of the proposed comprehensive fix, outlining— (a) The planned corrective steps; (b) The responsibilities for implementing those corrective steps; and If a proposed comprehensive fix is not fully developed within 10 working days, the perti- nent regulated entity should provide at least an overview of its comprehensive fix plans.

(c) A time schedule for completion of the fix.


C. In any event, a detailed description of the comprehensive fix should be provided to the principal inspector within 30 calendar days after the regulated entity initially notified the principal inspector of the apparent violation.

3.5 REVIEW BY THE FSI A.

The FSI works with the regulated entity to ensure that the comprehensive fix is acceptable to the FSI.

B.
B.

If the principal inspector determines that the proposed fix is acceptable, he/she will prepare a letter of correction that includes the date by which the comprehensive fix will be implemented and completed.

C. Following issuance of the letter of correction, the case is closed but remains subject to reopening in the event thatthe agreed-upon actions covered in the comprehensive fix are not completed to the satisfaction of the FSI.
Consultation with other FSI and/or INAVIC personnel may be accomplished when deemed appropriate by the principal inspector.

D. The principal inspector has the authority to close the case.

SECTION 4 IMPLEMENTATION & CLOSEOUT 4.1 IMPLEMENTATION OF A COMPREHENSIVE FIX A.

During the implementation period, the FSI and the pertinent regulated entity should continue to work together.

 The FSI may advise and assist the entity in correcting any identified systemic problems.
Changes can be made to the corrective action(s) outlined in the comprehensive fix when the need is identified and when the FSI concurs with the change.

 When a change to a comprehensive fix has been agreed upon, the principal inspector, or the inspector assigned to the case at the direction of the principal inspector, will prepare an amended letter of correction that reflects this change.

B.

The FSI monitors the implementation of the corrective steps.
Throughout the implementation period, the FSI assesses the pertinent regulated entity's corrective efforts and top management's awareness of these efforts.

 If, during this period, the FSI determines that the steps taken by the entity are not those documented in the comprehensive fix, the letter of correction may be rescinded, the investigative report may be reopened, and appropriate legal enforcement action may be initiated.
Issue Date: 31 December 2008 AC-01-005: VOLUNTARY SELF DISCLOSURE 7 C. Following completion of the agreed-upon corrective action(s), the regulated entity conducts a self-audit to ensure that the action taken remedies the problem that gave rise to the apparent violation.

D. At the conclusion of the implementation period, the principal inspector makes a final assessment.

 If all elements of the comprehensive fix have been adequately accomplished, the principal inspector finds the fix satisfactory.
A statement of follow-up investigation, confirming that the comprehensive fix was satisfactorily implemented and completed, shall be prepared to complete the FSI's investigative package.

E. If the same or similar violations are discovered subsequent to the FSI's completion of an investigative package, the FSI does not reopen the case unless it determines that the pertinent regulated entity failed to comply with all the elements of the comprehensive fix agreed upon by the FSI and the entity.
4.2 DISPUTE RESOLUTION A.

When disputes occur regarding the acceptance of a proposed comprehensive fix, or a modification thereto before the fix is considered satisfactory, the principal inspector and the pertinent regulated entity may request that the issue be resolved at the next level of management within the FSI.

B.

This procedure will provide for an independent assessment of the areas in disagreement.

4.3 SEPARATE ACTIONS AGAINST AIRMEN OR OTHER INDIVIDUAL AGENTS A.
The voluntary disclosure policy applies to individual airmen or other agents of an employing regulated entity when— 1) The apparent violation involves a deficiency of the employing entity's practices or procedures that causes the employing regulated entity to be in violation of a covered violation of an FSI regulation; 2) The airman or other agent of the employing entity, while acting on behalf of the employing entity, inadvertently violates the FSI's regulations as a direct result of a deficiency of the employing entity that causes the employing entity to be in violation of the regulations and/or—.
The voluntary disclosure policy does not apply to the airman or other agent when his/her apparent violation is the result of actions unrelated to the employing entity's deficiency.

 The airman or other agent immediately makes the report of his/her apparent violation to the employing entity; and The employing regulated entity immediately notifies the FSI of both the airman or other agent's apparent violation and the apparent deficiency in its practice or procedures.

B.
B.

When all the above conditions are met, a separate EIR is opened for the individual and closed with an administrative action.

C. If all the above conditions are not met, the principal inspector will review all facts associated with the case and determine what action is appropriate for individual airmen or other agents of the employing entity.

 This provision does not apply to matters concerning qualifications to hold an airman certificate.
Issue Date: 31 December 2008 8 AC-01-005: VOLUNTARY SELF DISCLOSURE 4.4 REPEATED VIOLATIONS A.

If a repeated violation occurs, notwithstanding the fact that a comprehensive fix was satisfactorily completed and followed, the procedures outlined in this AC may apply to the disclosure of the repeated violation.

B.
B.

The determination whether a repeated violation will be covered under this policy will be made by the FSI on a case-by-case basis, upon consideration of the facts and circumstances surrounding the repeated violation.

4.5 CONCLUSION A.

Development of internal evaluation programs should help to ensure that any apparent violations are promptly identified, corrected, and reported to the FSI.

B.
B.

While not required, the FSI strongly encourages regulated entities to make internal evaluation programs an integral part of their everyday management process so that the full benefits of voluntary disclosure can be realized.

C. Aviation safety is served by programs that allow the regulated entity to identify and correct.

End of Circular Text - Appendix Follows.


Issue Date: 31 December 2008 AC-01-005: VOLUNTARY SELF DISCLOSURE 9 APPENDIX A Sample Format To Be Followed When Submiting The Written Report The following sample is only a suggested format to be followed when preparing the written report that will be submitted to the FSI.

While a regulated entity should include at least all the elements specified below, the structure of the written report can be modified by the regulated entity to fit its particular needs.

1.
1.

General 1) Date.

2) Certificate type or equivalent.

3) Pertinent regulated entity number or equivalent.

4) Company name.

5) Company address.

6) Company official filing report.

 Name.

 Position.

 Telephone number.

2.

Description Of Apparent Violation 1) Applicable CASR.

2) Date apparent violation was discovered.

3) Location of discovery.

4) Company official who discovered the apparent violation.

 Name.

 Position.

 Telephone number.


5) Date and time of initial notification to the FSI.

6) Name of FSI official notified (principal inspector).

7) Company official making notification.

 Name.

 Position.

 Telephone number.

8) Duration of time apparent violation remained undetected.

 Hours.

 Cycles.

 Days.

Issue Date: 31 December 2008 10 AC-01-005: VOLUNTARY SELF DISCLOSURE 3.
Summary Of Apparent Violation The summary should be a brief statement that describes the nature of the apparent violation and identifies the specific aircraft, engines, appliances, facilities, checkpoint, gate, cargo, and/or individuals associated with the apparent violation.)

4.

Immediate Action When immediate action was taken— 1) Description of immediate action.

(This description should outline the immediate steps that were taken to cease the violative action.)
2) Company official responsible for immediate action.

 Name.

 Position.

 Telephone number.

5.

Analysis A.

Summary of evidence.

(This summary should describe the scope of the apparent violation and explain how it was detected.

In addition, conclusions reached regarding possible or probable systemic deficiencies, i.e., who, what, when, why, and how the noncompliance occurred, should be described.)

B.

Reasons why the apparent violation was inadvertent.
C. Supporting documentation.

(The evidence associated with the apparent violation should be attached.

This evidence should include a statement regarding how the regulated entity determined the extent of the apparent violation.)

6.

Comprehensive Fix Proposal A.

The proposed long-term corrective steps to be taken by the regulated entity to preclude recurrence of the apparent violation should be listed in this section.

B.
B.

Each corrective step should identify the individual or department responsible for implementing and completing the corrective step as well as the time allotted for completion of each corrective step.

C. Examples of types of questions or issues that a comprehensive fix proposal should address are as follows— Whether the apparent violation involves equipment, facilities, or individuals beyond those addressed in the initial notification and for which immediate action was taken.
Whether procedural or organizational changes are necessary.

 How it will be determined whether any procedural or organizational changes are effective.

 What procedures will be developed to ensure that the affected area is periodically reviewed in the future so that concerns can be identified before a violation occurs?

 Who will be responsible for performing periodic reviews?
D. To whom in the regulated entity's organization will the results of those periodic reviews be reported, and how will they be documented?

Issue Date: 31 December 2008 AC-01-005: VOLUNTARY SELF DISCLOSURE 11 7.

Responsibility For Monitoring The Implementation Of The Comprehensive Fix Name.

 Position.

 Telephone number.

 Signature.

8.

Fsi Acceptance (To Be Completed By The Fsi) Name.

 Position (principal-inspector).

 Date.
Date.

 Office.

9.

Signature End of Advisory Circular Issue Date: 31 December 2008 12 AC-01-005: VOLUNTARY SELF DISCLOSURE This Page Intentionally Left Blank Issue Date: 31 December 2008