AMC1 21.A.3A(a) Failures, malfunctions and defects

CAA ORS9 Decision No. 40

COLLECTION, INVESTIGATION, AND ANALYSIS OF EVENTS

In the context of the following AMC and GM to point 21.A.3A, the term ‘event’ refers to any failure, malfunction, defect, error, near miss, hazard identification, incident, accident, or other occurrence that is subject to a reporting system.

The ‘collection’, ‘investigation’, and ‘analysis’ functions of the system should include means:

- to analyse events and related available information;

- to identify adverse trends;

- to investigate the associated root cause(s); and

- to determine any necessary corrective action.

It should also allow the determination of reportable occurrences as required by point 21.A.3A(b)(1).

In addition, for parts whose failure could lead to an unsafe condition, the ‘analysis’ function of the system should ensure that reports and information sent, or available, to the design approval holder (DAH) are fully investigated so that the exact nature of any event and its effect on continuing airworthiness is understood. This may then result in changes to the design and/or to the instructions for continued airworthiness (ICA), and/or in establishing a mitigation plan to prevent or minimise the possibility of such occurrences in the future, as necessary. The ‘analysis’ is not limited to those occurrences that require the involvement of the CAA under point 21.A.3A(c)(1).