Quality Assurance in the Service of Safety

Quality Assurance in the Service of Safety

Dario Fakleš, B. Sc.

Tomislav Gradišar, B. Sc.

Croatia Airlines

Zagreb, Savska c. 41, Croatia

Sanja Steiner, D. Sc.

University of Zagreb

Faculty of Transport and Traffic Engineering

Zagreb, Vukelićeva 4, Croatia

IATA Operational Safety Audit (IOSA) in function of safety


Reaching uttermost system enhancements, traditional approach to safety assessment has drained its abilities. Imperative of safety, with stress on costs reduction and production increase, leads to development of a process model that leads to development of new tools used for data acquisition on information about safety and efficiency of flight operations. One of the most important tools for evaluation of flight operations safety and efficiency is auditing. Inter-auditing of airlines that was first started as tool for verification of service level and risk control, is now becoming significant tool for safety improvement. Sustained level of increasing code-share agreements accompanied with significant expansion of number of airline operational audits similar by intent and content, have led to unnecessary waste of resources. The solution to this problem, with improvement of audit process itself, was in global standardization and unification of the audit process. Therefore, IATA took the lead to develop IOSA. Even still imperfect, IOSA programme might become the most significant mean of safety assessment of flight operations.


Aviation Safety, Safety Culture, Error (Risk) Management, Flight Operations Safety, Safety Audit, IOSA (IATA Operational Safety Audit)


Transport system such as aviation has become ultra-safe without having such explicit models of how they achieve this. Aviation is very vulnerable to the sorts of organizational and technical change which is flooding over it at present. One of the biggest challenges in the next century of flight will be improving on the already very low accident rates of major air carriers. On the other hand, an international trend of aviation markets is the creation of larger, more cost-efficient airline business structures where economies of scale can operate. An example is the growth in global airline alliances and code-share agreements in recent years. The question that arises is can cost efficiency come without expense of safety? What tools are efficient enough to verify safety standards of airline carriers on world-wide scale? A promising step in that direction is being taken by IATA with development and implementation of IOSA programme.


2.1. Process approach in the assurance of air safety

Various socio-technological systems have advanced to be so vast and complex that the traditional methods of safety and accident prevention have lost their efficiency. Additionally, the public perception of organisation's safety has evolved and become an integrated value. Therefore, isolated interventions to safety become obsolete. As safety is now an integrated value of an organisation, safety management needs to be process oriented.

Each manufacture, service or sale can be disseminated to processes that can take place in parallel or one after another. These processes can often surpass organisation’s boundaries, which differentiate this model from the traditional and static vertical organisational model.

With its global growth, the system of air traffic is growing more complex. Changes are prompt and forceful, demanding the airlines to respond swiftly or disappear from the market. Amongst the most frequent changes are amendments of legislative, escalation in worldwide competition, development of the new technologies, upsurge of mergers and alliances etc.

These developments require increased productivity and efficiency bringing up the risk of reduced safety margins and necessitating better understanding of safety investments. While production processes are well defined and explicable, safety measures are more subtle and difficult to distinguish. The balance between profit and safety is constantly fluctuating and is more often than not altered towards production increase and cost reduction, leaving the organisation exposed to (never absent) threats. Also, safety developments are used not to reduce risks but to increase production, leaving the risk at level perceived as acceptable. This process is known as “risk compensation” Moreover, long periods with absence of an accident or incident can often result in slow degradation of safety levels in ever-present strives for production increase.

Better understanding of accident prevention and risk management requires the recognition of safety tools and levels of protection, which can be identified using the process approach.

2.2. Latent Errors

The necessary condition for an organisational accident is the rare conjunction of a set of errors in successive defences, allowing hazards to come into damaging contact with people and assets. The most obvious errors would be the ones performed at the “sharp end” of the system – by pilots, air traffic controllers, maintenance personnel and the like. Such unsafe acts are likely to have a direct impact on the safety of the system and, because of the immediacy of their adverse effects, these acts are termed “active failures”.

Today, such unsafe acts are seen more as consequences than as principal causes. Although fallibility is an inescapable part of the human condition, it is now recognised that people working in complex systems make errors or violate procedures for reasons that generally go beyond the scope of individual psychology. These reasons are “latent conditions”. Latent conditions are products of strategic decisions, brought by governments, regulators, manufacturers, designers, highest company management and low-level operational managers.

Figure 1 - “Swiss cheese”[1] model of accident causation.

The main distinction between active failures and latent conditions is that active failures usually have immediate and relatively short-lived effects whereas latent conditions can lie dormant for a time doing no particular harm until they interact with local circumstances to defeat the system’s defences. More importantly, whereas particular active failures tend to be unique to a specific event, the same latent conditions – if undiscovered and uncorrected – can contribute to a number of different accidents. This is the reason why more safety benefit can be gained by discovering (and correcting) latent conditions, than wasting time and resources to pinpoint and punish the executors of active failures. Moreover, for this reason, the latent condition discovered in one airline is very likely to exist in another airline.

2.3. Discovering latent conditions in air traffic

The system of air traffic is renown for its high level of safety. The steady decline in number of accidents lets us content with the system. However, the complexity of socio-technological system as this leaves no room for being complacent. Moreover, the dwindling number of accidents leaves us deprived of information about unsafe latent conditions developing in the fast-changing system of air traffic.

If any significant improvement in safety is to be done, methods and tools for discovery of latent conditions must be developed. The most popular safety tools, designed particularly to address latent conditions, are various technical “spies”, confidential reporting systems, confidential questionnaires and audits.

While technical “Flight Data Monitoring” tools like Flight Data Recorder and Quick Access Recorder can get a tremendous amount of data from each flight, leaving nothing to hide, it is only discovered what happened and not why. The answer to this, more important, question can only be obtained from those at the “sharp-end” of the system – operations and maintenance personnel.

Confidential questionnaires provide the general overview of safety culture and interaction between different elements of organisation as maintenance, ground handling and aircrews. Information obtained is also useful in introduction and acceptance of fundamental CRM concepts.

Confidential reporting schemes, grant priceless information on different aspects of a particular otherwise not reportable incident or near miss. Without such system, this information would be lost.

Detection of latent conditions:

-Unveils system errors before they become a cause of any damage.

-Reveal errors in the higher levels of organisation that would otherwise remain out of sight.

-Provide greater volume of safety data, producing a more realistic depiction of risk source and volume.

-Enable faster feedback on the yield of safety investments (or “savings”).


3.1. Inter-airline audits

One of the most important tools to monitor and evaluate both safety and efficiency of flight operations is company audit. An audit is independent system designed to gather relevant objective information about a certain company or its part, by means of systematic interviews and insight to company’s documentation. It is evaluation of company (system) status rather than workforce evaluation or pursuit of blameworthy individual. It is therefore important to distinguish Authority’s audit and inter-company audit. While Authority will investigate if all operations are conducted in compliance with relevant regulations, auditing carrier will seek confirmation that the level of service, as well as the overall safety of operations matches its own, permitting it to entrust its passengers to an audited carrier.

Therefore, the basis of inter-carrier auditing is commercial. Establishing a code-share agreement does not relief a carrier only selling tickets (marketing carrier) from the responsibility towards the passenger, which will in fact travel by another (operating) carrier.

Simultaneously with upsurge in number of code-share agreements, the last decade of the last century brought along another trend: the exponential increase in the number of aeroplanes operated by a third-party operator, weather on a dry or wet lease[2]basis. Furthermore, forming of global alliances makes it very usual for a carrier to sell a ticket for its flight, which will actually be operated by another carrier, but with an aeroplane and crew of the third. The need for a detailed systematic assessment of an associate carrier is now obvious.

3.2. Safety benefits for the audited airline

On the other hand, the audited carrier receives a useful opportunity for (almost) free expert assessment of its system, as well as a valuable benchmarking. Commonly helpful, deficiencies found on the lower levels of organisation only now get due attention from the upper levels. This phenomenon actively increases the efficiency of resource allocation and promotes investments in safety. Consequently, inter carrier auditing, although originally started as a legislative confirmation of the required service and risk control level, has now become a significant safety tool.

3.3. Limitations and deficiencies of inter-airline audits

Continuous increase of inter-carrier agreements, together with dramatic expansion of audits’ scope and depth recently revealed overwhelming waste of resources. Also, audits of different carriers often repeat themselves in questions and findings. This leads to a noteworthy loss of work-hours of the most expensive staff – the management.

Figure 2 - Airliners inter-auditing leads to waste of resources.


4.1. Goal

To provide a standardised audit programme based on internationally recognised standards and a structured system for sharing audits. This will help to improve operations and reduce the number of audits in the industry.

4.2. Background

The airline industry is subject to an ever-increasing proliferation of inspections, reviews and audits that often overlap in intent and content. The number of airline operational audits that have been conducted over the past several years has increased significantly, with many airlines subject to multiple audits and a wide variability of standards often producing uneven results. It has become evident to industry professionals that a considerable opportunity exists to standardize, harmonize and rationalize the audit process. Therefore, IATA took the lead to develop IOSA.

4.3. IATA's Role

Since 2001, in an intensive effort with the world's leading airlines, regulatory authorities and other industry entities, IATA has developed IOSA. The project has been overseen by an IOSA Advisory Group (IAG), which comprises technical experts from airlines, ICAO and regulatory authorities, providing a balanced geographical representation from the air transport industry.

IATA’s role is to oversee the entire IOSA Programme. Functions include the ongoing development of the standards, management of the training and audit organizations, organizer of the IOSA Oversight Cometee meetings, and keeper of the IOSA Registry.

4.4. Concept

The IATA Operational Safety Audit (IOSA) Programme is an internationally recognised and accepted evaluation system designed to assess the operational management and control systems of an airline. IOSA uses internationally recognised quality audit principles, and is designed so that audits are conducted in a standardised and consistent manner.

Figure3 - IOSA concept.

Inherent in the IOSA Programme is a degree of quality, integrity and security such that mutually interested airlines and regulators can all comfortably accept IOSA audit reports. As a result, the industry will be in a position to achieve the benefits of cost-efficiency through a significant reduction in audit redundancy.

4.5. Audit Reports

The IOSA Audit Report (IAR) reflects the acceptable closure of all findings and is the official record of an audit.

Figure4 - IOSA Audit reports and database.

One important benefit of IOSA is achieved through audit sharing. IATA is the official custodian of all IOSA Audit Reports, facilitating secure and confidential access to this information by interested and approved parties.

4.6. Industry Benefits

With the implementation and international acceptance of IOSA, airlines and regulators will achieve the following benefits:

  • The establishment of the first internationally recognised operational audit standards
  • A reduction of costs and audit resource requirements for airlines and regulators
  • Continuous updating of standards to reflect regulatory revisions and the evolution of best practices within the industry
  • A quality audit programme under the continuing stewardship of IATA
  • Accredited audit organisations with formally trained and qualified auditors
  • Accredited training organisations with structured auditor training courses
  • A structured audit methodology, including standardised checklists
  • Elimination of audit redundancy through mutual acceptance of audit reports
  • Development of auditor training courses for the airline industry

4.7. The downside

In the very beginnings of IOSA system, many airlines worldwide are expressing strong scepticism about it. Most of unquestionable deficiencies can be attributed to the hastily short development time. Although prepared by the large number of industry’s finest experts, political and legal issues forged the initial set of requirements to a mare compilation of FAA, JAA and ICAO regulations with some of the industry’s best practice. Combined together, these requirements are overwhelming for most carriers, preventing them from certification and therefore abolishing the possibility of an industry-wide standard. For that reason it is mandatory for future revisions of IOSA standards to give in to common practice and loose up on some of the mere legislative requirements.

The second shortcoming of the system is its imperative commonality, which makes it inflexible to carrier’s size or national and organisational surrounding. “Best practice” requirements are often taken from the major carriers and are frequently not viable or even oblivious to the small or regional carriers.

The third IOSA problem is undeniable influence of the major carriers, which will too easily be tempted to use the system to put on pressure on the smaller carriers. High requirements for the certification of audit organisations will limit the choice of IOSA audit organisations solely to the transformed quality assurance departments of the major carriers[3]. Although it has not yet happened, even suspicions of commercially influenced results will bring major credibility problem to the yet unproven system.

In the end, not neglectable is the high price of certification. The logic behind the pricing policy was estimated 40,000 USD for the auditing airline and 20,000 USD for the audited one. The unique price tag of 90,000 USD for IOSA certification therefore seems justified, but these estimates are simply not true for the smaller airlines. Also, for a smaller airline, this amount of money is possibly better invested elsewhere in safety enhancement.


In the era of global airline alliances, code-share and other commercial agreements, safety and quality standards are prone to deterioration. Standards produce control and transparency by making quality measurable and revealing differences among competitors. However, safety standards and rules leave a lot of room for interpretation. Effective tool in determination of safety and quality standards level is audit. The need for uniform audit standards that will be recognized by airlines through world has led to development and implementation of IOSA. IOSA programme with quality audit principles, standardized audit methodology and structured auditor qualifications standards is enabling airliners and regulators to share and accept audit results as valid,cost reducing and to avoid audit redundancy. Potential next step in developing IOSA programme could be expansion of the concept to cargo operations.While there is still much work to doand to prevent IOSA programme to becomecommercially influenced, in the next few years IOSA may become significant mean of safety assessment of flight operations.

Međunarodni sustav auditiranja letačkih operacija (IOSA) u funkciji sigurnosti


Dosizanjem krajnjih poboljšanja sustava, tradicionalni pristup osiguranja sigurnosti iscrpio je svoje mogućnosti. Imperativ sigurnosti, te rastući pritisak smanjenja troškova i povećanja produktivnosti, dovode do razvoja procesnog pristupa, čime se razvijaju novi alati prikupljanja informacija vezanih za sigurnost i učinkovitost letačkih operacija. Jedan od najvažnijih alata praćenja i vrednovanja sigurnosti i učinkovitosti letačkih operacija je auditiranje. Međusobno auditiranje zrakoplovnih kompanija, započeto kao alat potvrde razine usluge i kontrole rizika, postaje značajan alat poboljšanja sigurnosti. Kontinuirano povećanje broja code-share ugovora uz dramatičnu ekspanziju opsega i dubine samih audita ubrzo dovodi do prekomjernog rasipavanja resursa. Rješenje ovog problema, uz poboljšanje samog procesa, nalazi se u globalnoj standardizaciji i unifikaciji sustava auditiranja. Pod okriljem Međunarodne udruge zrakoplovnih prijevoznika (IATA), razvijen je Međunarodni sustav auditiranja letačkih operacija (IOSA). Iako još nesavršen, ovaj sustav bi u slijedećih nekoliko godina mogao postati najznačajnije sredstvo osiguranja sigurnosti letačkih operacija.