Bhuta Final Report - International Civil Aviation …cfapp.icao.int/fsix/AuditReps/CSAfinal/Bhutan_CSA_Final.pdfFINAL REPORT ON THE SAFETY OVERSIGHT AUDIT OF THE CIVIL AVIATION SYSTEM

ICAO Universal Safety Oversight Audit Programme

FINAL REPORT ON THE SAFETY OVERSIGHT AUDIT

OF THE CIVIL AVIATION SYSTEM

OF THE KINGDOM OF BHUTAN

(24 to 31 October 2006)

International Civil Aviation Organization

Final Safety Oversight Audit Report — Bhutan August 2007

TABLE OF CONTENTS Page 1. INTRODUCTION ........................................................................................................................ 1

1.1 Background ........................................................................................................................... 1 1.2 ICAO audit team composition ............................................................................................... 1 1.3 Acknowledgements ............................................................................................................... 2

2. OBJECTIVES AND ACTIVITIES OF THE AUDIT MISSION ............................................ 2 3. AUDIT RESULTS ....................................................................................................................... 3

3.1 Critical element 1 — Primary aviation legislation ................................................................. 3 3.2 Critical element 2 — Specific operating regulations ............................................................. 4 3.3 Critical element 3 — State civil aviation system and safety oversight functions ................... 6 3.4 Critical element 4 — Technical personnel qualification and training .................................... 8 3.5 Critical element 5 — Technical guidance, tools and the provision of safety critical information .......................................................................................................................... 10 3.6 Critical element 6 — Licensing, certification, authorization and/or approval obligations ... 11 3.7 Critical element 7 — Surveillance obligations .................................................................... 13 3.8 Critical element 8 — Resolution of safety concerns ............................................................ 13

4. VISITS TO THE INDUSTRY/SERVICE PROVIDERS ....................................................... 15 5. AUDIT FINDINGS AND DIFFERENCES DATABASE (AFDD) ........................................ 15 6. STATE AVIATION ACTIVITY QUESTIONNAIRE (SAAQ) ............................................. 15 7. COMPLIANCE CHECKLISTS (CCs) .................................................................................... 15 8. FOLLOW-UP ACTION ............................................................................................................ 16 APPENDICES

1 — Audit findings and recommendations 1-1 Findings and recommendations related to primary aviation legislation and civil aviation

regulations 1-2 Findings and recommendations related to civil aviation organization 1-3 Findings and recommendations related to personnel licensing and training 1-4 Findings and recommendations related to aircraft operations certification and supervision 1-5 Findings and recommendations related to airworthiness of aircraft 1-6 Findings and recommendations related to aircraft accident and incident investigation 1-7 Findings and recommendations related to air navigation services 1-8 Findings and recommendations related to aerodromes

2 — Graphic representation of the lack of effective implementation of the critical elements

3 — Corrective action plan proposed by Bhutan

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ICAO UNIVERSAL SAFETY OVERSIGHT AUDIT PROGRAMME

Final Report on the Safety Oversight Audit of the Civil Aviation System of Bhutan

(24 to 31 October 2006)

1. INTRODUCTION 1.1 Background 1.1.1 The 32nd Session of the ICAO Assembly (Assembly Resolution A32-11 refers) resolved the establishment of the ICAO Universal Safety Oversight Audit Programme (USOAP), comprising regular, mandatory, systematic and harmonized safety audits of all Contracting States. The mandate for regular audits foresaw the continuation of the Programme, and the term “safety audits” suggested that all safety-related areas should be audited. The expansion of the Programme “at the appropriate time”, as recommended by the 1997 Directors General of Civil Aviation Conference on a Global Strategy for Safety Oversight, had thus been accepted as an integral part of the future of the Programme. 1.1.2 The 35th Session of the ICAO Assembly considered a proposal of the Council for the continuation and expansion of the USOAP as of 2005 and resolved that the Programme be expanded to cover all safety-related Annexes (Assembly Resolution A35-6 refers). The Assembly also requested the Secretary General to adopt a comprehensive systems approach for the conduct of safety oversight audits. 1.1.3 Assembly Resolution A35-6 further directed the Secretary General to ensure that the comprehensive systems approach maintain as core elements the safety provisions contained in Annex 1 � Personnel Licensing, Annex 6 � Operation of Aircraft, Annex 8 � Airworthiness of Aircraft, Annex 11 � Air Traffic Services, Annex 13 � Aircraft Accident and Incident Investigation and Annex 14 � Aerodromes; to make all aspects of the auditing process visible to Contracting States; to make the final safety oversight audit reports available to all Contracting States; and also to provide access to all relevant information derived from the Audit Findings and Differences Database (AFDD) through the secure website of ICAO. 1.1.4 In accordance with Assembly Resolution A35-6, safety oversight audit reports have been restructured to reflect the critical elements of a safety oversight system, as presented in ICAO Doc 9734 —Safety Oversight Manual, Part A — The Establishment and Management of a State’s Safety Oversight System. ICAO Contracting States, in their effort to establish and implement an effective safety oversight system, need to consider these critical elements. 1.2 ICAO audit team composition 1.2.1 The safety oversight audit team was composed of: Mr. Nicolas Rallo, team leader, primary aviation legislation (LEG)/civil aviation organization (ORG)/aircraft accident and incident investigation (AIG); Mr. Arif Khan, team member, personnel licensing (PEL)/aircraft operations (OPS); Mrs. Tuhinanshu Sharma, team member, airworthiness of aircraft (AIR); Ms. Tay Siew Huang, team member, air navigation services (ANS); and Mr. Jaroon Meesomboon, team member, aerodromes (AGA).

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1.3 Acknowledgements 1.3.1 ICAO expresses its sincere appreciation for the assistance provided to the audit team during the preparation and conduct of the audit. The professionalism and enthusiasm of all personnel who interacted with the audit team greatly contributed to the success of the audit mission. 2. OBJECTIVES AND ACTIVITIES OF THE AUDIT MISSION 2.1 The comprehensive systems approach for the conduct of safety oversight audits consists of three phases. In the first phase, the level of implementation of Annex provisions is assessed and differences from ICAO Standards and Recommended Practices (SARPs) are identified for each Contracting State through a review of a duly completed State Aviation Activity Questionnaire (SAAQ) and Compliance Checklists (CCs) for all safety-related Annexes, as well as through a review of documents developed by the State to assist it in implementing SARPs and in maintaining an effective safety oversight system. In the second phase, the State being audited is visited by an ICAO audit team to validate the information provided by the State and to conduct an on-site audit of the State’s overall capability for safety oversight. The third phase of the audit process consists of the activities following the completion of the on-site audit. 2.2 The safety oversight audit of Bhutan was carried out from 24 to 31 October 2006 in accordance with the standard auditing procedures provided for in ICAO Doc 9735 — Safety Oversight Audit Manual and the Memorandum of Understanding (MOU) agreed to on 3 May 2005 between Bhutan and ICAO. The audit was carried out with the objective of fulfilling the mandate given by the Assembly which requires ICAO to conduct a safety oversight audit of all Contracting States (Assembly Resolutions A32-11 and A35-6 refer), reviewing a State’s compliance with ICAO SARPs set out in all safety related Annexes and their associated guidance material, as well as with related Procedures for Air Navigation Services (PANS). Furthermore, the objective was also to offer advice, as applicable, to Bhutan in implementing these provisions. 2.3 The audit team reviewed the SAAQ and the CCs submitted by Bhutan prior to the on-site audit in order to have a preliminary understanding of the civil aviation system established in the State, to determine its various functions as well as to assess the status of implementation of relevant Annex provisions. Information provided and assessed prior to the conduct of the audit was validated during the on-site audit phase. In this regard, particular attention was given to the presence of an adequate organization, processes, procedures and programmes established and maintained by Bhutan to assist it in fulfilling its safety oversight obligations. 2.4 The audit results including the findings and recommendations contained in this report reflect the capabilities and limitations of the civil aviation system of Bhutan as assessed by the audit team. They are thus based on evidence gathered during interviews by the audit team with Bhutan’s technical experts and background information provided by such personnel, review and analysis of civil aviation legislation, specific regulations, related documentation and file records. Considering the time that was available to conduct the audit and the fact that the safety oversight audit team members could only review and analyse information and documentation made available by the State, it is possible that some safety concerns may not have been identified during the audit. The findings and recommendations related to each audit area are found in Appendix 1 to this report.

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3. AUDIT RESULTS 3.1 Critical element 1 � Primary aviation legislation

“The provision of a comprehensive and effective aviation law consistent with the environment and complexity of the State’s aviation activity, and compliant with the requirements contained in the Convention on International Civil Aviation.”

3.1.1 The primary aviation legislation in Bhutan is the Civil Aviation Act of the Kingdom of Bhutan 2000 (hereinafter known as the Act), which was enacted and came into force on 14 July 2000. Article 6 of the Act empowers the Minister responsible for civil aviation (hereinafter named the Minister) to regulate civil aviation activities in Bhutan. In addition, as stated in Article 5 (c) and Article 13 of the Act, the Minister is also responsible for the construction and maintenance of all “government aerodromes and facilities.” 3.1.2 Article 11 of the Act establishes the Department of Civil Aviation (DCA) as the safety oversight authority in Bhutan and Article 12 describes its principal functions as follows:

“(a) to develop, issue and revise operating regulations and rules (means of compliance) consistent with the code of air navigation regulations and based on the provisions of the Annexes to the Convention on International Civil Aviation;

(b) to develop, issue and revise security regulations in accordance with Annex 17 to the Convention on International Civil Aviation and any associated Acts, Conventions or Protocols ratified by the Kingdom of Bhutan;

(c) to ensure the safety of air navigation; (d) to promote and encourage the orderly and economic development of civil aviation; (e) to ensure the observation of any regulations made under this Act; (f) to initiate and carry out surveys into any aspect of civil aviation; (g) to advise the Minister on all matters affecting civil aviation; and (h) to perform such other functions as the Minister may from time to time impose.”

3.1.3 Enforcement of the legislation and air navigation regulations is addressed in Articles 18 to 20 of the Act. The Act contains very few directly applicable requirements related to civil aviation safety. Such requirements are to be promulgated in the regulations. Overall, the Act constitutes an adequate legal framework for safety oversight in the areas of personnel licensing, aircraft operations, airworthiness and aerodromes. However, it is still limited in scope as it does not provide for the regulation and surveillance of Air Navigation Services (ANS) activities in the State. 3.1.4 The Act has not been amended since its promulgation. Any amendment in the future has to be submitted by the DCA to the Cabinet of the Ministry of Information and Communications and then transmitted to Parliament for adoption. Once adopted, there is no formal requirement for publication, but the DCA has to distribute copies of the amended legislation to all interested parties. 3.1.5 Bhutan ratified Article 83 bis of the Chicago Convention on 26 August 2005. To date, Bhutan has not entered into any agreement on the transfer of functions and duties from the State of Registry to the State of the Operator under the provisions of Article 83 bis of the Chicago Convention. Moreover, Bhutan’s primary aviation legislation has not been amended to reflect the ratification of Article 83 bis of the Chicago Convention.

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3.2 Critical element 2 � Specific operating regulations

“The provision of adequate regulations to address, at a minimum, national requirements emanating from the primary aviation legislation and providing for standardized operational procedures, equipment and infrastructures (including safety management and training systems), in conformance with the Standards and Recommended Practices (SARPs) contained in the Annexes to the Convention on International Civil Aviation.

Note.— The term ‘regulations’ is used in a generic sense to include instructions, rules, edicts, directives, sets of laws, requirements, policies, orders, etc.”

3.2.1 The civil aviation regulations in Bhutan are contained in the Bhutan Air Navigation Regulations (BANRs), which were issued by the Ministry of Information and Communications on 30 March 1999. These regulations and all relevant amendments are distributed by the DCA, which maintains a distribution list of all users. However, some users, in particular the air traffic service (ATS) provider, are not included in this distribution list. 3.2.2 For some aspects related to personnel licensing, aircraft operations and airworthiness, the BANRs refer to specific provisions of the Joint Aviation Requirements (JARs) issued by the Joint Aviation Authorities (JAA). For other aspects, the BANRs spell out Bhutan’s own requirements. However, the references made to the JARs do not specify the version that is considered. 3.2.3 Although aircraft operations, airworthiness and aerodrome inspectors have access to all relevant facilities, there are no explicit provisions in the State’s legislation or regulations that provide the inspectors with unrestricted and unlimited access to aircraft and all aviation facilities, except in the area of aerodromes. There is therefore no clear delegation of authority to DCA inspectors to access aircraft and aviation facilities. Regarding access by civil aviation inspectors to aviation documents, provisions exist in the BANRs to enable access, but these provisions do not include access to ANS related documents. The DCA of Bhutan has also established official credentials for its inspectors, which are of the expiring type. However, some of the credentials were found to have been expired for several years. In addition, no credentials are issued to enable inspections in the ANS area, as these inspections are not provided for by the State’s legislation and regulations. 3.2.4 A number of differences exist between the ICAO Standards and Bhutan’s regulations and practices. However, ICAO has not been notified of many of the differences. The DCA has not established documented procedures for reviewing all ICAO Annex amendments in an effective and timely manner, monitoring compliance with the ICAO SARPs, and amending its regulations when appropriate. 3.2.5 As far as exemptions are concerned, the DCA has not developed policies and procedures for the issuance of exemptions, except in the area of aerodromes. 3.2.6 Regarding personnel licensing, Section 12 of the BANRs deals with the licensing of flight crew and aircraft maintenance engineers (AMEs), while Chapter 2 of Section 7 relates to the licensing of air traffic controllers. As the DCA does not have the facilities or the expertise to conduct ground examinations or flight tests, it issues licences based on JAA licences. Bhutan licences are then maintained and renewed according to JAA standards. For flight crew licences, references are made to JAR-FCL 1 and JAR-FCL 2 for aeroplane and helicopter licences, respectively. For medical standards, references are made to JAR-FCL 3. For the licensing of AMEs and air traffic controllers, Bhutan’s own requirements are laid down in the BANRs. However, these requirements do not fully comply with the provisions of ICAO Annex 1.

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3.2.7 As for aircraft operations, regulations are also provided in the BANRs. Section 2 of the BANRs deals with commercial flight operations (Fixed Wing), Section 3 with commercial flight operations (helicopter), Section 4 with general aviation, and Section 5 with the transport of dangerous goods by air. However, the provisions of the BANRs related to aircraft operations are not comprehensive and do not fully conform to the SARPs contained in ICAO Annex 6 and Annex 18 — The Safe Transport of Dangerous Goods by Air. Several essential provisions of Annex 6 and Annex 18 have not been transposed into the BANRs. In particular, a number of provisions regarding the systems, procedures and documents to be established by the air operator are missing. 3.2.8 With respect to airworthiness, Sections 2 and 3 of the BANRs contain the regulations on maintenance of airworthiness for commercial flight operations for aeroplanes and helicopters. Regulations relating to general aviation are found in Section 4 of the BANRs. All provisions of the JAR OPS-1 Subpart M and the JAR 145 have been adopted for the approval of aircraft maintenance organizations as referenced in the BANRs. In addition to the regulatory provisions of the BANRs, the DCA has issued a document entitled Bhutan Aviation Requirements – Airworthiness Procedures (BAR-AW), which prescribes the requirements for design, certification, maintenance, modification and repair of civil aircraft registered in the State, including requirements regarding individuals performing aircraft maintenance. The BAR-AW also addresses elements of airworthiness certification which are not addressed in the JAR-OPS and the JAR 145. However, Bhutan has not ensured compliance with all airworthiness-related ICAO SARPs, especially regarding Annex 16 — Environmental Protection, Volumes I — Aircraft Noise and II — Aircraft Engine Emissions, as Bhutan does not have airworthiness regulations related to Annex 16. In particular, there are no requirements for aeroplanes to comply with the noise certification standards of Annex 16, Volume I or for the carriage of a noise certificate on the aircraft. 3.2.9 In the area of ANS, a very limited number of regulatory provisions have been promulgated. The provisions contained in Sections 7 and 8 of the BANRs address matters pertaining to air traffic control (ATC) and to the licensing of air traffic controllers. Section 7 of the BANRs contains a requirement for an “Aerodrome Information Service Manual”; however this document has not been defined. No other regulatory provisions were promulgated to implement the ICAO Annex provisions related to ANS. 3.2.10 Regarding aerodromes, Section 10, Chapter 2 of the BANRs addresses the aerodrome certification requirements, which apply to aerodromes serving air transport operations of domestic or international air operators. These regulations make reference to another document entitled Bhutan Aerodrome Standards Manual, which outlines the provisions to be complied by aerodrome facilities and the relevant operation procedures. However, the Bhutan Aerodrome Standards Manual issued by the DCA was based on the third edition of Annex 14, dated July 1999, and the manual has never been amended. The BANRs detail the process for the granting of an aerodrome certificate, the refusal of such a grant, endorsement of conditions, duration and surrender of the aerodrome certificate, as well as its cancellation and suspension. An aerodrome certificate is also non-transferable. 3.2.11 Aircraft accident investigation is addressed in Section 11 of the BANRs. The introduction of this Section states:

“The investigation of aircraft accidents is a complex and highly technical process requiring considerable expertise in both operational and airworthiness disciplines, as well as considerable investigative abilities. It will take many years before Bhutan has accumulated the required skills to undertake its own investigations in the event of an aircraft accident. The following regulations are therefore an interim measure to cover the period up to the point when Bhutan is able to conduct its own investigations.”

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3.2.12 Apart from providing essential definitions, Section 11 of the BANRs contains a very limited number of provisions regarding the notification and investigation of accidents. The BANRs do not contain any provision on the notification and investigation of serious incidents. As per Section 11 of the BANRs, the notification to other States of aircraft accidents that have occurred in Bhutan is the responsibility of the DCA. However, there are no provisions for the notification to the State of Design or to ICAO, when applicable. As for the investigation of aircraft accidents that have occurred in Bhutan, Section 11 of the BANRs states that the DCA shall request for “an authorized investigation team” to conduct the investigation, as follows:

“a) if the accident occurs to an aircraft registered in Bhutan, the Department will request the State of Manufacture to conduct the investigation; or

b) if the accident occurs to an aircraft registered in another State of Registry,” the DCA will request the State of Registry to conduct the investigation.

The same regulation adds that “in both cases, the Department shall reserve the right to appoint an accredited representative to attend such investigations.” The existing provisions in the BANRs are not sufficient to provide for an effective and adequate conduct of aircraft accident and serious incident investigations. 3.3 Critical element 3 � State civil aviation system and safety oversight functions

“The establishment of a civil aviation authority (CAA) and/or other relevant authorities or government agencies, headed by a Chief Executive Officer, supported by the appropriate and adequate technical and non-technical staff and provided with adequate financial resources. The State authority must have stated safety regulatory functions, objectives and safety policies.

Note.— The term ‘State civil aviation system’ is used in a generic sense to include all aviation-related authorities with aviation safety oversight responsibility which may be established by the State as separate entities, such as: CAA, airport authorities, air traffic service authorities, accident investigation authority, meteorological authority, etc.”

3.3.1 The DCA is the organization in charge of the oversight of aviation activities in Bhutan and it reports to the Ministry of Information and Communications of the Royal Government of Bhutan. The DCA offices are located at Paro, a 10-minute drive from the Paro International Airport. The DCA does not have regional offices. Headed by a Director, the DCA has nine sections, namely:

1) the Airworthiness Section, 2) the Flight Operations Section, 3) the Aerodrome Section, 4) the Air Traffic Service Section, 5) the Communications and Navigation Section, 6) the Meteorology Section, 7) the Rescue and Fire Fighting Section, 8) the Security Section, and 9) the Airport Management Section.

3.3.2 Three of these sections (i.e. the Airworthiness Section, the Flight Operations Section, and the Aerodrome Section) have a dedicated safety oversight role, including the tasks and responsibilities for rule making, licensing/certification and surveillance. The other sections however carry out the tasks of service providers or aerodrome operator. With the organizational structure in place, some of the ANS areas (including

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air traffic services (ATS), aeronautical information services (AIS), communications, navigation and surveillance (CNS), and meteorological services (MET)) do not have clear separation of functions between the service provider and the regulatory body/safety oversight authority. Regarding aerodromes, there is also a lack of clear separation of functions, as the fact that the aerodrome operator resides within the DCA creates potential conflict of interests. 3.3.3 The DCA does not have dedicated technical staff to carry out safety oversight tasks in the ANS areas. Overall, the DCA is underfunded. It does not have sufficient resources to enable its inspectors to carry out inspections of line stations and of foreign approved maintenance organizations (AMOs).The DCA is also not able to retain all the necessary qualified staff, including flight inspectors. Its technical staff is mostly civil servants recruited in accordance with the procedure of the Royal Civil Service Commission (RCSC). The RCSC is the central body which decides on staffing levels for the DCA, while the Ministry of Finance provides the budget for the Ministry of Information and Communications which, in turns, provides the DCA budget. Requests for additional staff may be made to the RCSC during a review that occurs every five years. 3.3.4 There is no dedicated personnel licensing section within the DCA. Functions related to flight crew licensing are carried out by the Flight Operations Section headed by the Flight Safety Officer, who is responsible for the overall management of flight crew licensing, including issuance, renewal and validation of licences. This officer is assisted by an Assistant Flight Safety Officer. The issuance of AME licences is the responsibility of the Airworthiness Section of the DCA. There is no entity designated to carry out functions related to the licensing of air traffic controllers and such licences have not been issued. No licences are issued for flight dispatchers. The current staffing level of the DCA in the area of personnel licensing is sufficient, considering the number of licences. The functions of the Flight Operations Section and job descriptions of the personnel licensing officers are adequately defined. The medical aspects of personnel licensing are handled by two medical examiners from the Health Department of the Government of Bhutan, duly authorized by the Director of the DCA. These medical examiners also work as medical assessors. 3.3.5 The Flight Operations Section is responsible for the regulation, certification and surveillance tasks in the area of aircraft operations. The functions of the Flight Operations Section and the job descriptions of the officers of this section are adequately defined. Druk Air is the only air operator certificate (AOC) holder in Bhutan, operating two Airbus A319 and two BAe 146. There is no general aviation activity in Bhutan. Considering the level of civil aviation activity, the number of officers in the Flight Operations Section is adequate. 3.3.6 With respect to airworthiness and maintenance of aircraft, safety oversight activities are carried out by the Airworthiness Section of the DCA. The Airworthiness Section is responsible for aircraft type acceptance, registration of aircraft, issuance and renewal of certificate of airworthiness, approval for changes to the type acceptance certificate, approval of aircraft maintenance organizations, certification of aircraft, licensing of aircraft maintenance personnel and continuing airworthiness of aeronautical products. The Airworthiness Section has four permanent posts for airworthiness officers, which is sufficient for the level of activity in the State. Job descriptions have been established for the officers of the Airworthiness Section. 3.3.7 In the area of ANS, no authority in Bhutan is currently providing the regulatory and surveillance functions. As far as service provision is concerned, several sections are established within the DCA to provide limited ANS services, namely the ATS, AIS, CNS services and MET services. For the remaining ANS areas, such as search and rescue (SAR), Procedures for Air Navigation Services — Aircraft Operations (PANS-OPS), and aeronautical maps and charts (MAP), Bhutan has not yet designated any entities to provide such services within the territory under its sphere of responsibility.

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3.3.8 ATS and MET services in Bhutan are provided by the Air Force Element (AFE) of the Indian Military Training Team (IMTRAT). This military unit has been present since June 1966, when it was first formed to manage a military helipad at Paro. Headed by a Squadron Leader, the AFE of IMTRAT is located next to the terminal building of the Paro International Airport. Eleven air traffic controllers and two meteorological assistants work between the hours of sunrise and sunset to provide ATS (including alerting services) and MET services at the Paro International Airport, which is a VFR only aerodrome. Daily scheduled traffic movements average between four and five, with occasional military traffic. 3.3.9 No entities are established to provide flight design and cartographic services, and there are no specialists available within the DCA for the production, review or initiation of revisions of aeronautical charts. The applicable charts for the Paro International Airport have not been published. Bhutan has not established any entity to provide SAR services, and there is no documented evidence of any delegation of SAR services to another entity/authority. No letters of agreement for SAR operations with its two neighbouring States have been signed. Currently, alerting services are provided by the air traffic controllers at the Paro International Airport, who inform the Indian Air Force stations located at Bagdogra and Guwahati 3.3.10 The Aerodrome Section of the DCA carries out the functions of a Directorate of Aerodrome Safety and Standards (DASS). These functions, which are not yet documented, include rule making, certification and surveillance in the area of aerodrome safety. Bhutan has only one aerodrome, Paro International Airport, which is surrounded by high terrain and where flights are operated only under VFR conditions. In addition, there are more than 60 helicopter landing areas, which were originally set up by the AFE of IMTRAT and are sometimes used by chartered helicopter flights. Such helicopter landing areas do not have to be certified in accordance with ICAO or national regulations. The Aerodrome Section has only one officer and the DCA does not have a suitable mix of technical disciplines, or access to such disciplines, to adequately carry out its regulatory and surveillance functions. The DCA also serves as aerodrome operator through its Airport Management Section. The Rescue and Fire Fighting Section is also a section established within the DCA. 3.3.11 With respect to aircraft accidents and incidents, while Bhutan’s policy, as reflected in the BANRs, is to delegate all aircraft accident investigations to other States, Bhutan has not adopted any policy regarding the investigation of serious incidents, including considerations on whether such serious incidents would be delegated to other States or what organization should be put in place in Bhutan to investigate them. No entity or personnel has been formally designated to carry out investigation-related tasks. No budget has been planned to ensure that the initial phase of an accident investigation can be adequately carried out. As far as the notification of accidents is concerned, although this is under the DCA’s responsibility as per the BANRs, no entity or personnel within the DCA has been formally designated to carry out notification tasks. 3.4 Critical element 4 � Technical personnel qualification and training

“The establishment of minimum requirements for knowledge and experience of the technical personnel performing safety oversight functions and the provision of appropriate training to maintain and enhance their competence at the desired level. The training should include initial and recurrent (periodic) training.”

3.4.1 The selection of DCA staff is made by the RCSC based on the general criteria of the civil service and the specific requirements of the DCA. The DCA establishes the qualification requirements for the recruitment of its technical staff charged with safety oversight tasks, and it has a representative in the selection boards set up by the RCSC for the recruitments of all civil aviation officers. However, the DCA does not have an active role in the final selection of the officers. In the area of airworthiness, the selection process has not

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enabled the DCA to recruit an avionics engineer. 3.4.2 Over the last years, most of the training which was provided to the technical staff of the DCA was conducted through the ICAO COSCAP-South Asia Programme and the European Union (EU)-South Asia Civil Aviation Project. The DCA is allocated a yearly budget by the Ministry of Information and Communications, which comprises budget lines related to training. However, the DCA does not have a training policy for its safety oversight staff. Training programmes and training plans detailing the type of training to be provided to technical staff in each position have not been developed for all areas. In addition, DCA staff training records are not kept in a consistent manner. 3.4.3 Regarding personnel licensing, no qualification requirements and no formal training programme have been established for the officers in charge of this area. However, the technical staff of the Flight Operations Section has been trained to assume personnel licensing-related responsibilities. They are also provided with recurrent and refresher courses to maintain and enhance their knowledge and competency. Aviation medical examiners are qualified in aviation medicine. 3.4.4 There is also no formal training programme for the aircraft operations officers of the Flight Operations Section. Operations officers are provided with recurrent and refresher courses, and their training records are kept. However, although the Assistant Flight Safety Officer is a pilot and currently flies with the national airline, he is only type-rated on the BAe 146, and not on the Airbus A319. 3.4.5 As for airworthiness officers, the minimum qualification and experience requirements have been laid down in the job description used by RCSC for the selection process. Upon their selection, the airworthiness officers are provided with initial training, including on-the-job training (OJT) before being assigned their airworthiness tasks. The officers also undergo type training courses on the aircraft registered in Bhutan. Additional training is provided under the ICAO COSCAP-South Asia Programme and the EU-South Asia Civil Aviation Project. However, some of the elements of training (such as recurrent training for individual officers) are not implemented. The DCA has recently issued a document entitled Airworthiness Inspector Manual – Inspector Qualifications Training and Duties, which lays down in detail the training to be provided to the airworthiness officers before they are assigned technical tasks. The manual also details the duties to be performed by the officers based on the training received. However, the training required under this manual has not yet been fully provided. 3.4.6 In the area of ANS, while Bhutan has not yet established a safety oversight system, there are no qualified and experienced inspectors in the ANS areas to conduct regulatory and surveillance functions. The DCA has not yet established qualification and experience requirements with respect to the recruitment of ANS inspectors, and no training programmes have been developed for these inspectors. 3.4.7 No qualification requirements have been established for the sole officer in the Aerodrome Section of the DCA. The incumbent officer has a background in electrical engineering and has received training from the COSCAP-South Asia Programme and the EU-South Asia Civil Aviation Project. The training provided covered all aspects of the aerodrome certification process. The aerodrome regulatory officer has attended a course in safety management systems (SMS) but has not yet been trained in all necessary aerodrome technical disciplines. Training records are not formally kept. 3.4.8 With respect to accident and incident investigation, two officers of the Airworthiness Section of the DCA have attended basic and advanced courses and seminars. However, there are no established training programme and plans prioritizing the type of training that should be provided to the technical staff in Bhutan who would carry out tasks related to the notification, investigation or reporting of aircraft accidents and

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incidents. No qualification requirements have been established for the personnel in charge of the investigation tasks. 3.5 Critical element 5 � Technical guidance, tools and the provision of safety critical information

“The provision of technical guidance (including processes and procedures), tools (including facilities and equipment) and safety critical information, as applicable, to the technical personnel to enable them to perform their safety oversight functions in accordance with established requirements and in a standardized manner. In addition, this includes the provision of technical guidance by the oversight authority to the aviation industry on the implementation of applicable regulations and instructions.”

3.5.1 The DCA staff is provided with adequate offices and with a central technical library. In addition, they have access to Internet from their computers. The DCA does not however have any web site or Intranet. While the DCA has issued some guidance material to its safety oversight staff, a number of procedures have not yet been documented and manuals are still missing in some technical areas. 3.5.2 As far as personnel licensing is concerned, the DCA has not developed guidance material and checklists to assist its staff in carrying out their functions. The only guidance issued is a medical manual to provide guidance to aviation medical examiners. The DCA has established a secure filing system for personnel licensing. 3.5.3 In the area of aircraft operations, although the DCA has developed some guidance material and checklists, these are not comprehensive enough to enable the staff to effectively undertake their functions. The guidance material issued by the DCA consists of a Certification, Inspection and Surveillance Manual, which is based on ICAO Doc 8335 — Manual of Procedures for Operations Inspection, Certification and Continued Surveillance. 3.5.4 As for airworthiness, the BANRs and the BAR-AW are the essential material available to assist the DCA officers in carrying out their functions. Although airworthiness inspectors are carrying out their duties and responsibilities using standardized checklists, the DCA has not issued comprehensive technical guidance to assist its airworthiness inspectors in effectively performing their assigned tasks. Furthermore, the procedures in place do not address the maintenance of an aircraft register for all aircraft registered in Bhutan. 3.5.5 With respect to ANS, Bhutan has not yet issued an aeronautical information publication (AIP), as the document available is still in draft form. Other safety critical information, such as AIP Supplements, Notices to Airmen (NOTAMs) and Aeronautical Information Circulars (AICs), are also not issued. In addition, no guidance material has been issued to ANS providers and operators on regulations related to ANS, and the aeronautical information regulation and control (AIRAC) system is not used. A properly organized quality system containing procedures, processes and resources has not been established for the MET and AIS services in accordance with the provisions of ICAO’s Annex 3 — Meteorological Service for International Air Navigation and Annex 15 — Aeronautical Information Services, respectively. 3.5.7 Bhutan has not developed and promulgated contingency plans to address the disruption or potential disruption of international ATS and related supporting services, such as radio communication contingencies and emergency separation. In addition, documented procedures regarding the interception of civil aircraft, the assistance to stray or unidentified aircraft, the provision of service to aircraft in the event of emergencies, and the assistance to pilots in case of air-ground radio communications failure have not been

- 11 -


established. 3.5.8 A draft document entitled ATS Operations Manual and dated 27 August 2001 has been developed by the DCA. Similarly, the Communications and Navigation Section has prepared a draft document entitled Technical Manual, dated 13 October 2006, which contains substantial CNS guidance. Developed on the initiative of the section chiefs, all of these documents are still in draft form. 3.5.9 In the area of aerodromes, the DCA has issued guidance material to its staff in the form of a Manual of Aerodrome Certification Procedures, dated April 2005, and an Aerodrome Inspector’s Handbook, dated September 2006. The Aerodrome Inspector’s Handbook was issued to provide guidance for the issue or refusal of the aerodrome certificate in accordance with the BANRs. A checklist developed by COSCAP is used as a tool for checking compliance with the standards contained in the Bhutan Aerodrome Standards Manual. However, guidance material and procedures are still missing for a number of specialized technical areas. In addition, the DCA has not developed procedures for evaluating the impacts that changes to the aerodrome’s physical characteristics would have on the safety of existing operation. Although the BANRs contain provisions for granting exemptions in case of non-compliances at aerodromes, the DCA has not issued guidance material to the operators and its regulatory staff on the use of risk assessments and evaluation. The DCA has not established a procedure for the amendment of the aerodrome certificate. 3.5.10 With respect to aircraft accident and incidents, Bhutan has not provided the designated technical personnel who would be carrying out investigation tasks in Bhutan with the necessary investigation equipment (including investigation field kits and protective equipment), means of communication, means of transportation, and documentation. No documented processes, procedures or other guidance material have been established in order to ensure the effective and timely completion of notification and investigation tasks that remain under the responsibility of Bhutan. In particular, Bhutan has not developed any policy on how the initial phase of an investigation would be carried out, particularly regarding the preservation and collection of relevant evidence. 3.6 Critical element 6 � Licensing, certification, authorization and/or approval obligations

“The implementation of processes and procedures to ensure that personnel and organizations performing an aviation activity meet the established requirements before they are allowed to exercise the privileges of a licence, certificate, authorization and/or approval to conduct the relevant aviation activity.”

3.6.1 With respect to personnel licensing, the DCA does not conduct direct examination or testing of applicants, as there is no aviation training organization in Bhutan. Flight crew licences are issued on the basis of foreign licences. However, there is no documented system in place to systematically verify whether the original license has been issued in full compliance with Annex 1. In addition, in case the original licence is not in full compliance with Annex 1, there are no requirements to be met by the applicant before the validation or conversion of the licence. Furthermore, the DCA has not set up a system to re-establish privileges of expired licences and ratings. AME licences are issued according to the requirements outlined in Chapter 4 of Section 12 of the BANRs and there is no provision in Bhutan for the validation of foreign AME licences. ATC licences are not issued, although this is required by the BANRs. Medical examinations required for specific types of licences are conducted by the duly authorized medical officers. 3.6.2 In the absence of comprehensive regulatory requirements, the DCA does not review a number of aspects in aircraft operations before it grants an AOC. Those aspects of the air operator’s system that are not

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reviewed include the flight safety documents system, the details of the certification limitations and operating limitations in the aircraft operations manual, the system to provide aircraft operating information to the operations staff and flight crew, the flight safety and accident prevention programme, as well as the dangerous goods procedures and training programmes. 3.6.3 The Airworthiness Section issues the AOC under the regulatory provisions of the BANRs and the JAR OPS-1, with sufficient coordination with the Flight Operations Section of the DCA. The Airworthiness Section also issues type acceptance approvals for new aircraft as well as Certificates of Registration. It issues and renews Certificates of Airworthiness and approvals of AMOs. The approval of the operator’s maintenance programmes, minimum equipment lists (MEL), and approvals for specific operations are also carried out by the Airworthiness Section. 3.6.4 As for ANS, all the four DCA officers (assisted by several technicians) who head their respective ANS sections, i.e. ATS (including AIS), Communications and Navigation, and Meteorology, have ATC backgrounds. For the ANS services provided by the DCA, the number of technical staff currently employed by the DCA is insufficient to fulfil the service providers’ responsibilities. Consequently, minimal service activities are conducted. 3.6.5 In terms of MET and AIS provisions, Bhutan has not implemented a well organized quality system, including the provision of a national AIP. An ATS safety programme has not been established, including the identification of the required resources and development of guidelines to implement such programmes. 3.6.6 Bhutan has not established and implemented procedures for the issuance of ATC licences to personnel providing ATS, although there are requirements for the licensing of air traffic controllers in the BANRs. Nevertheless, the military air traffic controllers currently providing ATS at the Paro International Airport are issued ATC ratings by the AFE of IMTRAT in accordance with the requirements detailed in some documents issued under the authority of the Chief of Air Staff of India. Refresher training is also conducted in accordance with established continuity training programmes. The military air traffic controllers receive their ATC training at a military centre in India, followed by a “Categorization and Facility Rating Scheme” before they are posted for ATC duties on a two-year rotational basis. Documentation for ATC job-related requirements at the Paro International Airport are published under the authority of the Chief of Air Staff of India. Military meteorological assistants are also attached to the ATC tower at the Paro International Airport and perform MET-related functions, such as issuance of local routine reports and briefing of pilots who depart from the airport. In addition, satellite imagery reports on the Indian sub-continent are downloaded from the web site of Thailand’s Aeronautical Meteorology Division. 3.6.7 With respect to aerodromes, the Paro International Airport was granted an aerodrome certificate by the DCA in October 2006 in accordance to the aerodrome certification process outlined in the BANRs. However, the type of use, exemptions, and operational conditions imposed on the aerodrome are not attached to the aerodrome certificate. The DCA has approved the Aerodrome Manual developed by the aerodrome operator. Some exemptions for non-compliances have been granted, including one related to the lack of implementation of an SMS, which is valid until 2008. The aerodrome certificate is open-ended, but the Director may suspend or cancel the aerodrome certificate if there are reasonable grounds to believe that a condition for the issue of the certificate has been breached or that the aerodrome facilities, operations or maintenance do not meet the standards required in line with safety concerns. The DCA has established and implemented a process for the certification of the Paro International Airport. However, the DCA has not verified the implementation of a number of requirements, including the testing of the emergency plan or the control of use of vehicles on the aerodrome.

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3.7 Critical element 7 � Surveillance obligations

“The implementation of processes, such as inspections and audits, to proactively ensure that aviation licence, certificate, authorization and/or approval holders continue to meet the established requirements and function at the level of competency and safety required by the State to undertake an aviation-related activity for which they have been licensed, certified, authorized and/or approved to perform. This includes the surveillance of designated personnel who perform safety oversight functions on behalf of the CAA.”

3.7.1 With respect to personnel licensing, the DCA has established a surveillance system for flight crew and AME licences. However, the activities of aviation medical examiners and facilities are not supervised. As air traffic controller’s licences are not issued, there is no surveillance in this field. 3.7.2 With respect to aircraft operations, although the DCA has established a system of annual audits to control and supervise aircraft operations in Bhutan, it is not fully implemented, with only ten percent of the planned inspections carried out. Apart from an annual audit, neither random audits nor inspections are performed. The opportunities for the DCA to identify deficiencies are therefore limited. In addition, cabin safety surveillance is not performed. In the area of the transport of dangerous goods by air, the DCA has not established inspection, surveillance and enforcement procedures with a view to ensuring compliance with the regulations. No random inspections are carried out in this field by the DCA. 3.7.3 In the area of airworthiness, the DCA has developed an annual programme for the continued surveillance of the AOC holders and AMOs. However, there are no policy and procedures established to ensure that airworthiness inspectors perform a comprehensive and conclusive assessment of the continuing competence of the operator and the AMO. The DCA has conducted less than ten percent of the planned inspections. In particular, the DCA has not conducted any surveillance inspection of line stations and foreign AMOs as per the planned surveillance programme. The ongoing monitoring of the operator’s approved reliability programme is also not accomplished by the section. As part of the renewal of certificate of airworthiness process, officers of the section conduct an annual inspection of the aircraft registered in Bhutan. 3.7.4 With respect to ANS, in the absence of a safety oversight system, the DCA does not conduct any surveillance. At the Paro International Airport, the non-directional radio beacon (NDB) “PR” has been unserviceable for more than two years while the periodic check on the Doppler VOR (DVOR)/distance measuring equipment (DME) “PRO” has ceased since 19 January 2005. 3.7.5 Concerning aerodromes, as the aerodrome certificate for the Paro International Airport was granted only in October 2006, the DCA has not yet started to conduct surveillance inspections. The aerodrome certificate was granted with exemptions and conditions were imposed. The DCA has not yet established a programme or developed procedures for the continuing surveillance of the aerodrome operator. 3.8 Critical element 8 � Resolution of safety concerns

“The implementation of processes and procedures to resolve identified deficiencies impacting aviation safety, which may have been residing in the aviation system and have been detected by the regulatory authority or other appropriate bodies.

Note.— This would include the ability to analyse safety deficiencies, forward recommendations, support the resolution of identified deficiencies as well as take enforcement action, when appropriate.”

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3.8.1 The DCA has issued a manual entitled Enforcement Manual, which outlines the penalty provisions for the violation of the applicable legislation and regulations. 3.8.2 Regarding personnel licensing, the BANRs provide for enforcement actions through the amendment, suspension and revocation of licences as well as the imposition of fines. There has not been any case of enforcement action in the area of personnel licensing. 3.8.3 With respect to aircraft operations, the deficiencies identified during inspections were followed by a requirement for corrective actions. Corrective actions were implemented in a timely manner by the operator. However, as the DCA’s inspection programme has not been fully implemented, not all deficiencies may have been identified and addressed. Regarding the transport of dangerous goods by air, the DCA’s Enforcement Manual does not contain any penalty provision for the violation of the applicable regulations. 3.8.4 In the area of airworthiness, deficiencies found during surveillance (including inspection for the renewal of the certificate of airworthiness) are addressed using standardized audit finding forms. The forms also identify the level of seriousness. The operator or the AMO is required to correct the deficiencies by completing the audit finding forms, along with the establishment of target dates. Although the section ensures that the deficiencies are corrected within a time frame set according to the level of seriousness of the deficiencies, the DCA has not defined the actions to be taken in case the deficiencies identified during such surveillance are not rectified within a reasonable period of time. In addition, there is no action defined to deal with serious safety concerns identified during ramp inspections, such as the grounding of aircraft in such instances. As in the area of aircraft operations, the fact that only a small percentage of the planned airworthiness inspections are effectively conducted limits the capacity of the DCA to identify all existing deficiencies and ensure that they are addressed. 3.8.5 With respect to ANS, no surveillance is conducted and no mechanism is established for the resolution of safety concerns. In addition, there is no system for the ATS provider to report ATC incidents to the DCA. 3.8.6 In the area of aerodromes, although the DCA is provided with enforcement powers, enforcement actions may be limited as the aerodrome operator resides within the DCA. The Director of the DCA is able to endorse conditions on the aerodrome certificate, when necessary, in the interests of safety. When deficiencies are found during an inspection, the aerodrome operator is notified and is required to respond with corrective actions within a required time frame. However, some non-compliances identified during the certification audit (e.g. regarding immoveable objects in the obstacle limitation surfaces) have not been forwarded to the aerodrome operator for corrective actions or risk assessment. 3.8.7 As far as accident and incident investigation and prevention are concerned, no documented procedures, policies or guidance material have been developed for the issuance of safety recommendations or for the completion and submission of Accident/Incident Reporting System (ADREP) reports. Although, some provisions exist in the regulations calling for the mandatory reporting of incidents, these provisions do not cover all civil aviation activities. In addition, the accident and incident information received by the DCA has not been stored in a database. The DCA has not carried out analyses of the accident and incident information received. Bhutan has not established a voluntary incident reporting system to facilitate the collection of safety information that may not otherwise be captured by the State’s mandatory incident reporting system.

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4. VISITS TO THE INDUSTRY/SERVICE PROVIDERS 4.1 Accompanied by staff members of the State’s civil aviation system, the audit teams visit aviation service providers, operations and maintenance departments of operators and maintenance organizations, aeronautical product/equipment manufacturers, aviation training institutes, etc. The objective of the visits is to validate the capability of the State to supervise the activities of these service providers, airlines and organizations. 4.2 In the case of Bhutan, the audit team visited the following organizations:

1) Druk Air (OPS) 2) Druk Air approved maintenance organization (AIR) 3) Office of the AFE of the IMTRAT at the Paro International Airport (ANS) 4) ATC Control Tower at the Paro International Airport (ANS) 5) Equipment room located below the ATC Control Tower (ANS) 6) Paro International Airport (AGA)

5. AUDIT FINDINGS AND DIFFERENCES DATABASE (AFDD) 5.1 The general objective of the AFDD is to assist States in identifying the elements that need attention in the implementation of the proposed corrective action plan. The information is also intended to assist States in establishing a priority of actions to be taken to resolve safety concerns identified by the audits. Appendix 2 to this report contains a graphic representation of the lack of effective implementation of the critical elements of the safety oversight system (ICAO Doc 9734, Part A refers) in Bhutan and at a global level (average results from all States audited). The graphic representation enables the audited State to prioritize the necessary corrective actions and to identify assistance requirements based on its personnel, technical and financial capabilities in consideration of its safety oversight obligations. 6. STATE AVIATION ACTIVITY QUESTIONNAIRE (SAAQ) 6.1 The SAAQ is one of the major tools required for conducting a comprehensive systems approach-based safety oversight audit. As such, all Contracting States are required to complete the SAAQ and submit it to ICAO for proper evaluation and recording. The submitted information enables ICAO to maintain an up-to-date database on the State’s activities. Bhutan has submitted its SAAQ to ICAO, which can be found at www.icao.int/soa. 7. COMPLIANCE CHECKLISTS (CCs) 7.1 The CCs are one of the main tools used in the conduct of safety oversight audits under the comprehensive systems approach. As such, all Contracting States are required to complete the CCs and submit them to ICAO for evaluation and recording. The submitted information enables ICAO to maintain an up-to-date database on the State’s level of compliance to the ICAO SARPs and assist in facilitating the conduct of a standardized audit of all Contracting States. As a result, States will be enabled to have a clear picture of the implementation status of the relevant SARPs. Bhutan has partially submitted its CCs to ICAO (only for Annexes 1, 6, 11 and 14, Volume II), which can be found at www.icao.int/soa.

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8. FOLLOW-UP ACTION 8.1 In accordance with the MOU agreed to between Bhutan and ICAO, Bhutan submitted an action plan on 28 March 2007 and an update on 4 April 2007. The action plan submitted was reviewed by the Safety Oversight Audit (SOA) Section and was found to partially address the findings and recommendations contained in this report. The proposed action plan, including comments and clarifications provided by the State, is attached as Appendix 3 to this report. Comments by ICAO on each corrective action are found in Appendix 1 to this report.

— — — — — — — —

APPENDIX 1

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-01

LEG/01BHUTAN

FINDINGS AND RECOMMENDATIONS RELATED TO

PRIMARY AVIATION LEGISLATION AND CIVIL AVIATION REGULATIONS

1.005; 7.003; 7.005; 7.009; 7.041;

DOCUMENT REFERENCE:

Refer to Doc 9735, Appendix F for the document references associated with the protocol questions identified in this finding.

CE-1 X CE-2 X CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

Article 6 of the Civil Aviation Act of the Kingdom of Bhutan 2000 empowers the Minister responsible for civil aviation to

regulate civil aviation activities in Bhutan. However, the legal framework for civil aviation safety oversight in Bhutan is

limited in scope as it does not enable safety oversight of the Air Navigation Services (ANS) activities in the State. As such,

regulations are missing in many ANS-related areas. In addition, there is no legal basis to provide for the delegation of legal

authority to inspectors in the ANS area.

RECOMMENDATION:

Bhutan should amend the State’s legislation and regulations in order to enable effective safety oversight of the ANS

activities in the State. The legislation and regulations should cover the following:

• the empowerment of the Minister to promulgate regulations covering all ANS-related areas;

• the effective promulgation of comprehensive regulations in the ANS areas; and

• the delegation of legal authority to inspectors in the ANS area.

CORRECTIVE ACTION PLAN PROPOSED BY THE STATE:

Corrective action plan and comments submitted by the State are found at Appendix 3-1-1 of this report.

COMMENTS BY ICAO:

The corrective action plan submitted by the State partially addresses this ICAO finding and recommendation. The State has

not provided sufficient detail to address the finding.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-02

LEG/02BHUTAN



1.009; 1.025; 1.205; 3.005; 3.007; 3.011; 4.003; 4.005;

4.011; 4.333; 5.005; 5.007; 6.015; 6.017; 7.011; 7.013;

8.003; 8.015;

DOCUMENT REFERENCE:

Refer to Doc 9735, Appendix F for the document references associated with the protocol questions identified in this

finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

The Department of Civil Aviation (DCA) has not established documented procedures for the review of all ICAO Annex

amendments in an effective and timely manner, monitoring of compliance with the ICAO SARPs and amendment of its

regulations when appropriate. ICAO has not been notified of a number of existing differences from ICAO Standards. In

addition, significant differences are not made available to all users, as Bhutan has not yet issued an Aeronautical

Information Publication (AIP).

RECOMMENDATION:

The DCA should establish and follow documented procedures for the review of all ICAO Annex amendments in an

effective and timely manner, monitor compliance with the ICAO SARPs, and amend its regulations, when appropriate.

These procedures should, in particular, ensure the effective and timely notification to ICAO of all differences from ICAO

Standards. In addition, the DCA should issue an AIP and ensure that all significant differences are stated in the AIP.



COMMENTS BY ICAO:


not addressed the implementation aspects (i.e. actual notification of all existing differences to ICAO and publication of

significant differences in the AIP).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-03

LEG/03BHUTAN



1.029; 3.009; 4.007; 5.009;

DOCUMENT REFERENCE:


finding.


FINDING:

The Bhutan Air Navigat ion Regulat ions (BANRs) make reference to speci f ic provis ions of the Jo in t Avia t ion

Requirements (JARs) issued by the Joint Aviation Authorities (JAA). However, these references do not specify the version

of the JARs that is considered.

RECOMMENDATION:

Bhutan should review the BANRs in order to specify the version of the JARs that is considered when references are made

about the JARs.



COMMENTS BY ICAO:

The corrective action plan submitted by the State does not address this ICAO finding and recommendation.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-04

LEG/04BHUTAN



1.011;

DOCUMENT REFERENCE:


finding.

CE-1 X CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

The DCA maintains a distribution list for forwarding any amendment to the BANRs. However, some users, in particular

the air traffic service (ATS) provider, are not included in this distribution list.

RECOMMENDATION:

The DCA should ensure that the State’s legislation and regulations are made available to all users, including the ATS

provider.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-05

LEG/05BHUTAN



1.027; 3.419; 4.107;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 CE-6 X CE-7 X CE-8

FINDING:

The DCA has not developed policies and procedures for the issuance of exemptions, except in the area of aerodromes.

RECOMMENDATION:

The DCA should establish policies and procedures for the issuance of exemptions, covering all civil aviation activities in

the State.



Estimated Implementation Date: 30/10/2007

COMMENTS BY ICAO:

The corrective action plan submitted by the State fully addresses this ICAO finding and recommendation.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-06

LEG/06BHUTAN



1.031; 1.033;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan ratified Article 3 bis of the Chicago Convention on 26 August 2005. The BANRs contain some provisions relating

to the interception of aircraft, but these provisions are not comprehensive. For example, there is no requirement for the

pilot-in-command to comply with interception orders. There are no provisions in Bhutan’s legislation or regulations to

make compliance to interception orders from other States mandatory for any civil aircraft registered in Bhutan or operated

by a Bhutanese operator.

RECOMMENDATION:

Bhutan should promulgate regulatory provisions that:

• comprehensively cover the interception of aircraft in the airspace for which Bhutan is responsible; and

• make compliance to interception orders from other States mandatory for any civil aircraft registered in Bhutan or

operated by a Bhutanese operator.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-07

LEG/07BHUTAN



1.101; 1.103; 1.107;

DOCUMENT REFERENCE:


finding.

CE-1 X CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

There are no provisions in the State’s legislation that provide civil aviation inspectors with unrestricted and unlimited

access to aircraft and all aviation facilities, except in the area of aerodromes. There is also no clear delegation of authority

to DCA inspectors with respect to access to aircraft and aviation facilities. Regarding access of civil aviation inspectors to

aviation documents, while provisions do exist in the BANRs for such access, these provisions do not include access to

ANS-related documents.

RECOMMENDATION:

Bhutan should amend the State’s legislation or regulations in order to provide civil aviation inspectors with unlimited and

unrestricted access to aircraft and to all aviation facilities. The DCA should also establish clear delegation of authority to

its inspectors with respect to access to aircraft and aviation facilities. Bhutan should also amend the BANRs in order to

provide civil aviation inspectors access to all aviation documents, including those related to ANS.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-08

LEG/08BHUTAN



1.105; 4.035; 5.035; 8.045;

DOCUMENT REFERENCE:


finding.

CE-1 X CE-2 CE-3 X CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

The DCA of Bhutan has established official credentials for its inspectors, which are of the expiring type. However, these

credentials make reference to Articles 11 and 12 of the Civil Aviation Act of the Kingdom of Bhutan 2000 , which do not

explicitly empower the DCA inspectors. In addition, some of the credentials were found to have been expired for several

years. Furthermore, no credentials are issued to enable inspections in the ANS area, as such inspections are not provided

for by the State’s legislation and regulations.

RECOMMENDATION:

The DCA should do the following:

• issue credentials that make reference to the empowering legislation, once this legislation has been promulgated;

• control the validity of credentials issued to its inspectors; and

• ensure that credentials are issued to its ANS inspectors, once the State’s legislation has been amended to provide

for inspections in the ANS area.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-09

LEG/09BHUTAN



1.201;

DOCUMENT REFERENCE:


finding.


FINDING:

Through reference to provisions contained in the JARs, the BANRs contain requirements about documents to be carried

on-board an aircraft. However, there is no explicit requirement for the passenger manifest and the cargo manifest to be

carried on-board an aircraft.

RECOMMENDATION:

Bhutan should amend the State’s regulations in order to require that all documents listed in Article 29 of the Chicago

Convention be carried on-board an aircraft, including the passenger manifest and the cargo manifest.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-10

LEG/10BHUTAN



1.301;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not established formal requirements regarding the specific units of measurement to be used in air and ground

operations.

RECOMMENDATION:

Bhutan should amend the State’s regulations in order to establish formal requirements regarding the specific units of

measurement to be used in air and ground operations in accordance with ICAO Annex 5.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-11

LEG/11BHUTAN



1.151; 4.385; 5.347;

DOCUMENT REFERENCE:


finding.

CE-1 X CE-2 CE-3 CE-4 CE-5 X CE-6 CE-7 CE-8

FINDING:

Bhutan ratified Article 83 bis of the Chicago Convention on 26 August 2005 but it has not amended its primary aviation

legislation in order to:

• recognize certificates and licences issued/renewed by a State which has entered into an Article 83 bis agreement as

a State of the Operator with the State of Registry; and

• allow for the transfer of duties and responsibilities as envisaged by Article 83 bis in case Bhutan enters into an

Article 83 bis agreement as State of the Operator or State of Registry.

In addition, related procedures and guidance have not been established by the DCA.

RECOMMENDATION:

Bhutan should amend its primary aviation legislation in order to:

• recognize certificates and licences issued/renewed by a State which has entered into an Article 83 bis agreement as

a State of the Operator with the State of Registry; and

• allow for the transfer of duties and responsibilities as envisaged by Article 83 bis in case Bhutan enters into an

Article 83 bis agreement as State of the Operator or State of Registry.

The DCA should also establish the related procedures and guidance.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-12

LEG/12BHUTAN



1.055;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 X CE-6 CE-7 CE-8

FINDING:

The DCA has issued a manual entitled Enforcement Manual, which outlines the penalty provisions for the violation of the

applicable legislation and regulations. However, regarding the transport of dangerous goods by air, the Enforcement

Manual does not contain any penalty provision for the violation of the applicable regulations. In addition, the DCA has not

defined the actions to be taken in case the deficiencies identified during surveillance inspections are not rectified within a

reasonable period of time. Furthermore, enforcement procedures established for some ANS areas are not appropriate, as

they are not related to existing regulations and practices.

RECOMMENDATION:

The DCA should review its policies and procedures related to enforcement in order to ensure that they are applicable and

comprehensive.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-1-13

LEG/13BHUTAN



3.001; 3.003; 3.801; 3.803; 4.001;

DOCUMENT REFERENCE:

Refer to Doc 9735, Appendix F for the document reference(s) associated with the protocol questions identified in this

finding.


FINDING:

The provisions of the BANRs on personnel licensing and aircraft operations are, for the most part, based on the provisions

of the JARs, and, for some specific ones, on Bhutan’s own requirements. However, these provisions are not complete and

do not fully conform to the SARPs contained in ICAO Annex 1 - Personnel Licensing and Annex 6 - Operation of Aircraft.

For instance, although Section 12, Chapter 4 of the BANRs provides for the licensing requirements of aircraft maintenance

engineers (AMEs), these are not in accordance with the provisions of Annex 1. Moreover, the DCA has not issued any

order, directive or instruction in support of its personnel licensing activities.

RECOMMENDATION:

Bhutan should amend the provisions of the BANRs on personnel licensing and aircraft operations in order to ensure that

they address all required aspects and that they fully conform to the SARPs contained in Annexes 1 and 6. In addition, the

DCA should issue the necessary orders, directives or instructions in support of its personnel licensing activities.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-2-01

ORG/01BHUTAN


CIVIL AVIATION ORGANIZATION

2.011; 5.023; 7.053; 7.057; 7.203; 7.205; 7.271; 7.273;

7.327; 7.329; 7.375; 7.377; 7.419; 7.421; 7.489; 7.491;

8.033; 8.035;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

The DCA has an established organizational structure. However, the functions and responsibilities of the various sections

within the DCA have not all been formally established. In addition, detailed job descriptions have not been developed for

all DCA staff carrying out safety oversight tasks.

RECOMMENDATION:

The DCA should document and disseminate within the organization the detailed functions and responsibilities of each of

its sections. The DCA should also develop detailed job descriptions for all its staff carrying out safety oversight tasks.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-2-02

ORG/02BHUTAN



2.021; 7.051; 7.265; 8.011;

DOCUMENT REFERENCE:


finding.


FINDING:

Among the nine sections established within the DCA, three have a dedicated safety oversight function, including

rule-making, licensing/certification and surveillance tasks and responsibilities. The other six sections carry out the tasks of

service providers or aerodrome operator. In the area of aerodromes as well as in some of the ANS areas, including

aeronautical information services (AIS), communications, navigation and surveillance (CNS), meteorological services

(MET) and aeronautical maps and charts (MAP), there is no clear separation of functions between the service provider and

the regulatory body/safety oversight authority.

RECOMMENDATION:

Bhutan should ensure that a clear separation of functions is established between the regulatory body/safety oversight

authority on one hand, and the aerodrome operator and all ANS providers, on the other hand.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-2-03

ORG/03BHUTAN



2.051; 2.053; 2.103;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA does not have sufficient resources to enable its inspectors to carry out inspections of line stations and foreign

approved maintenance organizations (AMOs). In addition, the DCA is not able to retain all the necessary qualified staff,

including flight inspectors. Furthermore, Bhutan does not have technical staff to carry out safety oversight tasks in the

ANS areas.

RECOMMENDATION:

Bhutan should ensure that the DCA has and keeps sufficient funding and human resources to meet its national and

international obligations related to civil aviation safety oversight, including in the ANS areas.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-2-04

ORG/04BHUTAN



2.105; 3.113; 3.115; 3.117; 4.051; 4.053; 4.055; 5.049;

5.051; 5.055; 7.065; 7.067; 7.069; 7.071; 7.073; 7.211;

7.213; 7.215; 7.217; 7.219; 7.277; 7.279; 7.281; 7.283;

7.285; 7.333; 7.335; 7.337; 7.339; 7.341; 7.381; 7.383;

7.385; 7.387; 7.389; 7.425; 7.427; 7.429; 7.431; 7.433;

8.057;

8.055;8.053;8.051;7.503;7.501;7.499;7.497;7.495;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 X CE-5 CE-6 CE-7 CE-8

FINDING:

The DCA does not have a training policy for all its safety oversight staff. Training programmes and training plans detailing

the type of training to be provided for each technical staff position have not been developed for all areas. In addition, DCA

staff training records are not kept in a consistent manner.

RECOMMENDATION:

Bhutan should ensure that a training policy is established covering all the staff with aviation safety oversight tasks,

including the current safety oversight staff of the DCA as well as the ANS inspectors to be recruited. The DCA should

establish training programmes and periodic training plans for all their safety oversight staff. It should also monitor the

implementation of the training programmes and plans as well as establish an adequate system for the maintenance of

training records.



COMMENTS BY ICAO:


not provided sufficient detail to address the f inding and has not addressed the need to ensure consistency in the

maintenance of training records.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-2-05

ORG/05BHUTAN



2.101;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA establishes the qualification requirements for the recruitment of its technical staff charged with safety oversight

tasks. However, it does not have an active role in their selection. The selection process is controlled by the Royal Civil

Service Commission (RCSC). For example, in the area of airworthiness, the selection process has not enabled the DCA to

recruit an avionics engineer.

RECOMMENDATION:

Bhutan should enable the DCA to have an active role in the selection and recruitment of its technical staff charged with

safety oversight tasks in order to ensure that the DCA has all the necessary experts to accomplish its functions and

responsibilities.



COMMENTS BY ICAO:

The corrective action plan submitted by the State does not address this ICAO finding and recommendation. The corrective

action is not within the authority of the action office identified (DCA).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-01

PEL/01BHUTAN


PERSONNEL LICENSING AND TRAINING

3.111;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not established the minimum qualification and experience requirements for its personnel licensing staff.

RECOMMENDATION:

The DCA should establish the minimum qualification and experience requirements for its personnel licensing staff.



COMMENTS BY ICAO:

The corrective action plan submitted by the State partially addresses this ICAO finding and recommendation. It does not

address the approval and implementation of the new provisions.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-02

PEL/02BHUTAN



3.155; 3.313;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has developed a l imited number of guidance documents for i ts personnel l icensing staff . However, no

comprehensive guidance material is available to this staff to assist them in carrying out their licensing functions.

RECOMMENDATION:

The DCA should develop appropriate guidance material to assist its personnel licensing staff in carrying out their

functions. In particular, adequate procedures should be developed for the validation of AME licences issued by another

State.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-03

PEL/03BHUTAN



3.207;

DOCUMENT REFERENCE:


finding.


FINDING:

There is no procedure for appeals against a decision of the DCA in the area of personnel licensing.

RECOMMENDATION:

Bhutan should ensure that a procedure is established for appeals against the DCA’s decisions on personnel licensing.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-04

PEL/04BHUTAN



3.309; 3.311;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 CE-6 X CE-7 CE-8

FINDING:

Personnel licensing activities in Bhutan consist of the validation or conversion of licences issued by other Contracting

States. However, there is no system in place to systematically verify if the original licence has been issued in full

compliance with ICAO Annex 1. In addition, if the original licence is not in full compliance with Annex 1, there are no

requirements that the applicant has to satisfy before the licence can be validated or converted. Furthermore, the DCA has

not established a system to re-establish the privileges of expired licences and ratings.

RECOMMENDATION:

Bhutan should promulgate additional requirements that an applicant must satisfy before a licence validation or conversion

is issued, if the original licence is not in full compliance with Annex 1. In addition, the DCA should systematically verify

whether the original licence, on the basis of which Bhutanese licence is to be issued, has been issued in full compliance

with Annex 1. Furthermore, the DCA should establish a system to re-establish the privileges of expired licences and

ratings.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-05

PEL/05BHUTAN



3.451; 3.453; 3.455; 3.457; 3.459; 3.461;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 X CE-5 CE-6 CE-7 X CE-8 X

FINDING:

The DCA has not established a system for the supervision and control of aviation medical examiners. There is no policy

and procedures in place for action to be taken against aviation medical examiners in case they fail to perform their duties in

accordance to the prescribed procedures.

RECOMMENDATION:

The DCA should establish and implement a system for the supervision and control of aviation medical examiners and for

action to be taken against the aviation medical examiners in case they fail to perform their duties in accordance to the

prescribed procedures.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-06

PEL/06BHUTAN



3.651;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not established requirements regarding language proficiency for flight crew and air traffic controllers in

conformance with the provisions of Annex 1 and Annex 6 of the Chicago Convention.

RECOMMENDATION:

Bhutan should establish and implement requirements regarding language proficiency for flight crew and air traffic

controllers in conformance with the provisions of Annex 1 and Annex 6 of the Chicago Convention.



COMMENTS BY ICAO:


address the approval and implementation of the new provisions. In addition, the State has not indicated whether the new

requirements will be applicable to both flight crew and air traffic controllers.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-07

PEL/07BHUTAN



3.771;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 X CE-7 CE-8

FINDING:

Bhutan has not established requirements regarding the approval of foreign training organizations, although in practice

foreign training organizations are authorized by the DCA for flight crew training purposes.

RECOMMENDATION:

Bhutan should promulgate requirements for the approval of training organizations in conformance with the provisions of

Annex 1 to the Chicago Convention. Furthermore, the DCA should establish and implement associated procedures for the

approval of such organizations.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-3-08

PEL/08BHUTAN



3.317;

DOCUMENT REFERENCE:


finding.


FINDING:

Although BANRs require the licensing of air traffic controllers, this requirement has not been implemented and the DCA

has not established any procedures to this effect.

RECOMMENDATION:

The DCA should implement the national requirements regarding the licensing of air traffic controllers.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-01

OPS/01BHUTAN


AIRCRAFT OPERATIONS CERTIFICATION AND SUPERVISION

4.047; 4.049;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 X CE-8 X

FINDING:

The DCA delegates functions related to maintenance of competency of flight crew members to the operator. However,

there is no oversight on the delegated tasks and no procedure established to ensure that appropriate action will be taken in

case deficiencies are identified.

RECOMMENDATION:

The DCA should carry out an oversight of the tasks delegated to the operator’s staff for the maintenance of competency of

flight crew and also establish appropriate procedures to resolve any identified deficiency.



COMMENTS BY ICAO:


not addressed the implementation aspects (e.g. actual conduct of the oversight on the delegated tasks, with associated

estimated implementation date).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-02

OPS/02BHUTAN



4.075; 4.125; 4.127;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA’s operation inspectors are provided with guidance material to perform their functions based on the requirements

outlined in the BANRs. However, the guidance material is not comprehensive. For example, there is insufficient guidance

provided to the staff in the following areas:

• review, acceptance or approval, as applicable, of the contents of the operations manual;

• approval of the training manual and the minimum equipment list/configuration deviation list as part of the air

operator’s operations manual; and

• renewal, suspension or revocation of the air operator certificate (AOC) or other authorizations.

RECOMMENDATION:

The DCA should ensure that the guidance material provided to its operations inspectors addresses the whole spectrum of

their activities and responsibilities. In particular, detailed procedures should be developed in the following areas:

• review, acceptance or approval, as applicable, of the contents of the operations manual;

• approval of the training manual and the minimum equipment list/configuration deviation list as part of the air

operator’s operations manual; and

• renewal, suspension or revocation of the AOC or other authorizations.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-03

OPS/03BHUTAN



4.129; 4.131; 4.133; 4.135; 4.137; 4.143; 4.147; 4.149;

4.151; 4.153; 4.155; 4.161; 4.163; 4.165; 4.171; 4.181;

4.183; 4.185; 4.187; 4.189; 4.211; 4.221; 4.263; 4.271;

4.273; 4.283; 4.285; 4.287; 4.289; 4.321; 4.323; 4.325;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 X CE-6 X CE-7 X CE-8

FINDING:

Bhutan does not require and the DCA does not ensure that the air operator:

• has and keeps a system to maintain all required flight safety documents;

• has included all required provisions and procedures in its operations manual;

• has a system to provide its operations staff and flight crew with all necessary aircraft operating information and

route guide;

• has established a policy and procedures for flight crew to record and report routine meteorological observation,

special and other non-routine observations during any phase of the flight as well as volcanic activity;

• has established procedures for the preparation and dissemination to flight crew and operational personnel of such

information published through AIP, aeronautical information circular (AIC), aeronautical information regulation

and control (AIRAC), and Notice to Airmen (NOTAM);

• publishes, distributes and maintains comprehensive training manual;

• provides adequate ground and flight training facilities, simulators and/or cockpit procedure training devices,

computer-based training and syllabus materials; and

• has established an appropriate system for managing all ground handling functions.

RECOMMENDATION:

Bhutan should review the process for the issuance of AOC in order to ensure that before an AOC is granted, the air

operator:

• has and keeps a system to maintain all required flight safety documents;

• has included all required provisions and procedures in its operations manual;

• has a system to provide its operations staff and flight crew with all necessary aircraft operating information and

route guide;

• has established a policy and procedures for flight crew to record and report routine meteorological observation,

special and other non-routine observations during any phase of the flight as well as volcanic activity;

• has established procedures for the preparation and dissemination to flight crew and operational personnel of such

information published through AIP, AIC, AIRAC, and NOTAM;

• publishes, distributes and maintains comprehensive training manual;

• provides adequate ground and flight training facilities, simulators and/or cockpit procedure training devices,

computer-based training and syllabus materials; and

• has established an appropriate system for managing all ground handling functions.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-03

OPS/03BHUTAN



4.129; 4.131; 4.133; 4.135; 4.137; 4.143; 4.147; 4.149;

4.151; 4.153; 4.155; 4.161; 4.163; 4.165; 4.171; 4.181;

4.183; 4.185; 4.187; 4.189; 4.211; 4.221; 4.263; 4.271;

4.273; 4.283; 4.285; 4.287; 4.289; 4.321; 4.323; 4.325;



COMMENTS BY ICAO:


not provided sufficient detail to address the finding. In addition, it has not addressed the implementation aspects (e.g.

comprehensive review of the air operator’s status of compliance with the newly established provisions).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-04

OPS/04BHUTAN



4.157; 4.201; 4.203; 4.205;

DOCUMENT REFERENCE:


finding.


FINDING:


• has established a safety management system or an accident prevention and flight safety programme;

• nominates a staff member to be responsible for the development and establishment of the accident prevention and

flight safety programme, and that his/her functions and responsibilities are clearly defined and well documented in

the flight safety documents system; and

• establishes and maintains a flight data analysis programme as part of its accident prevention and flight safety

programme and that the flight data analysis programme is non-punitive and contains adequate safeguards to protect

the source(s) of the data.

RECOMMENDATION:

The DCA should ensure that the air operator:


• nominates a staff member to be responsible for the development and establishment of the accident prevention and

flight safety programme, and that his/her functions and responsibilities are clearly defined and well documented in

the flight safety documents system; and

• establishes and maintains a flight data analysis programme as part of its accident prevention and flight safety

programme and that the flight data analysis programme is non-punitive and contains adequate safeguards to protect

the source(s) of the data.



COMMENTS BY ICAO:


not addressed the implementation aspects (e.g. comprehensive review of the air operator’s status of compliance with the

newly established provisions).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-05

OPS/05BHUTAN



4.335;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not formally designated and specified to ICAO the State authority responsible for the transport of dangerous

goods by air.

RECOMMENDATION:

Bhutan should formally designate and specify to ICAO the State authority responsible for the transport of dangerous goods

by air.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-06

OPS/06BHUTAN



4.355; 4.357; 4.359; 4.371;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 X CE-6 X CE-7 X CE-8 X

FINDING:

There is no requirement for the air operator authorized to transport dangerous goods by air to establish in-flight procedures

for emergency response to aircraft incidents involving dangerous goods. The DCA has not established inspection,

surveillance and enforcement procedures aimed at achieving compliance with its dangerous goods regulations. No random

inspections are carried out in this field by the DCA. In addition, the DCA’s Enforcement Manual does not contain any

penalty provision for the violation of the applicable regulations regarding the transport of dangerous goods by air.

RECOMMENDATION:

Bhutan should amend the BANRs to incorporate the requirement for the air operator authorized to transport dangerous

goods by air to establish in-flight procedures for emergency response to aircraft incidents involving dangerous goods. The

DCA should establish and implement inspection (including random inspection), surveillance and enforcement procedures

aimed at achieving compliance with the associated regulations. In addition, the DCA should amend the Enforcement

Manual to include penalty provision for the violation of the applicable regulations regarding the transport of dangerous

goods by air.



COMMENTS BY ICAO:


not addressed the implementation aspects (e.g. actual conduct of the inspections).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-07

OPS/07BHUTAN



4.367;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not established any requirements for the air operator authorized to transport dangerous goods by air to

incorporate procedures and training programmes related to dangerous goods into either the operations manual or a separate

document as part of the flight safety documents system.

RECOMMENDATION:

Bhutan should amend the BANRs to incorporate the requirement for the air operator authorized to transport dangerous

goods by air to establish procedures and training programmes on dangerous goods in either the operations manual or a

separate document. Furthermore, the DCA should ensure that the air operator’s flight safety documents system complies

with the relevant requirements.



COMMENTS BY ICAO:


not addressed the implementation aspects (e.g. review of the air operator’s status of compliance with the newly established

provisions).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-08

OPS/08BHUTAN



4.381; 4.383;

DOCUMENT REFERENCE:


finding.


FINDING:

There are no provisions in the regulation regarding aircraft leasing. The DCA has not established comprehensive guidance

material for the acceptance/approval of such leases, as only isolated checklists are available.

RECOMMENDATION:

Bhutan should promulgate regulatory provisions regarding aircraft leasing. The DCA should develop and follow guidance

material for the acceptance/approval of such leases.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-4-09

OPS/09BHUTAN



4.443; 4.445; 4.451;

DOCUMENT REFERENCE:


finding.


FINDING:

Although the DCA has established an annual surveillance programme for the inspection of AOC holders in order to ensure

compliance with national regulations and international standards, the inspection programme is not fully implemented. Only

ten percent of the planned inspections are carried out; therefore not all potential deficiencies can be identified and

addressed.

RECOMMENDATION:

The DCA should ensure that its surveillance program for the inspection of AOC holders is fully implemented. The DCA

should also establish an effective system for monitoring deficiencies and the resulting action taken by the air operators.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-01

AIR/01BHUTAN


AIRWORTHINESS OF AIRCRAFT

5.001; 5.161; 5.163; 5.165;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 X CE-6 CE-7 CE-8

FINDING:

Regulatory provisions related to airworthiness are contained in a document entitled Bhutan Aviation Requirements -

Airworthiness Procedures (BAR-AW) issued by the DCA. However , there are no regulat ions to implement the

airworthiness-related provisions of Annex 16 - Environmental Protection, Volume I - Aircraft Noise and Volume II -

Aircraft Engine Emissions. Furthermore, the existing regulations do not provide for all aeroplanes to comply with the noise

certification standards of Annex 16. There is no requirement for a document attesting to noise certification to be carried

on-board the aircraft. Consequently, the DCA has not developed procedures to grant or validate noise certificates for

aircraft registered in Bhutan.

RECOMMENDATION:

The DCA should amend the BAR-AW in order to transpose the airworthiness-related provisions of Annex 16, Volume I and

Volume II on environmental protection into its regulations and to provide for all aeroplanes to comply with the noise

certification standards of Annex 16. The regulations should also provide for the carriage of document attesting to noise

certification on-board the aircraft. In addition, the DCA should develop procedures to grant or validate noise certificates

for aircraft registered in Bhutan.



COMMENTS BY ICAO:


not addressed the need to promulgate additional regulatory provisions. In addition, it has not addressed the approval of the

procedures mentioned in the corrective action plan.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-02

AIR/02BHUTAN



5.107; 5.183; 5.243; 5.245; 5.305; 5.327;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 X CE-6 X CE-7 CE-8

FINDING:

Although airworthiness inspectors are carrying out their duties and responsibilities using standardized checklists, the DCA

has not issued comprehensive technical guidance to assist its airworthiness inspectors in effectively performing their

assigned tasks.

RECOMMENDATION:

The DCA should issue an inspectors’ handbook/procedures manual or an equivalent document to assist its airworthiness

inspectors in effect ively performing the i r ass igned tasks , inc luding s tandard procedures for the evaluat ion of

documentation and demonstration of operational suitability for initial certification and continued surveillance of its

operators and AMOs. The manual should cover the entire spectrum of functions performed by the airworthiness inspectors.



COMMENTS BY ICAO:


not addressed the need to include comprehensive procedures, and not only checklists, in the inspectors’ handbook,

procedures manual or equivalent document.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-03

AIR/03BHUTAN



5.125; 5.127;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not developed procedures for the issuance of an aircraft registration certificate and for the maintenance of a

current aircraft register in accordance with provisions of Annex 7 - Aircraft Nationality and Registration Marks .

Furthermore, the DCA does not maintain a current register in accordance with the provisions of Annex 7.

RECOMMENDATION:

The DCA should establish and follow procedures for the issuance of an aircraft registrat ion cert if icate including

procedures for the de-registration of an aircraft. The DCA should also maintain a current aircraft register in the form of a

bound book/ledger to record, for each aircraft registered, the information contained in the certificate of registration as per

the provisions of Annex 7.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-04

AIR/04BHUTAN



5.145; 5.147;

DOCUMENT REFERENCE:


finding.


FINDING:

The BAR-AW provides the requirements for the issuance of a Type Acceptance Certificate. However, there are no

procedures in place to ensure that the aircraft type is in compliance with the mandatory requirements and design standards

of the State of Design as well as the requirements, operating conditions and airworthiness policies of Bhutan.

RECOMMENDATION:

The DCA should establish and follow procedures for the issuance of a Type Acceptance Certificate. These procedures

should in particular ensure that, prior to the issuance of the certificate, the aircraft type is in compliance with the

mandatory requirements and design standards of the State of Design as well as the specified requirements, operating

conditions and airworthiness policies of Bhutan.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-05

AIR/05BHUTAN



5.173; 5.175;

DOCUMENT REFERENCE:


finding.


FINDING:

The BAR-AW contains requirements for modifications and repairs to be approved as well as the requirements to be met for

obtaining such an approval. However, the DCA has not developed procedures for the approval of modifications and

repairs.

RECOMMENDATION:

The DCA should establish and follow procedures for the approval of modifications and repairs. The procedures should

cover the following:

• the determination as to whether the modification requires amendments to the type certificate/supplemental type

certificate;

• the need to contact the State of Design as part of the assessment;

• the need to consider the compatibility between the proposed design change and other existing design changes;

• the need to evaluate the impact on noise certification; and

• the impact on mass and balance of the aircraft.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-06

AIR/06BHUTAN



5.233;

DOCUMENT REFERENCE:


finding.


FINDING:

Although the BANRs and BAR-AW provide for the issuance of special flight permits, the DCA has not developed

procedures for such issuance.

RECOMMENDATION:

The DCA should establish and follow procedures for the issuance of special flight permits. The procedures should in

particular cover the review and acceptance of the criteria necessary for safe flight as well as the limitations to be specified

on such a permit.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-07

AIR/07BHUTAN



5.251; 5.253; 5.255;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not developed procedures for the reporting of suspected unapproved parts. Furthermore, the DCA has yet to

develop guidance to the industry on the proper usage of parts removed from an aircraft that is no longer in service and for

the disposal of scrapped parts.

RECOMMENDATION:

The DCA should establish and follow procedures for the reporting of suspected unapproved parts. The DCA should also

issue guidelines to the industry regarding the proper usage of parts removed from an aircraft that is no longer in service and

the disposal of scrapped parts.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-08

AIR/08BHUTAN



5.261;

DOCUMENT REFERENCE:


finding.


FINDING:

The BANRs do not require that an air operator may only operate an aircraft that has been maintained and released to

service by an AMO.

RECOMMENDATION:

Bhutan should require that an air operator may only operate an aircraft that has been maintained and released to service by

an AMO.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-09

AIR/09BHUTAN



5.281; 5.285;

DOCUMENT REFERENCE:


finding.


FINDING:

The BANRs do not provide for the air operator to submit an operator maintenance manual to the DCA for review and

approval.

RECOMMENDATION:

Bhutan should amend the State’s regulations to require air operators to submit an operator maintenance control manual for

review and approval by the DCA. Furthermore, the DCA should establish and follow procedures for the review and

approval of the operator maintenance control manual.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-10

AIR/10BHUTAN



5.321; 5.323;

DOCUMENT REFERENCE:


finding.


FINDING:

The BANRs do not provide for the air operators to prepare and submit for review and approval by the DCA a Minimum

Equipment List (MEL) on the basis of the Master Minimum Equipment List (MMEL).

RECOMMENDATION:

Bhutan should amend the State’s regulations to require air operators to prepare and submit an MEL on the basis of the

MMEL for review and approval by the DCA. Furthermore, the DCA should establish and follow procedures which involve

both the Airworthiness Section and the Flight Operations Section of the DCA for such approvals.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-11

AIR/11BHUTAN



5.331; 5.333;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not developed procedures for the authorization of air operators to conduct operations in navigational areas

requiring reduced vertical separation minimum (RVSM) approval.

RECOMMENDATION:

The DCA should establish and follow procedures for the authorization of air operators to conduct operat ions in

navigational areas requiring RVSM approval, involving both the Airworthiness Section and the Flight Operations Section

of the DCA in the approval process.



COMMENTS BY ICAO:


not addressed the approval of the procedures mentioned in the corrective action plan.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-12

AIR/12BHUTAN



5.341; 5.343; 5.345;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 X CE-6 X CE-7 CE-8

FINDING:

There are no requirements for the approval of leases (dry, wet or damp) among commercial air transport operators.

RECOMMENDATION:

Bhutan should establish airworthiness requirements for the approval of leases among commercial air transport operators.

Furthermore, the DCA should establish and follow procedures, as they relate to airworthiness, for the approval of leases

among commercial air transport operators. These procedures should, in particular, cover the signing of maintenance

releases as well as the responsibilities relating to AD compliance and completion of maintenance programme tasks.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-13

AIR/13BHUTAN



5.373; 5.375; 5.391; 5.413;

DOCUMENT REFERENCE:


finding.


FINDING:

The BANRs require that both domestic and foreign aircraft AMOs be approved by the DCA before they carry out work for

aircraft registered in Bhutan. Although the DCA approves AMOs on the basis of the provisions contained in the JAR 145,

it has not yet developed procedures for the approval of such organizations, including the review of the AMO maintenance

procedures manual and the inspection of their facilities.

RECOMMENDATION:

The DCA should establish and follow procedures for the approval of domestic as well as foreign AMOs. These procedures

should cover all aspects related to the approval of such organizations, including the review and approval of the AMO

maintenance procedures manual and the inspection of their facilities.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-14

AIR/14BHUTAN



5.443; 5.445; 5.447; 5.449;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 X CE-6 CE-7 X CE-8 X

FINDING:

In the area of airworthiness, the DCA develops an annual programme for the continued surveillance of the AOC holders

and AMOs. However, there is no policy and procedures established to ensure that airworthiness inspectors perform a

comprehensive and conclusive assessment of the air operator’s and AMO’s continuing competence. In addition, the DCA

has not defined the actions to be taken in case deficiencies identified during surveillance inspections are not rectified

within a reasonable period of time or in case serious safety concerns are identified during ramp inspections. In practice, the

DCA has conducted less than ten percent of the planned inspections. In particular, the DCA has not conducted any

surveillance inspection of line stations and foreign AMOs as per the planned surveillance programme.

RECOMMENDATION:

The DCA should establish and follow a surveillance policy and related procedures to ensure comprehensive and conclusive

assessments of the air operator’s and AMO’s continuing competence. The policy should in part icular address the

following:

• the need to complete the annual surveillance programme;

• the actions to be taken in case deficiencies identified during the surveillance are not rectified within a reasonable

period of time; and

• the actions to be taken in case deficiencies indicating serious safety concerns are identif ied during ramp

inspections, including the grounding of aircraft.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-5-15

AIR/15BHUTAN



5.451; 5.453;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA does not conduct oversight of reliability programmes for the air operator under its responsibility.

RECOMMENDATION:

The DCA should conduct oversight of reliability programmes for the air operator under its responsibility, and should

initiate a special evaluation or impose special instructions if information obtained from reliability programmes indicates

degraded level of safety.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-01

AIG/01BHUTAN


AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION

6.001; 6.003; 6.005; 6.007; 6.009; 6.011; 6.013; 6.021;

6.023; 6.025; 6.027; 6.029; 6.031; 6.033; 6.035; 6.355;

DOCUMENT REFERENCE:


finding.


FINDING:

The provisions contained in the legislation and regulations of Bhutan are insufficient to provide for the effective and

adequate conduct of aircraft accidents and serious incident investigations in Bhutan. In particular, there are no provisions

for the following:

• the conduct of serious incident investigations;

• the independence and the purpose of the investigation process, as well as the separation of the process from

administrative and judicial proceedings that may apportion blame or liability;

• the immediate notification of all accidents and serious incidents that have occurred in Bhutan to the State’s

authorities;

• the powers of the investigators;

• the protection and custody of the aircraft and all relevant evidence;

• the non-disclosure of the elements listed in paragraph 5.12 of ICAO Annex 13 - Aircraft Accident and Incident

Investigation;

• the participation of accredited representatives of all the States concerned as per ICAO Annex 13 provisions; and

• the re-opening of an investigation when new and significant evidence becomes available.

RECOMMENDATION:

Bhutan should amend the State’s legislation and regulations in order to provide for the effective and adequate conduct of

aircraft accidents and serious incident investigations. In particular, provisions should be promulgated for the following:

• the conduct of serious incident investigations;

• the independence and the purpose of the investigation process, as well as the separation of the process from

administrative and judicial proceedings that may apportion blame or liability;

• the immediate notification of all accidents and serious incidents that have occurred in Bhutan to the State’s

authorities;

• the powers of the investigators;

• the protection and custody of the aircraft and all relevant evidence;

• the non-disclosure of the elements listed in paragraph 5.12 of ICAO Annex 13;

• the participation of accredited representatives of all the States concerned as per ICAO Annex 13 provisions; and

• the re-opening of an investigation when new and significant evidence becomes available.



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-01

AIG/01BHUTAN



6.001; 6.003; 6.005; 6.007; 6.009; 6.011; 6.013; 6.021;

6.023; 6.025; 6.027; 6.029; 6.031; 6.033; 6.035; 6.355;

COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-02

AIG/02BHUTAN



6.101; 6.105; 6.107; 6.109; 6.111; 6.113; 6.115; 6.117;

6.119; 6.121; 6.301; 6.343; 6.345;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 X CE-5 X CE-6 CE-7 CE-8

FINDING:

While Bhutan's policy, as reflected in the BANRs, is to delegate all aircraft accident investigations to other States, Bhutan

has not adopted any policy regarding the investigation of serious incidents, including whether or not these would be

delegated to other States, or what organization should be put in place for Bhutan to investigate them. In addition, Bhutan

has not developed any policy on how the initial phase of an investigation would be carried out, including the preservation

of evidence and the first actions to be taken at the occurrence site. In particular, no entity or personnel has been formally

designated for such actions. No qualification requirements or job descriptions have been established for the personnel in

charge of investigation tasks. No budget has been planned to ensure that the initial phase of an accident investigation is

adequately carried out.

RECOMMENDATION:

Bhutan should es tabl ish pol ic ies and processes regarding the conduct of a i rcraf t accident and ser ious incident

investigations. Bhutan should, in particular, define the organization to be put in place for initiating aircraft accident and

serious incident investigations. Bhutan should also formally designate the technical personnel to be in charge of

investigations tasks, on the basis of clear qualification requirements, and provide said personnel with the necessary

delegation of authority to enable them to perform their tasks. Furthermore, Bhutan should establish mechanisms to provide

the necessary funding for the relevant tasks to be carried out during the initial phase of the investigation.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-03

AIG/03BHUTAN



6.123; 6.125; 6.127; 6.129; 6.131;

DOCUMENT REFERENCE:


finding.


FINDING:

Two DCA officers have attended courses and seminars on accident/ incident investigation. However, there are no

established training programmes and plans prioritizing the type of training to be provided to the technical staff in Bhutan

who would carry out tasks related to the notification, investigation or reporting of aircraft accidents and incidents.

RECOMMENDATION:

Bhutan should ensure that training programme and periodic training plans are established and implemented for the

designated personnel in Bhutan who would carry out tasks related to the notification, investigation or reporting of aircraft

accidents and incidents. These training programmes and plans should include initial, basic and on-the-job (OJT) training

that are adapted to the particular tasks to be performed by the designated personnel. They should also include training

related to the safety at the accident site.



COMMENTS BY ICAO:


not addressed the implementation aspects (e.g. actual delivery of the training to the designated personnel and associated

estimated implementation date).

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-04

AIG/04BHUTAN



6.133; 6.135;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not established any measures to ensure that if DCA experts or experts from any other organization in Bhutan

are used for an aircraft accident or serious incident investigation, they would be relieved from their regular duties during

the period required to adequately complete their tasks. In addition, Bhutan has not established any measures to avoid any

conflict of interest when such experts are used for an investigation.

RECOMMENDATION:

Bhutan should establish measures to ensure that if DCA experts or experts from any other organization in Bhutan are used

for an aircraft accident or serious incident investigation, they would be relieved from their regular duties during the period

required to adequately complete their tasks. Bhutan should also establish measures to avoid any conflict of interest when

such experts are used for an investigation.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-05

AIG/05BHUTAN



6.201; 6.203; 6.205; 6.207; 6.209;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not provided technical personnel designated to carry out investigation tasks in Bhutan with the necessary

investigation equipment (including investigation field kits and protective equipment), means of communication, means of

transportation, and related documentation.

RECOMMENDATION:

Bhutan should provide technical personnel designated to carry out investigation tasks in Bhutan with the necessary

investigation equipment (including investigation field kits and protective equipment), means of communication, means of

transportation, and related documentation.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-06

AIG/06BHUTAN



6.313;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not provided ICAO with a contact phone number that is operational 24 hours a day so that it can be used for

the immediate not if icat ion by other Sta tes of accident and ser ious incidents involving Bhutanese-regis tered or

Bhutanese-operated aircraft.

RECOMMENDATION:

The DCA should provide ICAO with a contact phone number that is operational 24 hours a day so that it can be used for

the immediate not if icat ion by other Sta tes of accident and ser ious incidents involving Bhutanese-regis tered or

Bhutanese-operated aircraft.



COMMENTS BY ICAO:

The corrective action plan submitted by the State does not address this ICAO finding and recommendation. The complete

contact details used for immediate notification of accidents and serious incidents has to be conveyed officially to the AIG

section at ICAO headquarters.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-07

AIG/07BHUTAN



6.311; 6.315; 6.317; 6.319; 6.321; 6.323; 6.325; 6.327;

6.329;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 CE-5 X CE-6 CE-7 CE-8

FINDING:

The DCA is the entity designated in the BANRs to deal with notifications of aircraft accidents. No mention is made in any

regulation or guidance material about the notification of serious incidents. No documented processes, procedures or other

guidance material have been established in order to ensure the effective and timely forwarding and processing of aircraft

accident and serious incident notifications. When a serious incident occurred to a transport aircraft in Bhutan in 2004, the

DCA did not forward the required notification to the States involved or to ICAO.

RECOMMENDATION:

The DCA should establish and implement procedures to ensure the effective and timely forwarding and processing of

aircraft accident and serious incident notifications.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-08

AIG/08BHUTAN



6.303; 6.347; 6.349; 6.351; 6.353; 6.357; 6.359; 6.361;

6.363; 6.365; 6.367; 6.369; 6.371; 6.373; 6.375; 6.377;

6.379; 6.381; 6.391; 6.393; 6.395; 6.397;

DOCUMENT REFERENCE:


finding.


FINDING:

No procedures, processes or other guidance material have been established by Bhutan regarding the conduct of aircraft and

serious incident investigations or regarding participation in investigations conducted by other States.

RECOMMENDATION:

Bhutan should ensure that comprehensive guidance, processes and procedures are established and implemented regarding

the following:

• the conduct of investigations of aircraft accidents and serious incidents that have occurred in Bhutan; and

• the participation in investigations conducted by other States when Bhutan is the State of Registry or the State of

the Operator.



COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-09

AIG/09BHUTAN



6.401; 6.403; 6.405; 6.407; 6.409; 6.411; 6.413; 6.415;

6.417; 6.421; 6.423; 6.431; 6.433; 6.435; 6.437;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 X CE-6 CE-7 CE-8 X

FINDING:

No procedures, processes or other guidance material have been established by Bhutan regarding the completion and release

of final reports, the issuance of safety recommendations, or the completion and forwarding of accident/incident reporting

system (ADREP) reports.

RECOMMENDATION:

Bhutan should ensure that comprehensive guidance, processes and procedures are established and implemented regarding

the completion and release of final reports, the issuance of safety recommendations as well as the completion and

forwarding of ADREP reports.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-10

AIG/10BHUTAN



6.425;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8 X

FINDING:

The DCA has not established a documented process and procedures for informing a State which has issued a safety

recommendation to Bhutan of the preventive action that Bhutan has taken, the action under consideration, or the reason

that no action will be taken.

RECOMMENDATION:

The DCA should establ ish a documented process and procedures for informing a Sta te that has issued a safety

recommendation to Bhutan of the preventive action that Bhutan has taken, the action under consideration, or the reason

that no action will be taken.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-11

AIG/11BHUTAN



6.501; 6.507; 6.509; 6.511;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 CE-8 X

FINDING:

Although some provisions exist in the regulations for the mandatory reporting of incidents, these provisions do not cover

all civil aviation activities. In addition, the DCA has not stored the accident and incident information that it has received in

a database nor has it carried out analyses of the information received.

RECOMMENDATION:

Bhutan should ensure that a mandatory incident reporting system, covering all civil aviation activities, is established and

implemented through the appropriate legislation and mechanisms. The DCA should establish and maintain a database to

store the accident and incident information that it has received through the existing reporting mechanisms. It should also

carry out analyses of the accident and incident information received in order to identify any preventive action necessary.



COMMENTS BY ICAO:


not provided sufficient detail to address this finding and has not addressed the need to establish regulatory requirements for

the mandatory reporting of incidents in all civil aviation activities in the State.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-6-12

AIG/12BHUTAN



6.503; 6.505;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 CE-6 CE-7 CE-8 X

FINDING:

Bhutan has not established a voluntary incident reporting system to facilitate the collection of safety information that may

not otherwise have been captured by the State’s mandatory incident reporting system.

RECOMMENDATION:

Bhutan should ensure that a voluntary incident reporting system, covering all civil aviation activities, is established and

implemented through the appropriate legislation and mechanisms in order to facilitate the collection of safety information

that may not otherwise have been captured by a mandatory incident reporting system. It should also establish the means to

ensure that the voluntary incident reporting system is non-punitive and that the sources of information are protected, as

stipulated in ICAO Annex 13.



COMMENTS BY ICAO:


not provided sufficient detail to address this finding.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-01

ANS/01BHUTAN


AIR NAVIGATION SERVICES

7.033; 7.035; 7.037; 7.059; 7.061; 7.063; 7.119; 7.121;

7.207; 7.209; 7.229; 7.231; 7.233; 7.241; 7.243; 7.245;

7.269; 7.275; 7.287; 7.289; 7.325; 7.331; 7.343; 7.345;

7.351; 7.353; 7.355; 7.373; 7.379; 7.391; 7.403; 7.405;

7.417; 7.423; 7.435; 7.437; 7.453; 7.455; 7.457; 7.487;

7.537;7.535;7.533;7.507;7.505;7.493;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 X CE-5 X CE-6 X CE-7 X CE-8 X

FINDING:

The DCA has not established a safety oversight system in the ANS areas. There are no qualified and experienced

inspectors, no policies and procedures, and no surveillance in the fields of Air Traffic Management (ATM), Procedures for

Air Navigation Services - Aircraft Operations (PANS-OPS), AIS, MAP, CNS, MET, and Search and Rescue (SAR).

RECOMMENDATION:

The DCA should establish an effective safety oversight system in the ANS areas, including the appointment of qualified

and experienced inspectors with appropriate legal authority, comprehensive policies and procedures, and effective

surveillance programmes in the fields of ATM, PANS-OPS, AIS, MAP, CNS, MET and SAR.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-02

ANS/02BHUTAN



7.017; 7.019; 7.309;

DOCUMENT REFERENCE:


finding.


FINDING:

Bhutan has not issued any safety critical information, including an AIP, AIP Supplements, NOTAMs and AICs, and the

AIRAC system is not used. In addition, no guidance material has been issued to ANS providers and operators on

regulations related to ANS.

RECOMMENDATION:

The DCA should ensure the issuance and dissemination of safety critical information, including an AIP, AIP Supplements,

NOTAMs and AICs, as well as the use of the AIRAC system. In addition, the DCA should provide ANS providers and

airline operators/aviation community with adequate guidance material on regulations related to ANS.



COMMENTS BY ICAO:


not defined an estimated implementation date for all parts of the corrective action plan. In addition, no detail is provided to

address the lack of aeronautical information in the transition period before completion of the corrective action plan.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-03

ANS/03BHUTAN



7.007; 7.151; 7.155; 7.157;

DOCUMENT REFERENCE:


finding.


FINDING:

No documented procedures have been established for the following:

• the interception of civil aircraft;

• assistance to and safeguard of stray or unidentified aircraft;

• provision of service to aircraft in the event of emergencies, including unlawful interference, aircraft bomb threats

and emergency descents; and

• assistance to pilots in case of air-ground radio communications failure.

RECOMMENDATION:

The DCA should ensure that procedures have been established for the following:

• the interception of civil aircraft;

• assistance to and safeguard of stray or unidentified aircraft;

• provision of service to aircraft in the event of emergencies, including unlawful interference, aircraft bomb threats

and emergency descents; and

• assistance to pilots in case of air-ground radio communications failure.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-04

ANS/04BHUTAN



7.043;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA does not ensure that the ANS service providers adopt policies and procedures on Human Factors principles.

RECOMMENDATION:

The DCA should ensure that the ANS service providers adopt policies and procedures on Human Factors principles.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-05

ANS/05BHUTAN



7.161; 7.163; 7.165; 7.167; 7.169; 7.171; 7.173; 7.175;

7.177; 7.179; 7.181;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 X CE-4 CE-5 X CE-6 X CE-7 X CE-8

FINDING:

The DCA has not developed an ATS safety programme. It has not identified required resources, nor has it developed

guidelines to implement such a programme.

RECOMMENDATION:

The DCA should develop an ATS safety programme, identify the resources required, and develop guidelines to implement

such a programme.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-06

ANS/06BHUTAN



7.183; 7.185; 7.187; 7.189;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 CE-6 CE-7 X CE-8 X

FINDING:

There is no system for reporting air traffic control (ATC) incidents. Safety reviews are not regularly conducted by

qualified personnel in accordance with the provisions of ICAO’s Doc 4444 - Air Traffic Management . In addition, a

runway safety programme has not been established.

RECOMMENDATION:

The DCA should establish a system for reporting ATC incidents and should ensure that safety reviews are regularly

conducted by qualified personnel, in accordance with the provisions of ICAO’s Doc 4444. In addition, the DCA should

ensure the implementation of a runway safety programme which contains procedures and measures aimed at minimizing

potential hazards, including inadvertent runway incursions.



COMMENTS BY ICAO:


not provided sufficient detail to address the finding. In addition, it has not addressed the need to ensure the implementation

of a runway safety programme.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-07

ANS/07BHUTAN



7.107; 7.131; 7.411; 7.413; 7.415;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 X CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

ATS and MET services at the Paro International Airport are provided by the Air Force Element (AFE) of Indian Military

Training Team (IMTRAT). However, there is no evidence of any formal delegation by Bhutan of these service provisions

within the territory under its responsibility. In addition, there is no evidence of any operational agreement for MET

services between Bhutan and the MET service provider.

RECOMMENDATION:

Bhutan should formally designate the service providers for ATS and MET. In addition, it should ensure that an operational

agreement for MET is established with the entity providing MET.



COMMENTS BY ICAO:

The corrective action plan submitted by the State partially addresses this ICAO finding and recommendation. The

corrective action is not within the authority of the action office identified (DCA). In addition, the State has not defined an

estimated implementation date.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-08

ANS/08BHUTAN



7.081; 7.083; 7.085; 7.087; 7.089; 7.091;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has not ensured that the ATS provider has established a policy and procedures for, but not l imited to,

determining staffing-related requirements and qualifications in order to ensure the provision of an adequate ATS system.

RECOMMENDATION:

The DCA should ensure that the ATS service provider establishes a policy and procedures for determining staffing-related

requirements and qualifications in order to ensure the provision of an adequate ATS system.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-09

ANS/09BHUTAN



7.153; 7.159;

DOCUMENT REFERENCE:


finding.


FINDING:

Contingency plans have not been developed for implementation in the event of disruption or potential disruption of ATS,

radio communication contingencies, and emergency separation.

RECOMMENDATION:

The DCA should ensure that contingency plans are established for implementation in the event of disruption or potential

disruption of ATS, radio communication contingencies, and emergency separation.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-10

ANS/10BHUTAN



7.201; 7.221; 7.223; 7.249; 7.253; 7.255;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 X CE-4 CE-5 X CE-6 CE-7 X CE-8

FINDING:

With regard to flight procedures design, no criteria have been laid out for flight procedures design and no entity has been

established for the provision of flight procedures design services and all related matters.

RECOMMENDATION:

The DCA should ensure that criteria are laid down for flight procedures design and that an entity is established for the

provision of flight procedures design and all related matters.



COMMENTS BY ICAO:


not addressed the need to ensure that criteria are laid down for flight procedures design.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-11

ANS/11BHUTAN



7.267; 7.307; 7.311; 7.451;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 CE-5 X CE-6 X CE-7 X CE-8

FINDING:

Bhutan has not yet issued an AIP, as the document available is still in draft form. In addition, a properly organized quality

system containing procedures, processes and resources has not been established for the MET and AIS services in

accordance with the provisions of ICAO’s Annex 3 - Meteorological Service for International Air Navigation and Annex

15 - Aeronautical Information Services, respectively, including the publication of a national AIP.

RECOMMENDATION:

Bhutan should ensure that an AIP is finalized and issued, following the format specified in Annex 15. The DCA should

ensure that a properly organized quality system containing procedures, processes and resources is established for the MET

and AIS services in accordance with the provisions of ICAO’s Annex 3 and Annex 15, respectively.



COMMENTS BY ICAO:


not provided sufficient detail in the second part of the corrective action plan.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-12

ANS/12BHUTAN



7.393; 7.395;

DOCUMENT REFERENCE:


finding.


FINDING:

There are no requirements for flight inspection of navigational aids. In addition, the DCA has not established a mechanism,

including t ime frames, for the e l iminat ion of any def ic iency ident i f ied. At the Paro In ternat ional Airpor t , the

non-directional radio beacon (NDB) “PR” has been unserviceable for more than two years while the periodic check on the

Doppler VOR (DVOR)/distance measuring equipment (DME) “PRO” has been expired since 19 January 2005.

RECOMMENDATION:

Bhutan should promulgate requirements for flight inspection of navigational aids, including the periodicity of these flight

inspections. The DCA should ensure that such flight inspections are adequately carried out. The DCA should also establish

a mechanism, including time frames, for the elimination of deficiencies identified, in particular regarding the “PR” and

“PRO” navigational aids.



COMMENTS BY ICAO:


not addressed the need to establish time frames for the elimination of deficiencies identified regarding navigational aids. In

addition, the State has not indicated the immediate action that it intends to take regarding the “PRO” navigational aid.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-13

ANS/13BHUTAN



7.321; 7.323; 7.357; 7.359; 7.361; 7.363;

DOCUMENT REFERENCE:


finding.


FINDING:

A cartographic service has not been established and there is no specialist available within the DCA for the production,

review or initiation of revisions of aeronautical charts. There is no mechanism in place to ensure that aeronautical data

quality requirements related to data integrity and charting resolution are followed. The applicable charts for the Paro

International Airport, which is a visual aerodrome, have not been published.

RECOMMENDATION:

The DCA should ensure that a cartographic service is established so that aeronautical charts are accurate before they are

made available. In addition, the DCA should establish a mechanism to ensure that aeronautical data quality requirements

related to the data integrity and charting resolution are in accordance with the provisions of Tables 1 to 5 in Appendix 6 of

ICAO’s Annex 4 - Aeronautical Charts . The DCA should ensure that the applicable charts for the Paro International

Airport are published.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-14

ANS/14BHUTAN



7.481; 7.483; 7.513; 7.517; 7.519;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 X CE-4 CE-5 CE-6 CE-7 CE-8

FINDING:

Bhutan has not established an entity to provide SAR services within the territory under its sphere of responsibility. There is

no documented evidence of any delegation of SAR services to another entity/authority. In addition, no letters of agreement

for SAR operations with neighbouring States have been concluded.

RECOMMENDATION:

Bhutan should ensure that an entity is designated to provide SAR services within the territory under i ts sphere of

responsibility. It should also ensure that letters of agreement for SAR operations with all neighbouring States are

concluded.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-7-15

ANS/15BHUTAN



7.485; 7.515; 7.521; 7.523; 7.525; 7.527; 7.529; 7.531;

7.539; 7.543; 7.545;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 X CE-4 CE-5 X CE-6 X CE-7 X CE-8

FINDING:

Bhutan has not ensured that SAR services are established to meet the provisions of ICAO’s Annex 12 - Search and Rescue.

The following deficiencies were identified:

a) There is no legal framework, no responsible author i ty designated, no organized resources avai lable , no

communication facilities and workforce skilled in coordination and operational functions.

b) No arrangements have been established to enable aircraft, local services and facilities which are not part of the

SAR organization to cooperate fully with the latter in SAR operations and to extend any possible assistance to the

survivors of aircraft accidents.

c) Arrangements have not been made for the use of SAR units and other available facilities to assist aircraft or its

occupants who appear to be in a state of emergency.

d) No SAR point of contact for the receipt of COSPAS-SARSAT distress data has been designated.

e) No detailed plans of operation have been prepared for the conduct of SAR operations within its areas.

f) There is insufficient workforce skilled in coordination and operational functions in SAR operations.

g) No appropriate SAR exercises are arranged.

RECOMMENDATION:

Bhutan should ensure that all requirements for SAR services are implemented in accordance with the provisions of ICAO’s

Annex 12.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-01

AGA/01BHUTAN


AERODROMES

8.031; 8.039; 8.069;

DOCUMENT REFERENCE:


finding.


FINDING:

The functions of the Directorate of Aerodrome Safety and Standards (DASS) are carried out by the Aerodrome Section of

the DCA, which has only one staff member. Although there is only one aerodrome in Bhutan, the DCA does not have a

suitable mix of technical disciplines, or access to such disciplines, to carry out its regulatory and surveillance functions.

Furthermore, guidance material and procedures for each technical specialist area have not been developed.

RECOMMENDATION:

The DCA should ensure that there is a suitable mix of technical disciplines, or access to such disciplines, to carry out its

regulatory and surveillance functions in the area of aerodrome safety. The DCA should also develop guidance material and

procedures for each technical specialist area related to aerodrome safety oversight.



COMMENTS BY ICAO:


not addressed the need to develop guidance material and procedures for each technical specialist area related to aerodrome

safety oversight. In addition, the State has not provided sufficient detail on how it will ensure the availability of experts in

all the necessary technical disciplines.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-02

AGA/02BHUTAN


AERODROMES

8.101; 8.105;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has issued an aerodrome certificate to the Paro International Airport in October 2006. However, the type of use,

exemptions, and operational conditions imposed on the certified aerodrome are not attached to the aerodrome certificate. In

addition, a procedure for the amendment of aerodrome certificate has not been established.

RECOMMENDATION:

The DCA should include the type of use, exemptions, and operational conditions on the aerodrome certificate. The DCA

should also establish a procedure for the amendment of the aerodrome certificate.



COMMENTS BY ICAO:


not addressed the need to establish a procedure for the amendment of the aerodrome certificate.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-03

AGA/03BHUTAN


AERODROMES

8.121;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has approved the aerodrome manual for the Paro International Airport. However, the DCA has not established a

documented process to be followed for subsequent amendments of the aerodrome manual.

RECOMMENDATION:

The DCA should develop a documented process to be followed for subsequent amendments of the aerodrome manual.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-04

AGA/04BHUTAN


AERODROMES

8.145;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 X CE-8

FINDING:

Bhutan has established a requirement for the aerodrome operator to assess and report runway surface conditions in

accordance with the provisions of Annex 14, paragraph 2.9.4 when water is present on the runway. However, the DCA

does not ensure compliance with this requirement.

RECOMMENDATION:

The DCA should ensure that the aerodrome operator develops and implements procedures in accordance with the

provisions of Annex 14, paragraph 2.9.4 for the assessment and reporting of runway surface conditions when water is

present on the runway.



COMMENTS BY ICAO:



Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-05

AGA/05BHUTAN


AERODROMES

8.131; 8.133; 8.135; 8.137; 8.151;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 X CE-4 CE-5 X CE-6 X CE-7 CE-8

FINDING:

There is no established process in Bhutan to ensure the accuracy, integrity and protection of aeronautical data through a

quality system. In addition, the DCA has not yet documented a process to verify the accuracy of the aerodrome data,

including pavement bearing strength (PCN) and information concerning the capability to remove disabled aircraft on or

adjacent to the movement area.

RECOMMENDATION:

The DCA should ensure that a quality system is established and implemented to ensure the accuracy, integrity and

protection of aeronautical data throughout the data transfer process. The DCA should also establish and follow a

documented process to verify the accuracy of the aerodrome data.



COMMENTS BY ICAO:


not addressed the need to ensure coordination between AIS and the airport, as well as the need to ensure that the

aerodrome operator provides contact information for the remove of disabled aircraft.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-06

AGA/06BHUTAN


AERODROMES

8.161; 8.169; 8.171;

DOCUMENT REFERENCE:


finding.


FINDING:

The checklist used by the DCA for the aerodrome certification does not identify all non-compliances related to physical

characteristics, facilities and equipment. In addition, some non-compliances identified in the certification audit report (e.g.

regarding immoveable objects in the Obstacle Limitation Surfaces) have not been forwarded to the aerodrome operator for

corrective actions or risk assessment. Furthermore, Bhutan has not established a formal requirement or a procedure for an

aerodrome operator to notify changes to the aerodrome’s physical characteristics, facilities or equipment.

RECOMMENDATION:

The DCA should develop a comprehensive checklist to enable the identification of all non-compliances related to the

physical characteristics, facilities and equipment of the aerodrome. The DCA should also establish a formal requirement or

a procedure for an aerodrome operator to notify changes to the aerodrome’s physical characteristics, facil i t ies or

equipment. It should also establish a mechanism in which a formal evaluation of the impact of such a change to the safety

of the existing operation can be made.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-07

AGA/07BHUTAN


AERODROMES

8.293;

DOCUMENT REFERENCE:


finding.


FINDING:

Although the DCA has established requirements for aerodrome emergency planning, the requirement for the periodic

testing and review of the emergency plan has not been implemented.

RECOMMENDATION:

The DCA should ensure that the aerodrome operator’s emergency plan is tested and that the testing is renewed at the

required periodicity.



COMMENTS BY ICAO:

The corrective action plan submitted by the State does not address this ICAO finding and recommendation. The finding

was addressed from the aerodrome operator’s standpoint, when it should have been addressed from the oversight

authority’s standpoint.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-08

AGA/08BHUTAN


AERODROMES

8.297;

DOCUMENT REFERENCE:


finding.


FINDING:

Paro International Airport is situated on difficult terrain. However, the aerodrome emergency plan does not contain

provisions to guarantee the availability and coordination of specialist rescue services. Such specialist rescue services are

not available in Bhutan outside the aerodrome area.

RECOMMENDATION:

The DCA should ensure that the aerodrome emergency plan contains provisions to guarantee the availabil i ty and

coordination of specialist rescue services, and that these provisions can be implemented.



COMMENTS BY ICAO:




Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-09

AGA/09BHUTAN


AERODROMES

8.149; 8.323;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has established requirements for snow, slush, and ice to be removed as rapidly and completely as possible to

minimize accumulation. However, the approved aerodrome manual does not contain procedures for the following:

• the timely removal of snow, slush, and ice; and

• the issuance of special series NOTAM (SNOWTAM).

RECOMMENDATION:

The DCA should ensure that the aerodrome operator establish and implement procedures for the following:

• the timely removal of snow, slush, and ice; and

• the issuance of special series SNOWTAM.



COMMENTS BY ICAO:




Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-10

AGA/10BHUTAN


AERODROMES

8.099; 8.367; 8.369; 8.373; 8.375; 8.377;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 X CE-3 CE-4 CE-5 X CE-6 CE-7 X CE-8

FINDING:

The aerodrome certification process includes procedures for accepting non-compliances. However, there are no procedures

to assist the DCA staff in carrying out risk assessments. In addition, there is no regulatory requirement or statement to

define the circumstances and rationale under which aeronautical studies and/or risk assessments may be used, and no

guidance has been made available to aerodrome operators and regulatory staff on the processes to be followed.

RECOMMENDATION:

The DCA should do the following:

• establish and follow procedures for accepting non-compliances;

• promulgate regulatory requirement or statement to define the circumstances and rationale under which aeronautical

studies and/or risk assessments may be used;

• issue comprehensive guidance on the development , evaluat ion and use of aeronaut ica l s tudies and r i sk

assessments;

• control the use of aeronautical studies and risk assessments in granting exemptions or exceptions; and

• assess the outcomes of the use of aeronautical studies and risk assessments, and ensure that these outcomes are

published.



COMMENTS BY ICAO:


not addressed the publication of the outcomes of risk assessments and aeronautical studies.

Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-11

AGA/11BHUTAN


AERODROMES

8.401; 8.403;

DOCUMENT REFERENCE:


finding.

CE-1 CE-2 CE-3 CE-4 CE-5 CE-6 CE-7 X CE-8

FINDING:

The DCA has not established a programme for the continuing surveillance of the aerodrome operator and has not

developed procedures for such continuing surveillance.

RECOMMENDATION:

The DCA should establish a programme for the continuing surveillance of the aerodrome operator. The DCA should also

develop and implement comprehensive procedures for such continuing surveillance.




COMMENTS BY ICAO:


Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-12

AGA/12BHUTAN


AERODROMES

8.327;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA has established requirements for the aerodrome operator to carry out a bird strike hazard assessment. However,

although the aerodrome operator has established actions to decrease the hazard of bird strike, a formal bird strike hazard

assessment has not been carried out.

RECOMMENDATION:

The DCA should ensure that the aerodrome operator carries out a formal bird strike hazard assessment, and that bird strike

reports are recorded and analysed.



COMMENTS BY ICAO:




Auditee:

Audit Period: 24/10/2006 - 31/10/2006

APPENDIX 1-8-13

AGA/13BHUTAN


AERODROMES

8.287; 8.289;

DOCUMENT REFERENCE:


finding.


FINDING:

The DCA requires the aerodrome operator to control the use of vehic les on the aerodrome and to oversee the

implementation of the established requirements regarding drivers of a vehicle on the movement area. These requirements

have not yet been implemented by the aerodrome operator.

RECOMMENDATION:

The DCA should ensure that the aerodrome operator controls the use of vehicles on the aerodrome and oversees the

implementation of the established requirements regarding drivers of a vehicle on the movement area.



COMMENTS BY ICAO:




APPENDIX 2

CRITICAL ELEMENTS OF A SAFETY OVERSIGHT SYSTEMLACK OF EFFECTIVE IMPLEMENTATION (%)

28.07

33.64

42.2639.48

54.07

32.19

41.38

45.0747.83

54.17

76.47

85.90

66.89

45.29

52.94

66.67

0

10

20

30

40

50

60

70

80

90

100

Primary AviationLegislation

Specific OperatingRegulations

Civil Aviation Systemand Safety Oversight

Functions

Qualification andTraining of Technical

Staff

Procedures andTechnical Guidance

Licensing andCertificationObligations

SurveillanceObligations

Resolution of SafetyConcerns

Global: (58) Audited States: 39.51% Audit of: BHUTAN 62.01%

APPENDIX 3

APPENDIX 3-1-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO PRIMARY AVIATION LEGISLATION AND

CIVIL AVIATION REGULATIONS

AUDIT FINDING LEG/01

Article 6 of the Civil Aviation Act of the Kingdom of Bhutan 2000 empowers the Minister responsible for civil aviation to regulate civil aviation activities in Bhutan. However, the legal framework for civil aviation safety oversight in Bhutan is limited in scope as it does not enable safety oversight of the Air Navigation Services (ANS) activities in the State. As such, regulations are missing in many ANS-related areas. In addition, there is no legal basis to provide for the delegation of legal authority to inspectors in the ANS area.

STATE’S COMMENTS AND OBSERVATIONS∗∗∗∗

The CAA agrees with the finding of the ICAO audit team.

CORRECTIVE ACTION(S) PROPOSED∗∗∗∗ ACTION OFFICE

ESTIMATED IMPLEMENTATION

DATE(S)

Article 6 of the Civil Aviation Act 2000 and regulations will be amended to conform to Doc 9735, Appendix F.

DCA Before December 2007

∗ Text reproduced as submitted by Bhutan

APPENDIX 3-1-2




The Department of Civil Aviation (DCA) has not established documented procedures for the review of all ICAO Annex amendments in an effective and timely manner, monitoring of compliance with the ICAO SARPs and amendment of its regulations when appropriate. ICAO has not been notified of a number of existing differences from ICAO Standards. In addition, significant differences are not made available to all users, as Bhutan has not yet issued an Aeronautical Information Publication (AIP).


The DCA agrees with the finding of the ICAO audit team.



DATE(S)

Establish a documented procedures for the review of all ICAO Annex amendments in an effectively manner, monitor compliance with ICAO SARPs.

DCA Before May 2007


APPENDIX 3-1-3




The Bhutan Air Navigation Regulations (BANRs) make reference to specific provisions of the Joint Aviation Requirements (JARs) issued by the Joint Aviation Authorities (JAA). However, these references do not specify the version of the JARs that is considered.


The DCA agrees with the findings of the ICAO audit team.



DATE(S)

Establish a documented procedures for the review of all ICAO Annex amendments in an effectively manner, monitor compliance with ICAO SARPs.

DCA Before 1st October 2007


APPENDIX 3-1-4




The DCA maintains a distribution list for forwarding any amendment to the BANRs. However, some users, in particular the air traffic service (ATS) provider, are not included in this distribution list.





DATE(S)

Develop a procedure manual to include for the issuance of an aircraft registration certificate and maintain a separate file for each aircraft.

DCA Before 30 Oct 2007


APPENDIX 3-1-5




The DCA has not developed policies and procedures for the issuance of exemptions, except in the area of aerodromes.





DATE(S)

Develop procedures for the issuance of exemptions, covering all civil aviation activities in the state.



APPENDIX 3-1-6




Bhutan ratified Article 3 bis of the Chicago Convention on 26 August 2005. The BANRs contain some provisions relating to the interception of aircraft, but these provisions are not comprehensive. For example, there is no requirement for the pilot-in-command to comply with interception orders. There are no provisions in Bhutan’s legislation or regulations to make compliance to interception orders from other States mandatory for any civil aircraft registered in Bhutan or operated by a Bhutanese operator.





DATE(S)

Develop new regulations under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan, regarding support to the Capacity Development Project (CDP), is enclosed.



APPENDIX 3-1-7




There are no provisions in the State’s legislation that provide civil aviation inspectors with unrestricted and unlimited access to aircraft and all aviation facilities, except in the area of aerodromes. There is also no clear delegation of authority to DCA inspectors with respect to access to aircraft and aviation facilities. Regarding access of civil aviation inspectors to aviation documents, while provisions do exist in the BANRs for such access, these provisions do not include access to ANS-related documents.





DATE(S)

Develop new legislation or regulations under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan, regarding support to the Capacity Development Project (CDP), is enclosed.



APPENDIX 3-1-8




The DCA of Bhutan has established official credentials for its inspectors, which are of the expiring type. However, these credentials make reference to Articles 11 and 12 of the Civil Aviation Act of the Kingdom of Bhutan 2000, which do not explicitly empower the DCA inspectors. In addition, some of the credentials were found to have been expired for several years. Furthermore, no credentials are issued to enable inspections in the ANS area, as such inspections are not provided for by the State’s legislation and regulations.





DATE(S)

DCA issued credentials that makes reference to empowering legislation, control the validity now

DCA Implemented December 2006

Credentials will be issued to ANS inspectors once the State’s legislation has been amended.

DCA End of 2008


APPENDIX 3-1-9




Through reference to provisions contained in the JARs, the BANRs contain requirements about documents to be carried on-board an aircraft. However, there is no explicit requirement for the passenger manifest and the cargo manifest to be carried on-board an aircraft.





DATE(S)

Develop new regulations under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan, regarding support to the Capacity Development Project (CDP), is enclosed.

DCA End of 2008


APPENDIX 3-1-10




Bhutan has not established formal requirements regarding the specific units of measurement to be used in air and ground operations.





DATE(S)

Develop new requirements under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan, regarding support to the Capacity Development Project (CDP), is enclosed.

DCA End of 2008


APPENDIX 3-1-11




Bhutan ratified Article 83 bis of the Chicago Convention on 26 August 2005 but it has not amended its primary aviation legislation in order to: • recognize certificates and licences issued/renewed by a State which has entered into an Article 83 bis agreement as a State of the Operator with the State of Registry; and • allow for the transfer of duties and responsibilities as envisaged by Article 83 bis in case Bhutan enters into an Article 83 bis agreement as State of the Operator or State of Registry. In addition, related procedures and guidance have not been established by the DCA.





DATE(S)


DCA End of 2008


APPENDIX 3-1-12




The DCA has issued a manual entitled Enforcement Manual, which outlines the penalty provisions for the violation of the applicable legislation and regulations. However, regarding the transport of dangerous goods by air, the Enforcement Manual does not contain any penalty provision for the violation of the applicable regulations. In addition, the DCA has not defined the actions to be taken in case the deficiencies identified during surveillance inspections are not rectified within a reasonable period of time. Furthermore, enforcement procedures established for some ANS areas are not appropriate, as they are not related to existing regulations and practices.





DATE(S)

DCA will review and amend its Enforcement Manual to cover applicable and comprehensive regulations.



APPENDIX 3-1-13




The provisions of the BANRs on personnel licensing and aircraft operations are, for the most part, based on the provisions of the JARs, and, for some specific ones, on Bhutan’s own requirements. However, these provisions are not complete and do not fully conform to the SARPs contained in ICAO Annex 1 — Personnel Licensing and Annex 6 — Operation of Aircraft. For instance, although Section 12, Chapter 4 of the BANRs provides for the licensing requirements of aircraft maintenance engineers (AMEs), these are not in accordance with the provisions of Annex 1. Moreover, the DCA has not issued any order, directive or instruction in support of its personnel licensing activities.





DATE(S)


DCA End of 2008


APPENDIX 3-2-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO CIVIL AVIATION ORGANIZATION

AUDIT FINDING ORG/01

The DCA has an established organizational structure. However, the functions and responsibilities of the various sections within the DCA have not all been formally established. In addition, detailed job descriptions have not been developed for all DCA staff carrying out safety oversight tasks.


The DCA does not agree with the ICAO team finding. The detail job description of each individual and organizational structure was shown to the auditors during the audit.



DATE(S)

Attached copy of organizational structure and a sample of one official job description attached.

DCA Implemented in 2003


APPENDIX 3-2-2



Among the nine sections established within the DCA, three have a dedicated safety oversight function, including rule-making, licensing/certification and surveillance tasks and responsibilities. The other six sections carry out the tasks of service providers or aerodrome operator. In the area of aerodromes as well as in some of the ANS areas, including aeronautical information services (AIS), communications, navigation and surveillance (CNS), meteorological services (MET) and aeronautical maps and charts (MAP), there is no clear separation of functions between the service provider and the regulatory body/safety oversight authority.





DATE(S)

Develop clear separation of function between the service providers and the DCA.

DCA End of 2008


APPENDIX 3-2-3



The DCA does not have sufficient resources to enable its inspectors to carry out inspections of line stations and foreign approved maintenance organizations (AMOs). In addition, the DCA is not able to retain all the necessary qualified staff, including flight inspectors. Furthermore, Bhutan does not have technical staff to carry out safety oversight tasks in the ANS areas.





DATE(S)

DCA submitted the proposal to the Royal Government. This will still remain as finding.

DCA Open

The plan programme for line stations and foreign approved maintenance organization (AMO) inspections was not approved by the Ministry of Information and Communication.


APPENDIX 3-2-4



The DCA does not have a training policy for all its safety oversight staff. Training programmes and training plans detailing the type of training to be provided for each technical staff position have not been developed for all areas. In addition, DCA staff training records are not kept in a consistent manner.


The DCA does not agree with ICAO audit team. The training records of individuals and plan training for the safety oversight staff was provided to the auditors during the audit period.



DATE(S)

Developed training programmes and periodic training plan for the safety oversight staff.

DCA Implemented in 2005


APPENDIX 3-2-5



The DCA establishes the qualification requirements for the recruitment of its technical staff charged with safety oversight tasks. However, it does not have an active role in their selection. The selection process is controlled by the Royal Civil Service Commission (RCSC). For example, in the area of airworthiness, the selection process has not enabled the DCA to recruit an avionics engineer.





DATE(S)

DCA will be involved in future in selection and recruitment of its technical staff.

DCA Before June 2007


APPENDIX 3-3-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO PERSONNEL LICENSING AND TRAINING

AUDIT FINDING PEL/01

The DCA has not established the minimum qualification and experience requirements for its personnel licensing staff.





DATE(S)

DCA has developed a DRAFT regulation titled “Personnel Licensing Procedures” as Chapter 8 of Section 12 (Personnel Licensing) of BANRs. It provides minimum qualification and experience requirements of its personnel licensing staff.



APPENDIX 3-3-2



The DCA has developed a limited number of guidance documents for its personnel licensing staff. However, no comprehensive guidance material is available to this staff to assist them in carrying out their licensing functions.





DATE(S)

DCA has developed a DRAFT regulation titled “Personnel Licensing Procedures” as Chapter 8 of Section 12 (Personnel Licensing) of BANRs. It provides comprehensive guidance on the personnel licensing functions.


DCA has developed a DRAFT regulation titled “Validation of Foreign Licenses” as Chapter 6 of Section 12 (Personnel Licensing) of BANRs. It provides comprehensive guidance on the subject of validation.


APPENDIX 3-3-3



There is no procedure for appeals against a decision of the DCA in the area of personnel licensing.





DATE(S)

Paragraph 43 “Appeals” has been added in the DRAFT regulation Chapter 4 of Section 12 (Personnel Licensing) of BANRs titled “Personnel Licensing & Medical Policies” that provides a procedure for appeal against a decision of the DCA in the area of personnel licensing.



APPENDIX 3-3-4



Personnel licensing activities in Bhutan consist of the validation or conversion of licences issued by other Contracting States. However, there is no system in place to systematically verify if the original licence has been issued in full compliance with ICAO Annex 1. In addition, if the original licence is not in full compliance with Annex 1, there are no requirements that the applicant has to satisfy before the licence can be validated or converted. Furthermore, the DCA has not established a system to re-establish the privileges of expired licences and ratings.





DATE(S)

DRAFT regulation Chapter 1 of Section 12 (Personnel Licensing) of BANRs titled “Personnel Licensing & Medical Policies” provides the policies with regard to the issue of Bhutani licence on the basis of foreign licence.


DRAFT regulation Chapter 6 of Section 12 (Personnel Licensing) of BANRs titled “Validation of foreign licenses” covers in detail the aspects of verification and additional requirements to be met.


DRAFT regulation Chapter 2 of Section 12 (Personnel Licensing) of BANRs titled “Licenses & Rating — Aircrew” covers in detail the aspects of renewal and revalidation of Licenses.



APPENDIX 3-3-5



The DCA has not established a system for the supervision and control of aviation medical examiners. There is no policy and procedures in place for action to be taken against aviation medical examiners in case they fail to perform their duties in accordance to the prescribed procedures.





DATE(S)

Para 16 has been added in the DRAFT regulation Chapter 1 of Section 12 (Personnel Licensing) of BANRs titled “Personnel Licensing & Medical Policies” that provides for monitoring of the performance of the medical examiners in the execution of their duties in accordance with the prescribed procedures and withdrawal of their authorization in case they are found to be in non-conformance of their duties.



APPENDIX 3-3-6



Bhutan has not established requirements regarding language proficiency for flight crew and air traffic controllers in conformance with the provisions of Annex 1 and Annex 6 of the Chicago Convention.





DATE(S)

DRAFT regulation Chapter 5 of Section 12 (Personnel Licensing) of BANRs titled “FRTO and English Proficiency” has been developed that addresses this subject in detail with regard to training of flight radio telephony and conduct of practical test of radio phraseology in English language.



APPENDIX 3-3-7



Bhutan has not established requirements regarding the approval of foreign training organizations, although in practice foreign training organizations are authorized by the DCA for flight crew training purposes.





DATE(S)

DRAFT regulation Chapter 1 of Section 12 (Personnel Licensing) of BANRs titled “Personnel Licensing & Medical Policies” provides for the policies with regard to the approval of foreign training organizations.


DRAFT regulation Chapter 7 of Section 12 (Personnel Licensing) of BANRs titled “Basic Training” provides in detail the Bhutani requirements for training organizations and their approval.


DRAFT regulation Chapter 8 of Section 12 (Personnel Licensing) of BANRs titled “Personnel Licensing Procedures” further provides the details about the approval of foreign training organizations and guidance on the approval of flight training devices.



APPENDIX 3-3-8



Although BANRs require the licensing of air traffic controllers, this requirement has not been implemented and the DCA has not established any procedures to this effect.





DATE(S)

DRAFT regulation Chapter 9 of Section 12 (Personnel Licensing) of BANRs titled “Air Traffic Controller Licence/Authorization” provides the detailed requirements and guidance for the training and the issuance of a licence or authorization to an Air Traffic Controller.



APPENDIX 3-4-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO AIRCRAFT OPERATIONS CERTIFICATION AND SUPERVISION

AUDIT FINDING OPS/01

The DCA delegates functions related to maintenance of competency of flight crew members to the operator. However, there is no oversight on the delegated tasks and no procedure established to ensure that appropriate action will be taken in case deficiencies are identified.





DATE(S)

Chapter 16 Section 2 and Chapter 17 of Section 3 of BANRs are being developed to cover the safety oversight aspect of check airmen of the operator.



APPENDIX 3-4-2



The DCA’s operation inspectors are provided with guidance material to perform their functions based on the requirements outlined in the BANRs. However, the guidance material is not comprehensive. For example, there is insufficient guidance provided to the staff in the following areas: • review, acceptance or approval, as applicable, of the contents of the operations manual; • approval of the training manual and the minimum equipment list/configuration deviation list as part of the air operator’s operations manual; and • renewal, suspension or revocation of the air operator certificate (AOC) or other authorizations.





DATE(S)

BANRs Chapter 17 of Section 2 and Chapter 18 of Section 3 titled “Operations Manual” are being developed to cover the subject of “Operations Manual” comprehensively.



APPENDIX 3-4-3




• has and keeps a system to maintain all required flight safety documents; • has included all required provisions and procedures in its operations manual; • has a system to provide its operations staff and flight crew with all necessary aircraft

operating information and route guide; • has established a policy and procedures for flight crew to record and report routine

meteorological observation, special and other non-routine observations during any phase of the flight as well as volcanic activity;

• has established procedures for the preparation and dissemination to flight crew and operational personnel of such information published through AIP, aeronautical information circular (AIC), aeronautical information regulation and control (AIRAC), and Notice to Airmen (NOTAM);

• publishes, distributes and maintains comprehensive training manual; • provides adequate ground and flight training facilities, simulators and/or cockpit

procedure training devices, computer-based training and syllabus materials; and • has established an appropriate system for managing all ground handling functions.





DATE(S)

BANRs Chapter 17 of Section 2 and Chapter 18 of Section 3 titled “Operations Manual” are being developed to cover the subject of “Operations Manual” comprehensively.



APPENDIX 3-4-4





• nominates a staff member to be responsible for the development and establishment of the accident prevention and flight safety programme, and that his/her functions and responsibilities are clearly defined and well documented in the flight safety documents system; and

• establishes and maintains a flight data analysis programme as part of its accident prevention and flight safety programme and that the flight data analysis programme is non-punitive and contains adequate safeguards to protect the source(s) of the data.





DATE(S)

BANRs Chapter 18 of Section 2 and Chapter 19 of Section 3 titled “Safety Management System” are being developed to cover the subject of safety management, accident prevention and safety programme, including the aspect of “flight data analysis” comprehensively



APPENDIX 3-4-5



Bhutan has not formally designated and specified to ICAO the State authority responsible for the transport of dangerous goods by air.





DATE(S)

Bhutan will specify to the ICAO the State’s authority responsible for the transport of dangerous goods.



APPENDIX 3-4-6



There is no requirement for the air operator authorized to transport dangerous goods by air to establish in-flight procedures for emergency response to aircraft incidents involving dangerous goods. The DCA has not established inspection, surveillance and enforcement procedures aimed at achieving compliance with its dangerous goods regulations. No random inspections are carried out in this field by the DCA. In addition, the DCA’s Enforcement Manual does not contain any penalty provision for the violation of the applicable regulations regarding the transport of dangerous goods by air.





DATE(S)

BANRs Chapter 5, Section 5, titled “Responsi-bilities of Operator” with regard to the Transport of Dangerous Goods is being amended to include flight procedures for emergency response for aircraft incidents involving dangerous goods.


Chapter 7, Section 5, titled “Compliance with Dangerous Goods Regulations” is being developed to provide the methodologies and procedures for compliance with dangerous goods regulations.


“Enforcement Manual” is being amended to include penalties for Dangerous Goods viol-ations.



APPENDIX 3-4-7



The DCA has not established any requirements for the air operator authorized to transport dangerous goods by air to incorporate procedures and training programmes related to dangerous goods into either the operations manual or a separate document as part of the flight safety documents system.





DATE(S)

BANRs Chapter 17, Section 2 and Chapter 18, Section 3 titled “Operations Manual” are being developed. These Chapters shall comprehend-sively cover the aspects of dangerous goods procedures and training programmes.



APPENDIX 3-4-8



There are no provisions in the regulation regarding aircraft leasing. The DCA has not established comprehensive guidance material for the acceptance/approval of such leases, as only isolated checklists are available.





DATE(S)

Chapter 19, Section 2 and Chapter 20, Section 3 titled “Aircraft Leasing” are being developed. These Chapters shall comprehensively cover the aspects of aircraft leasing.



APPENDIX 3-4-9



Although the DCA has established an annual surveillance programme for the inspection of AOC holders in order to ensure compliance with national regulations and international standards, the inspection programme is not fully implemented. Only ten percent of the planned inspections are carried out; therefore not all potential deficiencies can be identified and addressed.





DATE(S)

The number of inspections is being increased to achieve the target of annual inspections.

DCA With immediate effect


APPENDIX 3-5-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO AIRWORTHINESS OF AIRCRAFT

AUDIT FINDING AIR/01

Regulatory provisions related to airworthiness are contained in a document entitled Bhutan Aviation Requirements — Airworthiness Procedures (BAR-AW) issued by the DCA. However, there are no regulations to implement the airworthiness-related provisions of Annex 16 — Environmental Protection, Volume I - Aircraft Noise and Volume II — Aircraft Engine Emissions. Furthermore, the existing regulations do not provide for all aeroplanes to comply with the noise certification standards of Annex 16. There is no requirement for a document attesting to noise certification to be carried on-board the aircraft. Consequently, the DCA has not developed procedures to grant or validate noise certificates for aircraft registered in Bhutan.





DATE(S)

Draft procedures to grant or validate noise certificate for aircraft registered in Bhutan.

DCA Before 1st July 2007


APPENDIX 3-5-2



Although airworthiness inspectors are carrying out their duties and responsibilities using standardized checklists, the DCA has not issued comprehensive technical guidance to assist its airworthiness inspectors in effectively performing their assigned tasks.





DATE(S)

Airworthiness procedures manual develop for carrying out their duties and responsibilities using standardized checklists.



APPENDIX 3-5-3



The DCA has not developed procedures for the issuance of an aircraft registration certificate and for the maintenance of a current aircraft register in accordance with provisions of Annex 7 — Aircraft Nationality and Registration Marks. Furthermore, the DCA does not maintain a current register in accordance with the provisions of Annex 7.


The DCA agrees with the finding of the ICAO audit team. The procedures for the issuance of an aircraft registration certificate are laid down in the BAR-AW Chapter 2 para 2.8 but the detail procedures are not covered.



DATE(S)




APPENDIX 3-5-4



The BAR-AW provides the requirements for the issuance of a Type Acceptance Certificate. However, there are no procedures in place to ensure that the aircraft type is in compliance with the mandatory requirements and design standards of the State of Design as well as the requirements, operating conditions and airworthiness policies of Bhutan.


The DCA agrees with the finding of the ICAO audit team. The procedures for the issuance of a Type Acceptance Certificate are laid down in BAR-AW. The detail procedures are not covered.



DATE(S)

Develop a procedure manual to include for the issuance of a Type Acceptance Certificate.



APPENDIX 3-5-5



The BAR-AW contains requirements for modifications and repairs to be approved as well as the requirements to be met for obtaining such an approval. However, the DCA has not developed procedures for the approval of modifications and repairs.





DATE(S)

Develop procedures for the approval of modifications and repairs.



APPENDIX 3-5-6



Although the BANRs and BAR-AW provide for the issuance of special flight permits, the DCA has not developed procedures for such issuance.





DATE(S)

Develop procedures for the issuance of the special flight permits.

DCA Before 1st of July 2007


APPENDIX 3-5-7



The DCA has not developed procedures for the reporting of suspected unapproved parts. Furthermore, the DCA has yet to develop guidance to the industry on the proper usage of parts removed from an aircraft that is no longer in service and for the disposal of scrapped parts.





DATE(S)

Develop procedures for the reporting of suspect of unapproved parts and guidance to industry on the proper usage of parts removed from an aircraft that is no longer in service and for the disposal of scrapped parts.

DCA Before 1st November 2007


APPENDIX 3-5-8



The BANRs do not require that an air operator may only operate an aircraft that has been maintained and released to service by an AMO.





DATE(S)

Develop new requirements under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Department of Civil Aviation of Aid & Dept Management, Ministry of Finance, Bhutan, regarding Support to the Capacity Development Project, CDP, for the Development of Civil Aviation is enclosed.

DCA End of November 2008


APPENDIX 3-5-9



The BANRs do not provide for the air operator to submit an operator maintenance manual to the DCA for review and approval.





DATE(S)




APPENDIX 3-5-10



The BANRs do not provide for the air operators to prepare and submit for review and approval by the DCA a Minimum Equipment List (MEL) on the basis of the Master Minimum Equipment List (MMEL).


The DCA agrees with the finding of the ICAO audit team. DCA in principle reviewed the Manual submitted for approval in line with the DOC 9735, Appendix F.



DATE(S)




APPENDIX 3-5-11



The DCA has not developed procedures for the authorization of air operators to conduct operations in navigational areas requiring reduced vertical separation minimum (RVSM) approval.





DATE(S)

Draft procedure for the authorization of air operators to conduct operators in navigational areas requiring reduced vertical separation minimum (RVSM).



APPENDIX 3-5-12



There are no requirements for the approval of leases (dry, wet or damp) among commercial air transport operators.





DATE(S)




APPENDIX 3-5-13



The BANRs require that both domestic and foreign aircraft AMOs be approved by the DCA before they carry out work for aircraft registered in Bhutan. Although the DCA approves AMOs on the basis of the provisions contained in the JAR 145, it has not yet developed procedures for the approval of such organizations, including the review of the AMO maintenance procedures manual and the inspection of their facilities.





DATE(S)



Draft procedures covers all aspects related to the approval of such organizations, including the review and approval of the AMO maintenance procedures manual and the inspection of their facilities.


APPENDIX 3-5-14



In the area of airworthiness, the DCA develops an annual programme for the continued surveillance of the AOC holders and AMOs. However, there is no policy and procedures established to ensure that airworthiness inspectors perform a comprehensive and conclusive assessment of the air operator’s and AMO’s continuing competence. In addition, the DCA has not defined the actions to be taken in case deficiencies identified during surveillance inspections are not rectified within a reasonable period of time or in case serious safety concerns are identified during ramp inspections. In practice, the DCA has conducted less than ten percent of the planned inspections. In particular, the DCA has not conducted any surveillance inspection of line stations and foreign AMOs as per the planned surveillance programme.





DATE(S)

The annual surveillance programme in airworthi-ness section will remain as deficiencies. The developed annual surveillance programme has not been approved by the Ministry of Information & Communications.

AWO


APPENDIX 3-5-15



The DCA does not conduct oversight of reliability programmes for the air operator under its responsibility.


The DCA does not agree with the ICAO audit team. DCA evaluated the reliability programmes submitted by the operators, accept no written down procedures.



DATE(S)

Draft procedure covers a initiate of special evaluation or impose special instructions if information obtained from reliability programmes indicates degraded level of safety.



APPENDIX 3-6-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO AIRCRAFT ACCIDENT AND INCIDENT INVESTIGATION

AUDIT FINDING AIG/01

The provisions contained in the legislation and regulations of Bhutan are insufficient to provide for the effective and adequate conduct of aircraft accidents and serious incident investigations in Bhutan. In particular, there are no provisions for the following:

• the conduct of serious incident investigations; • the independence and the purpose of the investigation process, as well as the

separation of the process from administrative and judicial proceedings that may apportion blame or liability;

• the immediate notification of all accidents and serious incidents that have occurred in Bhutan to the State’s authorities;

• the powers of the investigators; • the protection and custody of the aircraft and all relevant evidence; • the non-disclosure of the elements listed in paragraph 5.12 of ICAO Annex 13 -

Aircraft Accident and Incident Investigation; • the participation of accredited representatives of all the States concerned as per ICAO

Annex 13 provisions; and • the re-opening of an investigation when new and significant evidence becomes

available.





DATE(S)

Develop new requirements under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan regarding support to the Capacity Development Project, CDP, for the Development of Civil Aviation is enclosed.



APPENDIX 3-6-2



While Bhutan's policy, as reflected in the BANRs, is to delegate all aircraft accident investigations to other States, Bhutan has not adopted any policy regarding the investigation of serious incidents, including whether or not these would be delegated to other States, or what organization should be put in place for Bhutan to investigate them. In addition, Bhutan has not developed any policy on how the initial phase of an investigation would be carried out, including the preservation of evidence and the first actions to be taken at the occurrence site. In particular, no entity or personnel has been formally designated for such actions. No qualification requirements or job descriptions have been established for the personnel in charge of investigation tasks. No budget has been planned to ensure that the initial phase of an accident investigation is adequately carried out.





DATE(S)

Develop new requirements under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan regarding support to the Capacity Development Project, CDP, for the Development of Civil Aviation is enclosed.

DCA Before the end of 2008


APPENDIX 3-6-3



Two DCA officers have attended courses and seminars on accident/incident investigation. However, there are no established training programmes and plans prioritizing the type of training to be provided to the technical staff in Bhutan who would carry out tasks related to the notification, investigation or reporting of aircraft accidents and incidents.





DATE(S)

Develop training programme and periodic training plans including initial and on job training for the designated personnel.

DCA Before end of 2007


APPENDIX 3-6-4



Bhutan has not established any measures to ensure that if DCA experts or experts from any other organization in Bhutan are used for an aircraft accident or serious incident investigation, they would be relieved from their regular duties during the period required to adequately complete their tasks. In addition, Bhutan has not established any measures to avoid any conflict of interest when such experts are used for an investigation.





DATE(S)




APPENDIX 3-6-5



Bhutan has not provided technical personnel designated to carry out investigation tasks in Bhutan with the necessary investigation equipment (including investigation field kits and protective equipment), means of communication, means of transportation, and related documentation.





DATE(S)

Develop policy manual for accident and serious incident to cover adequate requirements.



APPENDIX 3-6-6



The DCA has not provided ICAO with a contact phone number that is operational 24 hours a day so that it can be used for the immediate notification by other States of accident and serious incidents involving Bhutanese-registered or Bhutanese-operated aircraft.





DATE(S)

The following phone numbers that is operational 24 hours

DCA implemented

1. 00975-8-271610 2. 00975-17600779


APPENDIX 3-6-7



The DCA is the entity designated in the BANRs to deal with notifications of aircraft accidents. No mention is made in any regulation or guidance material about the notification of serious incidents. No documented processes, procedures or other guidance material have been established in order to ensure the effective and timely forwarding and processing of aircraft accident and serious incident notifications. When a serious incident occurred to a transport aircraft in Bhutan in 2004, the DCA did not forward the required notification to the States involved or to ICAO.





DATE(S)

Develop a procedure to ensure the effective and timely forwarding and processing of aircraft accident and serious incident notifications.



APPENDIX 3-6-8



No procedures, processes or other guidance material have been established by Bhutan regarding the conduct of aircraft and serious incident investigations or regarding participation in investigations conducted by other States.





DATE(S)




APPENDIX 3-6-9



No procedures, processes or other guidance material have been established by Bhutan regarding the completion and release of final reports, the issuance of safety recommendations, or the completion and forwarding of accident/incident reporting system (ADREP) reports.





DATE(S)

Develop a procedure to include the comprehend-sive guidance for release of final reports, the issuance of safety recommendations as well as the completion and forwarding of ADREP report.



APPENDIX 3-6-10



The DCA has not established a documented process and procedures for informing a State which has issued a safety recommendation to Bhutan of the preventive action that Bhutan has taken, the action under consideration, or the reason that no action will be taken.





DATE(S)

Develop procedures for informing a State that has issued a safety recommendation to Bhutan of the preventive action that Bhutan has taken, the action under consideration, or the reason that no action will be taken.



APPENDIX 3-6-11



Although some provisions exist in the regulations for the mandatory reporting of incidents, these provisions do not cover all civil aviation activities. In addition, the DCA has not stored the accident and incident information that it has received in a database nor has it carried out analyses of the information received.





DATE(S)

Develop a database to store the accident and incident information to carry out analyses of the accident and incident information received.



APPENDIX 3-6-12



Bhutan has not established a voluntary incident reporting system to facilitate the collection of safety information that may not otherwise have been captured by the State’s mandatory incident reporting system.





DATE(S)

Develop new requirements under the Capacity Development Project (CDP) for the Department of Civil Aviation funded by the Swedish International Development Cooperation Agency. The agreement signed between SIDA and the Royal government of Bhutan regarding support to the Capacity Development Project (CDP) is enclosed.



APPENDIX 3-7-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO AIR NAVIGATION SERVICES

AUDIT FINDING ANS/01

The DCA has not established a safety oversight system in the ANS areas. There are no qualified and experienced inspectors, no policies and procedures, and no surveillance in the fields of Air Traffic Management (ATM), Procedures for Air Navigation Services - Aircraft Operations (PANS-OPS), AIS, MAP, CNS, MET, and Search and Rescue (SAR).





DATE(S)

Develop procedures and establish a safety oversight system in the ANS area with qualified and experienced inspector.

DCA End of 2008


APPENDIX 3-7-2



Bhutan has not issued any safety critical information, including an AIP, AIP Supplements, NOTAMs and AICs, and the AIRAC system is not used. In addition, no guidance material has been issued to ANS providers and operators on regulations related to ANS.





DATE(S)

All the safety critical information will be used once Bhutan AIP is finalized and issued.

AIS 1st January 08

DCA will provide ANS and airline operator/ aviation community with adequate guidance material on regulation related to ANS once the DCA ATS is fully functional/after takeover from the AFE. Meanwhile matter is also planed during the AIS development project.

DCA/AIS Long term


APPENDIX 3-7-3



No documented procedures have been established for the following:

• the interception of civil aircraft; • assistance to and safeguard of stray or unidentified aircraft; • provision of service to aircraft in the event of emergencies, including unlawful

interference, aircraft bomb threats and emergency descents; and • assistance to pilots in case of air-ground radio communications failure.





DATE(S)

Will conform to Doc 9735, Appendix F, in developing the procedures for various types of aircraft emergencies and incorporated in the BANRs, section 6 ATS

ATS By mid July 2008


APPENDIX 3-7-4



The DCA does not ensure that the ANS service providers adopt policies and procedures on Human Factors principles.





DATE(S)

Policies on Human Factor principles will be developed with the assistance from CDP in conformity with the Doc 9735, Appendix F.

ATS End of 2008


APPENDIX 3-7-5



The DCA has not developed an ATS safety programme. It has not identified required resources, nor has it developed guidelines to implement such a programme.





DATE(S)

To develop the safety programme with the assistance from CDP conforming to Doc 9736 appendix F.

ATS By mid 2008


APPENDIX 3-7-6



There is no system for reporting air traffic control (ATC) incidents. Safety reviews are not regularly conducted by qualified personnel in accordance with the provisions of ICAO’s Doc 4444 — Air Traffic Management. In addition, a runway safety programme has not been established.





DATE(S)

Develop a system for reporting ATC incidents regularly by qualified personnel, in accordance with the provisions of ICAO’s Doc 4444.

DCA End of 2008


APPENDIX 3-7-7



ATS and MET services at the Paro International Airport are provided by the Air Force Element (AFE) of Indian Military Training Team (IMTRAT). However, there is no evidence of any formal delegation by Bhutan of these service provisions within the territory under its responsibility. In addition, there is no evidence of any operational agreement for MET services between Bhutan and the MET service provider.





DATE(S)

Sign a letter of agreement with India DCA No comments


APPENDIX 3-7-8



The DCA has not ensured that the ATS provider has established a policy and procedures for, but not limited to, determining staffing-related requirements and qualifications in order to ensure the provision of an adequate ATS system.





DATE(S)

Policy and procedures to be developed in accordance to ICAO Standard procedures and practices.

ATS By mid 2008

Propose to HRD the requirements with the qualification requirements and provide training

ATS End 2008


APPENDIX 3-7-9



Contingency plans have not been developed for implementation in the event of disruption or potential disruption of ATS, radio communication contingencies, and emergency separation.





DATE(S)

Develop contingency plans with the assistance from CDP.

ATS Mid of 2008

Install back up communication facilities DCA/COM


APPENDIX 3-7-10



With regard to flight procedures design, no criteria have been laid out for flight procedures design and no entity has been established for the provision of flight procedures design services and all related matters.





DATE(S)

CDP to provide the DCA an expert in cartography to develop flight and emergency procedures and all related matters.

ATS By mid 2008


APPENDIX 3-7-11



Bhutan has not yet issued an AIP, as the document available is still in draft form. In addition, a properly organized quality system containing procedures, processes and resources has not been established for the MET and AIS services in accordance with the provisions of ICAO’s Annex 3 - Meteorological Service for International Air Navigation and Annex 15 - Aeronautical Information Services, respectively, including the publication of a national AIP.





DATE(S)

Bhutan AIP will be issued only after finalizing and thoroughly checked/verified by experts of the Capacity Development Project.

AIS Before 1st October 07

AIS Quality system containing Procedures, process and resources will be established in accordance with the Annex 15, once the ATS takeover from the AFE. All corrective measures and actions will also be planed during the AIS development project.

AIS 30th April 07 to 31st Dec 08


APPENDIX 3-7-12



There are no requirements for flight inspection of navigational aids. In addition, the DCA has not established a mechanism, including time frames, for the elimination of any deficiency identified. At the Paro International Airport, the non-directional radio beacon (NDB) “PR” has been unserviceable for more than two years while the periodic check on the Doppler VOR (DVOR)/distance measuring equipment (DME) “PRO” has been expired since 19 January 2005.





DATE(S)

The non-directional radio beacon (NDB) “PR” which was reported unserviceable due site relocation requirement has been re-commissioned.

DCA Comm/Nav

Completed December 2006

Forth coming Periodicity flight inspection requirement plan

DCA Comm/Nav

End of 2007

Promulgation of requirements for flight inspection of navigation aids, including periodicity of these flight inspections.

DCA Comm/Nav

End of 2008


APPENDIX 3-7-13



A cartographic service has not been established and there is no specialist available within the DCA for the production, review or initiation of revisions of aeronautical charts. There is no mechanism in place to ensure that aeronautical data quality requirements related to data integrity and charting resolution are followed. The applicable charts for the Paro International Airport, which is a visual aerodrome, have not been published.





DATE(S)

Develop and publish aeronautical charts for Paro International Airport in accordance with the provisions of Tables 1 to 5 in Appendix 6 of ICAO’s Annex 4 — Aeronautical Charts and published in the AIP.

• CDP to provide cartographic expert to develop aeronautical charts for Paro Airport.

ATS/AIS By mid 2008

• Train a specialist in cartography from the DCA for the production, review or initiation of revisions of aeronautical charts.

DCA By mid 2009


APPENDIX 3-7-14



Bhutan has not established an entity to provide SAR services within the territory under its sphere of responsibility. There is no documented evidence of any delegation of SAR services to another entity/authority. In addition, no letters of agreement for SAR operations with neighbouring States have been concluded.





DATE(S)

Initially to develop a sub SAR Center with the assistance from CDP.

ATS Mid 2009

Sign a letter of agreement with the neighboring States for SAR operations.

DCA End of 2009


APPENDIX 3-7-15



Bhutan has not ensured that SAR services are established to meet the provisions of ICAO’s Annex 12 - Search and Rescue. The following deficiencies were identified:

a) There is no legal framework, no responsible authority designated, no organized resources available, no communication facilities and workforce skilled in coordination and operational functions.

b) No arrangements have been established to enable aircraft, local services and facilities which are not part of the SAR organization to cooperate fully with the latter in SAR operations and to extend any possible assistance to the survivors of aircraft accidents.

c) Arrangements have not been made for the use of SAR units and other available facilities to assist aircraft or its occupants who appear to be in a state of emergency.

d) No SAR point of contact for the receipt of COSPAS-SARSAT distress data has been designated.

e) No detailed plans of operation have been prepared for the conduct of SAR operations within its areas.

f) There is insufficient workforce skilled in coordination and operational functions in SAR operations.

g) No appropriate SAR exercises are arranged.





DATE(S)

Develop legal framework, SAR team to be set up, resources and communication facilities from CAD.

ATS End of 2008

Train personnel in SAR.

DCA Mid 2008

Sign a letter of agreement with local authorities regarding SAR.

SAR services implemented in accordance with the provisions of ICAO’s Annex 12 with the assistance from CAD.

ATS End of 2008


APPENDIX 3-8-1

CORRECTIVE ACTION PLAN PROPOSED BY BHUTAN RELATED TO AERODROMES

AUDIT FINDING AGA/01

The functions of the Directorate of Aerodrome Safety and Standards (DASS) are carried out by the Aerodrome Section of the DCA, which has only one staff member. Although there is only one aerodrome in Bhutan, the DCA does not have a suitable mix of technical disciplines, or access to such disciplines, to carry out its regulatory and surveillance functions. Furthermore, guidance material and procedures for each technical specialist area have not been developed.





DATE(S)

The recruitment of the additional staff has already been process with RCSC.



APPENDIX 3-8-2



The DCA has issued an aerodrome certificate to the Paro International Airport in October 2006. However, the type of use, exemptions, and operational conditions imposed on the certified aerodrome are not attached to the aerodrome certificate. In addition, a procedure for the amendment of aerodrome certificate has not been established.





DATE(S)

Attach the type of use of the aerodrome certificate, exemptions and the operational conditions.

DCA Before Feb. 2008


APPENDIX 3-8-3



The DCA has approved the aerodrome manual for the Paro International Airport. However, the DCA has not established a documented process to be followed for subsequent amendments of the aerodrome manual.





DATE(S)

Establish a documented procedures for subse-quent amendments of the aerodrome manual in an effectively manner, monitor compliance with the ICAO SARPs.

DCA Before Dec. 2007


APPENDIX 3-8-4



Bhutan has established a requirement for the aerodrome operator to assess and report runway surface conditions in accordance with the provisions of Annex 14, paragraph 2.9.4 when water is present on the runway. However, the DCA does not ensure compliance with this requirement.





DATE(S)

Develop a plan to ensure compliance with the established requirements.

DCA Before May 2008


APPENDIX 3-8-5



There is no established process in Bhutan to ensure the accuracy, integrity and protection of aeronautical data through a quality system. In addition, the DCA has not yet documented a process to verify the accuracy of the aerodrome data, including pavement bearing strength (PCN) and information concerning the capability to remove disabled aircraft on or adjacent to the movement area.





DATE(S)

Established process to ensure the accuracy, integrity and protection of aeronautical data.


Document a process to verify the accuracy of the aerodrome data.


APPENDIX 3-8-6



The checklist used by the DCA for the aerodrome certification does not identify all non-compliances related to physical characteristics, facilities and equipment. In addition, some non-compliances identified in the certification audit report (e.g. regarding immoveable objects in the Obstacle Limitation Surfaces) have not been forwarded to the aerodrome operator for corrective actions or risk assessment. Furthermore, Bhutan has not established a formal requirement or a procedure for an aerodrome operator to notify changes to the aerodrome’s physical characteristics, facilities or equipment.





DATE(S)

Include the process to identify all non-compliances related to physical characteristic, facilities and equipment.

DCA Before Nov 2008

The non-compliances identified in the certifi-cation audit report to be forwarded to aerodrome operator for corrective actions or risk assessment.

Establish a formal requirement or procedure for an aerodrome operator to notify changes to the aerodrome’s physical characteristics, facilities or equipment.

Establish a mechanism for formal evaluation of the impact of change to safety of the existing operations.


APPENDIX 3-8-7



Although the DCA has established requirements for aerodrome emergency planning, the requirement for the periodic testing and review of the emergency plan has not been implemented.





DATE(S)

Establish a documented procedure for the periodic testing and review of the emergency plan.

DCA Before Nov. 2008


APPENDIX 3-8-8



Paro International Airport is situated on difficult terrain. However, the aerodrome emergency plan does not contain provisions to guarantee the availability and coordination of specialist rescue services. Such specialist rescue services are not available in Bhutan outside the aerodrome area.





DATE(S)

Establish a provision to guarantee the availability and coordination of specialist rescue services outside the aerodrome areas.



APPENDIX 3-8-9



The DCA has established requirements for snow, slush, and ice to be removed as rapidly and completely as possible to minimize accumulation. However, the approved aerodrome manual does not contain procedures for the following:

• the timely removal of snow, slush, and ice; and • the issuance of special series NOTAM (SNOWTAM).





DATE(S)

Include the timely removal of snow, slush and ice: the issuance of special series NOTAM (SNOWTAM) in the aerodrome manual.



APPENDIX 3-8-10



The aerodrome certification process includes procedures for accepting non-compliances. However, there are no procedures to assist the DCA staff in carrying out risk assessments. In addition, there is no regulatory requirement or statement to define the circumstances and rationale under which aeronautical studies and/or risk assessments may be used, and no guidance has been made available to aerodrome operators and regulatory staff on the processes to be followed.





DATE(S)

Establish a procedure to assist the DCA staff in carrying out risk assessments.


Develop regulatory requirements or statements for the use of aeronautical studies and risk assessments.

Develop guidance to aerodrome operators and regulatory staff on the processes to be followed on risk assessment.


APPENDIX 3-8-11



The DCA has not established a programme for the continuing surveillance of the aerodrome operator and has not developed procedures for such continuing surveillance.





DATE(S)

Establish a programme and procedures for the continuing surveillance of the aerodrome operator.

DCA Before May 2008


APPENDIX 3-8-12



The DCA has established requirements for the aerodrome operator to carry out a bird strike hazard assessment. However, although the aerodrome operator has established actions to decrease the hazard of bird strike, a formal bird strike hazard assessment has not been carried out.





DATE(S)

Develop a plan to carry out the formal bird hazard assessment.



APPENDIX 3-8-13



The DCA requires the aerodrome operator to control the use of vehicles on the aerodrome and to oversee the implementation of the established requirements regarding drivers of a vehicle on the movement area. These requirements have not yet been implemented by the aerodrome operator.





DATE(S)

Develop procedures for access and control of vehicles to the airside.

DCA Before May 2008

Implement the requirements regarding drivers of a vehicle on the movement area.

Provide training to all the drivers requiring driving on the movement area.

— END —


Documents

Bhuta Final Report - International Civil Aviation …cfapp.icao.int/fsix/AuditReps/CSAfinal/Bhutan_CSA_Final.pdfFINAL REPORT ON THE SAFETY OVERSIGHT AUDIT OF THE CIVIL AVIATION SYSTEM