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The Art of Safety
Auditing
A Tutorial for Regulators
The Art of Safety
Auditing
A Tutorial for Regulators

Sasho Andonov
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2020 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-0-367-35108-3 (Paperback)

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Contents

Acronyms and Abbreviations ..............................................................................ix

Definitions of the Terms Used..............................................................................xi
Preface......................................................................................................................xv
Author.................................................................................................................... xix

1 Introduction......................................................................................................1
1.1 Who Can Benefit from This Book?...................................................... 1
1.2 General Explanation Regarding the Book.......................................... 2
1.3 Axioms.....................................................................................................4

2 Clarifications of General Terms...................................................................7

2.1 Introduction............................................................................................ 7
2.2 Management and Engineering............................................................ 7
2.3 Hazard, Threat, and Risk...................................................................... 8
2.4 Two Types of Safety............................................................................... 9
2.5 Quality versus Safety.......................................................................... 10
2.6 Safety versus Security......................................................................... 14
2.7 Oversight versus Audit....................................................................... 14
2.8 Inspection versus Audit...................................................................... 15
2.9 Compliance versus Conformance...................................................... 16
2.10 What Is a Management System?........................................................ 17
2.11 Establishing a Management System.................................................. 18
2.12 Understanding Procedures................................................................. 19
2.13 Records.................................................................................................. 20
2.14 AMC.......................................................................................................22
2.15 Validation versus Verification............................................................ 23
2.16 Safety Case............................................................................................ 24
2.17 Human Factors (HF)............................................................................ 25
2.18 Mistake versus Error........................................................................... 26
2.19 Just Culture........................................................................................... 27

3 Regulation....................................................................................................... 31
3.1 Introduction.......................................................................................... 31
3.2 How to Pass a Regulation?.................................................................. 31
3.3 Accreditation, Certification, Licensing, Attestation, Approval......... 34
3.4 Standards versus Recommendations................................................ 38
3.5 Regulation and Regulators................................................................. 39
3.6 “Grey Area” of Regulation.................................................................. 40
3.7 Regulation and Auditors..................................................................... 41
3.8 Post-holder............................................................................................42

v
vi Contents

3.9 “Personality” of Regulators................................................................44

3.10 Who to “Blame” If There Is Non-Compliance?............................... 47

4 Types of Audits.............................................................................................. 51
4.1 Introduction.......................................................................................... 51
4.2 Internal Audits..................................................................................... 51
4.3 External Audits..................................................................................... 56
4.3.1 Second Party Audits............................................................... 56
4.3.2 Third Party Audits.................................................................. 57
4.3.2.1 Categories of Third Party Audits.......................... 58
4.4 Frequency of Audits............................................................................ 60

5 Companies and Audits.................................................................................63

5.1 Introduction..........................................................................................63
5.2 “Personality” of the Company...........................................................64
5.3 Understanding the Audit of the Company...................................... 67
5.3.1 What Is the Purpose of the Audit?....................................... 67
5.3.2 How the Companies Are Reacting to Audits..................... 69

6 Check Lists (CLs)........................................................................................... 73

6.1 Introduction.......................................................................................... 73
6.2 Two Types of Check Lists.................................................................... 75
6.2.1 Target Check Lists................................................................... 75
6.2.2 Audit Check List..................................................................... 78
6.3 What to Do with Filled Audit CLs?................................................... 82
6.4 Compliance and Non-Compliance....................................................83
6.5 Audit Software..................................................................................... 86

7 Management of Findings............................................................................. 89
7.1 Introduction.......................................................................................... 89
7.2 Findings................................................................................................. 89
7.3 Objective Evidence...............................................................................90
7.4 Type of Findings................................................................................... 93
7.5 How to Present the Findings?............................................................ 96
7.6 What Is Next?........................................................................................ 97

8 Preparation for Audit.................................................................................... 99

8.1 Introduction.......................................................................................... 99
8.2 Schedule of Audits............................................................................. 101
8.3 Establishing the Audit Team............................................................ 102
8.4 Organizing the Approval Audit...................................................... 103
8.4.1 Documentation Audit.......................................................... 104
8.4.2 Preparing On-Site Audit...................................................... 106
8.4.3 Executing On-Site Audit...................................................... 109
Contents vii

8.5 Sampling............................................................................................. 110

8.5.1 How to Choose a Sample?................................................... 112
8.5.2 How to Use Sampling in Audits?....................................... 114

9 Conducting the Audit................................................................................. 117

9.1 Introduction........................................................................................ 117
9.2 How to Do Auditing?........................................................................ 117
9.2.1 Auditing Documentation..................................................... 117
9.2.2 Auditing Equipment............................................................. 119
9.2.3 Auditing Employees’ Qualifications.................................. 121
9.2.4 Auditing Safety Policy......................................................... 122
9.2.5 Auditing Safety Objectives.................................................. 126
9.2.6 Auditing Procedures............................................................ 128
9.2.7 Auditing Records.................................................................. 131
9.2.8 Auditing Preventive and Corrective Maintenance.......... 134
9.2.9 Auditing Preventive and Corrective Actions................... 136
9.2.10 Auditing Management of Change...................................... 137
9.2.11 Auditing Alarm Systems..................................................... 139
9.2.12 Auditing “Chronology of Events”...................................... 141
9.2.13 Auditing Human Factors (HF)............................................ 143
9.2.14 Auditing Process of Monitoring of SMS............................ 144
9.2.15 Auditing Training in the Company................................... 145
9.2.16 Auditing Handling, Storage, and Shipping...................... 146
9.2.17 Auditing Internal Audits..................................................... 147
9.2.18 Auditing Outsourcing and Partner Companies............... 148
9.3 Final Report........................................................................................ 149
9.4 What Next?.......................................................................................... 152
9.5 The Regulator and the Outcomes from the Audits....................... 152

10 “Challenges” for the Auditor during Audits......................................... 155

10.1 Introduction........................................................................................ 155
10.2 Time Gap............................................................................................. 155
10.3 Not Following the Audit Schedule.................................................. 158
10.4 Company Does Not Allow Access to Some Premises.................. 158
10.5 Company Is Lying.............................................................................. 159
10.6 Auditor Found Something Which Is Not in Target CLs.............. 160
10.7 There Is Not Enough Staff in Company to Maintain
Safe Operations.................................................................................. 161

11 Profile of the Auditor.................................................................................. 165

11.1 Introduction........................................................................................ 165
11.2 What Is Important for the Auditor?................................................ 166
11.3 Yearly Assessment of Auditors........................................................ 167
11.4 Improvements of Auditors................................................................ 169
viii Contents

11.5 Things for Which a Good Auditor Must Take Care..................... 169
11.6 Qualities of Auditor........................................................................... 171
11.6.1 Training in Audits................................................................ 172
11.6.2 Time Management................................................................ 172
11.6.3 Honesty.................................................................................. 173
11.6.4 Independence........................................................................ 174
11.6.5 Impartiality............................................................................ 174
11.6.6 Communication..................................................................... 175
11.6.7 Flexibility............................................................................... 176
11.6.8 Trustworthiness.................................................................... 177
11.6.9 Decisiveness........................................................................... 178
11.6.10 Analytical and Understanding........................................... 178
11.6.11 Persistence.............................................................................. 178
11.6.12 Trust in the Instincts............................................................ 179
11.6.13 Commitment and Determination....................................... 179
11.6.14 Professionalism..................................................................... 180
11.6.15 Team Work............................................................................. 180
11.7 The Most Important Thing!.............................................................. 181

Final Words ......................................................................................................... 185

Appendix: Axioms.............................................................................................. 187
Index...................................................................................................................... 189
Acronyms and Abbreviations

ADP Automatic Data Processing

AIS Aeronautical Information Services
AMC Acceptable Means of Compliance or Alternative Means of
Compliance
ANSP Air Navigation Service Provider
ATC Air Traffic Control
ATCo Air Traffic Controller
BP British Petroleum
CAA Civil Aviation Agency
CLs Check Lists
CNS Communication, Navigation, Surveillance
COM Communication
DFS Deutsche Flugsicherung
DGCA Directorate General of Civil Aviation
DME Distance Measuring Equipment
EASA European Aviation Safety Agency
FAA Federal Aviation Administration
FMS Financial Management System
GCAA General Civil Aviation Authority
GP Glide Path
HF Human Factors
HSE Health, Safety, and Environment
IAEA International Atomic Energy Agency
IANS Institute of Air Navigation Services
IATA International Air Transport Association
ICAO International Civil Aviation Organization
IT Information Technology
ISO International Organization for Standardization
LLZ Localizer
LMS Logistic Management System
MET Meteorological Services (in aviation)
MRO Maintenance, Repair, and Overhaul (Maintenance and Repair
Organization)
MTBF Mean Time Between Faults (Failure)
MTC Military Technological College
MTTR Mean Time To Repair
NAVAIDs Navigational Aids
NTSB National Transportation Safety Board
QMS Quality Management System
PMS Production Management System

ix
x Acronyms and Abbreviations

RDL Radiation Dose Limit

RPN Risk Priority Number
SAR Search and Rescue
SeMS Security Management System
SMS Safety Management System
SSP State Safety Program
SUV Sport Utility Vehicle
USOAP Universal Safety Oversight Audit Program
VHF Very High Frequency
VOR VHF Omnidirectional Range
Definitions of the Terms Used

Term Definition
Risky Industry These are the industries which can produce damage to, or deaths of,
humans, assets, and the environment (on a large scale!) by their
production process, by their products, by the processes of providing
services, or by services provided. Such industries are nuclear, chemical,
pharmaceutical, aviation, food industry, medical, etc.
Regulation This is a sum of laws, rules, standards, or procedures which are accepted
by a particular authority in the State and/or on the international level.
Regulator This is a body established by the State (as part of the State
Administration) which is tasked with, and responsible for, passing and
overseeing the fulfilment of regulations in a particular area in the State.
Audit One of the tools used to oversee the Management Systems (quality,
safety, environmental, financial, etc.) in an industry. It is a process of
overseeing (checking) the performance of various companies in the
industry to check have they implemented, monitored, controlled, and
maintained any Management System.
Auditor Person employed by the Regulator. This person is educated, trained, and
skilled in providing regulation and auditing the activities of the
companies in the areas of responsibility of that Regulator.
Auditee Person or entity (company) which is subject to auditing.
Audit Team This is a team of auditors established to do auditing in the company
because the audit is a complex job and one auditor cannot do it alone.
Incident This is an event which produces harm to humans (animals, nature, etc.)
and damage to assets.
Accident This is an event which produces deaths for humans (animals, nature,
etc.) or total damage to assets (they cannot be repaired and cannot be
used anymore!).
Post-holder This is a position in the company (in a Risky Industry!) which can be
given to the person who is subject of Approval from the Regulator.
Hazard It is a situation which has the capability of producing harm or death to
people and damage or destruction of the assets.
Risk When the hazard is quantified regarding the severity (how strong the
consequences are, if it happens) and frequency (how often it can
happen), we are speaking about Risk.
Risk Management It is the sum of processes for Hazard Identification, quantification of
hazards to obtain the Risks, risk elimination and/or risk mitigation,
preventive and/or corrective actions, sharing of safety-related
information, etc.
Fault It is a term used to express a problem with the equipment which causes
equipment to stop functioning, or the equipment to stop functioning
within specified tolerances for normal functioning. Fault is connected
only with equipment!

(Continued)

xi
xii Definitions of the Terms Used

Term Definition
Failure It is a term used to express problem with an operation which is not
conducted at all or is not within specified tolerances. Failure is
connected only with operations. It is not always the case, but the faults
of equipment can produce failures.
Preventive These are actions executed by the company with the intention to
Actions eliminate or mitigate the risk which was registered, and a particular
analysis (done in advance!) showed that it can materialize if not
treated. Simply put, these are actions which are done in advance to
eliminate or mitigate the risks.
Corrective These are two types of actions:
Actions (a) Actions undertaken to fix a particular problem in the company
which can possibly be the cause of incident and/or accident in the
future or to fix non-compliance in the Management System.
(b) Actions undertaken when an incident or accident happened and the
consequences must be eliminated or mitigated.
Verification This is the process of checking, testing, or approving some product,
service, and/or Management System which specifications are
requested by some international standard or by some regulatory
requirements.
Validation This is the process of checking, testing, or approving some product, service,
and/or Management System for which specifications are not requested by
some international standard or by some regulatory requirements, but are
actually the product of a design by the company itself.
Accreditation This is a formal process of recognition that a company or an individual
is capable of doing particular job in accordance with standardized
specifications (standards!).
Certification This is a formal process of recognition that a company or an individual
has achieved something which can be expressed by a particular level of
excellence, education, implementation, or status.
Attestation This is a formal process of recognition that a product is satisfying the
specification required by particular standard in that area.
Approval This is a formal process for approving a particular company or
individual to do their job.
Mistake A mistake is usually an outcome from a bad human choice. It is
connected to free Human choice, usually when the lack of proper
information, lack of understanding, or lack of knowledge is present.
Error Error can be made by humans and equipment and is connected with the
malfunction of something which is assumed to be OK (a code in
computer software, an operation (human and equipment), a rule
(human), etc.).
Safety Event This is any event which, if it happens, will increase the belief that the
safety performance of the company experiences problems.
Compliance The level of accordance of the performance of the company with the
regulation in that area.
“Personality” This is a term which applies to the Regulator and to companies. The
“Personality” of the Regulator can be defined as a combination of
attitude, style, and character in doing oversight activities. The
“Personality” of the company can be defined as a combination of
attitude, style, and character of doing business.
Definitions of the Terms Used xiii

Term Definition
Effectiveness It can be defined as the level of success of a particular process, operation,
activity, task, etc. Effectiveness is achieved if the particular process
(operation, activity, task, etc.) is successfully finished or it can be stated
that the process (operation, activity, task, etc.) was successful to a high
level, for example: The process was 93% successful.
Efficiency This is an economic category and it can be roughly defined as the ratio
of resources and production in the company. The more production and
fewer resources, the better the company is (more profit is gained!).
Objective For the purpose of auditing, it can be defined as data (in the form of
Evidence records, written statements or commands, measurements, reports, etc.)
presented to the auditor which will prove that the company is doing
(or not doing!) what is required by regulation.
Scope of Audit This can be defined as a measure for quantification and quality of details
which will be considered during the audit. It depends from the type of
audit.
Briefing This is a meeting where short information is provided or explained to
the employees regarding some issue, some activity, or some change.
Change This is a change of the operation, activity, procedure, equipment,
software, facility, employee, etc. for a new one.
Modification This is also a change, but it affects just a part of the operation, activity,
procedure, equipment, software code/program, facility, employee, etc.
that is changed with the new one or to a new setting.
Warning Signal (light, sound, etc.) which is triggered when the value of
something dangerous (temperature, radioactivity, concentration of
gasses, etc.) is coming close to the value when the control over the
process can be lost, or the process (if continued) will reach values to
damage humans, assets, or the environment.
Alarm Signal (light, sound, etc.) which is triggered when the value of
something dangerous (temperature, radioactivity, concentration of
gasses, etc.) is exceeding the value when control over the process can
be lost, and the process (if continued with these values) will damage
humans, assets, or the environment.
Measurand For the purposes of this book, the measurand is a value (temperature,
radioactivity, concentration, etc.) which is measured to provide
information regarding the normal performance of the processes
(operations, activities, etc.) in Risky Industries.
Preface

I am shocked by the fact that in the engineering community in industry, there

is a huge lack of proper understanding about quality! I am also shocked by
the fact that in the engineering community in Risky Industries, there is huge
lack of proper understanding about safety!
I started my “journey” in the area of Quality and Safety by command: One
day in the summer of 2005, my boss came into my office and told me: There
is a requirement from EUROCONTROL* to implement a Safety Management
System (SMS) in our company and I choose you to undertake the responsibil-
ity to implement it in the Technical Department. At that time, I was working
in the Planning and Development Department of the Civil Aviation Agency
in the Republic of Macedonia, and I was familiar with the newest develop-
ments in aviation regarding improvements of safety. I was aware that this
was a big movement forward for aviation subjects, but I wondered why we
were implementing an SMS when a Quality Management System (QMS) can
provide excellence in our operations.
The “journey” into the safety area which started that summer in 2005, I
am still travelling today! Of course, (later) I realized why we need Safety
Management and why Quality Management alone cannot provide better
safety in all Risky Industries.†
Later, in my professional life, I had a few positions which were connected
with implementations, maintenance, and auditing of the QMS and the SMS,
and I do believe that I have reached a level of knowledge, skills, experience,
and attitude in areas of Quality and Safety which make me satisfied. The
point is that by increasing my knowledge and experience, I noticed that
most of the people (in general) involved in industry do not understand
what Quality and Safety are. I started to provoke discussions on Safety and
Quality forums on the internet with the intention of improving understand-
ing, but it was also a chance for me to gather new knowledge and new expe-
rience through these discussions.
In 2014, I started to work for the Military Technological College (MTC) in
Muscat (Oman) as Senior Instructor EASA.‡ Our Aeronautical Department
was approved as an EASA Part 147 Training Organization and we were the
subject of EASA Regular Audits each year. Having in mind that by that time,
I had already 12 years’ extensive experience in the Quality and Safety areas,

* EUROCONTROL is the European Organization for the Safety of Air Navigation, with its
headquarters in Brussels, Belgium.
† Risky Industries are aviation, transport, nuclear, chemical, petroleum, pharmaceutical, med-

ical, etc. All industries which can produce extensive damage or deaths of Humans, assets,
and the environment are classified as Risky Industries.
‡ EASA is the European Aviation Safety Agency.

xv
xvi Preface

I could not just run away from my “safety attitude.” As an EASA Part 147
approved organization, we had to implement a QMS and an SMS, but in
my humble opinion, these systems were implemented in a very wrong way.
I tried to explain to my Head of Department that things were wrong, but
it just brought me problems which made me quit that job later. I thought
that maybe the EASA auditors would point to elementary deficiencies of our
QMS and SMS, but that was another shock for me: The two auditors, during
two different audits, did not registered any non-compliance!
I was very, very, very disappointed by EASA.
In 2015, I received an invitation to attend the Conference of Air Transport
Operations (CATO 2015) and I submitted a paper with fresh examples of sig-
nificant misunderstanding of Quality and Safety in airlines and MROs. After
the presentation of the paper, a young PhD student from Deutsches Zentrum
für Luft- und Raumfahrt (DLR) from Braunschweig sat next to me during
lunch and said: I am shocked by your presentation. I asked him did he have
some arguments against my presentation, so we could discuss that and he
responded: No, I am shocked by the fact that whatever you said makes sense.
If the EASA, as one of the well-recognized and respected organizations
regarding aviation safety in the world, cannot provide proper training for
their auditors, then there is huge gap in aviation safety. And this is inten-
tion of this book: To fill a gap in regulatory auditing, by providing knowl-
edge and advice to the Regulators (and their employed auditors!) of Safety
Management Systems to do their job as it needs to be done!
Am I qualified to write this book?
Let’s see my “credentials:”

• I have been working in the area of Quality and Safety in industry for
the last 15 years.
• I have passed the exam for the SAF AUDIT course in EUROCONTROL
IANS.
• I have passed exams for ICAO* USOAP† CMA Phase 1 and ICAO
USOAP CMA ANS courses.
• I am an Internal Auditor of ISO/TS 16949 and a Lead Auditor of ISO
14001.
• I have worked as a Safety Auditor/Advisor in CAA of Macedonia.
• I have worked as a QMS Manager in a Hi-Tech Corporation (Skopje,
Macedonia) where I implemented ISO/TS 16949 and AS (EN) 9100
and integrated them with the already implemented ISO 9001 (which
was “reshaped” before integration!).

* ICAO is the acronym for the International Civil Aviation Organization (the specialized UN
agency for aviation).
† USAOP stands for the Universal Safety Oversight Audit Program of ICAO.
Preface xvii

• I have “survived” two external audits in the Hi-Tech Corporation (by

auditors from Denmark and Serbia) for the Management Systems
which I implemented in the Hi-Tech Corporation and there were no
findings of non-compliance.
• I have worked as QA & Safety Manager (Post-holder) in Travel Air
(airline from Madang, Papua-New Guinea) where, in few months,
Copy-Pasted QMS and SMS from Quantas (Australia) were adapted
to the reality of Travel Air.
• I have worked as a CNS Expert for ICAO in New Delhi (India) where
I was helping DGCA of India to “establish safety oversight capabil-
ity” in the area of CNS.
• I have held two courses on Modern Audit Techniques in Indian
Aviation Academy in New Delhi.
• I have provided two on-the-job training sessions for ten of DGCA’s
CNS inspectors in India.
• I have already published two books in the USA regarding Quality
and Safety.

So, yes: I do believe that I am competent for the job!

I hope the book will provide enough good material, and it will help (by fol-
lowing my recommendations inside) to provide excellent audits which will
satisfy Regulators (auditors) and the companies (auditees).

Sasho Andonov
Author

Sasho Andonov is a Graduated Engineer in Electronics and

Telecommunications and has earned a Master’s Degree in Metrology and
Quality Management at Ss. Cyril and Methodius University in Skopje, North
Macedonia. Sasho has 24 years’ experience in aviation, especially in the area
of ATM/CNS and Quality and Safety Management, and 14 years’ experi-
ence in standardization and accreditation. He is a member of the technical
board in the electro-technics, information technology, and telecommunica-
tions area of the Institute of Standardization of Republic of Macedonia and
a member of the Sectors Committee for electrics, electronics, and electrical
machines of the Institute of Accreditation of Republic of Macedonia. Sasho
has contributed to 13 international conferences and symposiums, with his
papers mostly in the areas of satellite navigation, calibration and safety,
and quality management. He has already published two books: Quality-I is
Safety-II: The Integration of Two Management Systems and Bowtie Methodology:
A Guide for Practitioners.

xix
1
Introduction

1.1 Who Can Benefit from This Book?

This book is dedicated primarily for the auditors of Regulators in Risky
Industries. The intention of this book is to explain to these auditors what is
the audit’s purpose and how the audit must be conducted to provide a Win-
Win situation. By a “Win-Win situation,” I mean: The Regulator is doing its
job and the regulated company is happy with the overall performance!
Whatever you think about auditing, keep in mind that it is a complex activ-
ity, and to get real benefit from the audit, it needs to be conducted in the way
which I define as a way of producing Art! Similar to the artist who strives
to produce a masterpiece, the auditor must first become enough mature in
knowledge, skills, and experience. After that, there are activities of prepara-
tion and there are activities of conducting the audit. As the particular dedica-
tion, attitude, skills, knowledge and experience are needed from the master
artist, all these attributes are needed also from the auditor. As the artist puts
a lot of effort into creating his masterpiece, so the auditor must put a lot of
effort into providing a good audit.
Although it is a book for Safety Regulators, it applies for all types of audits
done in the general meaning of the term “industry.” Of course, any other
industry (different from Risky Industries) has its own specifics which have
to be taken into account during consideration of recommendations inside
this book. Proper understanding of everything mentioned in this book will
provide enough confidence to use this book in any other industries.
The main point with Risky Industries is that they are very well-regulated,
so if there are rules on what to ask during the audit, it is easy to conduct the
audit. Satisfying regulatory requirements for stronger regulation (as it is in
Risky Industries) will help companies from other industries to deal with less
strong regulation, as it is in their areas. And that is the reason that this book
is a good tutorial for all types of auditors of any management system in all
different parts of the industries.
I will try to explain in this book all the aspects of audits in a narrative way.
Anyway, I will present some axioms (in bold and italic in the text!) which
must not be violated! I will use my knowledge and experience gathered

1
2 T he Art of Safety Auditing

through my 20 years of professional life in aviation and industry, especially

in the area of quality and safety management from the regulatory, service,
and/or manufacturing point of view.
The book is dedicated primarily to Safety Regulator employees. How they
establish their attitude in the particular Risky Industry is the way the regu-
lated companies will behave. If the Safety Regulators earn the respect of the
regulated companies, then they can be successful in overseeing the safety
performance of the companies. The highest level of regulation behavior
in the State Safety Regulators must provide an atmosphere of dedication,
knowledge, skills, and attitude which, naturally, will be transferred to the
regulated companies. In general, the Regulator’s behavior overall can pro-
duce a lot of benefits or a lot of damage.
The book is written in a general style. There are many things which are
explained inside and all this is done having in mind good practice in con-
ducting audits. The reader can decide in many areas what to do. I tried to
produce a holistic book about regulation and audits and I put there a lot of
things (mostly explanations) why these things need to be done. As I men-
tioned in the Preface, I have seen a lot of misunderstandings regarding
audits, and I tried to clarify in this book what, and why, they are wrong.
From another side, I tried to emphasize good things which must be main-
tained to provide a good audit.
This is a book which needs to be read more than once. Reading just once
will not make you a good auditor, so this is more a manual than a book.
This book can also bring benefit to the companies which are subject of
safety regulation, especially for their managers. Providing safety is team
work and the necessary partnership between Regulators and companies is
of utmost importance. Without this partnership, where everybody is aware
of their responsibilities and duties, any type of safety can hardly be as effec-
tive and efficient as it has to be.

1.2 General Explanation Regarding the Book

What is an audit?
If you go on the internet and write “what is an audit,” you will have
approximately a few hundred thousand hits. There are different definitions,
some of them general and some of them sticking to a particular area (finan-
cial, quality, internal, etc.). For the purpose of this book, I will define the
safety audit as a process of examination (checking) of various companies in
Risky Industries to see if they have implemented, monitored, controlled, and
maintained a Safety Management System.
The process of auditing applies to the documentation and to the real situ-
ation in the company, so it must be done off-site (documentation) and on-site
Introduction 3

(implementation, monitoring, control, and maintenance). Whatever you are

thinking about audits, it is important to understand that auditors check the
capability of the company to maintain control over production processes
without endangering humans, assets, and the environment with its products
or with the services offered.
The process of auditing, especially in Risky Industries is a complex activ-
ity. It comes from a more complex area called Regulatory Oversight. Audit
is just one part of the oversight activities and it bears the same complexity
as other oversight tools. Having in mind that auditing is a complex activity,
there is a need for an Audit Team which will do the audit. The Audit Team
consists of a Team Leader* and Team Members (auditors).
So, this book is also complex in its constitution. I will speak about different
things and you must understand that all these different things have different
meanings when they are alone, and when they are just part of the whole pro-
cess of auditing. Please keep in mind that there is a need for all these parts to
be synthesized in one whole activity called auditing.
There is another aspect of this book which I would like to emphasize. This
is in regard to the terms used today in the industry and regulation: There is
complete chaos and for the same thing, there are a few names which some-
times could be pretty much contradictory. So, in the next chapter, I will try to
explain these “ambiguities” regarding particular terms and I hope it will be
accepted in the regulatory and manufacturing community.
I will try to express the facts and my opinions and eventually, you will
decide by yourself how it will change your understanding of audit activities.
Anyway, this book is written from the practical point of view and it is based
on my, and others’, practical experiences. Please, keep that in mind when you
read the book!
This is a place where I would like to give some general explanation of
the terms used in this book. I find it very important because the book is
written to be international, so different States, organizations, and/or Risky
Industries will use different terms.
As is mentioned in the Definition chapter, by the term Risky Industries,
I will understand the industries like aviation, transport, nuclear, chemical,
petroleum, pharmaceutical, medical, etc. In general, these are industries
which can produce harm and/or damage to the assets and environment and
harm and/or death of humans. These industries are very well regulated, and
there is regulatory requirement for each subject belonging to them, to estab-
lish, implement, maintain, and continually improve the Safety Management
System (SMS).
I will use the word “Regulator” for the State entities which are estab-
lished by each country as a part of the State administration with the task of

* Somewhere in the literature, you can find the expression Lead Auditor for the Team Leader.
There is nothing wrong with that, but I prefer to use the expression Team Leader for the per-
son who is in charge of Audit Team.
4 T he Art of Safety Auditing

overseeing the subjects belonging to Risky Industries. It can be any type of

agency, directorate, department in the ministry, or whatever it is named by
particular State.
I will use word “State” with capital first letter with the meaning of state
(country), such as USA, Germany, United Kingdom, etc. This meaning is dif-
ferent to the meaning of the word “state” as a situation, position (state of
being OFF or ON or on standby for Equipment, or being healthy or ill with
Humans), or verbal activity.
An auditor is a person who is doing the audit and could be employed by
the Regulator, or he or she can be employed by a company which provides
auditing services for the Regulator in a particular State in accordance with a
signed contract. An auditee is a company (department, unit, or person) being
audited.
I will use word “counterpart” for a company’s employee who joins the
auditor during the audit. During the audit, each auditor must be accompa-
nied by such a person who will help the auditor. This person will provide
valuable information for the auditor, and in addition, he will provide access
to the company’s premises and restricted areas during audits.
I will use word “equipment” with the meaning of hardware, software, and
aggregation of the hardware and software (systems!) for the machines, tools,
instrumentation, and whatever else is used in the company for manufactur-
ing products or offering services. This is important to understand, because
there are rules on how the hardware of the Equipment must be manufac-
tured in Risky Industries, and the companies mostly follow these rules. But
there are also rules on how the software should be produced and certified,
and these rules are not always followed.
I will repeat a few times the same things in different places in the book. I
found the expression “Repetitio est mater studiorum” (translation from Latin:
Repeating is mother of learning) very useful during my “teaching sessions”
with students, technicians, and engineers in my professional career, but the
real reason for repeating them is that mostly these things have different con-
texts in different areas.

1.3 Axioms
Axioms are statements which come from mathematics. They are used there
to provide statements which are accepted as TRUE and as such, they do not
need to be proved. So, in this book, I am using axioms as statements regard-
ing the audit rules which must be followed to provide a good audit.
Whatever you think about the axioms in this book, some of these axioms
are connected with rules which need to be followed, and some are just state-
ments which need to be accepted by the Regulator and by the company as
Introduction 5

an audit policy. This audit policy will help the Regulator to establish good
regulation and good Oversight of companies in the “fair game” which they
“play” with the companies in the area of safety.
The Regulator and the company must build respect for each other through
their ongoing cooperation and this “fair game” is product of this respect. By
the term “fair game,” I mean: Providing an impartial, balanced, and real-
istic audit as part of the overall oversight process which will contribute to
improvement of safety. This “fair game,” as I have said before, must be a
Win-Win situation: After the audit, both the Regulator and the company
must feel good.
Following the axioms is obligatory: I do believe that neglecting any of the
axioms will endanger the overall process of auditing.
2
Clarifications of General Terms

2.1 Introduction
There are terms and things which each person must understand to be a
safety auditor. Generally speaking, the auditor is not a guy with huge knowl-
edge or experience in particular area. It is a guy who understands the Safety
Management System (SMS) and who understand companies which are the
subject of safety auditing. As my old professor of electronics from university
used to say: The auditor does not need to be a chicken to lay an egg, but he
must have the capabilities and knowledge to determine which egg is good
and which one is bad!
That is the reason that I will try to provide some introduction to clarify the
terms and things which will be used by safety regulatory auditors during
the audits.

2.2 Management and Engineering

There is a considerable difference between Management and Engineering.
Roughly speaking, Management is the process of planning, implementing,
monitoring, controlling, and managing resources in a company for achiev-
ing company goals in a particular area. All these activities are conducted by
humans. Whatever resource the company would like to plan, implement,
monitor, control, or direct, the company will need humans called “employ-
ees.” Even in the High-Tech companies, which have extremely high levels of
complex equipment and automation, the companies need humans (employ-
ees) to analyze data and/or at least to maintain the equipment.
Engineering has two definitions. One defines Engineering as the transfor-
mation of science into practice and another defines it as a way to establish,
implement, and conduct manufacturing or some other type of process.
The main point is that Management is conducted by humans and Engineering
is conducted by equipment. So, in the area of auditing management systems,

7
8 T he Art of Safety Auditing

the emphasis should be on humans, not on equipment. Equipment should

be considered only in the context of human influence on the outcome of pro-
cesses where equipment is used. For example, in every Risky Industry, there
are strong regulations and recommendations regarding equipment perfor-
mance, established through regulatory requirements regarding availability,
reliability, accuracy, precision, integrity, continuity of service, etc. All these
requirements are in regard to the equipment, but also, they give informa-
tion about human performance in the context of equipment functioning.
Checking compliance with these requirements, the auditor checks humans:
Are humans capable of setting, conducting processes, calibrating and main-
taining the equipment with regard to these requirements? If not, they are
lacking understanding of their processes and their equipment.
Let’s elaborate this more thoroughly:
I have had a driving license for 25 years and I have driven a car in different
countries. I have had only three small incidents where some small damage
to my car was fixed without any big problems and I can say that I am not
so bad as a driver. But having a Formula 1 car will not make me competi-
tive in the F1 championship, simply because having a good car (equipment)
is not enough to produce good results (products, services). I need support
expressed through other humans which will deal with settings, mainte-
nance, race support, training, logistics, etc. So, having the best equipment
is not enough for good results. Humans using this equipment need particu-
lar knowledge, skills, experience, and attitude for good results. If all those
things are structured and organized in a systematic way, it means that the
companies need a management system.
Generally, I can say that Engineering (equipment) in the companies is sup-
ported by Management (humans).

2.3 Hazard, Threat, and Risk

Speaking about safety, we must start from the basics.
Everybody employed in a Risky Industry must understand and differ-
entiate between Hazards, Threats, and Risks. In SMS regulation, there is a
requirement for each subject to have a process of hazard identification and
risk assessment. In addition, they must produce list of hazards identified and
risks calculated and assessed.
A hazard is a situation which can produce harm or death to people and
damage or destruction of assets. There is hazard in driving a car (you can
have a crash!), but it does not necessarily mean that it will happen every time
you drive your car.
In quantifying the hazards regarding the severity (how strong the conse-
quences are if it happens) and frequency (how often it can happen), we are
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[669] Thirty-eight palmos long. Herrera, dec. ii. lib. x. cap. iii.

[670] According to Bernal Diaz this commission was arranged by the combined
influence of Olmedo and Duero, during Olmedo’s second visit to the camp. The
friar appears, however, to have been there but once, when he was expelled.
Knowing Salvatierra to be a blusterer, Bermudez, the alguacil mayor, proposed
that he should join the commission, but his intended victim, not caring to trust
himself within the power of Cortés, pleaded sickness and a dislike to speak with a
traitor. ‘Señor Veedor,’ chimed in Olmedo, ironically, ‘best it is to be prudent, and
you may have him prisoner before long.’ Hist. Verdad., 93.

[671] Duero was to receive the share of treasures claimed, a command in the
expedition equal to that of Cortés, and after the conquest a grant of towns similar
to his own. As a further inducement, sufficient gold was given to load his two
Cuban servants. On taking leave of the general, on pentecost morning, Duero
asked: ‘What has your worship to say, before I leave?’ ‘God be with you,’ was the
reply, ‘and see to it, Señor Duero, that it be done as arranged, or by my
conscience [Cortés’ favorite oath] I’ll be in your camp within three days, with all my
companions, and the first to receive the lance will be your worship, if I see aught
contrary.’ Bernal Diaz, Hist. Verdad., 94. Monjaras states that Duero and Leon
warned Cortés against opposing Narvaez’ army and commission. Cortés,
Residencia, ii. 49.

[672] Cortés to remain governor of the part to be allotted him till the king should
decide. Tapia, Rel., in Icazbalceta, Col. Doc., ii. 588. According to Gomara, who
sends Veedor Álvarez Chico, Juan Velazquez, and Juan del Rio, to carry the
message, Cortés proposed a private interview for the discussion of two points,
whether Narvaez would leave Mexico to him and go to Pánuco or elsewhere,
aided by Cortés with gold and supplies, or whether Narvaez preferred to take
Mexico and give him 300 or 400 men wherewith to pass on to new conquests.
Hist. Mex., 144. The last proposal could only have been a trap to secure Narvaez’
men. Prescott chooses to omit the proposal for an interview, and sends instead
the ultimatum with Duero, a glaring disregard of Cortés’ own text, as confirmed by
others. Cortés, Cartas, 121-2; Oviedo, iii. 314.

[673] ‘Dize Narvaez, y en todo su Real ay fama, qui si U. merced [Velazquez] vá

allâ, que luego yo [Cortés] soy deshecho.’ Bernal Diaz, Hist. Verdad., 95.

[674] Bernal Diaz states that Cortés made the request in a manner that appeared
to Velazquez an attempt to probe his loyalty. He therefore refused to take any
valuables with him, but was finally persuaded. Juan del Rio, Cortés’ equerry, kept
him company.
[675] Bernal Diaz adds that, these efforts being observed by Salvatierra, Narvaez
was urged to seize Velazquez, and this would have been done but for the
representations of Duero and others. During the dinner given in his honor, Captain
Diego Velazquez, nephew of the Cuban governor, alluded in one of his remarks to
Cortés as a traitor. The guest appealed to Narvaez against such expressions.
Diego repeated the term, and added that Juan did not deserve to bear the name
Velazquez. Grasping his sword the latter retorted, calling him a liar. He would
prove himself a better man than either uncle or nephew, if permission was
granted. The others had to interfere to prevent the clashing of swords, and
Narvaez was persuaded to order the turbulent visitor away. At leave-taking the
general showed his annoyance, and said that it would have been better had he not
come. Diego Velazquez, who stood by his side, added a threat, to which Juan
rashly retorted, with a twirl of his beard: ‘Before many days I shall see if your
prowess equals your boast.’ Alarmed at his want of self-control, Duero and other
sympathizers hurried him away before he could utter any more indiscretions. He
and the equerry had hardly left camp before some horsemen appeared, as if in
pursuit, and caused them to increase their pace. Hist. Verdad., 95-6; Herrera, dec.
ii. lib. x. cap. i.

[676] Cartas, 122. Bernal Diaz assumes that the proposal for an interview came
from Narvaez, through Duero, to whom he also confided the intended treachery.
Olmedo, who had pretended to be won over, was also informed. Hist. Verdad., 93.
Herrera supposes that Sandoval warns Cortés, who, according to Gomara, is still
at Mexico when the proposal comes. Hist. Mex., 144. Solis is more correct in
ascribing the warning to Duero. Hist. Mex., ii. 83.

[677] The fact that he allowed such dangerous men as Velazquez de Leon and
Olmedo to go free indicates that he harbored no treachery.

[678] Gomara sends them with Velazquez de Leon. Hist. Mex., 144. ‘Chico, é
Pedro Hernandez, escribano.’ Demanda de Ceballos, in Icazbalceta, Col. Doc., i.
440. Velazquez having gone on a mediatory mission, Chico must have been sent
after his departure.

[679] ‘La respuesta ... fué prender al escribano y á la persona que con mi poder ...
los cuales estuvieron detenidos hasta que llegó otro mensajero que yo envié.’
‘Escribí una carta al dicho Narvaez y otra á los terceros, diciéndoles cómo yo
habia sabido su mala intencion.’ Cortés, Cartas, 122-3. The reference to a
messenger indicates Cortés’ meaning to be that Chico preceded Velazquez de
Leon. Gomara assumes that Cortés’ pretext for withdrawing the proposal for an
interview was that Narvaez had declined to entertain the points to be there
discussed. See note 19. Chico had warned him of the intended treachery. Hist.
Mex., 144. ‘Y que supiesse que no auian de cantar dos gallos en vn muladar, y
que aparejasse las manos.’ Herrera, dec. ii. lib. ix. cap. xxi. Bernal Diaz sends the
message with Olmedo, ‘since no royal notary dare carry it,’ and gives Narvaez
three days in which to send in any commission he may possess signed by the
king. Without such commission he must leave the country, or Cortés will seize him
and inflict punishment for the outrage on Aillon and on the Indians. This ultimatum
was signed also by the captains and some soldiers, including Bernal Diaz. Hist.
Verdad., 92-3. An answer was demanded through the same messengers. Tapia,
Rel., in Icazbalceta, Col. Doc., ii. 588.

[680] ‘Daria dos mil pesos, a quien matasse a Hernando Cortes, o a Gonçalo de
Sandoual.’ Herrera, dec. ii. lib. x. cap. i. ‘Traia mandado de Diego Velazquez que
á mí y á ciertos de los de mi compañía que ... nos ahorcase.’ Cortés, Cartas, 121.
‘Hizo proceso en forma contra Cortés, y por su sentencia, le condenó á muerte.’
Ixtlilxochitl, Hist. Chich., 300; Gomara, Hist. Mex., 143, 146.

[681] ‘Dende a dos horas que se partiô el Juan Velazquez,’ says Bernal Diaz, Hist.
Verdad., 95.

[682] Implying that since Narvaez would not listen to reason, Cortés or he should
die. ‘Velazquez dixo al ... Cortés que adonde yva que yva a la carnesceria.’
Testimonio, in Cortés, Residencia, i. 249; ii. 9, 50, 185-6. On the way to Rio de
Canoas, where they arrived the day after leaving camp, two hogs, with navel on
the back, were killed, an incident which many interpreted as a sign of victory.
Velazquez having arrived with the messenger who carried the ultimatum, the army
proceeded. Bernal Diaz, Hist. Verdad., 95. ‘Anduvimos aquel dia casi diez leguas.’
Tapia, in Icazbalceta, Col. Doc., ii. 588.

[683] Two men were drowned in crossing the stream. Herrera, dec. ii. lib. x. cap. ii.

[684] ‘Dos leguas de los contrarios.’ Tapia, Rel., in Icazbalceta, Col. Doc.. ‘Fuimos
a dormir a vn riachuelo, adõde estava en aquella sazon vna puẽte obra de vna
legua de Cẽpoal.’ Bernal Diaz, Hist. Verdad., 96. Prescott here evidently follows
the erroneous topography of Solis, who confuses this creek with Rio Canoas. Hist.
Mex., ii. 85; Cortés, Residencia, i. 249; ii. 50.

[685] ‘Como yo deseaba evitar todo escándalo, parecióme que seria el menos, yo
ir de noche, sin ser sentido ... y prenderlo [Narvaez]; ... porque los demás querian
obedecer á la justicia, en especial que los mas dellos venian por fuerza.’ Cortés,
Cartas, 123-4.

[686] He also stated that offers had been made favorable to him alone, not to
them, hence he had declined them. ‘Muera el asno ó quien lo aguija.’ Any other
course will disgrace us, was the concluding remark, whereupon we lifted him upon
our shoulders and carried him round. Tapia, Rel., in Icazbalceta, Col. Doc., ii. 588-
9. ‘Hizo muchas ofertas, y prometimiẽtos, que seriamos todos muy ricos.’ Bernal
Diaz, Hist. Verdad., 98. It would be his fault, not theirs, if success failed. Herrera,
dec. ii. lib. x. cap. ii.

[687] ‘Gonzalo de Sãdoual, Alguazil mayor desta Nueua España, por su

Magestad, yo os mando q prendays el cuerpo de Panfilo de Narvaez, e si se os
defendiere, matadle, que assi conviene al servicio de Dios, y de su Magestad, y le
prendió a vn Oidor.’ Countersigned by Secretary Pedro Hernandez. Bernal Diaz,
Hist. Verdad., 98; Tapia, Rel., in Icazbalceta, Col. Doc., ii. 590.

[688] Herrera writes 3000, 1500, and 1000 pesos de oro. Cortés’ acts are said by
the men of Velazquez to have been prompted by ‘un diabólico pensamiento é
infernal osadía.’ Demanda de Ceballos, in Icazbalceta, Col. Doc., i. 441.

[689] The above agrees chiefly with Herrera, who assigns Sandoval 60 men, and
names a number of the leading members of each party. The parties were to keep
a stone’s throw apart. One of Cortés’ squads was to look to the cacique’s palace,
and another to Alcalde Yuste’s quarters. dec. ii. lib. x. cap. iii. He is evidently
confused on many points, and several names are guessed at. Bernal Diaz states
that Pizarro, with 60 young men, including himself, was charged to capture the
artillery; Sandoval received 60 men; Velazquez de Leon also a force of 60,
wherewith to attack Diego Velazquez’ quarters; Cortés remained with a reserve of
20. It is more likely that a higher officer, like Olid, received the order to capture the
artillery, rather than the comparatively unknown Pizarro. Velazquez de Leon does
not appear to have been detailed for his charge till afterward. Cortés names only
Sandoval as the leader of one party of 80 men, he himself following with the
remaining 170. Cartas, 123. Solis reverses Herrera’s order. Hist. Mex., ii. 91-2.

[690] The stout cacique had remonstrated with the general on his carelessness,
assuring him that Malinche with his Teules was far different. ‘When you least
expect it he will be here and will kill you.’ Although the warning was received with
laughter, yet the hint was not lost. Bernal Diaz, Hist. Verdad., 96.

[691] Eighty horsemen and 500 infantry. ‘Y llegó casi una legua de donde yo
estaba.’ Cortés, Cartas, 123.

[692] Laet, Nov. Orb., 221; Hakluyt’s Voy., iii. 467.

[693] Botello, known as the Astrologer, who had made several successful
predictions, had assured Cortés that a night attack would secure him the victory.
Herrera, dec. ii. lib. x. cap. xi.

[694] Cortés rallied him upon his capture, and addressed him as compadre. After
obtaining certain information, more was demanded. The prisoner declared that he
knew nothing more. ‘Well, then, you will swing,’ said Cortés, half jestingly. The two
pikemen who held the rope round his neck took this for a command, and hoisted
him. Rangel rode up, however, and saved his life, but the compression of the
throat troubled him for some time. dec. ii. lib. x. cap. ii.-iii. Carrasco warned him
against attacking the powerful Narvaez. Vetancvrt, Teatro Ecles., pt. iii. 137; Tapia,
Rel., in Icazbalceta, Col. Doc., ii. 589. Prescott says that he with ‘Spartan heroism’
remained silent, Mex., 257-8; but Prescott has evidently not understood his
authorities.

[695] At a cross-road a little farther on, says Herrera.

[696] May 28th. Chimalpain, Hist. Conq., 277. Clavigero and others assume it to
be the night between Saturday and Sunday, but the authorities are pretty clear in
mentioning the following night.

[697] Estimated by various authorities at from twelve to nineteen pieces.

Testimonio, in Cortés, Residencia, ii. 12, 168.

[698] Expressing the belief that Cortés would be foolhardy enough to attack in the
morning. Tapia, Rel., in Icazbalceta, Col. Doc., ii. 589.

[699] ‘Llegamos junto á las centinelas sin que nos sintiesen, é iban huyendo é
diciendo: Arma, arma!’ Id., 590. ‘Auisado Naruaez, y se estaua vistiendo vna cota:
y dixo aqui ẽ le auisò, no tengays pena, y mandò tocar al arma.’ Herrera, dec. ii.
lib. x. cap. iii.

[700] Bernal Diaz, Hist. Verdad., 99, calls the flies cocayos.

[701] Prescott, following Herrera, makes Cortés shout the password ‘Espíritu
Santo,’ which Bernal Diaz says was given as a secret word for mutual recognition.

[702] So say all the original authorities that refer to it, except Bernal Diaz, who
claims that four guns were fired, three balls passing overhead and the fourth killing
three men. Cortés acknowledges no casualties from it. Tapia even intimates that
no discharge took place, owing to the fact that to protect the touch-holes from rain
they had been covered with wax and tiles. Confused by the sudden alarm the
artillerists applied the match, forgetful of the wax, and ‘we saw that the charges
failed to go off.’ Rel., in Icazbalceta, Col. Doc., ii. 590. Perhaps he would have
been more correct in saying that the men were confused by the glittering bribes of
Usagre. Bachiller A. Perez testifies: ‘Dixo al artillero poned fuego a estos tiros ...
puso fuego e no salieron los tiros e oyo dezir este testigo que avian puesto cera
en los dichos tiros.’ Cortés, Residencia, ii. 85. This implies that the wax had been
smeared on by accomplices.
[703] With from 40 to 100 men, are the different estimates.

[704] ‘Vinien los contrarios á nuestra gente, creyendo que eran de los suyos, á
preguntar, “¿qué es esto?” é así los prendien.’ Tapia, Rel., in Icazbalceta, Col.
Doc., ii. 590. ‘De las otras dos torres ... no le acudierõ, porq̄ dizen algunos que se
hizieron sordos, otros que no pudieron llegar, por el impedimento de las tropas de
Cortes.’ Herrera, dec. ii. lib. x. cap. iii.; Cardona, in Cortés, Residencia, i. 181-2.

[705] ‘Uitoria, vitoria por los del nõbre del Espíritu Sãto, q muerto es Narvaez!’
Bernal Diaz, Hist. Verdad., 98. Even this authority now shouts forth the password!

[706] Solis assumes that Farfan gave also the thrust. Bernal Diaz’ text leads one
to suppose that Narvaez received the thrust before his followers were driven into
the building, but the other authorities state clearly: ‘al salir de su camara, le dieron
vn picaço.... Echaronle luego mano.’ Gomara, Hist. Mex., 147; Oviedo, iii. 510.
Monjaras states that Narvaez supplicated for his life: ‘Hidalgos, por amor de Dios
no me mateys!’ Testimonio, in Cortés, Residencia, ii. 51, 85, 107; i. 365. ‘Alonso
Dávila le sacó dichas provisiones reales de V. M. del seno, teniéndolo preso é
abrazado el dicho Pero Sanchez Farfán.’ Demanda de Ceballos, in Icazbalceta,
Col. Doc., i. 442. This occurred some time after the capture. Narvaez called upon
his fellow-prisoners to witness the deed, but Ávila shouted that the papers were
merely letters. They were given to Cortés. ‘Las avian quemado.’ Testimonio, in
Cortés, Residencia, i. 345, 365, 250; ii. 52, 187.

[707] He died, however, says Bernal Diaz, Hist. Verdad., 99. Herrera calls him
Diego de Rojas, whom Bernal classes as a captain.

[708] ‘Se retrajeron á una torre alta de un ídolo de aquel pueblo casi cuatrocientos
hombres, é muchos de los de caballo ... salieron al campo.’ Tapia, Rel., in
Icazbalceta, Col. Doc., 590. Herrera says that 300 intrenched themselves till the
morning. dec. ii. lib. x. cap. iv. Cortés reached the battery just in time to prevent a
catastrophe, as Tapia relates. A hot-blooded young companion of the latter,
carried away by excitement, rushed to powder barrels, eight in number, and
shouted, ‘Let us fire the powder and spoil it for the enemy!’ Cleaving a barrel, he
cast a brand into it, and threw himself flat upon the ground, commending his life to
God. It happened, fortunately, that this barrel contained sandals, which by some
mistake had been mixed up with the ammunition. After waiting in vain a while for
the explosion, the madcap discovered the reason and began to open another
barrel. At this moment Cortés came up, and learning of his intention he rushed
forward and snatched away the brand.

[709] Including also Juan Yuste, Juan Bono, and Gomara.

[710] Oviedo, iii. 510. Bernal Diaz lengthens Cortés’ reply: He thanked God for the
victory and for giving him such valiant gentlemen and companions to aid him. One
of the smallest things he had done in New Spain was to secure and defeat him; it
appeared more daring to seize an oidor of his majesty. Las Casas relates that
Narvaez had a not dissimilar surprise by night from Cuban Indians, during his
campaign for Velazquez, and had a narrow escape. Hist. Ind., iv. 6-8.
 CHAPTER XXII.
ALVARADO’S MERCILESS MASSACRE.

May, 1520.

After the Battle—Victory Made Secure—Conduct of the Conquered—A

General Amnesty—Disposition of the Forces—Affairs at the Capital—
Insurrection Threatened—The Spaniards Hold a Council—Alvarado’s
Resolve—The Great Day of the Feast—The Spaniards Proceed to the
Temple—The Grand Display there Witnessed—The Attack of the
Spaniards—Horrors upon Horrors.

Cortés was exultant. During the last brief hour how completely
had his fortunes changed! Again was his star ascendant, filling the
whole heavens with its brightness. Alas now for Montezuma and
Mexico! And Velazquez; this was his fourth attempt on Mexico, and
in some respects his greatest failure. Instead of annihilating the
outlaw with his grand army, the outlaw in one fell swoop had secured
the grand army, and was now master of all the ships, and men, and
munitions of war, which he so much needed in consummation of his
further designs. It seemed to be the fate of the fat governor out of his
solid substance to feed his enemy with wealth and honors.
Before it was fairly light Cortés had seized and placed in
confinement such persons as might question his rights as victor; the
remainder on surrendering their arms were permitted to go at large.
[711] In order to make more secure his magnificent prize before the
all-searching sun should disclose the paucity and poverty of the
victors, Cortés seated himself in state, arrayed in a wide orange-
colored robe, and ordered the conquered troops to pass before him,
and swear allegiance to the king, and fealty to him as captain-
general and justicia mayor. This was done by nearly all, some
humbling themselves and kissing his hand, while the late hostile
leaders and old acquaintances were recognized with friendly
greetings and embraces.[712]
Meanwhile Olid and Ordaz, each with a corps, set out on the
captured horses to summon stragglers and seek the forty troopers in
the field. Duero and other friends of Cortés being among them, little
persuasion was needed to win the party over, and shortly after dawn
the whole cavalcade came in to the sound of fife and drum, shouting
vivas for Cortés.[713] High above this noise were heard from a
window the voices of two women, named Ordaz, filling the air with
their loud philippics. “Villainous Dominicanos!” they cried to the
soldiers of their own party, “the distaff would better suit you than the
sword. A good account have you given of yourselves! Unfortunate
women we to have come to the wars with such men!” Truly might
Narvaez exclaim with Xerxes, as he beheld his fair ally, Queen
Artemisia, outwit her Athenian pursuers, “My men fight like women,
and my women like men.” The Ordaz women, however, fought only
with their tongues, and that after the issue of battle. And thus
relieved they immediately descended and did homage to the victor.
The general did all he could to check this excess of zeal, which he
feared might engender ill feeling, and he even seized some of the
noisiest enthusiasts, although they were afterward rewarded.
The cacique of Cempoala, who had been slightly wounded
during the battle, appeared like the rest to offer fealty to the victor by
crowning him with flowers. Cortés received his demonstrations as if
nothing had taken place to mar their intercourse, and took up his
abode with Catalina, whose hand he had accepted during his
previous occupation of the place. The chiefs vied with one another to
obliterate their unfortunate mistake by increased attention and
hospitality, while many among Narvaez’ men thought it necessary to
excuse their tardy surrender by pleading that they had been
deceived by their principals, who had assured them that Cortés was
a traitor. Great was their chagrin in the morning on discovering how
few the victors were and how poorly they were armed. And where
were the much talked of native auxiliaries? At the same time they
could not but admire a leader who had achieved such results with
such means. Narvaez and his supporters declared that the victory
was due wholly to treachery, particularly noticeable in the action of
the artillerists.[714] In this there was much truth, but the consummate
tact and soldierly qualities of Cortés shine no less brightly for all that.
And the cost of this glory and advantage, how insignificant it was!
Four of his own men and fifteen of the enemy, including a captain,
beside a number wounded on both sides; this was all.[715]
In his report to the king Cortés seeks to gloss over the
occurrence by stating that only two men were killed, intimating that it
was on both sides. There was a deeper reason for this and other
falsehoods than the wish to hide the bloody result of fratricidal
conflict. He was still doubtful as to the view taken in Spain of his
conduct, and could not afford to prejudice his case by laying bare
every misfortune. He was aware that even to the impartial observer
he must appear as a defaulter in the duty owing by him to a principal,
and in the agreement or partnership which he had formed, and also
as the usurper of an expedition fitted out in the name and under the
auspices, at least, of Velazquez. His plea rested on his brave and
masterly conquest of a rich country, and on his election to
independent command by a party formed on the pretence that the
superior interests of the sovereign demanded the immediate
subjugation of the country. But his acceptance of that command was
a breach of duty and of contract; the right of the party to act as it did
was doubtful, and its pretence hasty, or perhaps usurped from
Velazquez, who had first entertained it; while the commission to
undertake the conquest had already been conferred on the latter.
Velazquez held besides the right of a discoverer to this coast, and
above all the royal grant to it, vaguely worded though it was so far as
indicating the situation and extent of territory. He had a right to claim
his own; though circumstances had so changed, Cortés claimed, as
to render this perilous to the interests of God, the king, and the
people, which rose above those of individuals; and in ignoring the
orders of the audiencia to desist from war on his countrymen he
followed only natural law and justifiable impulse. In this respect
Cortés was equally guilty, since his duty was to yield to the rightful
claimant. He pleads in his letter to the king, however, that self-
preservation obliged him to resist, for Narvaez had determined to
hang him and several of his followers. Here he again hides the fact
that favorable terms were at one time offered. “Had Narvaez carried
off the victory,” he continues, “it would have been with a great loss,
which must have so weakened him as to surely enable the Indians to
succeed in their meditated revolt. This would have lost the country to
the king and to the faith, and twenty years would not have sufficed to
regain it.”[716] In brief, howsoever we admire Cortés, however much
we would prefer his banner to that of Velazquez or Narvaez, we must
admit that he had hardly a shadow of right on his side, and that no
position in which he could possibly place himself was tenable. He
was a defaulter, pirate, usurper, renegade, traitor, outlaw, hypocrite;
but he was a most lovable villain, an admirable soldier, a rare hero.
On the other hand, Velazquez was right. But, though deeply injured,
he was disagreeable; though foully wronged, he was vanquished.
And the Spanish monarch was not the first or last to smile on
iniquitous success, or turn the cold shoulder to whining, disappointed
virtue.
In the course of the morning the soldier Barrientos, who had
been staying in Chinantla, arrived with the promised Chinantec
warriors, two thousand in number.[717] They had reached the
rendezvous on pentecost day, as ordered, but Cortés had found it
convenient to advance on Cempoala sooner than he had intended.
An imposing sight they presented as they marched by amidst vivas
in a file of three abreast, gorgeous with plumes and shields, the
centre man with bow and arrows, while his companions on either
side carried the formidable pike, tipped with glistening iztli. It was
fortunate that they had failed to arrive in time, since much bloodshed
was saved thereby. In fact the soldiers of Narvaez expressed a fear
that they would have fared badly with such opponents. Cortés was
nevertheless delighted with their coming, since this proved not only
the sincerity of their friendship, but showed the conquered that he
did indeed control native armies. Distributing some beads and
trinkets, he bade them return peaceably under the supervising care
of Barrientos.
One of the first measures after the fight was to secure the fleet;
and for this purpose a suitable force was sent down to the port to
take the vessels to Villa Rica, and remove the sails and rudders, so
as to prevent the escape of any to Cuba.[718] Shortly after, when the
masters and crews had tendered allegiance, the vessels were
placed in charge of Pedro Caballero, captain of one of the vessels
under Narvaez, in whom Cortés had great confidence.[719] The
fortress was again garrisoned, with a larger force,[720] and thither
were sent Narvaez and Salvatierra in chains.[721]
As for the rest, Cortés applied himself with his usual skill to
recompense those who had remained true, and to conciliate the yet
unreconciled. He reminded them that they had come not to risk their
lives for Velazquez, but to gain honor and wealth under the banner of
the king, and he was prepared to aid in this by offering them equal
terms with his veterans. As an earnest he restored within two days
their arms to all except a few leaders, and ordered his men to return
the horses, weapons, and other effects taken by them as spoils of
war.[722] What with their admiration of the liberality and soldierly
qualities of Cortés, and the prospect of speedy advancement, there
were but few who did not immediately and cheerfully accept the
terms. But this was by no means to the taste of the aforesaid
veterans. They had seen with envy that rich presents were made to
the conquered, while they, whose courage and devotion had
achieved such magnificent results, received nothing, and were even
told to return what they regarded as lawful spoils; and, further, to
share with these late comers and intended despoilers the fruits of
their years of toil and victories. A general murmur arose, and many
soldiers refused to surrender the appropriated effects. Captain Ávila
and Father Olmedo being requested to remonstrate, did so
earnestly, and told Cortés that he acted like Alexander, who honored
more the conquered than those who won the battle. He and all he
possessed belonged to his comrades, was the reply, but at present it
was necessary to conciliate their invaluable acquisition, whose aid
was needed to overcome the threatening danger in Mexico, and who
being the more numerous party might otherwise rise against them.
Their aims effected, the entire resources of a vast and rich country
were theirs. Olmedo was convinced of the wisdom of the course,
although he considered that too great liberality had been shown. The
headstrong Ávila pressed the point with his natural haughtiness,
whereupon Cortés said: “I am for Mexico; those who please may
follow; those who do not, may leave it alone. There are yet women in
Spain to bear soldiers.” “Yes, and captains and governors,” retorted
Ávila. Cortés deemed it discreet to bandy no further words at
present. So spirited a tongue must be curbed with gifts; but Cortés
awaited his opportunity. He never forgot anything.
With a view chiefly to divert the troubled spirits two expeditions
were sent out, each of two hundred men, mostly from the ranks of
the late enemy. One was directed to Goazacoalco, as before, under
the command of Velazquez de Leon, who had already held this
commission, and two vessels were placed at his disposal to send to
Jamaica for live-stock, seeds, and other requirements of the
proposed colony. The other expedition was intrusted to Ordaz for the
occupation of Pánuco, with a view to anticipate Garay. Two vessels
were given him to explore the coast.[723]
While Cortés was thus risking all on the cast of fortune at
Cempoala the troops at Mexico had been exposed to even greater
perils. At the time of his departure for the coast, Toxcatl, the fifth
month, had begun, and with it the most solemn festival of the year. It
was in honor of Tezcatlipoca, the highest of the divinities, and
identified with a supreme god, although less conspicuous in the daily
worship of the people, for they appealed rather to the nearer minor
deities, whom they regarded as intercessors, than to their supreme
divinity, whom they greatly feared, and who was very far away. The
Mexicans had been permitted to hold the celebration in the great
temple, which had been partly dedicated to Christian worship, on
condition that no human sacrifices should take place.[724] A festival
of this prominence could not fail to recall with all its force to the
natives the indignities to which they and their gods had been
subjected. We have seen how narrowly an uprising on account of the
occupation of the great temple by strange religious emblems was
escaped, and how it was restrained only by the promise of the
speedy departure of the Spaniards. Before Cortés had left the capital
he saw the smouldering fire, and it was this that led him to
strengthen the defences of the fort, to obtain extra supplies from
Tlascala, and to enjoin the strictest watchfulness and moderation.
The hostile feeling was by no means diminished by the tidings of
another larger host of invaders with doubtful motives. At a meeting of
native leaders it was admitted that the promises and statements of
the newly arrived Spaniards could no more be relied upon than those
of the deceitful Malinche, and the deferred proposition to drive out or
to kill the Spaniards was renewed with ardor. A better opportunity for
carrying out such a measure could never again be found. The great
Cortés with his cunning controlling mind was absent. There
remained only a small force in charge of the city, and the troops on
the seaboard were divided against each other. On the other hand a
multitude of pilgrims were pouring in for the festival; and what better
subjects to be worked upon for an uprising than these, and what
better incentive than religion? Beside the appeal for vengeance on
the desecrators of their altars came the patriotic call for the release
of an oppressed sovereign, whose influence was still supreme with
many, and the alluring prospect of securing the rich spoils in
possession of the Spaniards and the Tlascaltecs, the latter still more
detested as an inferior race which after years of contest had now
assumed the galling attitude of master. The preparations made
during the late fermentation required only to be perfected. More arms
were made, the people were stirred by passionate appeals, warriors
were enrolled, and other measures taken.[725]
The utmost secrecy had been observed by the conspirators, but
with so many confidants, actuated by race jealousy, by ties of
friendship, by interest, and by one above all others, the love of
woman, that the rumor was whispered in Alvarado’s ear.[726] Yet to
the mistress, who in her devotion to the lover forgot her duty to home
and kindred, must not be charged more than is her due. Sharpened
by the remembrance of past wrongs suffered on battle-field and
stone of sacrifice, the wits of the Tlascaltecs discovered evidence
which their hatred failed not to magnify. Warnings were hardly
required, however, to indicate that something unusual was stirring,
for the demeanor of the Indians had undergone a yet more marked
change. Supplies were further diminished; servants sent to market
were abused and ill-treated, and insolence was shown even to the
Spaniards themselves.[727] A still more alarming sign was the
discovery of an undermined wall,[728] and after obtaining further
particulars from a devoted Tezcucan chief,[729] afterward known as
Don Hernando, Alvarado resolved to inspect the adjacent temple
where the chief celebration was held. Here a number of suspicious
circumstances were noticed, which the Castilians readily wrought
into threatening realities; among them several victims destined for
sacrifice, regardless of the promises given, while some bloody hearts
which they saw testified to the work already done by the knife.[730]
With the victims Alvarado seized their attendants and certain of the
emperor’s courtiers, from some of whom he tortured a confession. In
this manner he learned what he already partially knew, namely, that
many arms were prepared; that during the Incensing of
Huitzilopochtli, as the festival was called, the Christian emblems
would be cast out of the temple, and that the uprising was to take
place at the conclusion of the feast.[731]
A seeming confirmation of the proposed sacrilege came from
Montezuma himself, who sent to request the removal of the Christian
emblems from the summit of the great temple, pleading as high-
priest that the presence of strange images must prove irritating to the
worshippers of other gods. Alvarado indignantly refused; he would
rather fight. The Mexicans did not choose to see their festival broken
up before the appointed time, and so the point was waived. It was
then arranged that the Spaniards should attend the ceremonies, so
as to be assured that no indignities would be offered their images.
[732]

And now comes another of those diabolical deeds which, done in

the name of civilization, or religion, or any other entity or idea, fills us
with horror toward the gods and men for whom or by whom such
acts are consummated. The lion and the tiger are humane and
gentle beside the Spaniard, harboring thoughts born of bigoted zeal
or blind apprehension. And what are his thoughts? These: He would
enter the sanctuary, the holy temple of his god and their gods, and
while all the people, while priests and nobles, the flower of the Aztec
race, were celebrating the highest service of the highest festival, he
and his men would fall upon them and hew them in pieces! And this
because they had tired of harboring and feeding them. They desire
to be relieved of the self-invited guests, and since dismissal does not
avail they must be driven out or killed. But the intruders do not wish
to be exterminated, and if there is striking to be done, they propose
to strike first.
Pedro de Alvarado was no such man as Hernan Cortés. He was
scarcely fit to be his servant. There were a dozen prominent qualities
that combined to make up the great man in Cortés which were
absent in Alvarado. Both of them were loyal, brave, and merciless,
but there was a method in the excesses of Cortés which those of
Alvarado lacked. Cortés was deep, Alvarado shallow; Cortés was
patient under affront, Alvarado was violent; Cortés was cool in time
of danger, Alvarado was excited—and so on. And yet Alvarado was
a gallant cavalier.
The Spaniards now held a council, before which Alvarado placed
the information thus far obtained of the plot, and the necessity of
prompt measures was at once recognized. They did not believe
Montezuma to be taking any active part in the conspiracy, but that
swayed by hopes and fears he was allowing himself, with his usual
want of resolution, to yield to the stronger will of his courtiers a
passive consent to the efforts for his release.[733]
Less prudent than his chief, and less fertile in resources,
Alvarado did not look for preventives to check the conspiracy, but to
what he regarded as a decisive blow to crush it, such as that
administered at Cholula. He had not the foresight of his general with
regard to the proper adjustment of means to ends, nor his magic
influence over those around him, friend or foe. He remembered only
the good effect of the massacre on the effeminate Cholultecs, and
felt convinced that so excellent a measure must answer also for the
apparently abject Aztecs. It thoroughly suited his rash daring and
cruel disposition. To attack is to win, was his maxim. The difference
in circumstances hardly entered into consideration, chief among
which was the smaller force, unsupported by the neutrality of half the
city, as at Cholula, and without allies close at hand. The gathering of
so many nobles and military leaders in connection with the war-god
celebration provided the opportunity desired, since this would permit
the blow to be directed against those who were looked on as the
promoters of the revolt; and deprived of their leaders the people
would be likely to abandon any further attempt. This plan met with
general approval.[734]

The hour[735] having arrived for the visit to the temple,[736]

Alvarado selects half the force to accompany him,[737] and proceeds
thither, armed with more than usual care. Upon those who remain in
charge of the fort, says Tapia, devolves the safer, though even more
cruel task of slaughtering the greater part of the courtiers and
attendants,[738] who have this day presented themselves in larger
numbers than usual.
The Spaniards with their Tlascaltec followers are welcomed at
the sanctuary with great demonstrations by the unsuspecting nobles,
who see nothing to apprehend in the gleaming arms, since the
Spaniards never go forth without weapons. We must remember it is
a gala day, and the court presents a magnificent scene with its
festive decking of garlands, festoons, and drapery, and its gayly
attired audience. A procession of plumed priests and pages march
by with swinging censers, chanting weird music before the hideous
idols. Behind comes a file of nuns and novices, with red feathers and
painted faces, surmounted by garlands of toasted maize, and
bearing in their hands flags with black bars. Hidden musicians strike,
and the dance begins. Joining the priests, the consecrated women
and the tyros whirl round a large brazier, while two shield-bearers
with blackened faces direct their motions. A conspicuous figure is the
ixteocale, the living representative of the god, for whom he is fated to
die, like the more prominent proxy of Tezcatlipoca. Dressed like a
warrior ready for the fray, and prepared to lead in the chief dances
as is his duty, he seems to impersonate the omen of evil which
hovers over the scene.
Presently the Spaniards are conducted to a separate court,
wherein are assembled several hundred nobles and leading men,
arrayed in rich costumes glittering with gold and precious stones.
The centre of attraction is the new image of Huitzilopochtli, of tzoalli
dough, its jacket wrought with human bones. Before this image the
mazehualiztli dance now begins.[739] Rings are formed round the
music-stand, where two leaders direct the movements, the highest
nobles and the most aged composing the inner circles, and the
younger men the outer. When all is ready the music strikes up lightly
to a well known tune, and the dancers move off, chanting a song
bearing on the event of the day, and on gods and kings.[740]
Forewarned as the Spaniards are, they see treason in every act and
word, and many who understand somewhat the Aztec language
declare that the songs bear distinct allusions to the intended
uprising.
As the dance progresses a few of the soldiers, together with a
number of Tlascaltecs, take possession of the different entrances,
while the rest distribute themselves in suitable positions and watch
for the signal.[741] Instructed by his native allies, Alvarado waits the
time when the Indians shall install the war-god image in the chapel.
And now the sanguinary moment has come. Falling on the assembly
with pike and sword, some strike the idol and some its worshippers.
They hew down the priests and drive the cruel steel through the
bodies of the nobles. Few of the Indians possess any weapons with
which to defend themselves from the sharp Toledo blades. Taken
thus by surprise, panic-stricken, they tread one upon another, and
then fall helpless under the merciless thrusts of the enemy. Their first
impulse has been to rush for the gates, but lines of bristling pikes
oblige them to press back against the crowd, thereby increasing the
confusion. Some attempt to climb over the high walls, some to hide
in the temple buildings, even burrowing beneath the heaps of the
slain. Before an hour has passed there is nothing left in sight
deemed worthy of Spanish swords, so suddenly has this brilliant
assembly been transformed into loathsome masses of mangled
bodies. The pathway of the conquerors is everywhere slippery with
the blood of their victims.
In this horrible butchery, as we have seen, the lower classes
suffered less than the nobles. Desolation was brought home to
nearly every prominent family in the city. Their grief, shared by
dependants and adherents throughout the provinces, was
commemorated in plaintive ballads, by which the people kept alive
the hatred of their oppressors long after the conquest. The estimates
of the killed vary from four hundred to over three thousand, the most
common number being six hundred; and as this generally refers to
prominent personages it may be accepted as not too low.[742]
Finding no more to kill, or rather no more worth the killing, the
Spaniards and the Tlascaltecs proceeded to plunder. The reward
was rich, but even in the eyes of their national historians odium
attached to every trinket, for by such action, as Herrera observes,
they gave currency to the charge that the deed had been prompted
by avarice. But this interesting occupation was destined to be
interrupted. Shouts from the maddened multitude without were soon
heard, roaring in response to the death clamor of their countrymen.
Warned by the guard at the gates, the plunderers hastened to regain
the fort. Yells of execration greeted them as they issued from the
temple, and showers of stones and darts fell thick, while the front