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Operational Approvals Application Instructions and advice for completing this Application Form Note: The CAA Standard Rate hourly charge applies. Refer to Advisory Circular AC91-Ops1 for the instructions to complete this application. The charges associated with the operational approvals will be invoiced to the applicant. Applications must be submitted to CAA not less than 28 days prior to the date required. To reduce time and costs, this form is intended to be revised for additional applications after the initial approvals for an aircraft type. Brief Details Make: Model: Single aircraft Multiple aircraft (Complete Appendix A) Application Type: New Application Change being made: Revision History Revision No: Date: CAA Work Request No: (To be completed by the CAA) Part A – Details of Applicant Name of Operator: Client ID No. (if known) Address for Service: Civil Aviation Act, s8, requires applicants to provide an address for service (ie, a physical address) and to promptly notify the Director of any changes. Tel: Fax: Email: Postal Address: (If different from Address for Service.) Tel: Fax: Email: Person or organisation who can be contacted for further information concerning this application: Name: Designation: Page 1 of 21 CAA 24091/07 Rev 3 : May 2013

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Instructions and advice for completing this Application Form

Note: The CAA Standard Rate hourly charge applies.

(Refer to Advisory Circular AC91-Ops1 for the instructions to complete this application.

(The charges associated with the operational approvals will be invoiced to the applicant.

(Applications must be submitted to CAA not less than 28 days prior to the date required.

(To reduce time and costs, this form is intended to be revised for additional applications after the initial approvals for an aircraft type.

Brief Details

Make:     Model:     

Single aircraft FORMCHECKBOX

Multiple aircraft FORMCHECKBOX (Complete Appendix A)

Application Type: FORMDROPDOWN

Change being made:     

Revision History

Revision No:     Date:     

CAA Work Request No:       (To be completed by the CAA)

Part A – Details of Applicant

Name of Operator:

     

     

Client ID No. (if known)

Address for Service: Civil Aviation Act, s8, requires applicants to provide an address for service (ie, a physical address) and to promptly notify the Director of any changes.

     

     

     

     

Tel:

     

Fax:

     

Email:

     

Postal Address: (If different from Address for Service.)

     

     

     

Tel:

     

Fax:

     

Email:

     

Person or organisation who can be contacted for further information concerning this application:

Name:

     

Designation:

     

Address:

     

     

Tel:

     

Mob:

     

Email:

     

Approvals Sought: (Check those required)

RVSM FORMCHECKBOX

ILS Cat II FORMCHECKBOX

ILS Cat III FORMCHECKBOX

EDTO:

120 min FORMCHECKBOX

180 min FORMCHECKBOX

210 min FORMCHECKBOX

240 min FORMCHECKBOX

Navigation

RNP 10 FORMCHECKBOX

RNAV 5 FORMCHECKBOX

RNAV 2 FORMCHECKBOX

RNAV 1

FORMCHECKBOX

RNP 4 FORMCHECKBOX

RNP 2 FORMCHECKBOX

Basic RNP 1 FORMCHECKBOX

Advanced RNP FORMCHECKBOX

RNP APCH FORMCHECKBOX

RNP AR Ops FORMCHECKBOX

RF Legs FORMCHECKBOX

Baro VNAV FORMCHECKBOX

LPV FORMCHECKBOX

FANS 1/A FORMCHECKBOX

ADS-B Out

CASA CAO 82.5 FORMCHECKBOX

EASA AMC 20-24 FORMCHECKBOX

RTCA DO-260A FORMCHECKBOX

RTCA DO-260B FORMCHECKBOX

ADS-C

TBD FORMCHECKBOX

Part B – Aircraft and Equipment Details

Make:     Model:     

Serial No:     Line No:     Variable No:     

Registration Mark:   CAA Aircraft ID:     Mode S Code (hex):C8XXXX

Aircraft History:

New FORMCHECKBOX

Used FORMCHECKBOX

Previous Registration:     

Previous Operator:     

State / Country:     

For multiple aircraft of the same make and model complete the continuation sheet in Appendix A.

Aircraft Documentation

(Insert document number, revision / date and reference information)

Flight Manual:

Air No:     Manufacturer No:     Rev:     

RVSM Approvals

AFM Reference     

SIL / SB     

Navigation Approvals

AFM / Approval Doc References     

AFM / Approval Doc References     

AFM / Approval Doc References     

ADS-B Approvals

Approvals held FORMDROPDOWN

AFM Reference     

Relevant Approval Doc     

ADS-C Approvals     

Aircraft ELA     

Aircraft Software Configuration List     

Maintenance Planning Document     

Aircraft Maintenance Manual     

IPC     

Wiring Diagram Manual     

Structural Repair Manual     

Configuration Deviation List     

MMEL     

Operator MEL / DDPG     

Aircraft Equipment Details

Communications Systems

(Insert Make, Model & P/N)

Qty installed

VHF Model      FORMDROPDOWN

HF Model      FORMDROPDOWN

SATCOM Model     

SATCOM Data      FORMDROPDOWN

SATCOM Voice      FORMDROPDOWN

Is SCV integrated to audio, CVR and FDR systems? FORMDROPDOWN

Is an Exemption against §91.519 held for this aircraft? FORMDROPDOWN

Exemption No:     

Navigation Systems

Qty installed

Inertial Reference System

Model      FORMDROPDOWN

Part No     

Air Data Computers Model

Model      FORMDROPDOWN

Part No     

GNSS

Model      FORMDROPDOWN

Part No     

DME

Model      FORMDROPDOWN

Part No     

Flight Management Computer

Model      FORMDROPDOWN

Part No     

Software Version     

Flight Control Computer

Model      FORMDROPDOWN

Part No     

Software Version     

Mode Control Panel

Model     

Part No     

Pitot Static Probes

Model / Part No      FORMDROPDOWN

Angle of Attack Vanes

Model / Part No      FORMDROPDOWN

Surveillance Systems

Transponder 1

Model     Mode S FORMCHECKBOX

FORMDROPDOWN

Part No     

Software Version     

ELS FORMCHECKBOX

EHS FORMCHECKBOX

Extended Squitter FORMCHECKBOX

Transponder 2

Model     Mode S FORMCHECKBOX

FORMDROPDOWN

Part No     

Software Version     

ELS FORMCHECKBOX

EHS FORMCHECKBOX

Extended Squitter FORMCHECKBOX

Part C – Continued Airworthiness

Maintenance Organisation

Contact Details:

Name:     

Phone:     Mobile:     Email:     

Maintenance facilities to be used:     

Procedures for managing maintenance providers:     

Part 43 specified maintenance completed:

Part 43 App B Radio Station Inspection FORMCHECKBOX

Part 43 App D Altimeter Systems Tests & Inspections FORMCHECKBOX

Part 43 App E ATC Transponder Tests & Inspections FORMCHECKBOX

Comments:     

Maintenance Practices

(Insert document number, revision / date and reference information)

Maintenance schedule     

Configuration management     

Modifications / Repairs     

Maintenance Practices     

Use of BITE     

Static System Maintenance     

Skin Waviness Checks     

Non-Compliant Aircraft

Notification Procedure (maintenance)     

Notification Procedure (operations)     

Notification Procedure (CAA)     

Corrective Action Procedures     

Maintenance Training

Test Equipment     

Documentation     

RVSM Test Equipment

Accuracy (0.01% or 4:1)     

Calibration Schedule     

Audit Programme     

Maintenance Practices     

Comments:     

Part D – Operational Training and Competency

Contact Details:

Name:     

Phone:     Mobile:     Email:     

Training programme submitted:

RVSM FORMCHECKBOX

PBN: RNAV & RNP FORMCHECKBOX

FANS 1/A FORMCHECKBOX

ADS-B FORMCHECKBOX

ADS-C FORMCHECKBOX

Operator Practices and Procedures - RVSM

Flight Planning     

Pre-Flight     

Procedures prior to RVSM airspace entry     

In-Flight Procedures     

ATC Phraseology     

NAT Airspace Procedures     

Verification / Monitoring Programme     

Operator Practices and Procedures – PBN: RNAV & RNP

Flight Planning     

Pre-Flight     

Procedures prior to RNP airspace entry     

In-Flight Procedures     

ATC Phraseology     

Special Airspace Procedures     

Training     

Operator Practices and Procedures – RNP / FANS 1/A

Flight Planning

Pre-Flight

Procedures prior to RNP airspace entry

In-Flight Procedures

ATC Phraseology

Special Airspace Procedures

Training

Operator Practices and Procedures – ADS-B / ADS-C

Flight Planning     

Pre-Flight     

Procedures prior to ADS-B airspace entry     

In-Flight Procedures     

ATC Phraseology     

Special Airspace Procedures     

Training     

Crew training completed: FORMCHECKBOX

Comments:

     

Part E – Applicants Declaration

I am signing this form as:

A Senior Person in a Part 119 Certificated operator. FORMCHECKBOX

Owner / operator of an aircraft engaged in Part 91 operations only. FORMCHECKBOX

Agent or representative of an OWNER / OPERATOR of an aircraft engaged in Part 91 operations only. FORMCHECKBOX

Giving false or misleading information is an offence under the regulations.

1. I declare that the information provided in this application form is true and correct.

2. I understand that the information provided in this application will allow CAANZ to calculate an estimate for service for processing this application.

3. I understand and agree that the cost estimate may change, and processing the application may be delayed if:

· the application does not accurately and completely identify my/our requirements; or

· the details in this application are subsequently changed; or

· adequate supporting documentation has not been provided.

4. I understand and agree that for CAANZ to proceed with this application, I must:

· accept the cost estimate,

· forward the prescribed payment; and

· forward all supporting documentation to CAANZ.

5. If I am signing this application as an agent, I declare that I have obtained the necessary Power of Attorney authorising me to sign on behalf of the applicants.

Name:      Date:      

There is no signature required on this form; the presence of the name of the individual in this field is deemed to be a signature.

Part F – Submitting Your Application

Have you attached all required documentation as indicated throughout the application? All supplemental information should be in an electronic format.

After reviewing your application, CAANZ will advise you if any additional information is required.

Part G – CAA Assessment

1. Airworthiness:

a. RVSM:

i. The aircraft meets the airworthiness requirements specified in AC 91-4 approval for RVSM operations. FORMCHECKBOX

ii. Aircraft has dual independent communications:

VHF FORMCHECKBOX

HF FORMCHECKBOX

HF + SCV FORMCHECKBOX

iii. Aircraft meets the requirements for: FORMDROPDOWN

iv. Aircraft inspection required: FORMDROPDOWN

v. Inspection sheet raised: FORMCHECKBOX

b. The aircraft meets the airworthiness requirements specified in AC 91-XX for the following navigation operations:

i. RNP 10 (RNAV 10) FORMCHECKBOX

ii. RNAV 5 (BRNAV) FORMCHECKBOX

iii. RNAV 2 FORMCHECKBOX

iv. RNAV 1 (PRNAV) FORMCHECKBOX

v. RNP 4 FORMCHECKBOX

vi. RNP 2 FORMCHECKBOX

vii. Basic RNP 1 FORMCHECKBOX

viii. RNP 0.3 FORMCHECKBOX

ix. RNP APCH FORMCHECKBOX

x. RNP AR Operations FORMCHECKBOX

xi. Baro VNAV FORMCHECKBOX

xii. LPV FORMCHECKBOX

xiii. RF legs FORMCHECKBOX

xiv. FANS 1/A FORMCHECKBOX

xv. Inertial only navigation time for RNP 10:

x.x hours

xvi. Inertial only navigation time for RNAV 5:

x.x hours

Conditions / limitations / comments:

     

c. The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-B operations in airspace with the following requirements:

i. CASA CAO 82.5 FORMCHECKBOX

ii. EASA AMC 20-24 FORMCHECKBOX

iii. RTCA DO-260A FORMCHECKBOX

iv. RTCA DO-260B FORMCHECKBOX

Conditions / limitations / comments:

     

d. The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-C operations in airspace with the following requirements:

i. TBD FORMCHECKBOX

Conditions / limitations / comments:

     

2. Continued Airworthiness:

a. The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and

b. There are no significant differences from previously approved aircraft; FORMCHECKBOX

or

c. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-4 for the conduct of RVSM operations; FORMCHECKBOX

d. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of the navigation operations listed in 1. b above. FORMCHECKBOX

e. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of operations requiring ADS-B listed in 1. c above. FORMCHECKBOX

f. The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-XX for the conduct of the ADS-C operations listed in 1. d above. FORMCHECKBOX

3. Flight Operations:

a. The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and

b. There are no significant differences from previously approved aircraft; FORMCHECKBOX

or

c. The aircraft operator has been assessed as having the required training and operational competency for the conduct of RVSM operations in accordance with CAR §91 and AC 91-4 in domestic and oceanic airspace. FORMCHECKBOX

d. The aircraft operator has been assessed as having the required training and operational competency for the conduct of the navigation operations listed in 1. b above in accordance with CAR §91 and AC 91-XX. FORMCHECKBOX

e. The aircraft operator has been assessed as having the required training and operational competency for the conduct of operations in airspace requiring ADS-B as listed in 1. c above in accordance with CAR §91 and AC 91-XX. FORMCHECKBOX

f. The aircraft operator has been assessed as having the required training and operational competency for the conduct of operations in airspace requiring ADS-C as listed in 1. D above in accordance with CAR §91 and AC 91-XX. FORMCHECKBOX

Part G – CAA Approval

Approval Recommendation

Airworthiness FORMDROPDOWN

Name:     Date:     

Continued Airworthiness FORMDROPDOWN

Name:     Date:     

Flight Operations FORMDROPDOWN

Name:     Date:     

Manager Flight Operations Approval

The operations identified in Part G Section 1 are FORMDROPDOWN subject to the conditions and limitations specified below:

Conditions and Limitations

     

     

Manager Flight Operations Approval

Name:     Date:     

Approval Completion

1. RVSM inspection report received and satisfactory (if required). FORMDROPDOWN

2. Letter(s) of Authorisation issued. FORMCHECKBOX

3. Ops Specs revised and approved. FORMCHECKBOX

4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX

5. For RVSM, CAA Registration database updated. FORMCHECKBOX

6. ACU Operational Approvals database updated. FORMCHECKBOX

Appendix A: Additional Aircraft

Aircraft 2

Make:     Model:     

Serial No:     Line No:     Variable No:     

Registration Mark:   CAA Aircraft ID:     Mode S Code (hex):C8XXXX

Aircraft History:

New FORMCHECKBOX

Used FORMCHECKBOX

Previous Registration:     

Previous Operator:     

State / Country:     

Approval Completion

1. RVSM inspection report received and satisfactory (if required). FORMDROPDOWN

2. Letter(s) of Authorisation issued. FORMCHECKBOX

3. Ops Specs revised and approved. FORMCHECKBOX

4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX

5. For RVSM, CAA Registration database updated. FORMCHECKBOX

6. ACU Operational Approvals database updated. FORMCHECKBOX

Aircraft 3

Make:     Model:     

Serial No:     Line No:     Variable No:     

Registration Mark:   CAA Aircraft ID:     Mode S Code (hex):C8XXXX

Aircraft History:

New FORMCHECKBOX

Used FORMCHECKBOX

Previous Registration:     

Previous Operator:     

State / Country:     

Approval Completion

1. RVSM inspection report received and satisfactory (if required). FORMDROPDOWN

2. Letter(s) of Authorisation issued. FORMCHECKBOX

3. Ops Specs revised and approved. FORMCHECKBOX

4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX

5. For RVSM, CAA Registration database updated. FORMCHECKBOX

6. ACU Operational Approvals database updated. FORMCHECKBOX

Aircraft 4

Make:     Model:     

Serial No:     Line No:     Variable No:     

Registration Mark:   CAA Aircraft ID:     Mode S Code (hex):C8XXXX

Aircraft History:

New FORMCHECKBOX

Used FORMCHECKBOX

Previous Registration:     

Previous Operator:     

State / Country:     

Approval Completion

1. RVSM inspection report received and satisfactory (if required). FORMDROPDOWN

2. Letter(s) of Authorisation issued. FORMCHECKBOX

3. Ops Specs revised and approved. FORMCHECKBOX

4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX

5. For RVSM, CAA Registration database updated. FORMCHECKBOX

6. ACU Operational Approvals database updated. FORMCHECKBOX

Aircraft 5

Make:     Model:     

Serial No:     Line No:     Variable No:     

Registration Mark:   CAA Aircraft ID:     Mode S Code (hex):C8XXXX

Aircraft History:

New FORMCHECKBOX

Used FORMCHECKBOX

Previous Registration:     

Previous Operator:     

State / Country:     

Approval Completion

1. RVSM inspection report received and satisfactory (if required). FORMDROPDOWN

2. Letter(s) of Authorisation issued. FORMCHECKBOX

3. Ops Specs revised and approved. FORMCHECKBOX

4. For RVSM, PARMO Form F2 submitted. FORMCHECKBOX

5. For RVSM, CAA Registration database updated. FORMCHECKBOX

6. ACU Operational Approvals database updated. FORMCHECKBOX

Page 15 of 15CAA 24091/07

Rev 3 : May 2013