Instructions and advice for completing this Application Form
Note: The CAA Standard Rate hourly charge applies.Refer to Advisory Circular AC91-Ops1for 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 aircraftMultiple aircraft(Complete Appendix A)
Application Type:
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)
RVSMILS Cat IIILS Cat III
EDTO:
120 min180 min210 min240 min
Navigation
RNP 10RNAV 5RNAV 2RNAV 1
RNP 4RNP 2Basic RNP 1Advanced RNP
RNP APCHRNP AR Ops
RF LegsBaro VNAVLPV
FANS 1/A
ADS-B Out
CASA CAO 82.5EASA AMC 20-24
RTCA DO-260ARTCA DO-260B
ADS-C
TBD
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:
NewUsed
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
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
HF Model
SATCOM Model
SATCOM Data
SATCOM Voice
Is SCV integrated to audio, CVR and FDR systems?
Is an Exemption against §91.519 held for this aircraft?Exemption No:
Navigation Systems
Qty installed
Inertial Reference System
Model
Part No
Air Data Computers Model
Model
Part No
GNSS
Model
Part No
DME
Model
Part No
Flight Management Computer
Model
Part No
Software Version
Flight Control Computer
Model
Part No
Software Version
Mode Control Panel
Model
Part No
Pitot Static Probes
Model / Part No
Angle of Attack Vanes
Model / Part No
Surveillance Systems
Transponder 1
ModelMode S
Part No
Software Version
ELSEHSExtended Squitter
Transponder 2
ModelMode S
Part No
Software Version
ELSEHSExtended Squitter
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
Part 43 App D Altimeter Systems Tests & Inspections
Part 43 App E ATC Transponder Tests & Inspections
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
PBN: RNAV & RNP
FANS 1/A
ADS-B
ADS-C
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:
Comments:
Part E – Applicants Declaration
I am signing this form as:
A Senior Person in a Part 119 Certificated operator.
Owner / operator of an aircraft engaged in Part 91 operations only.
Agent or representative of an OWNER / OPERATOR of an aircraft engaged in Part 91 operations only.
Giving false or misleading information is an offence under the regulations.
- I declare that the information provided in this application form is true and correct.
- I understand that the information provided in this application will allow CAANZ to calculate an estimate for service for processing this application.
- 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.
- 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.
- 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.
Page 1of15CAA 24091/07
Rev3: May 2013
Part G – CAA Assessment
- Airworthiness:
- RVSM:
- The aircraft meets the airworthiness requirements specified in AC 91-4 approval for RVSM operations.
- Aircraft has dual independent communications:
VHFHFHF + SCV - Aircraft meets the requirements for:
- Aircraft inspection required:
- Inspection sheet raised:
- The aircraft meets the airworthiness requirements specified in AC 91-XX for the following navigation operations:
- RNP 10 (RNAV 10)
- RNAV 5 (BRNAV)
- RNAV 2
- RNAV 1 (PRNAV)
- RNP 4
- RNP 2
- Basic RNP 1
- RNP 0.3
- RNP APCH
- RNP AR Operations
- Baro VNAV
- LPV
- RF legs
- FANS 1/A
- Inertial only navigation time for RNP 10:x.x hours
- Inertial only navigation time for RNAV 5:x.x hours
Conditions / limitations / comments:
- The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-B operations in airspace with the following requirements:
- CASA CAO 82.5
- EASA AMC 20-24
- RTCA DO-260A
- RTCA DO-260B
Conditions / limitations / comments:
- The aircraft meets the airworthiness requirements specified in AC 91-XX for ADS-C operations in airspace with the following requirements:
- TBD
Conditions / limitations / comments:
- Continued Airworthiness:
- The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and
- There are no significant differences from previously approved aircraft;
or - The aircraft operator has the capability of maintaining the aircraft in compliance with its type design and AC 91-4for the conduct of RVSM operations;
- 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.
- 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.
- 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.
- Flight Operations:
- The aircraft operator is already approved for the conduct of the operations requested for the same aircraft make and model; and
- There are no significant differences from previously approved aircraft;
or - 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 91-4in domestic and oceanic airspace.
- 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.
- 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.
- 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.
Part G – CAA Approval
Approval Recommendation
Airworthiness
Name:Date:
Continued Airworthiness
Name:Date:
Flight Operations
Name:Date:
Manager Flight Operations Approval
The operations identified in Part G Section 1 are subject to the conditions and limitations specified below:
Conditions and Limitations
Manager Flight Operations Approval
Name:Date:
Approval Completion
- RVSM inspection report received and satisfactory
(if required). - Letter(s) of Authorisation issued.
- Ops Specs revised and approved.
- For RVSM, PARMO Form F2 submitted.
- For RVSM, CAA Registration database updated.
- ACU Operational Approvals database updated.
Page 1of15CAA 24091/07
Rev3: May 2013
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:
NewUsed
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
- RVSM inspection report received and satisfactory
(if required). - Letter(s) of Authorisation issued.
- Ops Specs revised and approved.
- For RVSM, PARMO Form F2 submitted.
- For RVSM, CAA Registration database updated.
- ACU Operational Approvals database updated.
Aircraft 3
Make:Model:
Serial No:Line No: Variable No:
Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX
Aircraft History:
NewUsed
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
- RVSM inspection report received and satisfactory
(if required). - Letter(s) of Authorisation issued.
- Ops Specs revised and approved.
- For RVSM, PARMO Form F2 submitted.
- For RVSM, CAA Registration database updated.
- ACU Operational Approvals database updated.
Aircraft 4
Make:Model:
Serial No:Line No: Variable No:
Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX
Aircraft History:
NewUsed
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
- RVSM inspection report received and satisfactory
(if required). - Letter(s) of Authorisation issued.
- Ops Specs revised and approved.
- For RVSM, PARMO Form F2 submitted.
- For RVSM, CAA Registration database updated.
- ACU Operational Approvals database updated.
Aircraft 5
Make:Model:
Serial No:Line No: Variable No:
Registration Mark:CAA Aircraft ID: Mode S Code (hex): C8XXXX
Aircraft History:
NewUsed
Previous Registration:
Previous Operator:
State / Country:
Approval Completion
- RVSM inspection report received and satisfactory
(if required). - Letter(s) of Authorisation issued.
- Ops Specs revised and approved.
- For RVSM, PARMO Form F2 submitted.
- For RVSM, CAA Registration database updated.
- ACU Operational Approvals database updated.
Page 1of15CAA 24091/07
Rev3: May 2013