European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
1 Approval Holder / Applicant
1.1 Company Name
1.2 Company Address
Street / Nr
(registered business
address/address of registry)
Post Code
City
Country
1.3 Contact Person
(responsible for this Notification)
Title
Mr.
Ms.
Name
First name
Job title
Phone/Fax
Email
2. Identification of Notification
2.1 Notification Reference
Please provide your internal and unique reference for this change
2.2 Approval Reference
Please provide the original EASA or other Competent Authority Approval reference
2.3 Issued by
Please indicate EASA or other Competent Authority
3. Proposed Change to Functional System
in accordance with the provision of Regulation (EU) No 1034/2011
3.1 Overall Description
Purpose of the Change
[description]
Justification for the
Change (including the
facts triggering the
change)
[description]
Planned date for
Introduction Into Service
[dd/mm/yyyy]
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 1 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
3.2 Functional System changes
Change to the system
[description]
Change to the procedures
[description]
Change to the human
resources
[description]
3.3 Change classification
Severity Class for the
potential effects of the
hazards identified
Severity class 1
Severity class 2
Severity class 3
Severity class 4
Severity class 5
Summary of the Initial Safety
Assessment for the Change
(including the justification for
the Severity Class
classification)
Does the implementation of
the change require the
introduction of new aviation
standards?
[description]
No
Yes (please specify)
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 2 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
3.4 Services/Functions impacted by the Change to Functional System
Air Traffic Services (ATS)
Type of Service
Part of Service
Air Traffic Control (ATC)
Flight Information Service (FIS)
Sub-part of Service
Area Control Service
N/A
Approach Control Service
N/A
Aerodrome Control Service
N/A
HF Operational Flight Information Service (OFIS)
Broadcasts
N/A
VHF Operational Flight Information Service (OFIS)
Broadcasts
N/A
Voice-Automatic Terminal Information Service (VoiceATIS) Broadcasts
N/A
Data Link Automatic Terminal Information Service
(D-ATIS)
N/A
VOLMET Broadcasts and/or D-VOLMET Service
N/A
Alerting Services (AL)
N/A
N/A
Advisory Service
N/A
N/A
N/A
N/A
Aerodrome Flight Information
Service (AFIS)
Description of the Change
impact
Communication, Navigation or Surveillance services (CNS)
Type of Service
Part of Service
Sub-part of Service
For flight information service
For area control service
Aeronautical Mobile Service (air-ground
communication)
For approach control service
Communications (C)
For aerodrome control service
Aeronautical Fixed Service (ground-ground
communications)
N/A
Aeronautical Mobile Satellite Service (AMSS)
N/A
Provision of NDB signal-in-space
N/A
Provision of VOR signal-in-space
N/A
Provision of DME signal-in-space
N/A
CAT I
Navigation (N)
CAT II
Provision of ILS signal-in-space
CAT III a
CAT III b
CAT III c
Provision of MLS signal-in-space
CAT I
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 3 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
CAT II
CAT III a
CAT III b
CAT III c
Provision of GNSS signal-in-space
GNSS Core System (GALILEO)
Satellite Based Augmentation System
(SBAS)
Ground Based Augmentation System
(GBAS)
Provision of data from Primary Surveillance Radar
(PSR)
N/A
Provision of data from Secondary Surveillance Radar
(SSR)
Mode A/C
Mode S
Surveillance (S)
Provision of data from Automatic Dependent
Surveillance (ADS)
ADS-C
ADS-B
Provision of data from Surface Movement Radar
(SMR)
N/A
Description of the Change
impact
Aeronautical Information Services (AIS)
Type of Service
AIS
Part of Service
Sub-part of Service
Provision of the whole AIS service as described in ICAO
Annex 15
N/A
Description of the Change
impact
Meteorological Services (MET)
Type of Service
MET
Part of Service
Sub-part of Service
Provision of whole MET service as described in ICAO
Annex 3
N/A
Description of the Change
impact
Network Management Function (NM)
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 4 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
Type of Function
Central Unit for Air Traffic Flow Management (ATFM)
Description of the Change
impact
European Route Network Design (ERND)
Description of the Change
impact
Radio Frequency Function
Description of the Change
impact
Transponder Code Function
Description of the Change
impact
Network Performance Monitoring and Improvement
Description of the Change
impact
Other (please specify):
Description of the Change
impact
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 5 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
4. List of documentation provided with the Notification
5. Declaration and Signature
I declare that I have the legal capacity to submit this Notification to EASA and that all information provided in this Notification form is
correct and complete.
Date/Place
Name
Signature
This Notification should be sent by e-mail or regular mail to:
European Aviation Safety Agency
ATM/ANS Standardisation & Oversight Section
Postfach 10 12 53
D-50452 Köln
Germany
E-mail: AtmAnsOrg@easa.europa.eu
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 6 of 7
European Aviation Safety Agency
Form
ATM-ANS Organisation Approval: Notification of Proposed
Change to Functional System
Completion Instructions for FO.AOA.00043-001
This Completion Instruction Sheet will provide you with any additional instructions and requirements necessary to complete the
Notification for Changes to Functional Systems related to ATM/ANS Service Provider Organisation Approval (AOA). Please
complete the form in a clearly legible way.
Chapter 1: Approval Holder / Applicant
1.1
Please enter the full name of the company as it appears on the Article/Certificate of incorporation of the company. If applicable also enter the Trade Name,
Doing-business-as and the Company registration number.
1.2
Please enter the address of the registered office as it appears on the Article/Certificate of incorporation of the company.
1.3
The name and contact details specified in this section are those of the person responsible for the Notification.
Chapter 2: Identification of Notification
2.1
Please provide an internal and unique reference to this change which EASA will use to identify this project in order to avoid duplications.
2.2
Indicate the reference of the existing Approval / initial Application for ATM/ANS Organisation Approval (e.g. EASA approval number)
2.3
Indicate the competent authority that issued the existing approval
Chapter 3: Proposed Change to Functional System
3.2
Description of the change will include the necessary level of details in order to have an initial understanding of the change to be implemented. Wherever
necessary, additional information can be provided by means of references to documents attached to this Notification form or other relevant documentation.
Documents should be listed in paragraph 4 of the Notification Form.
As per Regulation (EU) No 1034/2011, Functional system means a combination of systems, procedures and human resources organised to perform a function
within the context of ATM. The description of the change should cover each of these three areas (as applicable).
3.3
Severity Class shall be determined as result of the severity assessment conducted in accordance with Annex II, point 3.2.4 of Implementing Regulation (EU) No
1035/2011.
Summary of the Initial Safety Assessment should include those parts of the assessment that justifies the Severity Class identified and those that allows to
evaluate the risk posed by the introduction of the change. Wherever necessary, additional information can be provided by means of references to documents
attached to this Notification form or other relevant documentation.
3.4
Please tick the types of services or functions, their parts and sub-parts as they appear (if applicable) to describe the scope of services impacted by the change to
Functional System
Please provide a clear description of the change impact on the related Services. Wherever necessary, additional information can be provided by means of
references to documents attached to this Notification form or other relevant documentation.
FO.AOA.00043-002 © European Aviation Safety Agency. All rights reserved. ISO9001 Certified.
Proprietary document. Copies are not controlled. Confirm revision status through the EASA-Internet/Intranet.
An agency of the European Union
Page 7 of 7