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Kingdom of Belgium
Federal Public Service Mobility and Transport
Civil Aviation Authority
Commercial Aviation Dpt
Airworthiness Review Certificate Recommendation
Ref: EC 2042/2003, Annex I, M.A. 901(d) and Decision N° 2003/19/RM,
AMC M.A.901 (d)
Annexes:..................….
1. OPERATOR/OWNER INFORMATION
OPERATOR/OWNER NAME:.............................
AOC REFERENCE:.......................................
2. PART M SUBPART G ORGANISATION THAT PERFORMED THE AIRWORTHINESS
REVIEW
PART M SUBPART G NAME:
................................................................................
PART M SUBPART G REFERENCE:
...........................................................................
3. AIRCRAFT INFORMATION
AIRCRAFT TYPE:..............................................
S/N:....................................................................
TYPE CERTIFICATE REFERENCE AND
ISSUE:
TYPE CERTIFICATE DATA SHEET
REFERENCE AND ISSUE:
………………........................................................
………………........................................................
PREVIOUS REGISTRATION(*):.....................
MANUFACTURER:.......................................
BELGIAN REGISTRATION: OO-...................
MANUFACTURE DATE: ..............................
FLIGHT HOURS: ..........................................FH
on .................../ .........................../........................
FLIGHT CYCLES: ....................................FC
on .................../ .........................../........................
NOISE & EMISSION TYPE CERTIFICATE
REFERENCE AND ISSUE(*):
NOISE & EMISSION TYPE CERTIFICATE
DATA SHEET REFERENCE AND ISSUE(*):
………………........................................................
………………........................................................
LAST WEIGHT AND BALANCE DATE:
………………........................................................
EXPORT CERTIFICATE NUMBER(*):
…………………………………………………..
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4. ENGINE INFORMATION
ENGINE TYPE:................................................
MANUFACTURER:.......................................
ENGINE NBR 1 S/N:........................................
ENGINE NBR 1 FLIGHT HOURS:................FH
on .................../ .........................../........................
ENGINE NBR 1 FLIGHT CYCLES: .............FC
on .................../ .........................../........................
ENGINE NBR 2 S/N:........................................
ENGINE NBR 2 FLIGHT HOURS:................FH
on .................../ .........................../........................
ENGINE NBR 2 FLIGHT CYCLES: .............FC
on .................../ .........................../........................
ENGINE NBR 3 S/N:........................................
ENGINE NBR 3 FLIGHT HOURS:................FH
on .................../ .........................../........................
ENGINE NBR 3 FLIGHT CYCLES: .............FC
on .................../ .........................../........................
ENGINE NBR 4 S/N:........................................
ENGINE NBR 4 FLIGHT HOURS:................FH
on .................../ .........................../........................
ENGINE NBR 4 FLIGHT CYCLES: .............FC
on .................../ .........................../........................
APU TYPE:................................................
MANUFACTURER:.......................................
APU S/N:................................................
APU FLIGHT HOURS:...................................FH
on .................../ .........................../........................
5. MANUAL INFORMATION
FLIGHT MANUAL REFERENCE:
REVISION: ..........................................................
................................................................................
DATE: ...................................................................
MAINTENANCE PROGRAM REFERENCE:
................................................................................
REVISION: ..........................................................
COSL REFERENCE:
REVISION: ..........................................................
................................................................................
DATE: ...................................................................
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6. LIST OF ORGANISATIONS THAT CARRIED OUT CONTINUING AIRWORTHINESS
ACTIVITIES INCLUDING MAINTENANCE TASKS ON AIRCRAFT AND COMPONENTS
SINCE PREVIOUS ARC
NAME OF THE ORGANISATION
REFERENCE OF THE ORGANISATION
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
................................................................................
7. AIRWORTHINESS REVIEW
DOCUMENT REVIEW REFERENCE:
PHYSICAL SURVEY REFERENCE:
…………………………….
……………………………….
PLACE:……………………………………………..
PLACE:………………………………………………
DATE:……………………………………………….
DATE:…………………………………………………
AIRCRAFT AVAILIBILITY FOR BCAA
PLACE:……………………………………………….
PERIOD:………………………………………………
8. DOCUMENTS IN ANNEX
OPERATOR OFFICIAL REQUEST FOR THE ISSUANCE OF A NEW ARC
PART M SUBPART G APPROVAL CERTIFICATE (that performed the airworthiness review)
AIRWORTHINESS REVIEW STAFF LIST
REGISTRATION PAPERS
DOCUMENT REVIEW
PHYSICAL SURVEY
PROPOSED MAINTENANCE PROGRAM(*)
BRIDGING CHECK ANALYSE (*)
FIRST EXPORT CERTIFICATE (*)
COPY OF THE AFM AND SUPPLEMENTS (*)
COPY OF THE AD STATUS UP TO THE LATEST PUBLISHED ISSUE
(AIRFRAME,ENGINE,APU,APPLIANCES) (*)
LIFE LIMITED PART STATUS (COMPONENTS, ENGINE, APU, LANDING GEAR) (*)
LATEST WEIGHT AND BALANCE REPORT (*)
REPAIRS STATUS (*)
MODIFICATIONS STATUS (*)
COPY OF THE FLIGHT TEST PROGRAM (*)
(*) To be filled in case of import process.
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9. STATEMENT
I CERTIFY THAT AN AIRWORTHINESS REVIEW OF THIS AIRCRAFT HAS BEEN CARRIED OUT
IN ACCORDANCE WITH THE EUROPEAN AND BELGIAN REQUIREMENTS (EC N°2042/2003,
ANNEX I; CIR AIRW 17) AND,
I CONFIRM THAT THE AIRCRAFT IN ITS CURRENT CONFIGURATION COMPLIES WITH THE
FOLLOWING:
a) ADs up to the latest published issue;
b) Type Certificate Data Sheet;
c) Maintenance Program;
d) Component service life limitations (LLP);
e) The validity of the weight and balance;
f) The modification and repairs requirements;
g) The AFM including supplements;
h) The conformity of the AOM/FCOM with the applicable AFM including
supplements;
i) The operational requirements (RVSM, ETOPS, AWOPS,…),
AND I CONFIRM THAT ALL DOCUMENTS AND MAINTENANCE CHECKED ARE PROPERLY
ENTERED AND CERTIFIED IN THE AIRCRAFT CONTINUING AIRWORTHINESS RECORD
SYSTEM AND/OR IN THE OPERATOR'S TECHNICAL LOG AS REQUIRED.
I RECOMMEND THE ISSUE OF AN AIRWORTHINESS REVIEW CERTIFICATE.
PREPARED and CERTIFIED BY:
PART M SUBPART G
PART M SUBPART G
NAME:
APPROVAL NUMBER:
…………………..…..
…………………
AIRWORTHINESS REVIEW STAFF
AIRWORTHINESS REVIEW STAFF
NAME:
AUTHORISATION NUMBER:
…………………………..
…………………………..
SIGNATURE:....................................................
ARCR/Commercial Aviation Dpt.
Issue 1
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DATE:...................................................…………
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