Application for the Issue of a Permit to Fly According to Regulation (EC) No. 748/2012, Part 21, Subpart P

Transcription

1 Luftfahrt-Bundesamt Department T Braunschweig Application for the Issue of a Permit to Fly According to Regulation (EC) No. 748/2012, Part 21, Subpart P 1. Applicant: Name, address, telephone number 2. Registration mark: 3. Owner: 4. Manufacturer / Variant: 5. Serial number: 6. Purpose of the flight:* 1. Design (21A.701 No.1) 2. Proof of compliance of provisions or of certification specifications (21A.701 No.2) 3. Training of the flight crew of design or of production organisations (21A.701 No. 3) 4. Flight tests within the scope of the production of aircraft (21A.701 No. 4) 5. Flights of aircraft among the production organisations within the scope of their production (21A.701 No.5) 6. Flights of the aircraft in case of acceptance by the client (21A.701 No.6) 7. Delivery or export of the aircraft (21A.701 No.7) 8. Flights of the aircraft for the purpose of approval by the authority (21A.701 No.8) 9. Market survey, also training of the client s flight crew Description: (21A.701 No.9) 10. Aeronautical exhibitions and airshows (21A.701 No.10) 11. Flight of the aircraft to a place, where maintenance or airworthiness inspection is to be carried out or to a storage place (21A.701 No.11) 12. Flight of an aircraft having a mass above the certified maximum take-off mass when exceeding its normal range over water or over land, if there is no adequate landing capability or no suitable fuel available (21A.701 No.12) 13. Record flights, air races or comparable competitions (21A.701 No.13) 14. Flight of an aircraft that complies with the relevant airworthiness requirements before the compliance with the environmental protection requirements was proved (21A.701 No.14) 15. Non-commercial flights with individual, technically noncomplicated aircraft or types for which a Certificate of Airworthiness or a restricted Certificate of Airworthiness is not appropriate (21A.701 No.15) 7. Date and duration of the flight / the flights:* 8. Status of the aircraft:* 9. Approval of the flight conditions:* 10. Date: It is assured that the aircraft complies with the design specified in the approved flight conditions referring to 9. (EASA Form 18b). 11. Name and signature: applicant EASA Form 21 LBA No.04T4/Issue 2/April 2016 Page 1

2 *Exemplification point 6, 7, 8, und 9 of EASA Form 21: 6. Purpose of the flight Please tick the reasons according to 21A.701(a) and declare additional information for a detailed description of the purpose under Description! Several reasons are possible! Examples: No. 1 to 5 are used by Design or Product Organization only No. 6 Familiarization and training flights No. 7 Delivery from or into countries out of the European Union or from the manufacturer or from/to the client No. 8 Flights within the scope of inspection for continuing airworthiness for issuance of the Airworthiness Review Certificate (ARC) No. 9 Market survey used by Design or Product Organization only / training flights under specification of the pilot (name, license number) No. 10 Aeronautical exhibitions/airshows, please detailed information (place, date, duration etc.) No. 11 Ferry flights (CAMO) No. 12 to 15 are very special cases. The permit has to be applied for with EASA Form 18b, issued and certified by EASA, always!! 7. Date and duration of the flight / the flights Statement of the estimated beginning (date) and period fixed for the flight/s 8. Status of the aircraft Please insert Type Certificate Data Sheet, specifying number, edition and certification authority / certification state or any other certification specifications (e.g. STC) 9. Approval of the flight conditions Please name the institution authorizing the flight conditions, LBA or EASA (if appropriate, EASA project number, see note below in the box) Further hints: Please submit together with the application form (EASA form 21): Insurance Confirmation according to 106 para 1 LuftVZO (Air Navigation Certification Order) Certificate of Cancellation or of Non-Registration EASA Form 18b (LBA-approval of the flight conditions, see page 3) Declaration on Flight Conditions (see page 5) Attention! EASA is the competent authority for the approval of the flight conditions, if the approval is dependent on the safety of the design of the aircraft (21A.709). In this case, the application for the issue of a Permit to Fly first of all requires an additional application for the approval of the flight conditions (EASA Form 37) that has to be directly addressed to EASA in English. The form will be found on the EASA-homepage. The application for the issue of a Permit to Fly contains EASA Form 21 including EASA-approved form 18b and form 37 (and if applicable the above mentioned supporting documents) and has always to be addressed to the LBA, Department T4. If the safety of design of the aircraft is not affected, the flight conditions are approved by the LBA, Department T4. The application for the issue of a Permit to Fly contains Form 21, Form 18b and Declaration on Flight Conditions and the above mentioned supporting documents and has also to be addressed to the LBA, Department T4 Luftfahrt-Bundesamt Hermann-Blenk-Str Braunschweig Please fix a date before you visit us! You can reach the aircraft registration by phone From Monday to Friday from 09:00 a.m. to 12:00 noon Please note the publication on our homepage: LBA No.04T4/Issue 2/April 2016 Page 2

3 FLUGBEDINGUNGEN FÜR EINE FLUGGENEHMIGUNG ANTRAGSFORMULAR FLIGHT CONDITIONS FOR A PERMIT TO FLY APPROVAL FORM 1. Antragsteller Applicant 3. Hersteller / Muster des Luftfahrzeuges Aircraft manufacturer/type 2. Aktenzeichen Reference D- 4. Werknummer Serial number 5. Zweck des Fluges gemäß 21.A.701(a) / Purpose in accordance with 21.A.701(a) Dauer der Genehmigung Initial duration von from bis until 6. Luftfahrzeugkonfiguration / Aircraft configuration Das oben genannte Luftfahrzeug, für das die Fluggenehmigung beantragt wird, ist definiert in The above aircraft for which a Permit to Fly is requested is defined in 7. Begründung Substantiations 8. Bedingungen / Einschränkungen / Conditions/Restrictions Das oben genannte Luftfahrzeug muss unter den folgenden Bedingungen und / oder Einschränkungen betrieben werden/ The above aircraft must be used with the following conditions or restrictions: Die Genehmigung der Flugbedingungen bleibt gültig vorausgesetzt, dass die erklärte Konfiguration zutreffend ist, das Luftfahrzeug entsprechend den festgelegten Vorschriften instandgehalten wird und die Erfüllung von Lufttüchtigkeitsanweisungen beachtet wird. / The flight condition approval remains valid provided the declared configuration is applicable, the aircraft is maintained according with defined instructions, and compliance with airworthiness directives is observed. 9. Erklärung / Statement Die Flugbedingungen wurden festgelegt und begründet in Übereinstimmung mit 21A.708. / The flight conditions have been established and justified in accordance with 21A.708. Das in Nr. 6 definierte Luftfahrzeug hat keine Merkmale und Eigenschaften die es unsicher für den beabsichtigten Betrieb unter den ausgewiesenen Bedingungen und Einschränkungen machen würden. / The aircraft as defined in block 6 above has no features and characteristics making it unsafe for the intended operation under the identified conditions and restrictions. 10. Freigegeben durch Organisation Nr.: Approved under Organisation Approval Number (if applicable) 11. Ausstellungsdatum Date of issue 12. Name und Unterschrift Name and signature Datum Date Name Unterschrift Signature 13. Geprüft und genehmigt durch LBA / examined and approved by the LBA Dienstpostenkurzbezeichnung / short reference Datum / Date Unterschrift / signature EASA Formblatt 18b, Ausgabe 3 Note: Please complete all data fields (if appropriate) LBA No.04T4/Issue 2/April 2016 Page 3

4 Explanations: The preceding EASA-form 18b has to be used for Approval of Flight Conditions by LBA, only! Exemplification form 18b: Data field 1: Name of the applicant according to 21A.703 Data field 2: Data field 3: Data field 4: Data field 5: Data field 6: Data field 7: Data field 8: Data field 9: Registration mark and reference number of the applicant Name of manufacturer and type/variant of the aircraft corresponding to the Type Certificate Data Sheet serial number corresponding to type label, manufacturer s data etc. stating the purpose of flights corresponding to application data field 6 (Form21/see exemplifications page 2) and duration Add reference of the document/s, identifying the configuration of the aircraft, e.g. TCDS, STC Add detailed reason/s for the intended flight/s Reference to further applicable document Declaration on Flight Conditions and details of these conditions/restrictions or reference to relevant documents, including maintenance instructions and conditions to carry them out Statement that the flight conditions are fixed in compliance with 21A.708 and the intended operation is non-hazardous Data field 10: Name of the affirming organization Data field 11: Date of issue Data field 12: Name and signature of the affirming person Data field 13: Only used by the LBA LBA No.04T4/Issue 2/April 2016 Page 4

5 Attachment to the application for the approval of the flight conditions (EASA Form 18b), dated Registration mark: D - DECLARATION ON FLIGHT CONDITIONS Manufacturer / variant: Serial number: The flight conditions according to 21A.708 are proved as follows: In order to prove compliance tick the standard provision or insert an individual proof of compliance, please (if appropriate also by enclosing documents). Examined and approved by (only for LBA purposes) 21A.708 b) 1. Conditions or restrictions for flight path and/or airspace required for the flights 21A.708 b) 2. Conditions or restrictions the crew who is to operate the aircraft is subject to 21A.708 b) 3. Restrictions regarding the transport of persons, except the crew 21A.708 b) 4. Operational restrictions, specific procedures or technical conditions to be observed 21A.708 b) 5. Specific flight testing program 21A.708 b) 6. Specific measures taken for continued airworthiness, e.g. the maintenance instructions and the scope within they are executed Requirements as to the transit airspace are fulfilled (e.g. RVSM, RNP, MNPS etc.) Requirements of CR (EU) No. 1178/2011, Annex I, Part FCL, are fulfilled Only persons required to operate the aircraft may be transported Requirements concerning VFR-day/ night / IFR are fulfilled No Yes (please describe) The maintenance documents according to the maintenance program approved are to be applied The production information are to be applied Herewith it is confirmed that the a.m. aircraft was inspected and, complying with the a.m. flight conditions, can be operated without any risk. Date: Signature: LBA No.04T4/Issue 2/April 2016 Page 5