Annex A: Airworthiness Exemption/Deviation Request (Template)

Date: ________________________

Originator File No.: ________________________

Originator RDIMS No.: ________________________

SUBJECT: _____________________________________________________

EXECUTIVE SUMMARY:

PART 1 – APPLICANT REQUEST

1. Applicant Identification:
2. References:
3. Aircraft Type and Systems / Equipment Affected:
4. Airworthiness Requirement:
5. Airworthiness Issue and Rationale for the Request:
6. Exemption Request:
7. Publications Affected by Exemption:
8. Effect on, or Change to, the Level of Safety and Mitigating Actions:
9. Safety Assessment Summary:
10. Limitations and Restrictions:
11. Duration / Expiration of Exemption:
12. Action Item List:
13. Applicant Signature: __________________________

Appendix 1 – Safety Assessment (if required)

Appendix 2 – Copy of Record of Airworthiness Risk Assessment (if required)

PART 2 – TAA ASSESSMENT, APPROVAL AND RECOMMENDATION

Originator: _________________________

Date: _________________________

TAA File No.: _________________________ 

TAA RDIMS No.: _________________________ 

1. TAA Assessment:
2. Assessed Airworthiness Risk:
3. Applied Conditions or Mitigations:
4. Proposed Limitations and Restrictions:
5. Expiration:
6. TAA Staff Recommendation:
7. TAA Approved: _________ 
8. Rationale (if not approved):
9. TAA Recommendation to OAA (if required):  ___________________________ 

PART 3 – OAA REVIEW AND APPROVAL

Originator: _________________________

Date: _________________________

OAA File No.: _________________________

1. OAA Assessment:
2. Airworthiness Safety Assessment:
3. Operational Commanders' Acceptance of Risk (if applicable):
4. Required Mitigating Actions:
5. Imposed Limitations and Restrictions:
6. Expiration/Review:
7. TAA Approved:  _________ or Not Approved : __________
8. OAA Approval:______________________________________

Top of page

Back to TAA Advisory 2018-02