DEPARTMENT OF COMMUNICATIONS

DIRECTORATE GENERAL OF AIR COMMUNICATIONS DIRECTORATE OF AIRWORTHINESS CERTIFICATION Karya Bld. 22nd Floor, Jl. Medan Merdeka Barat No. 8 Jakarta Pusat Indonesia Phone : 62-2 !"#666$, !"#666" Fa%si&ile : 62-2 !"#666! APPROVED MAINTENANCE ORGANIZATION INSPECTION CHECKLIST . Na&e o' (o&)any 2. Business *ddress !. /o%ation o' Fa%ility : : +ene-al : *dditional +atin. (han.e o' /o%ation $. *))ro1al Nu&2er 6. 4. +atin.s: *I+F+*M5 (lass (lass 2 (lass ! (lass $ +*3I0 (lass (lass 2 (lass ! 8. /i&ited +atin.s: 8u2:e%t *I+F+*M5 Make and Model P065+P/*N7 (lass (lass 2 (lass ! IN87+9M5N7 (lass (lass 2 (lass ! (lass $ P+0P5//5+ (lass (lass 2 : 3o&esti% *M0 0ther Forei.n *M0 ". *))li%ation +e,uested Initial

*((5880+I58 (lass (lass 2 (lass !

5N;IN5
3*( For& $"-#$ +2 <#!-2##6= Pa.e o' "

8u2:e%t P+0P5//5+

Make and Model

IN87+9M5N7

+*3I0

*((5880+>

/*N3IN; ;5*+ (0MP0N5N7

F/0*7

5M5+;5N(> 5?9IPM5N7

+070+ B/*35

*I+(+*F7 F*B+I( 60+K

N0N-3587+9(7I@5 7587IN; A. /i&ited +atin. 'or 8)e%ialiBed 8er1i%e: 8u2:e%t 8)e%i'i%ation 9sed

3*( For& $"-#$ +2 <#!-2##6=

Pa.e 2 o' "

#. Cousin. and Fa%ility No. #. 8u2:e%t (o&)lian%e -ith (*8+ >es No +e&ark

Cousin. 'or 'a%ilities, e,ui)&ent, &aterials, and )ersonnel. #.2 Fa%ilities 'or )er'or&in. -ork:
a. 8u''i%ient -ork s)a%e and areas 'or the )ro)er se.re.ation D )rote%tion o' arti%les, 2. 8e.re.ation -ork areas ena2lin. en1iron&entally haBardous or sensiti1e o)erations <%leanin., )aintin., -eldin., &a%hinin., a1ioni% -ork, and ele%troni% -ork=, %. 8uita2le ra%ks, trays, stands, hoists, and other se.re.ation &eans 'or stora.e D )rote%tion, d. 8)a%e su''i%ient to se.re.ate arti%les D &aterials sto%ked 'or installation, e. @entilation, li.htin., te&)erature %ontrol, and hu&idity.

#.! #.$ #." #.6

Can.ar <'or air'ra&e ratin. or li&ited ratin.=. 0''i%e area. 6orksho) area. 3ust 'ree sho) 'or radio and instru&ent ratin.. MEFs,.'t.

7otal area *1aila2le: . Personnel

. 3esi.nated a%%ounta2le &ana.er. .2 *de,uate ,uali'ied )ersonnel to )lan, su)er1ise, ins)e%tion, )er'or& D a))ro1e 'or return to ser1i%e .! +oster D su&&ary e&)loy&ent o' &ana.e&ent,
su)er1isory, ins)e%tion D authoriBed )ersonnel 'or +78

7he nu&2er o' )ersonnel e&)loyed: 2. 7oolsF5,ui)&ent

7he nu&2er o' te%hni%al )ersonnel: /i%ensed: Non-li%ensed:

2. 7oolsFe,ui)&ent ne%essary to )er'or& the -ork. 2.2 (ontrollin. o' )eriodi% %ali2ration to national standard. 2.! *1aila2ility o' toolsFe,ui)&ent in ea%h unit. 2.$ 8torin. o' toolsFe,ui)&ent. !. 7e%hni%al Pu2li%ation !. *1aila2ility o' %urrent te%hni%al )u2li%ation related to the ratin. sou.ht: a. Maintenan%e &anual 2. Illustrated Parts (atalo.ue %. 6irin. dia.ra&
Pa.e ! o' "

3*( For& $"-#$ +2 <#!-2##6=

No.

8u2:e%t d. +e)airFo1erhaul &anual e. 8er1i%e 2ulletinsFlettersFinstru%tions '. *ir-orthiness 3ire%ti1e

(o&)lian%e -ith (*8+ >es No

+e&ark

$. Ins)e%tion 'or In%o&in. &aterialsF)arts $. $.2 $.! $.$ $." 3o%u&ent F %erti'i%ate -hi%h &ust atta%h. Candlin. o' sus)e%ted un-a))ro1ed )arts. 8hi))in. and )a%kin. %ondition. Physi%al %ondition o' the &aterialF)art. (ontrollin. o' shel' li'e ite&.

". +e%ord and +e)ort ". 5Ge%ution o' all 'or&s and ta.s, in%ludin. 3;*( 'or&s <su%h as $!-!!4, 2 - 8, $!-# , ".2 et%=. ".! (o&)letion o' ade,uate. ".$ Period o' ti&e to kee) ea%h re%ord. "." 7rea%ea2ility o' re%ord and re)ort syste&. +e)ortin. o' de'e%t or un-air-orthy %ondition. 6. (a)a2ility /ist 6. (a)a2ilities shel' e1aluation. 6.2 *%%e)ta2le 'or&at 'or a))ro1ed %a)a2ility list. 6.! 6ork )er'or&ed -ithin the *M0 a))ro1ed %a)a2ility list. 4. (ontra%t Maintenan%e 4. Maintenan%e 'un%tion %ontra%ted to outside 'a%ility.

8. 7rainin. Pro.ra& 8. Initial trainin. D %ontinuationFre%urrent 8.2 trainin.. Cu&an )er'or&an%e related to skills and 8.! kno-led.e trainin.. 8.$ 7rainin. re%ords retention. 7rainin. )ro.ra& de1elo)&ent. A. ;eneral A. 3is)layin. o' %erti'i%ate. A.2 *ssess&ent o' en1iron&ental )ollution <'or do&esti% *M0=. A.! /o%al authority a))ro1al <'or 'orei.n *M0=. A.$ Forei.n *M0 &ust &eet re,uire&ents (*8+ $"." <%=.

3*( For& $"-#$ +2 <#!-2##6=

Pa.e $ o' "

2#. *M0 and ?uality (ontrolF8yste& Manual <not a))li%a2le 'or ne- a))ro1al= +e1ision &ade to the *M0 Manual >es 3es%ri)tion o' the re1ision: No

+e1ision &ade to the ?uality (ontrolF8yste& Manual >es 3es%ri)tion o' the re1ision: No

Ins)e%tion Findin.<s=:

3uration o' (erti'i%ate:

@alid u) to:

I herby certify th t !! i"f#r$ ti#" b#%e h %e bee" $ &e i" cc#r& "ce 'ith the Ci%i! A%i ti#" S fety Re()! ti#"* "& i* tr)e t# the be*t #f $y +"#'!e&(e Pla%e and date o' Ins)e%tion: He & #f Secti#" I"*,ect#r -*.

Direct#r

De,)ty Direct#r

3*( For& $"-#$ +2 <#!-2##6= o' "

Pa.e "

ATTACHMENT OF DAC FORM /01230

7he 'ollo-in. do%u&ents or re)orts &ust 2e atta%hed 8u2:e%t . /e.al *s)e%t 'or 0r.aniBation +e,uire&ents <'or nere.istered= 2. /ist o' authoriBed )ersonnel 'or +78. !. (urri%ulu& @itae o' a%%ounta2le &ana.er D key )ersonnel <'or ne- re.istered andFor ne- )osition=. $. /etter o' assi.n&ent o' key )ersonnel D authoriBed )erson 'or +78 <'or ne- re.istered andFor ne- )osition=. ". /ist o' s)e%ial toolsFe,ui)&ent. 6. /ist o' eG)iry date o' &easurin. e,ui)&ent. 4. /ist o' te%hni%al )u2li%ation %o&)lete -ith the date o' last re1ision. 8. /ist o' the last 2 &onths or.aniBationHs -ork load. A. /ist o' *M0Hs su2-%ontra%tor. #. 7rainin. )ro.ra&. . (a)a2ility /ist <'or ne- re.istered andFor re1ised list=. *M0 and ?uality (ontrolF8yste& Manual (ontents <a))li%a2le 'or the 'irst a))ro1al= 8u2:e%t AMO M ") ! *%%ounta2le Mana.er ?uality 8tate&ent. Manual %ontents. /ist o' 5''e%ti1e Pa.es. 0r.aniBation (hart, in%ludin. &ana.e&ent )osition, area res)onsi2ility D their duties and res)onsi2ilities Pro%edures 'or &aintainin. and re1isin. &ana.e&ent, su)er1isory and ins)e%tion )ersonnel. 3es%ri)tion o' *M0Hs o)erations, in%ludin. housin. and 'a%ilities, e,ui)&ent and &aterials. Pro%edures 'or de1elo)in. and re1isin. %a)a2ility list and the shel' e1aluation re,uired. Pro%edures 'or de1elo)in. and re1isin. trainin. )ro.ra&. Pro%edures to .o1ern -ork at another lo%ation. Pro%edures 'or )er'or&an%e o' -ork. Pro%edures 'or &aintainin. and re1isin. o' the %ontra%t &aintenan%e.
*tta%h&ent o' 3*( For& $"-#$ +2 <#!-2##6= Pa.e o' 2

>es No

+e&ark

(o&)lian%e -ith (*8+ >es No

+e&ark

8u2:e%t 3es%ri)tion o' the re,uired re%ords D re%ord kee)in. Pro%edures 'or re1isin. *M0 &anual. 3es%ri)tion o' the syste& used to identi'y and %ontrol *M0 &anual. 4) !ity C#"tr#!5Sy*te$ M ") ! 3es%ri)tion o' the syste& and )ro%edures: - Ins)e%tion o' in%o&in. &aterial - Per'or&in. )reli&inary ins)e%tion - Ins)e%tion o' all arti%les that ha1e 2een in1ol1ed in an a%%ident 'or hidden da&a.e - 5sta2lishin. and &aintainin. )ro'i%ien%y o' ins)e%tion )ersonnel - 5sta2lishin. and &aintainin. %urrent te%hni%al data - ?uali'yin. and sur1eillin. non-%erti'i%ated )ersons -ho )er'or& the -ork - Per'or&in. o' 'inal ins)e%tion and return to ser1i%e - (ali2ratin. o' &easurin. and test e,ui)&ent - (orre%ti1e a%tion on de'i%ien%ies +e'eren%es to the &anu'a%turerHs ins)e%tion standards. 8a&)le o' ins)e%tion and &aintenan%e 'or&s and ta.s and the instru%tion ho- to 'ill it out. Pro%edures 'or re1isin. ?uality (ontrolF8yste& &anual. *))ro1al No. : 3ate Ins)e%tor : :

(o&)lian%e -ith (*8+ >es No

+e&ark

*tta%h&ent o' 3*( For& $"-#$ +2 <#!-2##6= 2

Pa.e 2 o'