Form 145-04R2

DEPARTMENT OF COMMUNICATIONS DIRECTORATE GENERAL OF AIR COMMUNICATIONS DIRECTORATE OF AIRWORTHINESS AIRWORTHINESS CERTIFICATION

Karya Bld. 22 nd Floor, Jl. Medan Merdeka Barat No. 8 Jakarta Pusat – Indonesia Phone : 62-2 !"#666$, !"#666$, !"#666" Fa%si&ile : 62-2 !"#666! APPROVED MAINTENANCE ORGANIZATION INSPECTION CHECKLIST

. Na&e o' (o&)any

:

". *))li%ation +euested  

2. Business *ddress

Initial

: +eneal

!. /o%at o%atio ion n o' Fa%i Fa%ili lity ty

*dditional +atin

:

(hane o' /o%ation $. *))ro1al Nu&er 6.

 

: 3o&esti% *M0

0ther 

Forein *M0

4. +atins: *I+F+*M5 (lass  (lass 2 (lass ! (lass $ +*3I0

P05+P/*N7 (lass  (lass 2 (lass ! IN7+9M5N7

(lass  (lass 2 (lass !

P+0P5//5+  (lass  (lass 2

*((50+I5

(lass  (lass 2 (lass ! (lass $

(lass  (lass 2 (lass !

8. /i&ited +atins: ue%t

Make and Model

*I+F+*M5

5N;IN5 3*( For& $"-#$ +2 <#!-2##6=

Pae  o' "

ue%t

Make and Model

P+0P5//5+ 

IN7+9M5N7

+*3I0

*((50+>

/*N3IN; ;5*+ (0MP0N5N7

F/0*7

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

+070+ B/*35

*I+(+*F7 F*B+I( 0+K 

 N0N-357+9(7I@5 757IN; A. /i&ited +atin 'or )e%ialied er1i%e: ue%t

3*( For& $"-#$ +2 <#!-2##6=

)e%i'i%ation 9sed

Pae 2 o' "

#. Cousin and Fa%ility  No.

ue%t

(o&)lian%e ith (*+ >es No

+e&ark 

#.

Cousin 'or 'a%ilities, eui)&ent, &aterials, and  )ersonnel. #.2 Fa%ilities 'or )er'or&in ork: a. u''i%ient ork s)a%e and areas 'or the )ro)er sereation D )rote%tion o' arti%les,  . ereation ork areas enalin en1iron&entally haardous or sensiti1e o)erations <%leanin,  )aintin, eldin, &a%hinin, a1ioni% ork, and ele%troni% ork=, %. uitale ra%ks, trays, stands, hoists, and other sereation &eans 'or storae D )rote%tion, d. )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. orksho) area. 3ust 'ree sho) 'or radio and instru&ent ratin.

7otal area *1ailale:

MEs.'t.

. Personnel . .2 .!

3esinated a%%ountale &anaer. *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 authoried )ersonnel 'or +7

7he nu&er o' )ersonnel e&)loyed:

7he nu&er o' te%hni%al )ersonnel: /i%ensed:

Non-li%ensed:

2. 7ools5ui)&ent 2. 2.2 2.! 2.$

7oolseui)&ent ne%essary to )er'or& the ork. (ontrollin o' )eriodi% %aliration to national standard. *1ailaility o' toolseui)&ent in ea%h unit. torin o' toolseui)&ent.

!. 7e%hni%al Puli%ation !. *1ailaility o' %urrent te%hni%al )uli%ation related to the ratin souht: a. Maintenan%e &anual  . Illustrated Parts (ataloue %. irin diara& 3*( For& $"-#$ +2 <#!-2##6=

Pae ! o' "

 No.

ue%t

(o&)lian%e ith (*+ >es No

+e&ark 

d. +e)airo1erhaul &anual e. er1i%e ulletinslettersinstru%tions '. *irorthiness 3ire%ti1e $. Ins)e%tion 'or In%o&in &aterials)arts $. $.2 $.! $.$ $."

3o%u&ent  %erti'i%ate hi%h &ust atta%h. Candlin o' sus)e%ted un-a))ro1ed )arts. hi))in and )a%kin %ondition. Physi%al %ondition o' the &aterial)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
(a)ailities shel' e1aluation. *%%e)tale 'or&at 'or a))ro1ed %a)aility list. ork )er'or&ed ithin the *M0 a))ro1ed %a)aility list.

4. (ontra%t Maintenan%e 4.

Maintenan%e 'un%tion %ontra%ted to outside 'a%ility.

8. 7rainin Prora& 8. 8.2

Initial trainin D %ontinuationre%urrent 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. A.2 A.! A.$

3is)layin o' %erti'i%ate. *ssess&ent o' en1iron&ental )ollution <'or do&esti% *M0=. /o%al authority a))ro1al <'or 'orein *M0=. Forein *M0 &ust &eet reuire&ents (*+ $"." <%=.

3*( For& $"-#$ +2 <#!-2##6=

Pae $ o' "

2#. *M0 and ?uality (ontrolyste& Manual es

No

>es

No

3es%ri)tion o' the re1ision:

+e1ision &ade to the ?uality (ontrolyste& Manual

3es%ri)tion o' the re1ision:

Ins)e%tion Findin
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 e atta%hed ue%t

>es

No

+e&ark

. /eal *s)e%t 'or 0raniation +euire&ents <'or ne reistered= 2. /ist o' authoried )ersonnel 'or +7. !. (urri%ulu& @itae o' a%%ountale &anaer D key )ersonnel <'or ne reistered andor ne )osition=. $. /etter o' assin&ent o' key )ersonnel D authoried )erson 'or +7 <'or ne reistered andor ne )osition=. ". /ist o' s)e%ial toolseui)&ent. 6. /ist o' eG)iry date o' &easurin eui)&ent. 4. /ist o' te%hni%al )uli%ation %o&)lete ith the date o' last re1ision. 8. /ist o' the last 2 &onths oraniationHs ork load. A. /ist o' *M0Hs su-%ontra%tor. #. 7rainin )rora&. . (a)aility /ist <'or ne reistered andor re1ised list=. *M0 and ?uality (ontrolyste& Manual (ontents
(o&)lian%e ith (*+ >es No

+e&ark  

AMO M")!

*%%ountale Manaer ?uality tate&ent. Manual %ontents. /ist o' 5''e%ti1e Paes. 0raniation (hart, in%ludin &anae&ent  )osition, area res)onsiility D their duties and res)onsiilities 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)aility 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

 

ue%t

(o&)lian%e ith (*+ >es No

+e&ark  

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 een in1ol1ed in an a%%ident 'or hidden da&ae - 5stalishin and &aintainin )ro'i%ien%y o' ins)e%tion )ersonnel - 5stalishin 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 - (aliratin o' &easurin and test eui)&ent - (orre%ti1e a%tion on de'i%ien%ies +e'eren%es to standards.

the

&anu'a%turerHs

ins)e%tion

a&)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 (ontrolyste& &anual. *))ro1al No. : 3ate

:

Ins)e%tor

:

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

Pae 2 o'