Identification du dossier :

Change / Repair
dossier xxxxxx

Status Authorized signatory

Issue x dated xx/xx/xxxx
Revisions Date Subject

1 Foreword
This documents has been prepared has been produced in accordance with an alternative
procedure to DOA.

2 Description and classification of the change to type design

2.1 Applicability
Aircraft type:
Serial number:
Registration:

2.2 Description

2.2.1 Reason for the change (or repair)

Describe here the reason for the change or the repair. In case of damages, illustrations
are recommended.

2.2.2 Brief description of the change (or repair)

Illustration, photos, sketches are recommended.

2.3 Classification

2.3.1 Classification proposal

Minor without further showing of compliance
Minor with further showing of compliance
Major (STC)

2.3.2 Classification justification

The classification must be done according information provided in 21A.91 and GM to
21A.91. Justification cannot be a basic statement, but must be substantiated. Wording
like “this change has no appreciable effect on weight and balance” should be avoided
and preferably replaced by “this change is adding 2 kg over the empty weight of 1550
kg, the weight is increasing by 0.1 %, which is negligible”.

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 Identification du dossier :

Change / Repair
dossier xxxxxx

3 Showing of compliance - substantiation

3.1 Certification basis
If the case is eligible to the use the certification basis incorporated in the type certificate
(see Part 21.A101), the information can be found in the type certificate data sheet of the
aircraft.
Applicant should be aware that in such a case, he must have a copy of the airworthiness
code used for the certification of the aircraft.

3.2 Relation with the TC holder

Organisation should explain whether it will identify any reinvestigation necessary to
show compliance of the changed product with the applicable certification basis process
using its own resources or through an arrangement with the type certificate holder
(21A.93 - 21A.113).
Where the organisation is not capable to use its own resources and has entered into an
arrangement with the TC holder, the modification dossier must include (21A.115):
- A statement of non technical objection from the TC holder
- A statement from the TC holder that he has agreed to collaborate with the STC
older to ensure discharge of all obligations for continued airworthiness of the
change product through compliance with 21A.44 and 21A.118A

3.3 Compliance check-list

MC0 Declaration MC5 Ground test (on aircraft)

MC1 Description MC6 Flight test
MC2 Analysis MC7 Inspection
MC3 Safety analysis MC8 Simulation
MC4 Test bench MC9 Equipment qualification
Certification specification impacted Showing of compliance
List here all CS paragraphs impacted by the design change Give information about:
- Mean of compliance (as above)
- Date planned or realized
- Description
- Link to compliance document or statement
Exemple :
CS 23.29 Empty weight and corresponding Mean of compliance: MC2 (Analysis)
centre of gravity Date planned : 31/12/2006
(a) The empty weight and corresponding Description:
centre of gravity must be determined by weighing - Weighting of aircraft after change
the aeroplane with – implementation showing that change has no
(1) Fixed ballast; impact on weight
(2) Unusable fuel determined under Compliance document or statement:
CS 23.959; and - Weight and balance report xxxPP121
(3) Full operating fluids, including –
(i) Oil;
(ii) Hydraulic fluid; and
(iii) Other fluids required for
normal operation of aeroplane systems,
except potable water, lavatory precharge
water, and water intended for injection in
the engines.

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 Identification du dossier :

Change / Repair
dossier xxxxxx

(b) The condition of the aeroplane at the time

of determining empty weight must be one that is
well defined and can be easily repeated.

4 Certification documents (definition dossier)

- Blue prints (master drawing list of the change)
- Program and test reports
- Analysis, technical notes
- IPC supplement
- Service bulletin
- Maintenance manual supplement
- Flight manual supplement
- Etc.

5 Declaration of compliance
I hereby declare that this modification dossier is showing evidence that this type design
change (or repair) is complying with the applicable certification basis and environmental
protection requirements, as specified in Part 21A.101.

Place _______________date________________

Name and signature :_____________________

© European Aviation Safety Agency, 2007. All rights reserved. Proprietary document. Page 3 of 3