Form EPF122

Rev.04
Date : 15 Jun 2020
1.a. SDR n°: A521/01083736/03
STRUCTURE DAMAGE REPORT 2. Page … of ….
1.b. NRC n°:
(A/C/WP No/NRC No…)

3. A/C TYPE : 4. A/C Reg. :A521 5. MSN : 6. Current FC : 7. Current FH :

8. Date :19/05/2023 9. Ref. WO : 10. ATA chapter : 57 11. Station: sgn

12. Damage reported during : Scheduled Line Base 13. Damage reported by : VJC11132
Other: (please specify)…………………………………………… Certificate Number :

14. Location:

Top Bottom Upper Lower Left Right Other: ………….

14.A Engine: Blades Nose cowl Pylon Thrust Reverser Other: ………………………..

14.B Component: Assembly Sub-assembly NHA Other: ………………………..

: Door Slat Flap Spoiler Wing
Elevator Rudder Aileron THS Other: ……………………

14.C Fuselage: Skin Frame Stringer Floor structure Other: ………..…….

15. Type of Damage : Crack Scratch Dent Abrasion Perforation

Delamination Gouge Hole Nick Burn mark

Distortion De-bonding Other:……………………

Corrosion : Level 1 Level 2 Level 3

16. Dimension: Length: ………40……..… Width: ………40………...Depth: …………0.7…………….(Unit): …mm…………

17. Description of the damage: P/N:……………….. S/N:……………….. N/A:

DENT ON LOWER LH OUTBOARD FLAP TAB ZONE 12 BTW HINGE 4 & HINGE 3C WITH DIM: LxWxD = 40x40x0.7 MM

18. Inspection Method : General Visual Detailed Visual Eddy Current Rototest Tap Test

X-Ray Ultrasonic Other :……………………………………………………

19. Rectification of the damage: SRM…57-53-00-283-071….. AMM …………………………………….

CMM ……………………………... Other ……………………………………. N/A

TEMPORARY REPAIR NOT REQUIRED. ADD# 01083736-03 RAISED FOR PERMANENT REPAIR WITHIN 1000 FC
NDT REPORT: VJC-NDT-23-132
 Form EPF122
Rev.04
Date : 15 Jun 2020
1.a. SDR n°: A521/01083736/03
STRUCTURE DAMAGE REPORT 2. Page … of ….
1.b. NRC n°:
(A/C/WP No/NRC No…)

20. Repair reference: Ref: ……………………………/ Rev…….. 21. Repair Classification: Major Minor

Other ref :…………………………………. Negligible damage

22. Repair Category: CAT A: permanent repair and no further action required.
CAT B: permanent repair with further inspection required.
CAT C: temporary repair.

23. Additional Inspection requirement: (for CAT B) 24. Repair life limitation (for CAT C): …………………..

- Threshold: ……………………………………………………………. ………………………………………………………………….

…………………………………………………………………
- Interval: …………………………………………………………………
………………………………………………………………….
- Method of inspection: ……………………..…………………….
25. Structure damage description sketch/photos:
 Form EPF122
Rev.04
Date : 15 Jun 2020
1.a. SDR n°: A521/01083736/03
STRUCTURE DAMAGE REPORT 2. Page … of ….
1.b. NRC n°:
(A/C/WP No/NRC No…)
 Form EPF122
Rev.04
Date : 15 Jun 2020
1.a. SDR n°: A521/01083736/03
STRUCTURE DAMAGE REPORT 2. Page … of ….
1.b. NRC n°:
(A/C/WP No/NRC No…)

Form EPF122 completion guidance:

Block 1.a.Entry a unique Reference Number of Structure Damage Report as A/C/TLP/No in which:
+ A/C : the Aircraft registration number.
+ TLP : Technical log page number.
+ Item No: Item number of the related TLP.
Block 1.b.
+ NRC number : Fill the NRC number/ (A/C/WP No/NRC No…) of the structure defect /damage
Block 2. Entry page number ‘’of’’ total pages of SDR
Block 3. Entry type of Aircraft
Block 4. Entry Aircraft Registration Number
Block 5. Entry Manufacture Serial Number
Block 6. Entry the current flight cycle of A/C
Block 7. Entry the current flight hours of A/C
Block 8. Entry date in the format dd mmm yyyy. E.g: 15 JUL 2010
Block 9. Entry reference Work Order
Block 10. Entry ATA chapter
Block 11. Entry station
Block 12. Entry the time period that the damage is found, by ticking on appropriate box, such as:
scheduled, line, base or other
Block 13 : Entry name, signature and certificate number of the Reporter.
Block 14.A/B/C Entry location of damage, tick on appropriate box for Engine / Fuselage / component.
Block 15. Entry type of damage and level of corrosion, tick on appropriate box
Block 16. Record dimension of damage include : length, width, depth.
Block 17. Entry description of the damage, record P/N S/N if damage for component.
Block 18. Entry inspection method by ticking on appropriate box, such as : general inspection, detail
visual, eddy current, rototest, tap test, X-Ray, Ultrasonic or other
Block 19. Entry detail action to rectify the damage, including action taken and action request
Block 20. Entry repair reference
Block 21. Entry repair classification by ticking on appropriate box.
Block 22. Entry Repair category by ticking on appropriate box
Block 23. Entry specific inspection requirements, consist of : threshold, interval, method of Inspection,
temporary repair life limitation
Block 24. Entry life limitation for temporary repair CAT C.
Block 25. Describe overall location of damage on aircraft or component by figure and describe detai-
led location and dimensions of the damage and distances to adjacent.