MINISTRY OF TRANSPORTATION

DIRECTORATE GENERAL OF CIVIL AVIATION

Office Complex Soekarno-Hatta International Airport, C3 St., Tangerang, Banten- Indonesia
Telp.: (+6221) 225 66288, (+6221) 256 08887 Fax. : (+6221) 225 66399
Website : hubud.dephub.go.id; e-mail:
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INSPECTION RECORDS ISSUANCE OF ORIGINAL / RECURRENT
CERTIFICATE OF AIRWORTHINESS
1) Inspection place and date : MASAMBA, JANUARI 2023

PART I. GENERAL DATA

2) A. AIRCRAFT MAKE MODEL: CESSNA AIRCRAFT COMPANY 208B

3) Nationality &
4) Registration 5) Serial 6) Aircraft
Registration 7) Mfg Year 8) Operator
Number Number Category
Marks
PT. Asi Pudjiastuti
PK-VVT 2632 208B2068 NORMAL 2009
Aviation
9) TC/TC Validation 10) TC/TC Validation 11) TC/TC Validation
12) MTOW
Number. Revision Date
A029 REVISION 3 31 MAY 2016 9062 lbs (4110.4 KG)

13) Total Time

a) Current DGCA Inspection b) Previous DGCA Inspection

TSN (FH) 12769.3 FH (19 Januari 2022)

CSN (FC) 16980 FC (19 Januari 2022)

14) Aircraft utilization during one year (per Hours: 1065.8 Cycles: 1338
Year: 2022
31 December)

15) B. ENGINE MAKE & MODEL: PRATT & WHITNEY CANADA PT6A-114A
No. 16) Serial Number 17) TSN 18) CSN 19) TBO 20) Remaining
1 PCE-PC1766 12240.3 FH 14372 FC 6100 FH 5014.8 FH
2
3
4

21) C. PROPELLER MAKE & MODEL: MC CAULEY 3GFR34C703

No. 22) Serial Number 23) TSN 24) CSN 25) TBO 26) Remaining
1 022306 6843.9 - 4000 FH/72 m 2914.8 FH
2
3
4
5
6

DGCA Form No. 21-40 (Oct 2017) Page 1 of 20

27) D. APU MAKE & MODEL: N/A
No. 28) Serial Number 29) TSN 30) CSN 31) TBO 32) Remaining

1 N/A N/A N/A N/A N/A

E. LANDING GEAR
Nomenclature Part Number Serial Number TBO Remaining

33) Nose L/G 2643100-20 377 40000 FC 21638 FC

34) Left Main L/G 2641013-8 1533 31500 FC 13138 FC

35) Right Main L/G 2641013-8 1527 31500 FC 13138 FC

PART II. AIRCRAFT STATUS

A. Aircraft Document & Manual (as applicable)

(check for currency and condition)
36) Satisfactory
Item Description 37) Remarks
Yes No

II.A.1 Certificate of Registration VUT : 10 JUL 2023

II.A.2 Certificate of Airworthiness VUT : 20 JAN 2023

II.A.3 Insurance VUT : 31 AUG 2023

II.A.4 Maintenance Manual REV. 38 : 20 OCT 2022

II.A.5 Weight & Balance Manual REV. 02 : 10 DES 2010

II.A.6 Wiring Diagram Manual REV. A1 : 22 MAR 2022

II.A.7 Structure Repair Manual REV. 9 : 01 AUG 2018

II.A.8 Illustrated Part Catalog REV. A1 : 21 FEB 2022

Aircraft Flight Manual / Pilot Operating
II.A.9 REV. 2 : DEC 2010
Handbook

II.A.10 Flight Crew Operating Manual REV. 1 : 01 AUG 2017

II.A.11 Quick Reference Handbook REV. 2 : 01 DES 2010

II.A.12 Master M.E.L and/or M.E.L REV. 6 : 01 JUN 2017

II.A.13 Noise Certificate or equivalent N1233R1

II.A.14 Aircraft Aeronautical Station License VUT : 28 APR 2023

DGCA Form No. 21-40 (Oct 2017) Page 2 of 20

B. Log Book and Test Report
36) Satisfactory
Item Description Yes No 37) Remarks

II.B.1 Aircraft Flight/Maintenance Log

II.B.2 Deferred item list (ie. HIL, CDL, DMI, DDR) NIL

II.B.3 Aiframe, Engine, Propeller

II.B.4 Compass Swing Data Report VUT : 31 DEC 2023

Weight & Balance Report

II.B.5 VUT : 31 JUL 2027
(CASR 121.153, CASR 135.153)
Altimeter & Static System Test Report
II.B.6 VUT : 29 DES 2024
(CASR 91.411, CASR 43 App. E)
ATC Transponder Test Report
VUT : 29 DES 2024
(CASR 91.413, CASR 43 App. F)
II.B.7
SSR MODE S CODE :
Mode S Transponder encoding 8A0342
II.B.8 VOR inspection for IFR (CASR 91.171)
II.B.9 ELT Test Report (CASR 91.207) 29 DEC 2023

C. Aircraft Inspection and Maintenance Records

36) Satisfactory
Item Description Yes No 37) Remarks
Statement of Build Standard (new aircraft)
II.C.1 N/A
from manufacturer
Statement of accident/incident from the last
II.C.2 N/A
operator (if any)
Approved Maintenance Program (Doc. No, SAP-16 REISSUE 2,
II.C.3
Revision, Date) REV. 0 - OCTOBER 2019
Inspection work package for compliance:
II.C.4 (CASR 91.409, 135.367,121.367)
Latest inspection type: 100 HOURS JOB NO. SA2212-9446
INSPECTION date: 31 DEC 2022 at :
13835.1 FH/ 18318 FC

Annual / 100 Hours Inspection

Structural Inspection Program

Corrosion Protection Control Program N/A

Non routine inspection

Component status (OC, CM, HT) & Life
II.C.5
Limited Part (for bridging ref AC 121-1)
Airworthiness Directives & Allert Service
II.C.6
Bulletin Status
Damage and Repair status and work package
II.C.7 N/A
report
Alteration/Modification status and work
II.C.8 N/A
package
II.C.9 Service Difficulty Report N/A

DGCA Form No. 21-40 (Oct 2017) Page 3 of 20

PART III. AIRCRAFT INSPECTION

A. External Visual Inspection

1. Landing gear / skid and wheel well area

36) Satisfactory
Item Description Yes No 37) Remarks

III.A.1.1 Data plate, placards and marking

III.A.1.2 Sign of corrosion, wear, chafing lines or wires
Structural integrity of gears and doors for
III.A.1.3 N/A
cracks, dents, other obvious damage
Sign of leaks (struts, actuators valves, tube
III.A.1.4 and hose)
III.A.1.5 Wheel installation and safety locking device
III.A.1.6 Tire condition
Brake installation for security, wear, condition
III.A.1.7 and leaks
III.A.1.8 Skids and floats for security and condition N/A
Steering mechanism for security, wear, and
III.A.1.9 condition
III.A.1.10 Brake pin indicator for minimum length N/A

III.A.1.11 Torque links for security and excessive play

III.A.1.12 Fairing for security and missing fasteners
III.A.1.13 Lighting for condition N/A

III.A.1.14 Main Gear Static Discharge N/A

2. Fuselage and Empenage

36) Satisfactory
Item Description Yes No 37) Remarks

Identification Plate (CASR 45.11)

a. Aircraft
It must be secured to the aircraft fuselage exterior
so that it is legible to a person on the ground, and
must be either adjacent to and aft of the rearmost
entrance door or on the fuselage surface near the
tail surfaces
b. Manned Free Balloons
It must be secured to the balloon envelope and
must be located, if practicable, where it is legible
III.A.2.1 to the operator when the balloon is inflated. In
N/A
addition, the basket and heater assembly must be
permanently and legibly marked with the
manufacturer's name, part number (or equivalent),
and serial number (or equivalent).
c. Power Parachute and Weight Shift Control
It must be secured to the aircraft fuselage exterior N/A
so that it is legible to a person on the ground.
d. Additional Identification Plate (Nationality &
Registration Marks) CASR 45.30).
It must be secured to the aircraft in a prominent
position near pilot's entrance

DGCA Form No. 21-40 (Oct 2017) Page 4 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
Nationality & Registration Marks and National
Flag for legibility, location and size, and other
III.A.2.2
marking requirements (CASR 45.21, 45.22,
45.23, 45.24, 45.25. 45.27, 45.29)
Structure for cracks, corrosion, dents, rubbing
III.A.2.3 NIL
and other obvious damages
Exterior Exit markings and exterior
III.A.2.4 emergency lighting and escape route (CASR
121.310, 135.349)
Drain holes for obstruction stain or other sign
III.A.2.5
of leaks
Radome, pitot tubes, static ports, stall
III.A.2.6 warning, windshield, wiper, sensors,
antennas, for condition, security & corrosion
III.A.2.7 Loose/missing improper fasteners NIL
Elevators, rudder and tabs for obvious
III.A.2.8 damage, cracks, corrosions, rubbing and
excessive play
III.A.2.9 Fire discharge dishes for indication N/A
Lavatory Servicing Areas (evidence of fresh
III.A.2.10 N/A
blue water streaks)
3. APU
36) Satisfactory
Item Description 37) Remarks
Yes No
III.A.3.1 Identification Plate N/A

III.A.3.2 Door for security and missing/loose fastener N/A

III.A.3.3 Any indication of wear, leak, chaffing line, wire N/A

III.A.3.4 Fire extinguisher and sensor N/A

4. Wings and Pylon

36) Satisfactory
Item Description 37) Remarks
Yes No
All lights for general condition and broken
III.A.4.1
lenses
Structure for cracks, corrosion, dents and
III.A.4.2 NIL
other damage
III.A.4.3 Fuel caps for security
III.A.4.4 Wing tip for general condition and damage
Anti/de-icing devices for condition and
III.A.4.5 N/A
damage
Leading edge for dents, abrasion, obvious
III.A.4.6 damage, and stall warning for function
condition
Leading edge devices, rubber boots, wiring,
III.A.4.7 N/A
hoses, for condition and leak
III.A.4.8 Evidence of fuel leaks NIL

DGCA Form No. 21-40 (Oct 2017) Page 5 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
Flaps and flaps track for cracks, corrosion,
III.A.4.9 leaks, abrasion, dents, delamination, and NIL
condition of wiring, lines and hoses
Aileron and tabs for obvious cracks,
III.A.4.10 NIL
corrosion, dents, delimination, excessive play
III.A.4.11 Static discharge for condition
Access panels/hatch/inspection door for
III.A.4.12
Security
5. Power plants
36) Satisfactory
Item Description 37) Remarks
Yes No
Engine Identification Plate (CASR 45.11)
III.A.5.1 It must be affixed to the engine at an accessible
location
Fan blade, turbine blade, and sensors for
III.A.5.2
Damage
III.A.5.3 Engine mount, cowling and pylons
Cowling & doors for security and
III.A.5.4
missing/loose fasteners
III.A.5.5 Inlet cowl for dents, corrosion and abrasion
Acoustic, access panel for security, dents,
III.A.5.6 N/A
corrosion, delimination and crack
III.A.5.7 Reverse doors for stowage security and leaks N/A
Exhaust for turbine/tail pipe damage and
III.A.5.8
Leaks
Fire extinguisher bottle gauge for security and
III.A.5.9 N/A
correct pressure
6. Propeller / Rotor
36) Satisfactory
Item Description 37) Remarks
Yes No
Propeller/rotor Identification Plate (CASR
III.A.6.1 45.11), It must be affixed to the propeller at an
accessible location
Propeller blade and deicer boots, for dent,
III.A.6.2 crack, deterioration, delamination and general
condition
Drive shaft, yoke, swash plate, rotor head for
III.A.6.3 wear, dent, crack, deterioration, delamination N/A
and general condition
III.A.6.4 Spinner for cracks and dent
Main rotor blades, for secured, wear, obvious
III.A.6.5 damage, and general condition (including N/A
color codes)
Tail rotor for secured, wear, obvious damage,
III.A.6.6 N/A
and general condition
Tail rotor gearbox, drive shaft and oil level for
III.A.6.7 security, cracks, damage, leaks and general N/A
condition

DGCA Form No. 21-40 (Oct 2017) Page 6 of 20

B. Interior Inspection

1. Lavatory Fire Protection (CASR 121.308, CASR 135.347)

36) Satisfactory
Item Description 37) Remarks
Yes No
Each lavatory in the airplane must be
equipped with a smoke detector system or
equivalent provides a warning light in the
III.B.1.1 N/A
cockpit or provides a warning light or audio
warning in the passenger cabin readily
detected by a flight attendant
Each lavatory in the airplane must be
equipped with a built-in fire extinguisher and
III.B.1.2 capable of automatic discharge, for each N/A
disposal receptacle for towels, paper, or
waste located in the lavatory
2. Emergency Equipment and Additional Emergency Equipment (CASR 91.207, 91. 533, CASR
121.309, CASR 121.310, CASR 121 App. A, CASR 135.349)
note: Each item of emergency and flotation equipment:
(1) Must be inspected regularly, and so indicated date of last inspection;
(2) Must be readily accessible to the crew;
(3) Must be clearly identified and clearly marked to indicate its method of operation; and
(4) When carried in a compartment or container, must be marked on the compartment or
container, the date of last inspection
Hand Fire Extinguisher
Note: HALON 1211
a. At least two of the required hand fire
extinguisher installed in passenger
carrying airplanes must contain Halon
1211 (CASR 121.309) or equivalent
extinguisher agent.
b. At least one of the required hand fire
extinguisher installed in passenger
carrying airplanes must contain Halon
1211 (CASR 135.349)
c. For individual Certificate of Airworthiness
is first issued on or after 31 December
2016 shall not be of a type listed in the
1987 Montreal Protocol (Annex A, Group
II)
III.B.2.1 1. Halon 1211
2. Halon 1301
3. Halon 2402
A. At least one hand fire extinguisher must
be conveniently located for use:
i. in each galley compartment N/A

ii. in each class E cargo compartment N/A

iii. on the flight deck

DGCA Form No. 21-40 (Oct 2017) Page 7 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
B. In passenger compartment, at least one
N/A
Halon 1211 (CASR 121.309)
7 - 30 at least one N/A

31 - 60 at least two N/A

61 – 200 Minimum 3 ea N/A

201 – 300 Minimum 4 ea N/A

301 – 400 Minimum 5 ea N/A

401 – 500 Minimum 6 ea N/A

III.B.2.1
(cont’d) 501 – 600 Minimum 7 ea N/A

> 600 Minimum 8 ea N/A

In passenger compartment (CASR
N/A
135.349)
>9 at least one N/A
In passenger compartment (CASR
N/A
91.533)
7 – 30 at least one N/A

> 30 at least two N/A

First Aid Kit, must be readily acessible to the
crew, stored securely, free form dust, N/A
moisture and temperature (CASR 121 App. A)
0 – 50 Minimum 1 ea N/A

51 – 150 Minimum 2 ea N/A

151 – 250 Minimum 3 ea N/A

> 250 Minimum 4 ea N/A

> 9 pax seat (CASR 135. 349) 1 EA

III.B.2.2 First Aid Kit, must be readily acessible to the
crew, stored securely, free form dust, N/A
moisture and temperature (CASR 91.533)
0 - 100 Minimum 1 ea N/A

101 - 200 Minimum 2 ea N/A

201 - 300 Minimum 3 ea N/A

301 - 400 Minimum 4 ea N/A

401 - 500 Minimum 5 ea N/A

>500 Minimum 6 ea N/A

Emergency Medical Kit (check contain in
N/A
accordance with appendix A)
III.B.2.3 At least one (CASR 121 Appendix A) N/A

In airplanes for which a flight attendant is N/A

required (CASR 135.349)

DGCA Form No. 21-40 (Oct 2017) Page 8 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No

Crash Axe
a. Each airplane accommodating more than
N/A
19 passengers (CASR 91.533)
b. Each airplane operated under CASR 135
III.B.2.4 that has a lockable non frangible door
1 EA
separating the flight deck from the
passenger cabin (CASR 135.349)
c. Each airplane operated under CASR 121
N/A
(CASR 121.309)
Megaphone (CASR 91.533, 121.309) N/A

III.B.2.5 61 - 99 1 ea (rearward) N/A

2 ea (forward &
> 99 N/A
rearward)
Emergency Exit (CASR 91.607, CASR
135.349, CASR 121.310)
a. Interior Emergency Exit marking,
placement and legibility
b. Lighting for interior emergency exit
III.B.2.6
marking
c. Emergency exit operating handles and
instruction
d. Emergency exit access, must be
unobstructed
Portable lights, ensure available for each flight
attendant seat and accesible from each flght
III.B.2.7 N/A
attendant seat (CASR 91.205, CASR
121.310, CASR 135.357)
Protective Breathing Equipment (CASR
N/A
121.337)
a. One in flight deck N/A
b. One PBE is required for each hand fire
N/A
III.B.2.8 extinguisher located for use in a galley
c. One PBE is required for each hand fire
extinguisher in pax compartment (located N/A
within 3 feet from hand firex)
d. One for use in each Class A, B, and E
N/A
cargo compartment
III.B.2.9 Portable Oxygen (CASR 121.333) N/A
Emergency Locator Transmitter, type 406
(CASR 91.207).
Note: If the aircraft installed with fixed and
deployable automatic type transmitters, it must be
attached to the airplane as far aft as practicable

a. Type of ELT
III.B.2.10
Automatic Fixed (AF) ARTEX ME 406

Automatic Portable (AP) N/A

Automatic Deployable (AD) N/A

Survival (S) N/A

DGCA Form No. 21-40 (Oct 2017) Page 9 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
b. < 20 passenger seat at least one
(automatic)
Record ELT Battery due:
III.B.2.10 c. > 19 passengers for which the individual
(cont’d) certificate of airworthiness is first issued
N/A
after 1 July 2008 at least two (one of
which shall be automatic)
Record ELT Battery due: .... and ........ N/A
d. ELT annual inspection (after the last
inspection) for:
(i) Proper installation
(ii) Battery corrosion
(iii) Operation of the controls and crash
sensor
(iv) The presence of a sufficient signal
radiated from its antenna

e. ELT encoding
3. Emergency Equipment for Overwater Operation
(CASR 91, 207, 91.223, CASR 121.309, 121.339, CASR
135.349, 135.351, 135.355)
4. Miscellaneous Equipment (CASR 121.313, 135.321) 

III.B.4.1 Spare of protective fuse or bulb (if installed) N/A

A windshield wiper or equivalent for each pilot
III.B.4.2 N/A
station
III.B.4.3 Two independent static pressure systems
A means to monitor from the flight deck side
of the door the area outside the flight deck N/A
III.B.4.4
door (except for cargo)
Door between the passenger and pilot or
crew rest compartments, for transport
III.B.4.5 category and/or cargo operation with a mtow N/A
in excess of 45.500 kg or with a passenger
seating greater than 60.
A placard on each door of access to a an
emergency exit, to indicate that it must be N/A
III.B.4.6 open during takeoff and landing
5. Passenger Information (CASR 121.317)
Passenger information marking and placard in
III.B.5.1 Bahasa or Bilingual (Bahasa – English)
(CASR 21.29 a.3)
a. Fasten seat belt sign or placard is visible
from each passenger seat
b. No smoking sign or placard, in cabin and
lavatory
6. Public Address System
Public Address System (more than 19 pax)
III.B.6.1 (CASR 121.318, CASR 135.331)
N/A
(note: Transport category manufactured after
December 1996)

DGCA Form No. 21-40 (Oct 2017) Page 10 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No

7. Crewmember Interphone System

Crewmember Interphone System (more than
III.B.7.1 N/A
19 pax) (CASR 121.319, CASR 135.333)
8. Passenger Briefing Card
Passenger Briefing Card (CASR 91.537(b),
III.B.8.1 CASR 121.503(b), CASR 135.107(b).
9. Seats, Safety Belts, Shoulder Harnesses, and Child Restraint Systems (CASR 121.311, CASR
135.119, CASR 91.521)
Passenger seats, seat belts,
cushion/upholstery materials, armrest for
III.B.9.1 condition, reclining mechanism for proper
operations
Exit seat, check table, reclining mechanism to
III.B.9.2 make sure not blocking emergency exit N/A
(CASR 121.585, 135.121)
III.B.9.3 Child Restraint System, check for security N/A
At each flight deck station equipped with a
III.B.9.4 combined safety belt and shoulder harness,
check for security.

10. Cargo and Bagggage Compartment (CASR 121.221)

Fire precaution N/A
A. Class “A” (All parts of the compartment
are easily accesible and fire therein would
be ready discernible to a crew member) N/A
There must be a hand fire extinguisher
available for each Class A compartment.
B. Class “B” (Enough access for crew
member to reach all the compartment and
no smoke, flame or extingushing agent
enter the compartment occupied by crew
or passanger)
(1) It must have a separate approved
smoke or fire detector system to give
N/A
warning at the pilot or flight engineer
station
(2) There must be a hand fire
III.B.10.1 extinguisher available for the
compartment
(3) It must be lined with fire resistant
material
C. Class “C” (Not conform with requirement
Class A, B, D or E)
(1) It must have a separate smoke or fire
detector system to give warning at
the pilot or flight engineer station
(2) It must have an approved built-in fire
extinguishing system controlled from N/A
the pilot or flight engineer station
(3) It must be designed to exclude
hazardous quantities of smoke,
flames, or extinguishing agents from
entering into any compartment
occupied by the crew or passenger
DGCA Form No. 21-40 (Oct 2017) Page 11 of 20
 36) Satisfactory
Item Description 37) Remarks
Yes No
C. Class “C” (Not conform with requirement
Class A, B, D or E) (cont’d)
(4) It must have ventilation and draft
III.B.10.1 controlled so that the extinguishing
N/A
(cont’d) agent provided can control any fire
that may start in the compartment
(5) It must be lined with fire resistant
material

D. Class “D” (Designed and constructed that

a fire occuring therein will be completely
confined without endargingthe safety of
the airplane or occupants)
(1) It must have a means to exclude
hazardous quantities of smoke,
flames, or noxious gases from N/A
entering any compartment occupied
by the crew or passengers
(2) Ventilation and drafts must be
controlled within each compartment
(3) It must be completely lined with fire
resistant material

E. Class “E” for Cargo only

(1) It must be completely lined with fire
resistant material
(2) It must have a separate system of
an approved type smoke or fire
detector to give warning at the pilot
or flight engineer station
(3) It must have a means to shut off the
ventilating air flow to or within the
compartment and the controls for N/A
that means must be accessible to
the flight crew in the crew
compartment
(4) It must have a means to exclude
hazardous quantities of smoke,
flames, or noxious gases from
entering the flight crew
compartment
Check cargo door for leaks, damage and
III.B.10.2
general condition

III.B.10.3 Smoke detectors for damage N/A

Lighting is operable and protective cover is

III.B.10.4 N/A
installed
Flooring and pallet system for general
III.B.10.5
condition
Placard of weight limitation for availability and
III.B.10.6
legibility

III.B.10.7 A 9G cargo net for condition (if applicable) N/A

DGCA Form No. 21-40 (Oct 2017) Page 12 of 20

C. COCKPIT INSPECTION
INSTRUMENT, EQUIPMENT MARKING, PLACARD ARE CORRECTLY INSTALLED AND LEGIBLE.
1. Instrument for VFR (day) (CASR 91.205)
36) Satisfactory
Item Description 37) Remarks
Yes No

III.C.1.1 Airspeed indicator N/A

III.C.1.2 Altimeter N/A

III.C.1.3 Magnetic Direction Indicator N/A

III.C.1.4 A tachometer for each engine N/A

A cylinder head temperature indicator for
III.C.1.5 each air cooled eng. N/A

III.C.1.6 Oil in temperature indicator for each engine N/A

III.C.1.7 A fuel quantity indicator for each fuel tank N/A

III.C.1.8 An oil pressure indicator for each engine N/A

III.C.1.9 A manifold pressure indicator for each engine N/A

Landing gear position indicator, if the aircraft
III.C.1.10 has a retractable landing gear N/A

2. Instrument for IFR (CASR 91.205), specified requirement VFR (day)

36) Satisfactory
Item Description
Yes No 37) Remarks

III.C.2.1 Gyroscopic rate of turn indicator N/A

III.C.2.2 Slip/Skid indicator N/A

Sensitive altimeter adjustable for barometric
III.C.2.3 pressure N/A

III.C.2.4 Clock N/A

III.C.2.5 Gyroscopic pitch and bank indicator (AH) N/A

Gyroscopic direction indicator (directional
III.C.2.6 gyro or equivalent) N/A

3. Flight and Navigation Instrument (CASR 121.305)

36) Satisfactory
Item Description
Yes No 37) Remarks
An airspeed indicating system with heated
III.C.3.1 pitot tube N/A

III.C.3.2 Two sensitive pressure altimeter N/A

III.C.3.3 Clock N/A

III.C.3.4 A free air temperture indicator N/A

III.C.3.5 Gyroscopic pitch and bank indicator (AH) N/A

Gyroscopic rate and turn indicator combined
III.C.3.6 with an integral skip/skid indicator (turn and N/A
bank indicator)

DGCA Form No. 21-40 (Oct 2017) Page 13 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
Gyroscopic direction indicator (dyrectional
III.C.3.7 gyro or equivalent) N/A

III.C.3.8 A magnetic compass N/A

A vertical speed indicator (rate of climb
III.C.3.9 indicator) N/A
Two Gyroscopic pitch and bank indicator (AH)
or :
Third Gyroscopic pitch and bank indicator
III.C.3.10 (AH) for : N/A
(i) turbojet ,or
(ii) turbo prop having pax seat >30 or
payload > 7500 lbs
4. Engine Instrument (CASR 121.307)
36) Satisfactory
Item Description 37) Remarks
Yes No

III.C.4.1 Oil in temperature indicator for each engine N/A

III.C.4.2 A fuel pressure indicator for each engine N/A

A means for indicating fuel quantity for each
III.C.4.3 N/A
fuel tank
III.C.4.4 An oil pressure indicator for each engine N/A

III.C.4.5 An oil quantity indicator for each oil tank N/A

An independent fuel pressure warning device
III.C.4.6 for each engine or a master warning device N/A
for all engines
5. Flight and navigation Instrument (CASR 135.305)
36) Satisfactory
Item Description 37) Remarks
Yes No

III.C.5.1 Two independent airspeed indicating system

III.C.5.2 Two independent sensitive altimeter system

III.C.5.3 Clock

III.C.5.4 A free air temperature indicator

Gyroscopic direction indicator (directional
III.C.5.5
gyro or equivalent)
III.C.5.6 A magnetic compass

III.C.5.7 Gyroscopic pitch and bank indicator (AH)

Vertical speed indicator (rate of climb
III.C.5.8
indicator)
Two Gyroscopic pitch and bank indicator (AH)
III.C.5.9
for turbojet and turbo prop.
Third Gyroscopic pitch and bank indicator
III.C.5.10 N/A
(AH) for turbojet

DGCA Form No. 21-40 (Oct 2017) Page 14 of 20

6. Engine Instrument (CASR 135.317)
36) Satisfactory
Item Description 37) Remarks
Yes No

III.C.6.1 A tachometer for each engine

A carburetor air temperature indicator for
III.C.6.2 N/A
each engine.
A cylinder head temperature indicator for
III.C.6.3 each air cooled eng. N/A

III.C.6.4 Oil in temperature indicator for each engine

III.C.6.5 A fuel pressure indicator for each engine N/A

A fuel flowmeter or fuel mixture indicator for
III.C.6.6 each engine not equipped with an automatic
altitude mixture control
A means for indicating fuel quantity for each
III.C.6.7 fuel tank

III.C.6.8 An oil pressure indicator for each engine

III.C.6.9 An oil quantity indicator for each oil tank N/A

An independent fuel pressure warning device
III.C.6.10 for each engine or a master warning device
for all engines

III.C.6.11 A device for each reversible propeller

III.C.6.12 A manifold pressure indicator for each engine N/A

7. Navigation and Radio Communication (CASR 91.205, CASR 91.175CASR, 91.215, CASR 121.99,
CASR 121.349, CASR 135.309, CASR 135.311, CASR 121.345,)
36) Satisfactory
Item Description 37) Remarks
Yes No
III.C.7.1 HF .............ea N/A

III.C.7.2 VHF 2 ea

III.C.7.3 ATC Transponder 1 ea

III.C.7.4 VOR 2 ea

III.C.7.5 DME 1 ea

III.C.7.6 ILS 2 ea

8. EQUIPMENTS
36) Satisfactory
Item Description 37) Remarks
Yes No

Weather Radar (CASR

III.C.8.1 1 ea
121.357, 135.315)

DGCA Form No. 21-40 (Oct 2017) Page 15 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No

1. TCAS (CASR 91.227) N/A

Turbine, MTOW> 33.000
lbs (15.000 Kg) for which
the individual
Airworthiness Certificate .............ea N/A
is first issued after 31
December 2015, shall be
equipped with TCAS II
2. TCAS (CASR 121.356) N/A
(i) Turbine; MTOW>
33.000 lbs (15.000 Kg),
III.C.8.2 - TSO 119a, version
6,04A Enhance or
equivalent installed
before May 1, .............ea N/A
2003
- TSO 119b, version
7.1 or a later or
equivalent
(ii) Combi airplane Pax
10 - 30 seat ...............ea N/A
- TCAS I TSO 118
(iii) Piston; MTOW>
33.000 lbs ...............ea N/A
- TCAS I TSO 118
TAWS (CASR 121.354,
CASR 135.319)
- TSO C-151Class A or
equivalent for >9 pax 1 ea
- TSO C-151Class B or
equivalent for 6 - 9
III.C.8.3 pax
CASR 91.229;
MTOW > 5700 kg or Pax
seat >9 .............ea. N/A
- TSO C-151 or
equivalent
GPS/INS/Doppler
Radar/ONS/IRS or FMS
III.C.8.4 2 ea
(CASR 121.355, CASR
121.358)
Low altitude windshear system
N/A
(CASR121.352)
Aeroplanes (except turboprop) manufactured
after 2 January 1991, must be equipped with
III.C.8.5 either an approved airborne windshear warning
& flight guidance system, an approved airborne N/A
detection & avoidance system, or combination
of these systems
Pitot Heat Indicating System (CASR 121.342,
CASR 135.325) N/A

III.C.8.6 (i) All transport category aicraft (CASR

N/A
121.342)
(ii) >20 pax (CASR 135.325) N/A

DGCA Form No. 21-40 (Oct 2017) Page 16 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
Flight Data Recorder, check for applicability
and type of FDR CASR 91.233 and Appendix N/A
E (Airplane), F (Helicopter)
AIRPLANE N/A
(i) All airplane first issue of C of A on or after
1January 1989 with maximum certificated
take-off mass more than 27.000 kg (Type N/A
I FDR)
(ii) All airplane first issue C of A on or after 1
Jan.1989 with maximum certificated take-
off mass more than 5.700 kg, up to and N/A
including 27.000 kg (Type II FDR)
(iii) All airplane first issue of C of A after 1
January 2005 with maximum certificated
take-off mass more than 5.700 kg (Type N/A
IA)
(iv) All turbine engine airplane first issue of C
of A on or after 1 January 2016 with a
seating configuration of more than 5 N/A
passenger seat and maximum certificated
III.C.8.7
take-off mass of 5700 kg or less (Type II)
HELICOPTER N/A
(i) All helicopters first issued of C of A on or
after 1 January 2016 with maximum
certificated take-off mass more than 3180 N/A
kg (Type IVA)
(ii) All helicopters first issued of C of A on or
after 1 January 1989 with maximum
certificated take-off mass more than 7000 N/A
kg or having a passanger seating
configuration of more than 19 (Type IV)
Record ULB Battery due: ............ N/A
Annual read out for required number of
parameter to be recorded and quality
(measurement range, recording interval, N/A
accuracy, resolution)
Calibration for 5 year or at least 2 year in
accordance with N/A
manufacturer recommendation
CVR/CARS (CASR 91.235) N/A

AIRPLANE N/A
(i) All turbine-engine airplanes, for which the
individual certificate of airworthiness was
III.C.8.8 first issued on or after 1 January 2016, with
a seating configurations of more than five
passenger seats and a maximum N/A
certificated take-off mass of 5 700 kg or
less shall be equipped with either a CVR or
a CARS.

DGCA Form No. 21-40 (Oct 2017) Page 17 of 20

 36) Satisfactory
Item Description 37) Remarks
Yes No
(ii) All turbine-engine airplanes for a maximum
certificated take-off mass of over 5 700 kg
for which the individual certificate of
airworthiness was first issued on or after 1 N/A
January 2016 and required to be operated
by more than one pilot shall be equipped
with a CVR.
(iii) All airplanes of a maximum certificated
take-off mass of over 27 000 kg for which
the individual certificate of airworthiness is N/A
first issued on or after 1 January 1987 shall
be equipped with a CVR.
HELICOPTER N/A
(i) All helicopters of a maximum certificated
take-off mass of over 7 000 kg for which
the individual certificate of airworthiness is
first issued on or after 1 January 1987 shall N/A
be equipped with a CVR. For helicopters
III.C.8.8 not equipped with an FDR, at least main
(cont’d) rotor speed shall be recorded on the CVR.
(ii) All helicopters of a maximum certificated
take-off mass of over 7 000 kg for which
the individual certificate of airworthiness
was first issued before 1 January 1987
N/A
shall be equipped with a CVR. For
helicopters not equipped with an FDR, at
least main rotor speed shall be recorded on
the CVR.
From 1 January 2016, a magnetic tape & wire
shall be discontinued, and capable of two N/A
hours recording
From 1 January 2016, all CVR shall be
capable of retaining the information recorded
N/A
during at least the last two hours of their
operation
Record ULB Battery, due: ......... N/A

Annual Read Out N/A

9. Lighting (CASR 91.209, CASR 121.323, CASR 135.307)

36) Satisfactory
Item Description 37) Remarks
Yes No
III.C.9.1 Instrument light
III.C.9.2 Anti Collision light
III.C.9.3 Position/Navigation light
III.C.9.4 Two Landing light
III.C.9.5 Taxi light
III.C.9.6 Logo light N/A

III.C.9.7 Cabin light (ceiling, windows, service, entry, exit,

etc)
DGCA Form No. 21-40 (Oct 2017) Page 18 of 20
PART IV. FUNCTIONAL CHECK (if necessary)

A. Aircraft System
36) Satisfactory
Item Description 37) Remarks
Yes No

IV.A.1 Flight control system

IV.A.2 Recording system (FDR, CVR) N/A

IV.A.3 Fire precaution (Engine, APU, Cargo) N/A

IV.A.4 Smoke detector system (Lavatory, Cargo) N/A

IV.A.5 Public address system & Interphone System N/A

Pitot heat indicating system CASR 121.342,
IV.A.6 CASR 135.325 N/A
Lighting (nav. light, anti-collision light, instrument
IV.A.7 light, landing light, emergency light, passenger
information light)
IV.A.8 ELT test

IV.A.9 Other applicable systems

B. Communication
36) Satisfactory
Item Description 37) Remarks
Yes No

IV.B.1 HF, VHF, ATC Transponder

C. Navigation
36) Satisfactory
Item Description 37) Remarks
Yes No

IV.C.1 ADF, VOR, DME, ILS

IV.C.2 Weather Radar

TAWS TSO C151 Class A & Windshear (CASR
IV.C.3 121.352) N/A

IV.C.4 TCAS N/A

GPS/INS/IRS/FMS
IV.C.5 (REFER TO C208B MEL AND
Nav. data base due period: OPSPEC : VFR DAY OPERATION
ONLY

PART V. GROUND RUN AND TEST FLIGHT (if necessary)

36) Satisfactory
Item Description 37) Remarks
Yes No
Ground run and test flight conducted according
V.1 to test plan N/A

V.2 Ground Run Test result N/A

V.3 Test Flight result N/A

DGCA Form No. 21-40 (Oct 2017) Page 19 of 20

ACTION TAKEN

Aircraft grounded by DGCA inspector

Corrective actions before issued the Airworthiness Certificate (C of A)

No remarks

REMARK OR FINDING (used separate sheet as required)

ANNUAL INSPECTION FOR C OF A RENEWAL HAS BEEN CARRIED OUT AT AIRCRAFT AND FOUND
AIRCRAFT IS IN AIRWORTHY

ASSIGNED INSPECTOR (S)

JANUARI 2023

Note:
This form can also be used to record airworthiness inspection for issuance of Export Certificate of
Airworthiness for Aircraft. Special requirements of importing country must be considered to include in the
inspection record. Finding must be clearly addressed prior to get an acceptance from importing country,
when it intended to be put as an exemption to Export Certificate of Airworthiness.

DGCA Form No. 21-40 (Oct 2017) Page 20 of 20