CA 21-15
14 August 2024
Page 1 of 3
Department:
AIRWORTHINESS
Telephone number:
0860 267 435
Email address:
Physical address:
Ikhaya Lokundiza, 16 Treur Close, Waterfall Park, Bekker Street, Midrand, Gauteng
Postal address:
Private Bag X73, Halfway House 1685
Website: www.caa.co.za
DETAILS OF BANK ACCOUNT FOR PAYMENT OF PRESCRIBED FEE
Bank: Standard Bank of SA Ltd
Branch: Brooklyn, Pretoria
Branch Code: 011245
Account Number: 013007971
APPLICATION FOR SPECIAL FLIGHT PERMIT
Please mark the appropriate block
Application for the issue of a special flight permit
Application for the amendment of a special flight permit
NOTES: * Please delete if not applicable.
(i) An application for the issuing of a Special Flight Permit, or amendment thereof, must comply with the provisions of
CAR 21.08.7; 21.08.8; 21.08.10.
(ii) The original application must be submitted to the Director of Civil Aviation.
(iii) Where the required information cannot be furnished in the space provided, the information must be submitted as a
separate memorandum and attached hereto.
AIRCRAFT REGISTRATION MARKS
Z
―
1.
PARTICULARS REGARDING THE OWNER / OPERATOR
1.1
Full name
1.2
Full business / residential address
1.3
Postal address
Postal Code
Postal Code
1.4
Telephone number
1.5
Details of organization/person to be contacted for further information concerning this application:
Name
Position
Postal address
Postal code
Telephone number
E-mail address
2.
PARTICULARS REGARDING THE AIRCRAFT
2.1
Manufacturer
2.2
Model designation
2.3
Constructor's serial number
2.4
Place of manufacture
2.5
Date of manufacture
2.6
Location of aircraft
2.7
Aircraft maintenance organisation
3.
PARTICULARS REGARDING THE PURPOSE OF THE FLIGHT
(Note: * Please mark the appropriate box)
Ferry flight
Aircraft evacuation
Flight testing
Customer demonstration
Other – specify
CA 21-15
14 August 2024
Page 2 of 3
3.1
Reason(s) why special flight permit is required
3.2
Proposed itinerary
3.3
Proposed flight crew (essential crew only)
3.4
Proposed operating limitations
3.5
The aircraft has been certified safe for flight by
(Name of AME /AMO)
4.
OTHER DETAILS REQUIRED FROM APPLICANT FOR ISSUE OF PERMIT
4.1
4.2
Crew required to operate aircraft and its equipment (e.g. pilot, co-pilot, navigator etc):
4.3
Ways, if any, in which aircraft does not comply with applicable airworthiness standards (e.g. defects, damage, unapproved
modifications, outstanding Airworthiness Directives):
4.4
Restrictions considered necessary by the applicant for safe operation of the aircraft:
4.5
Other information regarding the condition of the aircraft:
i.
Has the Maintenance Release expired?
YES
NO
If yes, for how long?
hours
Date of expiry
Y
Y
Y
Y
M
M
D
D
ii.
For what reason did the Maintenance Release expire?
iii.
When was the aircraft last flown?
Date
Y
Y
Y
Y
M
M
D
D
iv.
When was the engine last run?
Date
Y
Y
Y
Y
M
M
D
D
v.
Has the engine(s) been maintained to manufacturer’s procedures for inactive
protection?
YES
NO
If “NO”, supply details of alternative procedures
5.
Supporting Documents
YES
N/A
5.1
CRMA
5.2
Certificate of Airworthiness
5.3
Certificate of Registration
5.4
Flight Folio reflecting Safe to Fly
5.5
Permission letter from the owner to fly the aircraft
5.6
OEM recommendations
Note: If space provided, is not sufficient, kindly use attachments for items above.
CA 21-15
14 August 2024
Page 3 of 3
SIGNATURE OF AIRCRAFT
MAINTENANCE ENGINEER /
ORGANISATION
NAME IN BLOCK LETTERS
DATE
AME LICENCE NUMBER
6.
DECLARATION:
I hereby declare that I am the registered owner / owner's agent and to the best of my knowledge and belief, the particulars
contained in this application are accurate in every respect and show compliance with the regulations in Part 21 of the Civil
Aviation Regulations 2011, as amended. I am satisfied that the aircraft described above can be operated with safety for the
intended flight or flights.
SIGNATURE OF
OWNER OR AGENT
NAME IN BLOCK LETTERS
DATE
FOR OFFICIAL USE ONLY
Special flight Permit checklist
YES
NO
N/A
Invoice indicating correct proof of payment?
Confirm if aircraft is certified safe for the intended flight.
All necessary supporting documents submitted?
Application Referred to Airworthiness Technical Review Board?
Note: for post-accident permit the application shall be processed through the Aircraft Technical Review Board.
Ferry
Test flight
Inspector’s comments:
PERMIT
RECOMMENDED FOR ISSUE
PERMIT
NOT RECOMMENDED FOR
ISSUE
SIGNATURE OF AIRWORTHINESS
INSPECTOR
NAME IN BLOCK LETTERS
DATE
Manager’s comments:
APPLICATION APPROVED
APPLICATION
NOT APPROVED
SIGNATURE OF MANAGER
NAME IN BLOCK LETTERS
DATE