gaca_gov_sa · form · processed · 3 chunks
GACA الهييه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] SUSPECTED UNAPPROVED PARTS REPORTING <table><tr><td>1. Date the Part was Discovered</td><td colspan="3"></td></tr><tr><td>2. Part Name</td><td></td><td colspan="2"></td></tr><tr><td>3. Part Number</td><td></td><td colspan="2"></td></tr><tr><td>4. Part Serial Number</td><td></td><td colspan="2"></td></tr><tr><td>5. Quantity</td><td></td><td colspan="2"></td></tr><tr><td>6. Assembly Name and Number</td><td>Name</td><td></td><td>Number</td></tr><tr><td>7. Aircraft Make and Model</td><td>Make</td><td></td><td>Model</td></tr></table> Report on Safety Incident (ROSI) Reference 8. Name, Address and Description of the Company or Person Who Supplied or Repaired the Part <table><tr><td>Name</td><td>Address</td></tr><tr><td>City</td><td></td></tr><tr><td>Country</td><td>Phone Number</td></tr><tr><td colspan="2">Tick One of the Following Applicable to (Company or Person Who Supplied or Repaired the Part)</td></tr><tr><td>□ Air Carrier – Certificate #</td><td>□ Supplier</td></tr><tr><td>□ Mechanic – Certificate #</td><td>□ Production Approval Holder</td></tr><tr><td>□ Repair Station – Certificate #</td><td>□ Manufacturer</td></tr><tr><td>□ Distributor</td><td>□ Other</td></tr><tr><td>□ Owner/Operator</td><td>□ Unknown</td></tr></table> 9. Description of the Issue: (attach additional sheet if necessary) 10. Name and Address of the Company or Person Where the Part Was Discovered <table><tr><td>Name</td><td>Address</td></tr><tr><td>City</td><td></td></tr><tr><td>Country</td><td>Phone Number</td></tr></table> Tick One of the Following Applicable to the Company or Person Who Discovered the Part <table><tr><td>□ Air Carrier – Certificate #</td><td>□ Production Approval Holder</td></tr><tr><td>□ Engineer/Technician/Stores – Certificate #</td><td>□ GACA Inspector□ Foreign Civil Aviation Authority</td></tr><tr><td>□ Repair Station – Certificate #</td><td>□ Owner/Operator</td></tr><tr><td>□ Distributor</td><td>□ Other</td></tr><tr><td>□ Supplier</td><td>□ Unknown</td></tr></table> 11. Date of This Report 12. □ Tick this box if you request anonymity (Do not complete block 13) 13. Reporter's Details <table><tr><td>Name</td><td></td><td>Address</td></tr><tr><td>City</td><td></td><td></td></tr><tr><td>Country</td><td></td><td>Phone Number</td></tr><tr><td colspan="3">14. □ Tick this box if you request confidentiality</td></tr><tr><td colspan="3">15. □ Tick this box if you have attached additional information</td></tr></table> GACA-AVSES-AIR-F001 Rev: 4, Date: 14 Dec 25 Page 1 of 3 GACA الطبيه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] SUSPECTED UNAPPROVED PARTS REPORTING Suspected Unapproved Parts Report <table><tr><td colspan="6">Continue Sheet Page ( ) to ( )</td></tr><tr><td>Part Name</td><td>Part Number</td><td>Serial Number</td><td>Quantity</td><td>Assembly Name</td><td>Assembly Number</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>-</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td>-</td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>-</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td>-</td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td></tr></table> GACA-AVSES-AIR-F001 Rev: 4, Date: 14 Dec 25 Page 2 of 3 GACA الطبيه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] SUSPECTED UNAPPROVED PARTS REPORTING <table><tr><td colspan="6">Instructions: Please complete the form by following the provided instructions and including the specified information/ data in serial numbers within the form.</td></tr><tr><td colspan="6">1. Record the date of the part was discovered.</td></tr><tr><td colspan="6">2. Record the part name (or a description of the part).</td></tr><tr><td colspan="6">3. Record the part number or identification number of the part.</td></tr><tr><td colspan="6">4. Record the serial number on the part, if applicable</td></tr><tr><td colspan="6">5. Record the quantity of parts.</td></tr><tr><td colspan="6">6. Record the assembly's name and assembly number (where the part was or could be installed).</td></tr><tr><td colspan="6">Record additional part numbers on page 2 or on a blank sheet of paper with the same information. Example</td></tr><tr><td>Part Name:</td><td>Part Number:</td><td>Serial Number:</td><td>Quantity:</td><td>Assembly Name:</td><td>Assembly Number:</td></tr><tr><td>Strut</td><td>1234</td><td>678</td><td>1</td><td>Main Landing Gear</td><td>56789X</td></tr><tr><td colspan="6"></td></tr><tr><td colspan="6">7. Record the type of aircraft the part was (or could be) installed on.</td></tr><tr><td colspan="6">8. Record the complete name and address of the company or person who produced, repaired, and/or sold the part.Do not list a P.O. Box address unless a street address is not available.Check the box that describes the company or person and provide the certificate number, if known.Air Carrier – certified company or person who undertakes directly by lease, or other arrangement, to engage in air transportation.Engineer/Technician – A person holding an A&P or AMEL certificate with AMO.Repair Station/ AMO – Name of organization.Distributor – A broker, dealer, seller or other person or agency engaged in the sale of parts.Owner/Operator – The owner or operator of an aircraft.Supplier – A company or person who furnishes aircraft parts.Manufacturer – The original equipment manufacturer (OEM).Other – Record other types of business.Unknown</td></tr><tr><td colspan="6">9. Record a brief narrative stating why you believe the part is not approved. Include a description of the part (improper configuration, suspect marking, different material, etc.), where it was obtained, and what type of documentation was supplied with it.</td></tr><tr><td colspan="6">10. Record the complete name and address of the location where the part was found. Check the appropriate block to reflect the affiliation of the company or person who discovered the part.</td></tr><tr><td colspan="6">11. Record the date the form is being submitted.</td></tr><tr><td colspan="6">12. Tick this box if you request anonymity (do not wish to provide your identity) and do not complete block 13.</td></tr><tr><td colspan="6">13. Record your name, address and phone number, if desired. This information will enable GACA to contact you for additional information, if necessary.</td></tr><tr><td colspan="6">14. Tick this box if you request confidentiality of your personal information recorded in block 13.</td></tr><tr><td colspan="6">15. Tick this box if you have provided additional information (photos, invoices, certification statements, etc.)</td></tr><tr><td colspan="6">16. Attach the scanned copy of the ROSI report.</td></tr><tr><td colspan="6">Note: The information of the ‘Suspected Unapproved Parts’ will be listed on the GACA website for operator/organization information. Forward the completed GACA Form – ‘Suspected Unapproved Parts Reporting’ to:</td></tr><tr><td colspan="6">General Authority of Civil Aviation (GACA),Aviation Safety & Environmental Sustainability,Airworthiness Department, Repair Station SectionEmail: repairstation@gaca.gov.sa</td></tr></table> GACA-AVSES-AIR-F001 Rev: 4, Date: 14 Dec 25 Page 3 of 3