AIRWORTHINESS ASSESSMENT REPORT
SECTION I: SYSTEM INFORMATION
MDS
PROGRAM OFFICE
PROJECT TITLE
PROJECT NUMBER
CONTRACTOR(S)
CONTRACT NUMBER(S)
MODIFICATION TYPE
☐ Permanent ☐ Permanent-Safety ☐ Temporary-1 ☐ Temporary-2
SYSTEM DESCRIPTION
Describe the modification to the extent necessary to understand the airworthiness approach, reportability, certification
basis, and compliance report. If the description is contained in a separate document, include a reference to the
document (e.g. document number, title, date).
SECTION II: AIRWORTHINESS APPROACH AND REPORTABILITY DETERMINATION
AIRWORTHINESS APPROACH
Describe the airworthiness approach. Relevant information may include aircraft tail number applicability, new or
revised manuals, supporting certifications, and/or flight test and operational release approaches. Provide references to
any relevant information contained in a separate document.
BASELINE CONFIGURATION AIRWORTHINESS APPROVAL (MFR OR MTC)
Identify the baseline airworthiness approval.
OTHER EXISTING APPROVALS
Identify other existing approvals that will be leverages (e.g., FAA SB, USAF AW approval for similar configuration,
etc.)
I approve this project’s airworthiness approach and certify that it is clearly non-reportable and meets the criteria in AC-
19-05. Changes to the project description or airworthiness approach may invalidate this approval.
DELEGATED TECHNICAL AUTHORITY (Name, Title, Office)
SIGNATURE AND DATE
AFLCMC/EZZ Template 140-1, 20191202 Prescribed by AC-19-05 Page 1 of 4
