/ European Aviation Safety Agency / Form
ATM-ANS Organisation Approval:Notification of Proposed Change to Functional System

1Approval Holder / Applicant

1.1Company Name

1.2Company Address(registered business address/address of registry)

/ Street / Nr
Post Code
City
Country

1.3 Contact Person(responsible for this Notification)

/ Title / Mr. Ms.
Name
First name
Job title
Phone/Fax
Email

2. Identification of Notification

2.1 Notification Reference

/

Please provide your internal and unique reference for this change

2.2 Approval Reference

/

Please provide the original EASA or other Competent Authority Approval reference

2.3 Issued by

/

Please indicate EASA or other Competent Authority

3. Proposed Change to Functional System

in accordance with the provision of Regulation (EU) No 1034/2011

3.1 Overall Description

Purpose of the Change /

[description]

Justification for the Change (including the facts triggering the change) /

[description]

Planned date for Introduction Into Service /

[dd/mm/yyyy]

3.2 Functional System changes

Change to the system

/

[description]

Change to the procedures

/

[description]

Change to the human resources

/

[description]

3.3 Change classification

Severity Class for the potential effects of the hazards identified

/ Severity class 1
Severity class 2
Severity class 3
Severity class 4
Severity class 5

Summary of the Initial Safety Assessment for the Change (including the justification for the Severity Class classification)

/

[description]

Does the implementation of the change require the introduction of new aviation standards?

/ No
Yes (please specify)
3.4 Services/Functions impacted by the Change to Functional System
Air Traffic Services (ATS)
Type of Service / Part of Service / Sub-part of Service
Air Traffic Control (ATC) / Area Control Service / N/A
Approach Control Service / N/A
Aerodrome Control Service / N/A
Flight Information Service (FIS) / HF Operational Flight Information Service (OFIS) Broadcasts / N/A
VHF Operational Flight Information Service (OFIS) Broadcasts / N/A
Voice-Automatic Terminal Information Service (Voice-ATIS) Broadcasts / N/A
Data Link Automatic Terminal Information Service
(D-ATIS) / N/A
VOLMET Broadcasts and/or D-VOLMET Service / N/A
Alerting Services (AL) / N/A / N/A
Advisory Service / N/A / N/A
Aerodrome Flight Information Service (AFIS) / N/A / N/A
Description of the Change impact
Communication, Navigation or Surveillance services (CNS)
Type of Service / Part of Service / Sub-part of Service
Communications (C) / Aeronautical Mobile Service (air-ground communication) / For flight information service
For area control service
For approach control service
For aerodrome control service
Aeronautical Fixed Service (ground-ground communications) / N/A
Aeronautical Mobile Satellite Service (AMSS) / N/A
Navigation (N) / Provision of NDB signal-in-space / N/A
Provision of VOR signal-in-space / N/A
Provision of DME signal-in-space / N/A
Provision of ILS signal-in-space / CAT I
CAT II
CAT III a
CAT III b
CAT III c
Provision of MLS signal-in-space / CAT I
CAT II
CAT III a
CAT III b
CAT III c
Provision of GNSS signal-in-space / GNSS Core System (GALILEO)
Satellite Based Augmentation System (SBAS)
Ground Based Augmentation System (GBAS)
Surveillance (S) / Provision of data from Primary Surveillance Radar (PSR) / N/A
Provision of data from Secondary Surveillance Radar (SSR) / Mode A/C
Mode S
Provision of data from Automatic Dependent Surveillance (ADS) / ADS-C
ADS-B
Provision of data from Surface Movement Radar (SMR) / N/A
Description of the Change impact
Aeronautical Information Services (AIS)
Type of Service / Part of Service / Sub-part of Service
AIS / Provision of the whole AIS service as described in ICAO Annex 15 / N/A
Description of the Change impact
Meteorological Services (MET)
Type of Service / Part of Service / Sub-part of Service
MET / Provision of whole MET service as described in ICAO Annex 3 / N/A
Description of the Change impact
Network Management Function (NM)
Type of Function
Central Unit for Air Traffic Flow Management (ATFM)
Description of the Change impact
European Route Network Design (ERND)
Description of the Change impact
Radio Frequency Function
Description of the Change impact
Transponder Code Function
Description of the Change impact
Network Performance Monitoring and Improvement
Description of the Change impact
Other (please specify):
Description of the Change impact
4. List of documentation provided with the Notification

5.Declaration and Signature

I declare that I have the legal capacity to submit this Notification to EASA and that all information provided in this Notification form is correct and complete.
Date/Place / Name / Signature
This Notification should be sent by e-mail or regular mail to:
European Aviation Safety Agency
ATM/ANS Standards, Implementation & Oversight Section
Postfach 10 12 53
D-50452 Köln
Germany
E-mail:

Completion Instructions for FO.AOA.00043

This Completion Instruction Sheet will provide you with any additional instructions and requirements necessary to complete the Notification for Changes to Functional Systems related to ATM/ANS Service Provider Organisation Approval (AOA). Please complete the form in a clearly legible way.

Chapter 1: Approval Holder / Applicant
1.1 / Please enter the full name of the company as it appears on the Article/Certificate of incorporation of the company. If applicable also enter the Trade Name, Doing-business-as and the Company registration number.
1.2 / Please enter the address of the registered office as it appears on the Article/Certificate of incorporation of the company.
1.3 / The name and contact details specified in this section are those of the person responsible for the Notification.
Chapter 2: Identification of Notification
2.1
2.2
2.3 / Please provide an internal and uniquereference to this change whichEASA will use to identify this project in order to avoid duplications.
Indicate the reference of the existing Approval / initial Application for ATM/ANS Organisation Approval (e.g. EASA approval number)
Indicate the competent authority that issued the existing approval
Chapter 3: Proposed Change to Functional System
3.2 / Description of the change will include the necessary level of details in order to have an initial understanding of the change to be implemented. Wherever necessary, additional information can be provided by means of references to documents attached to this Notification form or other relevant documentation. Documents should be listed in paragraph 4 of the Notification Form.
As per Regulation (EU) No 1034/2011, Functional system means a combination of systems, procedures and human resources organised to perform a function within the context of ATM. The description of the change should cover each of these three areas (as applicable).
3.3 / Severity Class shall be determined as result of the severity assessment conducted in accordance with Annex II, point 3.2.4 of Implementing Regulation (EU) No 1035/2011.
Summary of the Initial Safety Assessment should include those parts of the assessment that justifies the Severity Class identified and those that allows to evaluate the risk posed by the introduction of the change. Wherever necessary, additional information can be provided by means of references to documents attached to this Notification form or other relevant documentation.
3.4 / Please tick the types of services or functions, their parts and sub-parts as they appear (if applicable) to describe the scope of services impacted by the change to Functional System
Please provide a clear description of the change impact on the related Services. Wherever necessary, additional information can be provided by means of references to documents attached to this Notification form or other relevant documentation.