Form SRG1169 "Examiner's Record - Fi(R)/Fi/Cri/Iri/Fic Authorisation Test/Check Schedules - Aeroplane" - United Kingdom

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Examiner’s Record - FI(R)/FI/CRI/IRI/FIC Authorisation Test/Check
Schedules - Aeroplane
Please complete this form online (preferred method) then print, sign and submit as instructed.
Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink.
Unique No. (to be completed by CAA)
Please read attached Guidance Notes before completing this form.
FALSE REPRESENTATION STATEMENT
It is an offence under Article 256 of the Air Navigation Order 2016 to make, with intent to deceive, any false
representation for the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission
or other document. This offence is punishable on summary conviction by a fine up to £5000, and on conviction on
indictment with an unlimited fine or up to two years imprisonment or both.
1. Applicant Details
To be completed by the Applicant
Surname......................................................................
Forename(s)...............................................................................
CAA reference number:
2. Test/Check Details
To be completed by the Applicant
Type of Test: ............................................................ Location: ...................................................... Date: .....................
A/C or STD reg & type: .................................................................... Off blocks: .................... On blocks: ....................
A/C or STD reg & type: .................................................................... Off blocks: .................... On blocks: ....................
Type (including variants): ....................................................................................................................................................
FSTD Identification Number of simulator used (which must be approved in accordance with Commission Regulation (EU)
1178/2011 as amended): ........................................................................................................................................................
Competent Authority issuing Qualification Certificate for the simulator: ...........................................................................
Date flying training complete: ............................................................................................................................................
SECTION 1: Theoretical Knowledge
Pass
Fail
Observations/Reasons for Failure
Long Briefing Title
a. Air law
b. Aircraft general knowledge
c. Flight performance and planning
d. Human performance and limitations
e. Meteorology
f. Navigation
g. Operational procedures
h. Principles of flight
i. Training administration
SECTION 2: Pre Flight Briefing
Pass
Fail
Observations/Reasons for Failure
a. Visual presentation and content
b. Technical accuracy
c. Clarity of explanation
d. Clarity of speech
e. Instructional technique including TEM/
CRM
f. Use of model and aids
g. Student participation
Form SRG 1169 Issue 04 August 2016
Page 1 of 3
4 copies required. Copies of the report shall be submitted to (1) The Applicant (2) The Applicant’s
Competent Authority (3) The Examiner (4) The Examiner’s Competent Authority (if different)
Examiner’s Record - FI(R)/FI/CRI/IRI/FIC Authorisation Test/Check
Schedules - Aeroplane
Please complete this form online (preferred method) then print, sign and submit as instructed.
Alternatively, print, then complete in BLOCK CAPITALS using black or dark blue ink.
Unique No. (to be completed by CAA)
Please read attached Guidance Notes before completing this form.
FALSE REPRESENTATION STATEMENT
It is an offence under Article 256 of the Air Navigation Order 2016 to make, with intent to deceive, any false
representation for the purpose of procuring the grant, issue, renewal or variation of any certificate, licence, approval, permission
or other document. This offence is punishable on summary conviction by a fine up to £5000, and on conviction on
indictment with an unlimited fine or up to two years imprisonment or both.
1. Applicant Details
To be completed by the Applicant
Surname......................................................................
Forename(s)...............................................................................
CAA reference number:
2. Test/Check Details
To be completed by the Applicant
Type of Test: ............................................................ Location: ...................................................... Date: .....................
A/C or STD reg & type: .................................................................... Off blocks: .................... On blocks: ....................
A/C or STD reg & type: .................................................................... Off blocks: .................... On blocks: ....................
Type (including variants): ....................................................................................................................................................
FSTD Identification Number of simulator used (which must be approved in accordance with Commission Regulation (EU)
1178/2011 as amended): ........................................................................................................................................................
Competent Authority issuing Qualification Certificate for the simulator: ...........................................................................
Date flying training complete: ............................................................................................................................................
SECTION 1: Theoretical Knowledge
Pass
Fail
Observations/Reasons for Failure
Long Briefing Title
a. Air law
b. Aircraft general knowledge
c. Flight performance and planning
d. Human performance and limitations
e. Meteorology
f. Navigation
g. Operational procedures
h. Principles of flight
i. Training administration
SECTION 2: Pre Flight Briefing
Pass
Fail
Observations/Reasons for Failure
a. Visual presentation and content
b. Technical accuracy
c. Clarity of explanation
d. Clarity of speech
e. Instructional technique including TEM/
CRM
f. Use of model and aids
g. Student participation
Form SRG 1169 Issue 04 August 2016
Page 1 of 3
4 copies required. Copies of the report shall be submitted to (1) The Applicant (2) The Applicant’s
Competent Authority (3) The Examiner (4) The Examiner’s Competent Authority (if different)
SECTION 3: Flight
Pass
Fail
Observations/Reasons for Failure
a. Arrangement of demonstration
b. Synchronising of speech/demo
c. Assessment and correction of student
faults
d. Aeroplane handling
e. Instructional technique
f. General airmanship/safety
g. Positioning and use of airspace
h. Risk assessment including TEM/CRM
Main Exercise Title and No.
i
j
SECTION 4: Mandatory Exercises and other
Pass
Fail
Observations/Reasons for Failure
exercises at Examiner's discretion
a. Spin avoidance (SE aeroplane)
b. Safety module
c. Take-off and climb, engine failure after
take-off (SE aeroplane)
d. Approach, landing, missed approach
e. Forced landing without power
(SE aeroplane)
Additional exercises Title and No.
f
g
SECTION 5: Multi engine (Aeroplane) - may be
Pass
Fail
Observations/Reasons for Failure
conducted in FNPT 2 or Simulator
a. Engine failure (simulated) after take-off or
on go-around
b. Asymmetric approach and go-around
c. Asymmetric approach and landing
SECTION 6: Instrument Exercises - give exercise
Pass
Fail
Observations/Reasons for Failure
Title and No. in space provided
a. Basic instrument flight
...................................................................
b. Applied instrument flight
...................................................................
c. Instrument approach
...................................................................
d. Limited panel and unusual attitudes
...................................................................
SECTION 7: Post Flight Debriefing
Pass
Fail
Observations/Reasons for Failure
a. Visual presentation and content
b. Technical accuracy
c. Clarity of explanation
d. Clarity of Speech
e. Instructional technique and facilitation
f. Use of model and aids
g. Student participation
Form SRG 1169 Issue 04 August 2016
Page 2 of 3
3. APPROVED TRAINING ORGANISATION
Approved Training Organisation (ATO): ....................................................
ATO Approval No: ......................................
Competent Authority issuing approval: .............................................................................................................................
Head of Training (block capitals): .......................................................................................................................................
Signature (Head of Training): ..............................................................................................
Date: ................................
PLEASE REFER TO FALSE REPRESENTATION STATEMENT ON PAGE 1
4. RESULT
Tick appropriate box
Pass
Fail
Partial
Retest Requirement: .............................................................
Rating Revalidated Until (if applicable): ........................
I have received information from the applicant regarding their experience and instruction and certify that this complies
with the requirements of EASA Part-FCL.
I have assessed the ICAO English Language Proficiency of the Applicant at Level 6: Yes
No*
Not Assessed
(*I have advised the Applicant to complete Form SRG 1199 and be assessed by an appropriate organisation, see CAP 804,
Section 4, Part M.) Assessment is not required if Applicant holds Level 6.
Examiner's Name (block capitals): .........................................
Examiners Number: .....................................................
Authorising Competent Authority: .........................................
Date of Examiners Briefing (if applicable): ...................
Signature (Examiner): ........................................................................................................
Date: ..................................
PLEASE REFER TO FALSE REPRESENTATION STATEMENT ON PAGE 1
5. TEST, CHECKS AND ASSESSMENTS OF COMPETENCE – NOTICE OF FAILURE
To be completed by examiner
You are hereby notified that you have failed the .......................................................... for the following reasons:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
In accordance with Part FCL an Approved Training Organisation shall determine and deliver the required refresher/
remedial training prior to the applicant reattempting the skill test, proficiency check or assessment of competence. The
applicant must provide evidence of this training to the examiner who conducts the next test, check or assessment of
competence.
Minimum training recommended by the Examiner:
...........................................................................................................................................................................................
I understand that I have failed the items notified above.
I understand that I may not exercise the privileges of my..................................................................... following the
failure of this test, check or assessment of competence until the successful completion of training and a further test,
check or assessment of competence.
Received (Applicant) Signature:
.................................................................
Date: ...........................................
PLEASE REFER TO FALSE REPRESENTATION STATEMENT ON PAGE 1
Civil Aviation Authority Regulation 6
Regulation 6(5) of the Civil Aviation Authority Regulations 1991 as follows: Any person who has failed any test or
examination which he is required to pass before he is granted or may exercise the privileges of a personnel licence may
within 14 days of being notified of his failure request that the Authority determine whether the test or examination was
properly conducted. In order to succeed you will have to satisfy the Authority that the examination or test was not properly
conducted. Mere dissatisfaction with the result is not sufficient reason for appeal.
Form SRG 1169 Issue 04 August 2016
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