Appendix 4 APPENDIX 4. SAMPLE DOCUMENTATION OF TECHNICAL
STANDARDS COMMITTEE FINDINGS (INSTRUCTIONS: Complete all blanks; insert N/A in blanks not applicable to this particular review; check off other applicable items (M as provided.)
ISSUED TO: ULTRALIGHT MAKE/MODEL:
ADDRESS: SERIAL NUMBER:
REGISTRATION NUMBER:
ENGINE MAKE/MODEL: PROPELLER MAKE/MODEL:
ENGINE MANUFACTURER'S PROPELLER DIAMETER:
RATED HORSEPOWER: PROPELLER PITCH:
FUEL CAPACITY: fuselage tank wing tank other TOTAL:
GROSS EMPTY WEIGHT -Exclusion for parachute system weight.
( ) hand-deployed ) ballistically deployed ) installed and operational ) standard allowance weight given ( ) parachute system weighed separately -Exclusion for floats..
( ) weighed in landplane configuration only ( ) weighed in floatplane configuration only ( ) standard allowance for floats-only given ( ) standard allowance for amphib floats given ( ) standard allowance for amphib fuselage given standard allowance for outrigger floats given ( ) all floats weighed separately FLOAT MAKE/ MODEL:
-Fuel on board at weighing.
TOTAL WEIGHT ALLOWANCES NET EMPTY WEIGHT (minus weight allowances).
MAXIMUM FULL-POWER LEVEL FLIGHT SPEED (calculated by AC 103-7, Appendix 1).
( ) engine manufacturer maximum rated horsepower used ( ) derated horsepower of engine= per engine manfacturer's specs DEMONSTRATED MAXIMUM FULL-POWER LEVEL FLIGHT SPEED..
() timed (average of a series of three level runs in both directions) ( ) radar gun (average series of level runs per timed instructions) ( ) speed adjusted to sea level conditions ( ) artificial restriction () power ( ) propeller ( ) aerodynamic DESCRIPTION OF RESTRICTION (should be included on the back of this form in sufficient written and graphic detail for an FAA inspector or other qualified person to ascertain that the restriction is in place and operational) MAXIMUM POWER-OFF STALL SPEED (calculated by AC 103-7, Appendix 2)..
operating weight used= maximum coefficient of lift used= DEMONSTRATED POWER-OFF STALL SPEED..
( ) average of six or more stalls (in level flight, with an airspeed reduction of approximately one knot per second until stall occurs ( ) high lift devices installed ( ) flaps ( ) slots ( ) other 1
Appendix 4 CONFIGURATION:
( ) provisions for one occupant only ( ) seat width 22 inches or less (inside measurement) ) single seatbelt/shoulder harness ) single controls located logically for a person sitting in the center of the seat ( ) no equipment is installed which could logically be construed as for a purpose other than sport/recreation of the operator, such as:
( ) towing hitches ( ) agricultural equipment ( ) advertisement on the wings AIRWORTHINESS CERTIFICATION:
( ) no U.S. or foreign airworthiness certificate is currently issued to this particular ultralight unit ( ) this ultralight has not been registered with the U.S. federal government.
LIST OF INSTALLED INSTRUMENTS AND EQUIPMENT:
OTHER:
ISSUED BY:
( ) A & P Mechanic; Name Certificate Number ( ) Technical Standards Committee: Names:
National pilot organization recognizing this committee:
DATE OF ISSUANCE OF THIS DOCUMENT:
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Washington, D.C. 20591 Official Business Penalty for Private Use $300