Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
CERTIFICATE HOLDER
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AIRPORT NAME
- Honolulu International Airport (HIA)
- Hilo International Airport (ITO)
- Kona International Airport (KOA)
- Kalaeloa Airport (JRF)
- Dillingham Airfield (HDH)
- Kahului Airport (OGG)
- Kapalua Airport (JHM)
- Hana Airport (HNM)
- Molokai Airport (MKK)
- Kalaupapa Airport (LUP)
- Lanai Airport (LNY)
- Lihue Airport (LIH)
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AIRPORT CLASSIFICATION
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AIRPORT ARFF INDEX
- Index A
- Index B
- Index C
- Index D
- Index E
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FAA ACSI (INSPECTORS)
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DATE & TIME OF START OF FAR 139 INSPECTION
FAR 139 PRE-INSPECTION MEETING
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Reviewed Airport Master Record (5010 Form)?
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List of changes to Airport Master Record (list changes by category and item numbers, give regulation or circular if applicable)
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Reviewed previous inspection?
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List issues from previous inspections that have not been addressed (explain mitigation and timeframe to correct this issue).
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Obstruction Chart Review
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Comments:
METHODS AND PROCEDURES FOR COMPLIANCE
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Compliance with Advisory Circulars (139.7)
EXEMPTIONS - NUMBER ON RECORD ( )
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Justification Still Valid (139.111)
AIRPORT CERTIFICATION MANUAL
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Compliance with ACM (201a)
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Preparation (201a)
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Content (203)
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Maintenance (201b)
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Comments:
RECORDS
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Furnished upon request (301a)
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Maintained for Specified Duration (301b)
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Comments
PERSONNEL
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Sufficient Qualified Personnel (303a)
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Properly Equipped (303b)
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Trained (303c)
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Records for Training for 24 CCM (303d)
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Use of Independent Organization or Designee (303f)
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Comments
PAVED AREA
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Lips (305a1)
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Holes (305a2)
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Cracks / Surface Variations (305a3)
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Debris / Contaminants (305a3)
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Chemical Solvents Removed (305a5)
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Drainage / Ponding (305a6)
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Comments
SAFETY AREAS
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Dimensions Maintained (309a)
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Rut / Surface Variations (309a)
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Drainage (309b2)
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Support Aircraft / Equipment (309b3)
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Objects in Safety Area / Frangible Mounting (309b4)
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Comments
MARKING, SIGNS, AND LIGHTING
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Runway Marking Meets Specs (311A1)
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Taxiway Centerline (311a2)
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Taxiway Edge Marking (311a3)
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Holding Position Marking (311a4)
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ILS Critical Area Marking (311a5)
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Sign Identifying Taxing Routes (311b1)
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Holding Position Sign (311b1ii)
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ILS Critical Area Sign (311b1iii)
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Signs Internally Illuminated (311b2)
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Runway Lighting Meets Specifications (311c1)
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Taxiway Lighting / Reflectors (311c2)
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Airport Beacons (311c3)
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Airport-owned Approach Lighting (311c4)
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Obstruction Marking / Lighting (311c5)
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Marking / Signs / Lighting Properly Maintained (311d)
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Other Lighting Shielded / Adjusted (311e)
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Comments
ARFF OPERATIONS
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ARFF Capability Meets Index Provided During ACR OPNS (319a)
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ARFF Requirements Meets for Increase in Index (319b)
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Reduction in ARFF Index Meets Conditions (319d)
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Vehicle Communication in Required Vehicles (319e)
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Vehicle Marking & Lighting (319f)
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Vehicle Readiness (319g)
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Response Drill (No. Vehicles) (319h)
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Personnel Properly Equipped (319f1)
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Personnel Properly Trained (319i2)
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Live-Fire Drill Every 12 Consecutive Calendar Months for all Personnel (319i3)
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Personnel Trained and Current in Basic Emergency Medical Care Provided for ACR OPNS (319i4)
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Records of Training for 24 CCM (319l5)
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Sufficient Personnel to Meet Requirement (319i6)
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Alert Procedures / Equipment Established (317i7)
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Hazardous Materials Guidance Available, ERG 2012 (319j)
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Comments
HAZARDOUS MATERIAL
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Procedures for Hazardous Substances and Materials (321a)
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Acceptables Fire Safety Standards Established (321b)
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Compliance to Fire Safety Standards (321c)
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Inspection of Fuel Facilities every 3 CCM (321d)
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Record of Inspection for 12 CCM (321d)
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Fueling Agent Supervisor Training Every 24 CCM (321e1)
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Fuel Agent On-the-Job Training Every 24 CCM (321e2)
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Written Confirmation Every 12 CCM that Training has been accomplished (321f)
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Required immediate Corrective Action / Notify FAA of Non-Compliance (321g)
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Comments
TRAFFIC / WIND INDICTORS
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Wind Cones Provided / Lighted (323a)
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Segments Circle, Landing Strip, and Traffic Pattern Indicators Provided When No ATCT (323b)
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Comments
AIRPORT EMERGENCY PLAN
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Develop / Maintain Plan / Procedures for Prompt Response / Sufficient Detail (325b)<br>
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Response Instructions Aircraft, Bomb, Structure, Fuel, Natural, Hazardous Materials, Sabotage / Hijack, Power, Water (325b)
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Must Address Medical, Transportation, Hospital, Ambulance, Inventory, Injured, Crowds, Disable Aircraft. (325c)
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Provides for Marshaling, Emergency Alarm, Coordination of ATCT Functions. (325d)
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Contains Procedures for Notifying Agencies of Accident Location and Other Information. (325e)
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Contains Provisions for Water Rescue to the Extent Practical. (325f)
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Coordinate and Develop Plan with Participating Agencies / Personnel. (325g1 & 2)
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Airport Personnel are Properly Trained (325g3)
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Review Plan every 12 CCM (325g4)
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Full-Scale Exercise every 36 CCM for Class 1 Airports. (325h)
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Consistent with the Approved Security Program (325i)
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Comments
SELF-INSPECTION PROGRAM
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Inspect Daily or As Required. (327a1)
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Inspect when Required by Unusual Conditions; Accidents (327a2 & 3)
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Equipment Provided (327b1)
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Procedures / Equipment for Dissemination of Information to User (327b2)
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Ensured Inspections Conducted by Qualified Personnel (327b3)
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Personnel Properly Trained (327b3)
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Reporting System to Ensure Prompt Correction of Unsafe Condition, including Wildlife Strikes (327c1)
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12 CCM of Records of Inspection Showing Conditions Found and all Corrective Actions (327c1)
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Record of Training for 24 CCM (327c2)
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Comments
PEDESTRIANS AND GROUND VEHICLES
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Limit Access Movement / Safety Area (329a)
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Establish / Implement Procedures for Safe Operation on Movement / Safety Area. (329b)
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Pedestrians and Vehicle Control with ATCT (329c)
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Pedestrians and Vehicle Control - No ATCT (329b)
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Pedestrians and Vehicle Operators Training on Airport Procedures & Consequences of Noncompliance. (329e)
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Records of Training for 24 CCM (329f1)
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12 CCM of Records for Accidents or Incidents Involving Pedestrians, Ground Vehicle, and or Aircraft. (329)
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Comments
OBSTRUCTIONS
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Objects within Airport Authority Determined to be an Obstruction Removed, Marked or Lighted. (331)
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Comments
PROTECTION OF NAVAIDS
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Prevent Construction that would Derogate NAVAIDs or at Facilities. (333a)
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Protect NAVAIDs from Vandalism & Thief. (333b)
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Prevent NAVAIDs Signal Interruptions. (333c)
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Comments
PUBLIC PROTECTION
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Prevent Inadvertent Entry to Movement Area by Unauthorized Person or Vehicles. (335a1)
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Reasonable Protection from ACFT Blast (335a2)
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Comments
WILDLIFE HAZARD MANAGEEEMENT
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Immediate Measure Taken to Alleviate Wildlife Hazards When Detected. (337a)
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Provide for a Wildlife Hazard Assessment when Required. (337b)
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Wildlife Hazard Assessment Conducted by Qualified Personnel. (337c)
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Wildlife Hazard Assessment Contents. (337e)
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Wildlife Hazard Assessment Submitted to FAA. (337d)
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Wildlife Hazard Management Plan Formulated and Implemented When Required by FAA. (337f6)
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Plan Addressees Required Contents. (337f)
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Procedures to Review and Evaluate the Plan every 12 CCM or as Required. (337f7)
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Airport Personnel Training Program by a Qualified Wildlife Biologist. (337f7)
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Comments
AIRPORT CONDITION REPORTING
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Collection / Dissemination of Airport Condition. (339a)
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Use of NOTAM / Other System. (339b)
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Provide Information on Required Conditions. (339c)
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12 CCM of Records of Each Dissemination. (339d)
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Comments
IDENTIFYING MARKING AND LIGHTING CONSTRUCTION AND OTHER UNSERVICEABLE AREAS
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Mark / Light Construction / Unserviceable Areas & Equipment. (341a1)
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Pre-Construction Review of Utilities. (341e2)
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Comments
NONCOMPLYING CONDITIONS
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Limit ACR OPNS to Safe Area when Uncorrected Unsafe Conditions Exist. (343)<br>
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Comments
METHODS AND PROCEDURES FOR COMPLIANCE
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Other
MISCELLANEOUS OBSERVATION(S)
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Miscellaneous Observations
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Miscellaneous Photos
FAR 139 POST-INSPECTION MEETING
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List issues from inspections that needs to be addressed (explain mitigation and timeframe to correct these issue).
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Comments
SIGNATURE OF OBSERVER & COMMENTS
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Name of Observer
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Observer's Comments
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Date & Time FAR 139 Inspection Completed
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Date of AIR-L, AIR-LF Review
