Form 8010-4 Malfunction or Defect Report

FEDERAL AVIATION ADMINISTRATION
ATA Code

Enter pertinent data

MANUFACTURER

1.

A/C Reg. No.

MODEL/SERIES

N-

OTHER

MALFUNCTION OR DEFECT REPORT

OPERATOR
DESIGNATION

8. Comments (Describe the malfunction or defect and the circumstances under which it
occurred. State probable cause and recommendations to prevent recurrence.)

OPER. Control No.

DEPARTMENT OF TRANSPORTATION

DISTRICT
OFFICE

OMB No. 2120-0003

08/31/2008

SERIAL NUMBER

COMMUTER

2.

AIRCRAFT
3.

FAA

POWERPLANT
4.

MFG.

PROPELLER
5. SPECIFIC PART (of component) CAUSING TROUBLE
Serial No.

Part/Defect Location.

)

MFG. Model or Part No.

(

AIR TAXI

Part Name

Optional Information:
Part TT

Part TSO

Part Condition

7. Date Sub.

Check a box below, if this report is related to an aircraft
Accident; Date

FAA FORM 8010-4

Incident; Date

TELEPHONE NUMBER

Serial Number

SUBMITTED BY:

Model or Part No.

OPER.

Manufacturer

REP.STA.

Comp/Appl Name

MECH.

6. APPLIANCE/COMPONENT (Assembly that Includes part)

(10-92) SUPERSEDES PREVIOUS EDITIONS

Use this space for continuation of Block 8 (if required).

PAPERWORK REDUCTION ACT STATEMENT: The information collected on this form is used to evaluate certification standards,
maintenance programs, and regulatory requirements. The information is required to ensure safety in air transportation. It is
estimated that it will take approximately 9 minutes to complete the form. Providing this information is mandatory. No assurance of
confidentiality is given. Please note that an agency may not conduct or sponsor, and a person is not required to respond to,a collection
of information unless it displays a currently valid OMB control number. The control number for this collection of information is
2120-0003. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at:
800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20

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IN THE

UNITED STATES

U.S. Department
of Transportation
Federal Aviation
Administration
Flight Standards Service
Aviation Data Systems Branch
P.O. Box 25082
Oklahoma City, OK 73125-5029

AFS-620

Official Business
Penalty for Private Use $300

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Oklahoma City, OK 73125-5029