Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report

FORM APPROVED FOR USE THROUGH 06/30/2009 BY OMB NO. 3147-0001

NATIONAL TRANSPORTATION SAFETY BOARD
NTSB Form 6120.1
PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT

The pilot/operator aircraft accident/incident report may be filed by
mailing in this form, per instructions on the last page. Copies of this form
may be obtained from the NTSB Web site , the
National Transportation Safety Board Regional Offices, and the Federal
Aviation Administration Flight Standards District Offices.

B. DEFINITIONS
1. “Aircraft Accident” means an occurrence associated with the
operation of an aircraft that takes place between the time any person
boards the aircraft with the intention of flight and all such persons have
disembarked, and in which any person suffers death, or serious injury, or
in which the aircraft receives substantial damage.

Rules pertaining to aircraft accidents/incidents, overdue aircraft, and
safety issues are contained in Part 830 of the National Transportation
Safety Board’s Regulations, 49CFR. These rules state the authority of the
Board, define accidents, incidents, injuries, and other terms, and provide
procedures for initial and immediate notification by aircraft pilots/operators.

2. “Substantial Damage” means damage or failure which adversely
affects the structural strength, performance or flight characteristics of the
aircraft, and which would normally require major repair or replacement of
the affected component. NOTE: Engine failure or damage limited to an
engine if only one engine fails or is damaged, bent fairing or cowling,
dented skin, small puncture holes in the skin or fabric, ground damage to
rotor or propeller blades, and damage to landing gear, wheels, tires, flaps,
engine accessories, brakes, or wing tips are not considered “substantial
damage” for purposes of this report.

A. APPLICABILITY
The pilot/operator of an aircraft shall file a report with the Regional
Office of the National Transportation Safety Board nearest the accident or
incident for which immediate notification is required by section 830.5(a)
The report shall be filed within ten (10) days after an accident for
which notification is required by Section 830.5 or when, after seven
(7) days, an overdue aircraft is still missing. An aircraft accident, as
defined in 49CFR 830.2, is determined as an occurrence that involves a
fatality, serious injury, or substantial damage. For occurrences that do not
involve a fatality, the determination that the occurrence is an accident can
be appealed by writing to the Director, Office of Aviation Safety, National
Transportation Safety Board, 490 L'Enfant Plaza, S.W., Washington, D.C.
20594.

3. “Operator” means any person who causes or authorizes the
operation of an aircraft, such as the owner, lessee, or bailee of an aircraft.
4. “Fatal Injury” means any injury that results in death within thirty (30)
days of the accident.
5. “Serious Injury” means any injury that (1) requires hospitalization for
more than 48 hours, commencing within 7 days from the date the injury
was received; (2) results in a fracture of any bone (except simple fracture
of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle,
or tendon damage; (4) involves injury to any internal organ; or (5) involves
second- or third-degree burns, or any burns affecting more than 5 percent
of the body surface.

The Pilot/Operator Aircraft Accident/Incident Report Form is used in
determining the facts, conditions, and circumstances for aircraft accident
prevention activities and for statistical purposes. It is necessary that ALL
questions be answered completely and accurately to serve the above
purposes.

INSTRUCTIONS TO PILOTS/OPERATORS FOR COMPLETING THIS FORM
It is necessary that ALL questions on this report be answered completely and accurately.
If more space is needed, continue on a blank sheet.
Nearest City/Place: Use the name of the nearest community that has a
Post Office in the state where the accident/incident occurred.

cargo/baggage compartment
emergency ground equipment.

Date & Time: Indicate the date and local time of the event. Be sure to
indicate the time zone.

Engine: Enter engine make and model information as indicated on the
engine data plate.

Phase of Operation: Indicate the phase of operation during which the
accident/incident occurred.

Owner/Operator Information: Enter the owner information as shown on the
registration certificate. Commercial operators, enter the operator
information, including “Doing Business as” when applicable, as shown on
the operator certificate.

Aircraft Information: Enter aircraft make and model information as
indicated on the aircraft registration certificate, including series. If the
involved aircraft is certified as "amateur-built," include the name of
manufacturer of the kit or plans when appropriate.

fire

suppression

system,

or

airport

Revenue Sightseeing Flight: Indicate whether the accident aircraft was
conducting revenue sightseeing operations under FAR Part 91 at the time
of the accident.

Max Gross Weight: Enter the certificated max gross weight for the aircraft
involved in the occurrence. This should be the same as the maximum
gross weight indicated on the aircraft weight and balance documents.

Public Use: Federal, state or local government flight operations such as
official travel, law-enforcement, low-level observation, aerial application,
firefighting, search and rescue, biological or geological resource
management, or aeronautical research. Military operations should not be
included under public use. If public use, also indicate whether the flight
was conducted by Federal, State, or Local government.

Airworthiness Certificate: For light sport aircraft, if aircraft certificated as
"Light Sport - Experimental", check both the “Light Sport” and
“Experimental" check boxes.
Type of Fire Extinguishing System: If a fire extinguishing system was used
to fight an aircraft fire, specify the type(s) of extinguishing system(s) used.
Examples include handheld extinguisher, engine fire bottle,

Air Medical Flight: Indicate whether accident flight was being conducted
for the purpose of carrying medical personnel, patient(s), or organs.

NTSB Form 6120.1 (rev. 10/2006). This form replaces 6120.1/2.

1

Purpose of Flight (FAR 91, 103, 133, 137): Indicate the type of operation
that was being conducted at the time of the occurrence using the following
definitions:

Condition of Runway/Landing Surface: Indicate the condition of the
intended runway/landing surface. If multiple conditions existed at the time
of the accident, check all that apply.

PERSONAL—Flying for personal reasons (excludes business
transportation) including pleasure or personal transportation. This also
includes practice or proficiency flights performed under flight instructor
supervision and not part of an approved flight training program.

Weather Information at the Accident/Incident Site: Indicate the weather
conditions reported at the accident/incident site at the time of occurrence.
If no weather reporting was available for the accident/incident site, indicate
the reported conditions at the nearest reporting site. Specify the weather
reporting site identifier, the observation time, and distance from the
accident/incident site.

BUSINESS—Includes all personal flying without a paid, professional
crew for reasons associated with furthering a business, including
transportation to and from business meetings or work. This does not
include corporate/executive operations, air taxi, or commuter
operations.

Sky/Lowest Cloud Condition: Indicate the height above ground level of the
lowest cloud condition present at the time of the accident and whether
coverage was reported as few, scattered, broken or overcast. Also
indicate the height above ground level and coverage of the lowest cloud
ceiling present at the time of the accident (reported as broken or
overcast).

EXECUTIVE/CORPORATE—Company flying with a paid, professional
crew.
OTHER WORK USE—Miscellaneous flight operations conducted for
compensation or hire such as construction work (not FAR Part 135
operation), parachuting, aerial advertising, towing gliders, etc.

NOTAMs ((D), (L) and FDC), AIRMETs, SIGMETs, PIREPs: Describe all
NOTAMs, AIRMETs, SIGMETs, PIREPs in effect near the
accident/incident. For NOTAMs, state if they were distant (D), local (L), or
Flight Data Center (FDC), if known.

INSTRUCTIONAL—Flying while under the supervision of a flight
instructor or receiving air carrier training. Personal proficiency flight
operations and personal flight reviews, as required by federal air
regulations, are excluded.

Pilot Information: Indicate the category that best describes the capacity
served by this flight crewmember at the time of the accident. The
designators “Pilot A” and “Pilot B” do not refer to a specific pilot position or
responsibility. If more than one pilot is aboard, they may be entered in any
order and their capacity entered as appropriate.

FERRY—Non-revenue flight under a special flight or “ferry” permit.
Refer to 14 CFR 21.197 for details of special flight permit issuance.
POSITIONING—Non-revenue flight conducted for the primary purpose
of moving the aircraft to a maintenance facility or to load passengers or
cargo, etc.

Degree of Injury: See Definitions on the top half of Page 1 of the
Instructions. Minor injury is not defined. If an injury does not meet the
criteria for another injury category, select Minor.

AERIAL APPLICATION—Operations using an aircraft to perform aerial
application or dispersion of any substance. Examples include
agricultural, health, forestry, cloud seeding, firefighting, insect control,
etc.

Date of Last Flight Review or Equivalent: Enter the date of the most recent
flight review, or equivalent, completed by this pilot. Refer to 14 CFR 61.56
for accepted equivalents.

AERIAL OBSERVATION—Aerial mapping/photography, patrol, search
and rescue, hunting, highway traffic advisory, ranching, surveillance,
oil and mineral exploration, criminal pursuit, fish spotting, etc.
AIR DROP—Aerial operations, other than aerial application, that are
intended to release items in flight.

Type Ratings: List all type ratings on the pilot certificate. If the pilot holds
no type ratings indicate “none”. If the pilot holds a pilot certificate other
than student, and was flying an aircraft requiring an endorsement enter
the type and date of any logbook endorsement(s) for that aircraft. See 14
CFR 61 for examples of required endorsements.

AIR RACE/SHOW—Includes any flight operations conducted as part of
an organized air race or public demonstration.

Student Endorsements: If the pilot holds a student pilot certificate, enter all
solo endorsements and dates on the student pilot certificate.

FLIGHT TEST—Flight for the purpose of investigating the flight
characteristics of an aircraft/aircraft component, or evaluating an
applicant for a pilot certificate or rating.

Flight Time: Complete the flight time matrix. Solo flight time should be
included as “Pilot-in-Command (PIC)” and all dual flight instruction given
should be included as “Time as Instructor”.

PUBLIC USE—See definition above.

Additional Flight Crew Members: Complete this section if there were more
than two required flight crew members on the aircraft. This also includes a
check airman performing official duties, but does not include cabin crew.
State the capacity served by each included crewmember at the time of the
accident.

UNKNOWN—Use only if the primary purpose of flight is not known.
Other Aircraft – Collision: For all accidents involving a collision with
another aircraft, including parked aircraft, check “Collision with other
aircraft” under Basic Information and complete this section indicating
details about the OTHER aircraft involved in the collision.

Passenger(s)/Other Personnel: Please enter identification and injury
severity information for all passengers and other personnel involved in the
accident. See page 1 of the instructions for the official definition of injury
levels. Occupants are considered “Revenue” passengers if they were
being carried for compensation or hire. The option “FAA” refers to any
FAA personnel performing a flight related function, including flight check,
airman practical test, etc.

Airport Information: Complete this section if the accident/incident occurred
on approach, takeoff, or within 3 miles of an airport. Please refer to the
FAA Airport/Facility Directory or other official source for airport
information.
Airport Identification: Provide the official 3 or 4 character airport identifier.
Runway: Indicate the number of the runway used, including L, R, or C if
applicable.

Several questions throughout the form allow for multiple responses;
when appropriate choose all responses that apply.

Runway/Landing Surface: Indicate the type of intended runway/landing
surface (do not indicate surface conditions). If the surface type was mixed,
check all that apply.

These instructions only pertain to major issue areas covered by the
NTSB Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report.
For additional definitions of questions and responses, please refer
to .

2

NATIONAL TRANSPORTATION SAFETY BOARD
PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT
This form to be used for reporting civil and public use aircraft accidents and incidents
BASIC INFORMATION
Accident/Incident Location

Date/Time

Nearest City/Place: _________________________________________ State: ________

Date: ______________________
mm/dd/yyyy

ZIP: ________________ Country: ___________________________________________

Local Time: _________________
Time Zone: _________________

Latitude: _____________ (dd:mm:ss N/S) Longitude: _____________ (ddd:mm:ss E/W)

Collision with Other Aircraft

Phase of Operation
Standing
Taxi
Descent

Takeoff (incl. initial climb)
Climb
Landing

Cruise
Maneuvering
Approach

Hover
Other
Unknown

Midair
On-ground
None

Altitude of In-Flight
Occurrence
_________________ ft MSL

AIRCRAFT INFORMATION
Manufacturer: _________________________________________________________

Max Gross Weight: _______________ lbs

Model: _________________________________________________________________

Weight at Time of Accident/Incident: _______________ lbs

Serial Number: _____________________________

Location of Center of Gravity at Time of Accident/Incident:
_____________ inches from
nose or
datum
-or- _____________ Percent Mean Aerodynamic Cord (% MAC)

Registration Number: __________________
Category of Aircraft
Airplane
Balloon
Blimp/Dirigible
Glider
Gyrocraft
Helicopter
Powered lift
Ultralight
Unknown

Amateur-built:

Type of Airworthiness Certificate
(Check all that apply)
Standard
Special
Normal
Utility
Acrobatic
Transport

IFR Equipped
No

ELT Installed
Yes

No

Yes

No

Engine Type
Reciprocating
Turbo Shaft
Turbo Prop

Engine

Turbo Jet
Turbo Fan
Unknown

Engine Manufacturer

Check any additional landing gear
configuration that applies:
Tailwheel

Cabin Crew: ________________

Amphibian
Emergency Float
Float
Hull
Unknown

High Skid
Skid
Ski
Ski/Wheel

Date Last Inspection: ________________

Continuous Airworthiness
Conditional Inspection
Unknown

mm/dd/yyyy

Airframe Total Time: __________________hrs
hours measured at (check one)
Last Inspection
Time of Accident/Incident

Yes

ELT Activated

Retractable

Tricycle

Passengers: _________________

100 Hour
AAIP
Annual

Landing Gear

Flight Crew: ________________

Type of Fire Extinguishing System

Stall Warning System Installed
Unknown

No

Unknown

None
Specify ___________________________________

ELT Manufacturer: ______________________________________

No

Model/Series: ___________________________________________

ELT Aided in Locating Accident/Incident
Yes

If Large Aircraft, how many seats for:

Last Inspection Type

Annual
Conditional (Amateur-built only)
Manufacturer’s Inspection Program
Other Approved Inspection Program (AAIP)
Continuous Airworthiness
Other, specify: _____________________________
Yes

No

Number of Seats: ___________

Restricted
Limited
Provisional
Experimental
Special Flight
Light Sport

Type of Maintenance Program

Yes

Serial Number: __________________________________________

Battery Type: _____________________________
Battery Exp. Date: _____________
Reciprocating Fuel
Propeller
System Type
Carburetor
Manufacturer: ________________________________________
Fixed Pitch
Fuel Injected

Engine
Model/Series

Controllable Pitch

Manufacturer’s
Serial Number

Eng. 1
Eng. 2
Eng. 3
Eng. 4

3

Model: _______________________________________________

Date
of Mfg.
mm/dd/yyyy

Engine Rated
Power Measured
as (check one)
Total
Horsepower or Time
lbs of Thrust
(hours)

Time
Since
Inspection
(hours)

Time
Since
Overhaul
(hours)

OWNER/OPERATOR INFORMATION
Registered Aircraft Owner

Owner Address

Name: __________________________________________________________________

City: ____________________________________
State: ___________ ZIP: ____________
Country: _________________________________

Fractional Ownership Aircraft:
Operator of Aircraft

Yes

No

Operator Address

Same As Registered Owner

Same As Registered Owner

Name: __________________________________________________________________
Doing Business As: _______________________________________________________
Air Carrier/Operator Designator (4 Character Code): _______________

City: ____________________________________
State: ___________ ZIP: ____________
Country: _________________________________

Regulation Flight Conducted Under

Revenue Sightseeing Flight

FAR 91
FAR 103
FAR 121
FAR 125

FAR 129
FAR 133
FAR 135
FAR 137

FAR 91 Special Flight
Non-US, Commercial
Non-US, Non-commercial
Armed Forces

Public Use (select type)
Federal
State
Local
Unknown

Purpose of Flight

Revenue Operation

for FAR 91, 103, 133, 137 (Select one)

for FAR 121, 125, 129, 135

Personal
Business
Executive/Corporate
Other Work Use
Instructional
Ferry
Positioning
Aerial Application
Aerial Observation
Air Drop
Air Race / Show
Flight Test
Public Use
Unknown

Yes

No

Air Medical Flight

(Check all that apply)
None
Flag Carrier Operating Certificate (121)
Supplemental
Air Cargo
Foreign Air Carriers (129)
Commuter Air Carrier (135)
On-Demand Air Taxi (135)
Large Helicopter (127)

Domestic or International
International

Cargo Operation
Passenger/Cargo
Passenger ____________How many?
Cargo ______________ lbs
Mail

OTHER AIRCRAFT – COLLISION

No

Type of Commercial Operating Certificate Held
(Select one)

Scheduled or Commuter
Non-Scheduled or Air Taxi

Domestic

Yes

Rotorcraft External Load (133)
- or -

Agricultural Aircraft (137)
Other Operator of Large Aircraft

(If air or ground collision occurred, complete this section for other aircraft)

Aircraft Registration Number

Manufacturer: ___________________________________________________

_________________________

Model: __________________________________________________________

Damage to Other Aircraft
Destroyed
Substantial

Minor
None

Registered Owner of Other Aircraft
First Name: ___________________________________________________
Middle Initial: _________
Last Name: ___________________________________________________

City: _________________________________________________
State: ___________ ZIP: ____________
Country: ______________________________________________

Pilot of Other Aircraft
First Name: ___________________________________________________
Middle Initial: _________
Last Name: ___________________________________________________

MECHANICAL MALFUNCTION/FAILURE
Was there Mechanical Malfunction/Failure?

Yes

City: _________________________________________________
State: ___________ ZIP: ____________
Country: ______________________________________________

(If more space is needed, continue on separate sheet)

No

Total Time/Cycles
On Part

Unknown

(If yes, list the name of the part, manufacturer, part no., serial no., and describe the failure.)

______________ Hours
______________ Cycles

Time Since This Part
Inspected/Overhauled
______________ Hours

DAMAGE TO AIRCRAFT AND OTHER PROPERTY
Aircraft Damage
None
Minor

Aircraft Fire
Substantial
Destroyed

None
In-Flight
On-Ground

Aircraft Explosion
Both Ground and In-Flight
Unknown Origin

4

None
In-Flight
On-Ground

Both Ground and In-Flight
Unknown Origin

Description of Damage to Aircraft and Other Property (use additional sheet if necessary)

AIRPORT INFORMATION

(If the accident/incident occurred on approach, takeoff or within 3 miles of an airport, complete this section)

Airport Identifier: ________________________________________

Distance From Airport Center: __________________SM

Airport Name: __________________________________________________

Direction From Airport: ________________ degrees MAG

Proximity to Airport

Airport Elevation: __________________________ ft. MSL

Off Airport/Airstrip

On Airport

On Airstrip

Approach Segment (Select one)
On Instrument Approach
Crosswind

Landing
Downwind

Base leg
Low Approach

PAR
Sidestep
ILS
Localizer Only
LOC-back course
RNAV

MLS
LDA
ASR
Visual
Contact
Circling

Practice
GPS
Loran
Unknown

None
Traffic Pattern
Straight-In
Valley/Terrain Following
Go Around
Full Stop

Stop and Go
Touch and Go
Simulated Forced Landing
Forced Landing
Precautionary Landing
Unknown

Condition of Runway/Landing Surface (Check all that apply)

Runway Information
Runway ID: ____________(L/R/C) Length: ____________ft Width: ____________ft

Runway/Landing Surface (Check all that apply)
Asphalt
Concrete
Dirt

Go Around

VFR Approach (Check all that apply)

IFR Approach (Check all that apply)
None
ADF/NDB
SDF
VOR/TVOR
VOR/DME
TACAN

Final
Aborted Landing (after touchdown)

Grass/Turf
Gravel
Ice

Macadam
Metal/Wood
Snow

Water
Unknown

Dry
Holes
Ice Covered
Rough
Rubber Deposits
Slush Covered

Snow-Compacted
Snow-Crusted
Snow-Dry
Snow-Wet
Soft
Vegetation

Water-Calm
Water-Choppy
Water-Glassy
Wet
Unknown

FLIGHT ITINERARY INFORMATION
Last Departure Point

Time of Departure

Airport ID: _______________
City: ________________________________

Time: _____________
Time Zone:_________

State: ____________________
Country: _____________________________

Destination

Type Flight Plan Filed

Airport ID: ___________________

None
Company VFR
Military VFR
VFR
Activated?
Yes

City: _________________________________
State: ________________________
Country: ______________________________

VFR/IFR
IFR
Unknown
No

Type of ATC Clearance/Service (Check all that apply)
None
VFR

Special VFR
IFR

Special IFR
VFR On Top

VFR Flight Following
Traffic Advisory

Cruise
Unknown / NA

Airspace where the accident/incident occurred (Check all that apply)
Class A
Class B
Class C
Class D

Class E
Class G
Demo Area
Warning Area

Prohibited Area
Restricted Area
Military Operations Area (MOA)
Airport Advisory Area

Jet Training Area
TRSA
FAR 93

Parachutists
Water
Chemical/Fertilizer/Seeds

Livestock
Unknown

Special
Air Traffic Control Area
Unknown

Aircraft Load Description (Check all that apply)
None
Passengers
Cargo

Towing Glider
Towing Banner
Other External

FUEL & SERVICES INFORMATION
Fuel on Board at Last Takeoff

Fuel Type

(convert from pounds, as necessary)
____________________________

Gallons

80/87
100 Low Lead
100/130

115/145
Jet A
Automotive

Other Services, if Any, Prior to Departure

5

JP3
JP4
JP5

Other, specify _________________________

EVACUATION OF AIRCRAFT
Was an emergency evacuation of the aircraft performed?

Yes

No

Method of Exit – Describe how the occupants exited and how many occupants evacuated each location

WEATHER INFORMATION AT THE ACCIDENT/INCIDENT SITE
Weather Observation Facility

Source of Weather Information

Method of Briefing

(Check all that apply)
National Weather Service
Flight Service Station
TV/Radio
Automated Report
Commercial Weather Service (DUATS)

Facility ID: ___________________________________
Observation Time: _____________________________
Time Zone: ___________________________________
Distance from Accident Site: __________________ NM

(Check all that apply)
In Person
Teletype
Telephone/Computer
Aircraft Radio
TV/Radio
Unknown

Company
Military
Internet
Unknown

Direction from Accident Site: _______________ degrees MAG

Briefing Type/Completeness

Light Condition

Full
Partial / Limited By Pilot
Partial / Limited By Briefer

Abbreviated
Unknown
Not Pertinent

Sky/Lowest Cloud Condition
Clear
Few
Partial Obscuration
Scattered

Visibility

Dawn
Day

Dusk
Night

Ceiling
Thin Broken
Thin Overcast
Unknown

Obscured
Indefinite
Unknown

Ceiling Height

___________________ ft AGL

___________________ ft AGL

Indicated:
_________degrees MAG

Wind Speed

Wind Gusts

Velocity: __________KTS
-or-

Velocity: _________KTS

Calm
Light and Variable

Variable

__________ miles

Restriction to Visibility (Check all that apply)

None (clear)
Broken
Overcast

Lowest Cloud Condition Height
Wind Direction

Dark Night
Bright Night
Not Reported
None
Blowing Dust
Blowing Sand
Blowing Snow
Blowing Spray
Dust

Fog
Ground Fog
Haze
Ice Fog
Smoke
Unknown

Type of Turbulence (Check all that apply)
None
Clear Air

In Clouds
Vicinity of Thunderstorm

Severity of Turbulence

Gusting
Not Gusting

Extreme
Severe

Moderate
Moderate Chop

Light

NOTAMs (D, L and FDC), AIRMETs, SIGMETs, PIREPs in effect at the time of the accident/incident

Icing Forecast
Temperature: _________ (C)
or _________ (F)

Altimeter Setting: ________ in. HG
or ________ MB

Density Altitude: ________________ ft
Dew Point: _________ (C)
or _________ (F)

Amount
None
Trace
Light

Type of Precipitation (Check all that apply)
Moderate
Severe

Type
Rime
Clear
Mixed

Moderate
Severe

Type
Rime
Clear
Mixed

Icing Actual
Amount
None
Trace
Light

6

None
Rain
Snow
Hail
Rain Showers
Freezing Rain
Snow Shower

Drizzle
Ice Pellets
Snow Pellets
Snow Grains
Ice Crystals
Ice Pellets Shower
Freezing Drizzle

Intensity of Precipitation
Light

Moderate

Heavy

PILOT “A” INFORMATION
Pilot “A” Responsibilities at the Time of Accident/Incident
Pilot

Co-Pilot

Student Pilot

Flight Instructor

Check Pilot

Flight Engineer

Other Flight Crew

Pilot “A” Identification
First Name: ___________________________________________________
Middle Initial: _________
Last Name: ___________________________________________________

City: _________________________________________________
State: ___________ ZIP: ____________
Country: ______________________________________________

Age at time of Accident/Incident: ________

Certificate Number: _____________________________________

Date of Birth: _____________
mm/dd/yyyy

Degree of Injury
None
Minor
Serious

Seat Occupied

Fatal
Unknown

Left
Right
Center

Seat Belt
Front
Rear
Single

Unknown

Used
Available

Shoulder Harness
Yes
Yes

No
No

Used
Available

Yes
Yes

No
No

Pilot Certificate(s) (Check all that apply)
None
Private

Student
Flight Instructor

Principal Occupation

Recreational
Sport

Commercial
Airline Transport

Medical Certificate

Pilot
Other
Unknown

None
Class 1
Class 2

Flight Engineer
U.S. Military

Medical Certificate Validity

Class 3
Driver’s License (Sport Pilot only)
Unknown

Foreign

Date of Last Medical

Without limitations/waivers
With limitations/waivers
Unknown

____________
mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Waivers

Date of Last Flight Review
or Equivalent, Including
FAR 121/135 Checks:
__________________
mm/dd/yyyy

Airplane Rating(s)
(Check all that apply)
None
Single-Engine Land
Single-Engine Sea
Multiengine Land
Multiengine Sea

Flight Review Aircraft
Make: ______________________________________________________________________________
Model: ______________________________________________________________________________

Other Aircraft Rating(s)
(Check all that apply)
None
Airship
Free Balloon
Glider
Gyroplane
Helicopter
Powered Lift

Instrument Rating(s)
(Check all that apply)

Instructor Rating(s)
(Check all that apply)

None
Airplane
Helicopter
Powered Lift

None
Airplane Single-Engine
Airplane Multi-Engine
Gyroplane
Powered Lift

Type Ratings

Flight Time (enter appropriate
number of hours in each box)

Instrument Airplane
Instrument Helicopter
Helicopter
Glider
Sport

Student Endorsements (Include dates)

All
Aircraft

This Make
& Model

Airplane
Single
Engine

Airplane
Multiengine

Total Time
Pilot in Command (PIC)
Time as Instructor
This Make/Model
Last 90 Days
Last 30 Days
Last 24 Hours

7

Instrument
Night

Actual

Simulated

Rotorcraft

Glider

Lighter
Than Air

PILOT “B” INFORMATION
Pilot “B” Responsibilities at the Time of Accident/Incident
Pilot

Co-Pilot

Student Pilot

Flight Instructor

Check Pilot

Flight Engineer

Other Flight Crew

Pilot “B” Identification
First Name: ___________________________________________________
Middle Initial: _________
Last Name: ___________________________________________________

City: _________________________________________________
State: ___________ ZIP: ____________
Country: ______________________________________________

Age at time of Accident/Incident: ________

Certificate Number: _____________________________________

Date of Birth: _____________
mm/dd/yyyy

Degree of Injury
None
Minor
Serious

Seat Occupied

Fatal
Unknown

Seat Belt

Left
Right
Center

Front
Rear
Single

Unknown

Used
Available

Shoulder Harness
Yes
Yes

No
No

Used
Available

Yes
Yes

No
No

Pilot Certificate(s) (Check all that apply)
None
Private

Student
Flight Instructor

Principal Occupation

Recreational
Sport

Commercial
Airline Transport

Medical Certificate

Pilot
Other
Unknown

None
Class 1
Class 2

Flight Engineer
U.S. Military

Medical Certificate Validity

Class 3
Driver’s License (Sport Pilot only)
Unknown

Without limitations/waivers
With limitations/waivers
Unknown

Foreign

Date of Last Medical
____________
mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Waivers

Date of Last Flight Review
or Equivalent, Including
FAR 121/135 Checks:
__________________
mm/dd/yyyy

Airplane Rating(s)
(Check all that apply)
None
Single-Engine Land
Single-Engine Sea
Multiengine Land
Multiengine Sea

Flight Review Aircraft
Make: ______________________________________________________________________________
Model: ______________________________________________________________________________

Other Aircraft Rating(s)
(Check all that apply)
None
Airship
Free Balloon
Glider
Gyroplane
Helicopter
Powered Lift

Instrument Rating(s)
(Check all that apply)

Instructor Rating(s)
(Check all that apply)

None
Airplane
Helicopter
Powered Lift

None
Airplane Single-Engine
Airplane Multi-Engine
Gyroplane
Powered Lift

Type Ratings

Flight Time (enter appropriate
number of hours in each box)

Instrument Airplane
Instrument Helicopter
Helicopter
Glider
Sport

Student Endorsements (Include dates)

All
Aircraft

This Make
& Model

Airplane
Single
Engine

Airplane
Multiengine

Total Time
Pilot in Command (PIC)
Time as Instructor
This Make/Model
Last 90 Days
Last 30 Days
Last 24 Hours

8

Instrument
Night

Actual

Simulated

Rotorcraft

Glider

Lighter
Than Air

ADDITIONAL FLIGHT CREW MEMBERS

(Exclusive of cabin attendants, complete the following information)

Pilot Name and Address

Degree of Injury

First Name: _______________________________________
Middle Initial: _________
Last Name: _______________________________________

None
Minor
Serious

City: _____________________________________
State: ___________ ZIP: ____________
Country: _______________________________

Pilot Certificate(s) (Check all that apply)

Yes

Commercial
Airline Transport

Flight Engineer
U.S. Military

Total Flight Time at the Time
of this Accident/Incident: ____________hrs

No

Pilot Name and Address

None
Minor
Serious

City: _____________________________________
State: ___________ ZIP: ____________
Country: _______________________________

Pilot Certificate(s) (Check all that apply)

Seat Occupied

Recreational
Sport
Yes

Commercial
Airline Transport

Flight Engineer
U.S. Military

Total Flight Time at the Time
of this Accident/Incident: ____________hrs

No

Pilot Name and Address

None
Minor
Serious

City: _____________________________________
State: ___________ ZIP: ____________
Country: _______________________________

Pilot Certificate(s) (Check all that apply)

Left
Right
Center

Foreign

Total Flight Time at the Time
of this Accident/Incident: ____________hrs

No

PASSENGER(S) / OTHER PERSONNEL

Flight Engineer
U.S. Military

Front
Rear
Single
Unknown

(Include flight attendants; continue on separate sheet if necessary)

Name and Address

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

First Name: _________________________________________
Middle Initial: _________
Last Name: _________________________________________

City: _____________________________________
State: ___________ ZIP: ____________
Country: __________________________________

____

9

Unknown

Yes

Commercial
Airline Transport

No Injury

Type Rating/Endorsement for
Accident/Incident Aircraft?

Fatal
Unknown

Seat Occupied

Recreational
Sport

Seat

Student
Flight Instructor

Front
Rear
Single
Unknown

Degree of Injury

First Name: _______________________________________
Middle Initial: _________
Last Name: _______________________________________
None
Private

Left
Right
Center

Foreign

Serious
Injury
Minor
Injury

Type Rating/Endorsement for
Accident/Incident Aircraft?

Fatal
Unknown

Fatal

Student
Flight Instructor

Front
Rear
Single
Unknown

Degree of Injury

First Name: _______________________________________
Middle Initial: _________
Last Name: _______________________________________
None
Private

Left
Right
Center

Foreign

FAA

Type Rating/Endorsement for
Accident/Incident Aircraft?

Seat Occupied

Recreational
Sport

Revenue
NonOccupant

Student
Flight Instructor

Crew
NonRevenue

None
Private

Fatal
Unknown

NARRATIVE HISTORY OF FLIGHT

(Please type or print in ink)

Describe what occurred in chronological order, including circumstances leading to and nature of accident/incident. Describe terrain and include
wreckage distribution sketch if pertinent. Attach extra sheets if needed. State time and point of departure, intended destination, and services obtained.

RECOMMENDATION

(How could this accident/incident have been prevented?)

Operator/Owner Safety Recommendation

10

ADDITIONAL INFORMATION (Please type or print in ink)
Use this space if additional space is needed for any answers.

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
Date of this Report
______________
mm/dd/yyyy

Signature and Name of Pilot/Operator
Signature:________________________________________________________________________________________
Type or Print Name: ________________________________________________________________________________

Signature and Name of Person Filing Report if Other than Pilot/Operator
Signature: ______________________________________________________________________________________________________________________
Type or Print Name: ______________________________________________________________________________________________________________
Title: __________________________________________________________________________________________________________________________

FOR NTSB USE ONLY
NTSB Accident/Incident No.

Reviewed by NTSB Regional Office

Name of Investigator

11

Date Report Received