Form 8010-4 Malfunction or Defect Report

Paperwork Reduction Act Statement: A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of
information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection
is 2120-0003. Public reporting for this collection of information is estimated to be approximately 9 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory per 14 CFR Part 145. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection
Clearance Officer, ASP-110.

ATA Code

MANUFACTURER

1.

A/C Reg. No.

MODEL/SERIES

N-

OTHER

MALFUNCTION OR DEFECT REPORT

OPERATOR
DESIGNATION

FEDERAL AVIATION ADMINISTRATION

Enter pertinent data

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

11/30/2014

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

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

FAA FORM 8010-4

(10-92) SUPERSEDES PREVIOUS EDITIONS

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)

NO POSTAGE

NECESSARY

IF MAILED

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

BUSINESS REPLY MAIL

FIRST CLASS PERMIT NO. 12438 WASHINGTON, D. C.

Federal Aviation Administration
AFS-620 (Alerts)
P.O. Box 25082
Oklahoma City, OK 73125-5029