Form NTSB 6120.1 NTSB 6120.1 Pilot/Operator Aircraft Accident Incident Report

FORM APPROVED FOR USE THROUGH xx/xx/xxxx BY OMB NO. 3147-0001

NATIONAL TRANSPORTATION SAFETY BOARD
NTSB Form 6120.1
PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT
Email the pilot/operator aircraft accident/incident report to the
investigator-in-charge of your accident/incident. If email is not available, mail
the report per the instructions below.

The NTSB uses this form for aircraft accident prevention activities and
for statistical purposes. NTSB regulations (49 CFR Part 830) require that
ALL questions be answered completely and accurately. Completion of this
form will take approximately 60 minutes. The NTSB does not guarantee
the privacy of any information provided in this form. You need not
complete this form unless it displays a valid OMB control number.

If your accident/incident occurred in Maine, Vermont, New Hampshire,
Massachusetts, Connecticut, Rhode Island, New York, New Jersey,
Pennsylvania, Maryland, Delaware, Virginia, West Virginia, Kentucky,
Tennessee, North Carolina, South Carolina, Mississippi, Alabama, Georgia,
Florida, the District of Columbia, Puerto Rico, or the US Virgin Islands, send
the form to: NTSB, ERA, 45065 Riverside Parkway, Ashburn, VA 20147.

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. For purposes of this
form, the definition of “aircraft accident” includes “unmanned aircraft
accident,” as defined at 49 CFR 830.2.

If your accident/incident occurred in Ohio, Michigan, Indiana,
Wisconsin, Illinois, Minnesota, Iowa, Missouri, Arkansas, Louisiana, North
Dakota, South Dakota, Nebraska, Kansas, Oklahoma, Texas, Colorado, or
New Mexico, send the form to: NTSB, CEN, 4760 Oakland Street, Suite
500, Denver, CO 80239.
If your accident/incident occurred in Montana, Wyoming, Idaho, Utah,
Arizona, Nevada, Washington, Oregon, California, Hawaii, or the territories
of Guam or American Samoa, send the form to: NTSB, WPR, 505 South
336th Street, Suite 540, Federal Way, WA 98003.

2. "Substantial Damage" means damage or failure that adversely
affects the structural strength, performance or flight characteristics of
the aircraft, and that 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.

If your accident/incident occurred in Alaska, send the form to: NTSB,
ANC, 222 West 7th Avenue, Room 216, Box 11, Anchorage, AK 99513.
Rules pertaining to notification of aircraft accidents and incidents, as
well as overdue aircraft are found in 49 Code of Federal Regulations
(CFR) Part 830 http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&tpl=/ecfrbrowse/
Title49/49cfr830_main_02.tpl. These rules state the authority of the NTSB,
define accidents, incidents, injuries, and other terms, and provide
procedures for initial and immediate notification of accidents and incidents
by aircraft pilots/operators.

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.

A. APPLICABILITY
The pilot/operator of an aircraft shall send a report to the office listed
above, based on accident/incident location; immediate notification is
required by 49 CFR 830.5(a). The report shall be filed within 10 days
after an accident for which notification is required by Section 830.5, or
after 7 days if an overdue aircraft is still missing.
An aircraft accident, as defined in 49 CFR 830.2, is determined as an
occurrence that involves a fatality or serious injury, or substantial damage to
the aircraft. 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, NTSB, 490 L'Enfant Plaza, S.W.,
Washington, D.C. 20594.

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.

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 of paper.
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,
cargo/baggage compartment fire suppression system, or airport emergency
ground equipment.

Nearest City/Place: Use the name of the nearest community in the
state where the accident/incident occurred.
DateTime: Indicate the date and local time of the event. Be sure to
indicate the time zone.

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.

Phase of Operation: Indicate the phase of operation during which
the accident/incident occurred.
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
the producer of the kit or plans, unless an NTSB employee instructs
otherwise.

Revenue Sightseeing Flight: Indicate whether the accident aircraft
was conducting revenue sightseeing operations under 14 CFR Part 91 at
the time of the accident.
Air Medical Flight: Indicate whether the accident flight was being
conducted for the purpose of carrying medical personnel, patient(s),
or organs.

Maximum Gross Weight: Enter the certificated maximum 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 Aircraft: 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. Indicate whether the flight
was conducted by the armed forces, federal, state, or local government.

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

NTSB Form 6120.1 (rev. 9/2013). This form replaces 6120.1/2.

1

FORM APPROVED FOR USE THROUGH xx/xx/xxxx BY OMB NO. 3147-0001

Purpose of Flight: 14 CFR Parts 91, 103, 133, 136, and 137: Indicate the Weather Information at the Accident/Incident Site: Indicate the weather
type of operation that was being conducted at the time of the occurrence 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
using the following definitions:
reported conditions at the nearest reporting site. Specify the weather
AERIAL APPLICATION--Operations using an aircraft to perform aerial reporting site identifier, the observation time, and distance from the accident/
application or dispersion of any substance. Examples include incident.
agricultural, health, forestry, cloud seeding, firefighting, insect control,
etc.
Sky/Lowest Cloud Condition: Indicate the height above ground level of the
AERIAL OBSERVATION--These flights include aerial mapping/ lowest cloud condition present at the time of the accident/incident and
photography, patrol, search and rescue, hunting, highway traffic whether coverage was reported as few, scattered, broken or overcast. Also
advisory, ranching, surveillance, oil and mineral exploration, criminal indicate the height above ground level and coverage of the lowest cloud
ceiling present at the time of the accident/incident (reported as broken or
pursuit, fish spotting, etc.
overcast).
AIR DROP--Aerial operations, other than aerial application, that
NOTAMs (D and FDC), AIRMETs, SIGMETs, PIREPs: Describe all
are intended to release items in flight.
NOTAMs (distant (D) or Flight Data Center (FDC), if known), AIRMETs,
AIR RACE/SHOW--Includes any flight operations conducted as part SIGMETs, and PIREPs in effect near the accident/incident.
of an organized air race or public demonstration.
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.
EXECUTIVE/CORPORATE--Company
professional crew.

flying

with

a

Flight Crewmember Information: Indicate the category that best describes
the capacity served by this flight crewmember at the time of the accident.
The designators "Flight Crewmember 1" and "Flight Crewmember 2" 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.

paid,

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.

FERRY--Non-revenue flight under a special flight or "ferry" permit.
Refer to 14 CFR 21.197 for details of special flight permit issuance.
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.

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.

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.

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.

OTHER WORK USE--Miscellaneous flight operations conducted for
compensation or hire such as construction work (not 14 CFR Part 135
operation), parachuting, aerial advertising, towing gliders, etc.

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

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.

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."

POSITIONING--Non-revenue flight conducted for the primary purpose
of relocating the aircraft. Examples include moving the aircraft to a
maintenance facility or to load passengers or cargo etc.

Additional Flight Crewmembers: Complete this section if there were more
than two required flight crewmembers 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: Enter identification and injury severity
information for all passengers, cabin crew, and other personnel involved in
the accident. See Page 1 of the instructions for the official definition of
injury levels.

Airport Information: Complete this section if the accident/incident occurred
on approach, landing, takeoff, departure, or within 3 statute miles of an
airport. Please refer to the FAA Airport/Facility Directory or other official
source for airport information.

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

Airport IdentifiHU: Provide the official 3 or 4 character airport identifier
number.
Runway: Indicate the number of the runway used, including L, R, or C
if applicable.

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

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.
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.
NTSB Form 6120.1 (rev. 9/2013). This form replaces 6120.1/2.

2

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

Accident/Incident Date/Time

Nearest City/Place: _________________________________________ State: ________

Date: ______________________
mm/dd/yyyy

ZIP: ________________ Country: ___________________________________________
Latitude: ____________________

Local Time: _________________
Time Zone: _________________

Longitude: _____________________

(Enter in decimal degrees or degrees:minutes:seconds)

Collision with Other Aircraft:

Midair

On-ground

None

AIRCRAFT INFORMATION
IFR-Equipped and Certified
Commercial Space Flight
Unmanned Aircraft

Registration Number: ____________________
Manufacturer: _________________________________________________________
Model: _________________________________________________________________
Serial Number: _____________________________

Maximum Gross Weight: _______________ lbs
Weight at Time of Accident/Incident: ______________ lbs

Year of Manufacture: _______________________

Number of Seats: ___________

Flight Crew Seats: ___________

Amateur-Built:

Cabin Crew Seats: ______________

Passenger Seats: _____________

Yes
No

Category of Aircraft
Airplane
Balloon
Blimp/Dirigible
Glider
Gyroplane
Helicopter
Powered Lift
Rocket
Ultralight
Unknown

Engine

If Yes:

Kit/Plans Make: ________________________
Original Design

Number of Engines: ____________
Landing Gear
Engine Type (Select one)
(Check all that apply)
Liquid Rocket
Reciprocating

Type of Airworthiness Certificate

(Check all that apply)

Standard

Normal
Aerobatic
Balloon
Commuter
Transport
Utility

Special

Restricted
Limited
Provisional
Special Flight
Experimental
Special Light-Sport
Experimental Light-Sport

Certificate of Authorization or Waiver (COA)
None
Unknown

Engine Manufacturer

Engine
Model/Series

Retractable

Tricycle

Tailwheel

Amphibian
Emergency Float
Float
Hull

High Skid
Skid
Ski
Ski/Wheel

Other Launch/Recovery System
None

Turbo Shaft
Turbo Prop
Turbo Jet
Turbo Fan
Electric

Solid Rocket
Hybrid Rocket
None
Unknown

Fuel System Type (Reciprocating)
Carburetor
Fuel-Injected

Unknown
Date
of Mfg.

Manufacturer’s
Serial Number

mm/dd/yyyy

Total
Rated Power
Horsepower or Time
lbs of Thrust
(hours)

Time Since:
Inspection Overhaul
(hours)
(hours)

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

100-Hour
AAIP
Annual

Continuous Airworthiness
Conditional Inspection
Unknown

Date Last Inspection: ________________
mm/dd/yyyy

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

Type of Maintenance Program (Select one)
Annual
Conditional (Amateur-built only)
Manufacturer’s Inspection Program
Other Approved Inspection Program (AAIP)
Continuous Airworthiness
Other, specify: _________________________

Description of Fire Extinguishing System
None
Specify:

Fixed Pitch
Controllable Pitch
Ground Adjustable
Manufacturer: ____________________________

Propeller 1

Last Inspection Type

Model: ___________________________________

ELT Installed:

Yes

If Yes:
ELT Manufacturer: ________________________
Model or Part No.: _________________________
TSO No.: C91 (121.5 MHz)
C91a (121.5 MHz)
C126 (406 MHz)

If not activated:
Indicate Reason:

No
No

No

Impact Damage
Fire Damage
Battery Expired/Damaged
Unknown

3

Model: ___________________________________

Additional Equipment (Check all that apply)

No

Was ELT still mounted in aircraft?
Yes
Was ELT still connected to antenna? Yes
Did ELT Activate?
Yes
No
If activated:
Did ELT Aid in Locating Aircraft:
Yes

Fixed Pitch
Controllable Pitch
Ground Adjustable
Manufacturer: ____________________________

Propeller 2

ADS-B
Airframe Parachute
Angle of Attack Indicator
Autopilot
Data Recorder
Electronic Flight Bag or Handheld Device
Electronic Multifunction Display
Electronic Primary Flight Display
Handheld GPS
Heads Up Display
Onboard Weather
Satellite Tracking Device
Stall Warning System
Video Recording Device
Other, Specify:

OWNER/OPERATOR INFORMATION

Registered Aircraft Owner

City: ______________________________________

Name: _____________________________________________________________

State: ___________

Fractional Ownership Aircraft:

Country: __________________________________

Operator of Aircraft

Yes

No

Same As Registered Owner

ZIP: _____________

Same Address as Registered Owner

Name: ____________________________________________________________

City: ______________________________________

Doing Business As: __________________________________________________

State: ___________

Air Carrier/Operator Designator (4 Character Code): _______________

Country: __________________________________

Operating Certificates Held
None
Flag Carrier Operating Certificate (FAR 121)
Supplemental
Air Cargo
Foreign Air Carriers (FAR 129)
Rotorcraft External Load (FAR 133)
Commuter Air Carrier (FAR 135)
On-Demand Air Taxi (FAR 135)
Commercial Air Tour (FAR 136)
Agricultural Aircraft (FAR 137)
Pilot School (FAR 141)
Certificate of Authorization or Waiver (COA)
Commercial Space Transportation
Experimental Permit
Commercial Space Transportation License
Other Operator of Large Aircraft

Revenue Sightseeing Flight
Yes

FAR 91
FAR 103
FAR 121
FAR 125

FAR 129
FAR 133
FAR 135
FAR 137

FAR 415
FAR 431
FAR 435
FAR 437

Passenger
Cargo
Mail Contract Only

Purpose of Flight for FAR 91, 103, 133, 137
(Select one)

Aerial Application
Aerial Observation
Air Drop
Air Race/Show
Banner Tow
Business
Executive/Corporate
External Load
Ferry

Unknown

Air Medical Flight
Yes

Domestic
International

Scheduled or Commuter
Non-Scheduled or Air Taxi

Public Aircraft (Select one)
Armed Forces
Federal
State
Local

Firefighting
Flight Test
Glider Tow
Instructional
Other Work Use
Personal
Positioning
Skydiving

Unknown

No

(Fill in if accident/incident occurred on approach, landing, takeoff, departure, or within 3 miles of an airport)

Airport Name: __________________________________________________
Airport Identifier: ________________________________________________
Proximity to Airport:
Off Airport/Airstrip
On Airport/Airstrip
N/A
Runway Information

Distance From Airport Center: __________________sm
Direction From Airport: _____________________ degrees true
Airport Elevation: __________________________ ft. msl
Condition of Runway/Landing Surface (Check all that apply)

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

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

(Select one for each group)

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

No

AIRPORT INFORMATION

Revenue Operation for FAR 121, 125, 129, 135

Regulation Flight Conducted Under

(Check all that apply)

ZIP: _____________

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

Approach/Departure Segment (Select one)
Taxi
Takeoff
Initial Climb

VFR Departure
IFR Departure Procedure/Clearance

On Instrument Approach
Landing

Low Approach
Go Around
Aborted Landing (after touchdown)
Unknown

VFR Approach (Check all that apply)

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

Downwind
Base
Final
Crosswind

None
PAR
Sidestep
ILS
Localizer Only
LOC-back course
RNAV

MLS
LDA
ASR
Visual
Contact
Circling

Practice
GPS

Unknown

4

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

“FLIGHT CREWMEMBER 1” INFORMATION

“Flight Crewmember 1” Responsibilities at the Time of Accident/Incident
Pilot

Co-Pilot

Student Pilot

Flight Instructor

“Flight Crewmember 1” was pilot flying

Yes

Check Pilot

Flight Engineer

Other Flight Crew

No

“Flight Crewmember 1” Identification
First Name: __________________________________________________

City of Residence: _____________________________________

Middle Initial: _________

State: _________________

ZIP: _______________

Last Name: _________________________________________________
Age at time of Accident/Incident: ________

Country: _____________________________________
Date of Birth: ____________________ mm/dd/yyyy

Certificate Number: ____________________
Degree of Injury
None
Minor
Serious

Seat Occupied

Fatal
Unknown

Left
Right
Center

Restraint Type
Front
Rear
Single

Unknown

Flight Instructor
Recreational
Sport

Principal Occupation

Commercial
Airline Transport
Flight Engineer

Pilot
Other
Unknown

None
Lap only
3-point
4-point
5-point
Unknown

None
Lap only
3-point
4-point
5-point
Unknown

US Military
Foreign

Medical Certificate
None
Class 1
Class 2

Used

Available

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

Inflatable Restraints

Date of Last Medical

Medical Certificate Validity

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

Without limitations/waivers
With limitations/waivers
Special Issuance

Not Installed
Installed
Not Deployed
Deployed
Unknown

Unknown
N/A

____________
mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Special Issuance

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
Balloon
Glider
Gyroplane
Helicopter
Powered Lift

Instrument Rating(s)
(Check all that apply)

Instructor Rating(s)
(Check all that apply)
None
Airplane Single-Engine
Airplane Multi-Engine
Gyroplane
Powered Lift

None
Airplane
Helicopter
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

5

Instrument
Night

Actual

Simulated

Rotorcraft

Glider

Lighter
Than Air

“FLIGHT CREWMEMBER 2” INFORMATION

“Flight Crewmember 2” Responsibilities at the Time of Accident/Incident
Pilot

Co-Pilot

Student Pilot

Flight Instructor

“Flight Crewmember 2” was pilot flying

Yes

Check Pilot

Flight Engineer

Other Flight Crew

No

“Flight Crewmember 2” Identification
First Name: __________________________________________________

City of Residence: _____________________________________

Middle Initial: _________

State: _________________

ZIP: _______________

Last Name: _________________________________________________
Age at time of Accident/Incident: ________
Degree of Injury
None
Minor
Serious

Seat Occupied

Fatal
Unknown

Left
Right
Center

Country: _____________________________________
Date of Birth: ____________________ mm/dd/yyyy

Certificate Number: ____________________
Restraint Type
Front
Rear
Single

Unknown

Flight Instructor
Recreational
Sport

Principal Occupation

Commercial
Airline Transport
Flight Engineer

Pilot
Other
Unknown

None
Lap only
3-point
4-point
5-point
Unknown

None
Lap only
3-point
4-point
5-point
Unknown

US Military
Foreign

Medical Certificate
None
Class 1
Class 2

Used

Available

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

Inflatable Restraints
Not Installed
Installed
Not Deployed
Deployed
Unknown

Date of Last Medical

Medical Certificate Validity

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

Without limitations/waivers
With limitations/waivers
Special Issuance

Unknown
N/A

____________
mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Special Issuance

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
Balloon
Glider
Gyroplane
Helicopter
Powered Lift

Instrument Rating(s)
(Check all that apply)

Instructor Rating(s)
(Check all that apply)
None
Airplane Single-Engine
Airplane Multi-Engine
Gyroplane
Powered Lift

None
Airplane
Helicopter
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

6

Instrument
Night

Actual

Simulated

Rotorcraft

Glider

Lighter
Than Air

ADDITIONAL FLIGHT CREWMEMBERS

(Exclusive of cabin crew, complete the following information)

Crew Name and Address
City of Residence: ___________________________

Middle Initial: _________

State: ______________

Last Name: _____________________________

Country: ____________________________

Flight Instructor
Recreational
Sport

Restraint Type:
Available
Used

US Military
Foreign

Commercial
Airline Transport
Flight Engineer

Type Rating/Endorsement for
Yes

No

of this Accident/Incident: ____________hrs

Crew Name and Address
City of Residence: ___________________________

Middle Initial: _________

State: ______________

Last Name: _____________________________

Country: _____________________________

ZIP: ____________

Type Rating/Endorsement for
Accident/Incident Aircraft?

Yes

No

PASSENGER(S) / OTHER PERSONNEL

Seat

State: _____ ZIP: _________

Last Name: ________________ Country: ________________
Passenger

Other

First Name: ________________ City : ____________________
Middle Initial: _________

State: _____ ZIP: _________

Last Name: ________________ Country: ________________
Crew

Passenger

Other

First Name: ________________ City : ____________________
Middle Initial: _________

State: _____ ZIP: _________

Last Name: ________________ Country: ________________
Crew

Passenger

Other

First Name: ________________ City : ____________________
Middle Initial: _________

State: _____ ZIP: _________

Last Name: ________________ Country: ________________
Crew

Passenger

Inflatable
Restraints
Not Installed
Installed
Not Deployed
Deployed
Unknown

None
Lap Only
3-point
4-point
5-point
Unknown

None
Minor
Serious
Fatal
Unknown

Inflatable
Restraints
Not Installed
Installed
Not Deployed
Deployed
Unknown

(Include cabin crew; continue on separate sheet if necessary)

First Name: ________________ City : ____________________

Crew

None
Lap Only
3-point
4-point
5-point
Unknown

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

Name and Address

Middle Initial: _________

US Military
Foreign

Commercial
Airline Transport
Flight Engineer

Front
Rear
Single
Unknown

Restraint Type:
Available
Used

Pilot Certificate(s) (Check all that apply)
Flight Instructor
Recreational
Sport

Left
Center
Right

None
Minor
Serious
Fatal
Unknown

Injury

Seat Occupied

First Name: _____________________________

None
Private
Student

None
Lap Only
3-point
4-point
5-point
Unknown

None
Lap Only
3-point
4-point
5-point
Unknown

Total Flight Time at the Time

Accident/Incident Aircraft?

Front
Rear
Single
Unknown

Left
Center
Right

ZIP: ____________

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

Injury

Seat Occupied

First Name: _____________________________

Other

Injury

Available
None
Minor
Serious
Fatal
Unknown

Left
Center
Right
Unknown
Row: ____

None
Lap Only
3-point
4-point
5-point
Unknown

Available
None
Minor
Serious
Fatal
Unknown

Left
Center
Right
Unknown
Row: ____

None
Lap Only
3-point
4-point
5-point
Unknown

Available
None
Minor
Serious
Fatal
Unknown

Left
Center
Right
Unknown
Row: ____

None
Lap Only
3-point
4-point
5-point
Unknown

Available
None
Minor
Serious
Fatal
Unknown

Left
Center
Right
Unknown
Row: ____

7

Inflatable
Restraints

Restraint Type

None
Lap Only
3-point
4-point
5-point
Unknown

Age

Used

None
Lap Only
3-point
4-point
5-point
Unknown

Not Installed
Under 5 years
Installed
Not Deployed If Under 5,
Deployed
Child Restraint
Unknown
Lap-Held
Unknown

Used

None
Lap Only
3-point
4-point
5-point
Unknown

Not Installed
Under 5 years
Installed
Not Deployed If Under 5,
Deployed
Child Restraint
Unknown
Lap-Held
Unknown

Used

None
Lap Only
3-point
4-point
5-point
Unknown

Not Installed
Under 5 years
Installed
Not Deployed If Under 5,
Deployed
Child Restraint
Unknown
Lap-Held
Unknown

Used

None
Lap Only
3-point
4-point
5-point
Unknown

Not Installed
Under 5 years
Installed
Not Deployed If Under 5,
Deployed
Child Restraint
Unknown
Lap-Held
Unknown

FLIGHT ITINERARY INFORMATION
Last Departure Point

Time of Departure

Airport ID: _______________
City: ________________________________

Time: _____________

Type Flight Plan Filed

Airport ID: ___________________

None
Company VFR
Military VFR
VFR
Activated?
Yes

City: _________________________________

Time Zone:_________

State: ____________________

Destination

State: ________________________

Country: _____________________________

Country: ______________________________

VFR/IFR
IFR
Unknown
No

Unknown

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

Special VFR
IFR

Special IFR
VFR On Top

VFR Flight Following
Traffic Advisory

Airspace where the accident/incident occurred (Check all that apply)

Military Operations Area (MOA)
Airport Advisory Area
Jet Training Area
TRSA
FAR 93

Class G
Demo Area
Warning Area
Prohibited Area
Restricted Area

Class A
Class B
Class C
Class D
Class E

Special
Air Traffic Control Area
Unknown

Cruise
Unknown / NA

Altitude of In-Flight
Occurrence:
_____________ ft msl

WEATHER INFORMATION AT THE ACCIDENT/INCIDENT SITE

Source of Pilot Weather Information
(Check all that apply)
National Weather Service
Flight Service Station
TV/Radio
Automated Report
Commercial Weather Service (DUATS)
On-Board Weather

Weather Observation Facility

Time Zone: ___________________________________
Distance from Accident Site: __________________ nm
Direction from Accident Site: _________________ degrees true

Dawn
Day

VMC
IMC
Unknown

Sky/Lowest Cloud Condition
Clear
Few
Partial Obscuration
Scattered

___________________ ft agl
Wind Direction

None (Clear)
Broken
Overcast

-orDirection: ________degrees true

Intensity of Precipitation
Light
Moderate
Heavy
N/A
Unknown

Temperature: __________ (C) or __________(F)
Dew Point: ___________ (C) or __________(F)
Altimeter Setting: ___________ in. Hg
or ___________ MB

___________________ ft agl
Wind Gusts

Calm
Light and Variable
-orSpeed: ______________kts

Not Gusting
-orSpeed: ______________kts

Drizzle
Ice Pellets
Snow Pellets
Snow Grains
Ice Crystals

Icing Actual
Amount
None
Trace
Light
Moderate
Severe
Unknown

Visibility

_____________ miles
RVR: _____________feet
RVV: _____________miles

Density Altitude: ________________ ft
Restriction to Visibility (Check all that apply)

Type of Precipitation (Check all that apply)
None
Rain
Snow
Hail
Rain Showers

Type
N/A
Rime
Clear
Mixed
Unknown

Obscured
Indefinite
Unknown

Ceiling Height

Wind Speed

Variable

Unknown

Dark Night
Bright Night

Dusk
Night

Ceiling
Thin Broken
Thin Overcast
Unknown

Lowest Cloud Condition Height

Amount
None
Trace
Light
Moderate
Severe
Unknown

Observation Time: _____________________________

Light Condition

Basic Conditions

Icing Forecast

Facility ID: ___________________________________

Company
Military
Internet
None
Unknown

Freezing Rain
Snow Shower
Ice Pellets Shower
Freezing Drizzle

Type
N/A
Rime
Clear
Mixed
Unknown

None
Blowing Dust
Blowing Sand
Blowing Snow
Blowing Spray
Dust

Turbulence

Type (Check all that apply)
None
Clear Air
Terrain-Induced
Convective Turbulence

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

8

Fog
Ground Fog
Haze
Ice Fog
Smoke
Unknown
Severity
Light
Moderate
Severe
Extreme

DAMAGE TO AIRCRAFT AND OTHER PROPERTY
Aircraft Damage
None
Minor

Aircraft Fire

Substantial
Destroyed
Unknown

None
In-Flight
On-Ground

Aircraft Explosion

Both Ground and In-Flight
Fire at Unknown Time
Unknown

None
In-Flight
On-Ground

Both Ground and In-Flight
Explosion at Unknown Time
Unknown

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

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 departure time and and location, services obtained, and intended
destination. Provide as much detail as possible.

9

RECOMMENDATION

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

Operator/Owner Safety Recommendation

MECHANICAL MALFUNCTION/FAILURE
Was there Mechanical Malfunction/Failure?

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

Yes

Total Time/Cycles
On Part

No

(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

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
Jet A-1

Jet B
JP8
Automotive

Other, specify _________________________

Other Services, if Any, Prior to Departure

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

OTHER AIRCRAFT – COLLISION

(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

Pilot of Other Aircraft

Name: ___________________________________________________
City: ____________________________________________________
State: ________________ZIP: _______________________________
Country: _________________________________________________

Name: ______________________________________________
City: _______________________________________________
State: ________________ZIP: __________________________
Country: ____________________________________________

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

Name of Pilot/Operator: _____________________________________________________________________

______________

Signature: ________________________________________________________________________________

mm/dd/yyyy

-- or --

Check here to electronically sign this document

If a Person Other than Pilot/Operator is Filing Report
Name: __________________________________________________________________

Title: ___________________________________

Signature: _______________________________________________________________
-- or --

Check here to electronically sign this document

NTSB Accident/Incident No.

FOR NTSB USE ONLY

Reviewed by NTSB Regional Office

Name of Investigator

11

Date Report Received