2120-0756 2021 HAA Flight Operations Reporting Template

Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations

Copy of 2021 HAA Flight Operations Reporting Template.xlsx

OMB: 2120-0756

Document [xlsx]

Download: xlsx | pdf

Overview

INSTRUCTIONS
Pg1 GENERAL + BASE LOCATIONS
Pg2 BASE LOCATIONS (optional)
Pg 3 BASE LOCATIONS (optional)
Pg 4 BASE LOCATIONS (optional)
Pg 5 BASE LOCATIONS (optional
Pg 6 BASE LOCATIONS (optional)
Pg7 ACCIDENT SUMMARY
Sheet1

Sheet 1: INSTRUCTIONS

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

INSTRUCTIONS

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 2120-0756. Public reporting for this collection of information is estimated to be approximately 6-16 hours 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 according to Public Law 112-95. 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.

This Data Collection Worksheet is the method authorized by the FAA Administrator for collection of Helicopter Air Ambulance Operations Flight Activity Data. Each Helicopter Air Ambulance Operator authorized by Operations Specification paragraph A021 must submit a report regarding their flight operations as directed below. This collection effort is mandated by Congress via Section 306 of the FAA Modernization and Reform Act of 2012.

This is a multi-page Micorsoft Exel 2003 .xls workbook, compatible with most installed Excel systems. The DETAILED INSTRUCTIONS, BY TOPIC below will explain how to properly complete this form. Make entries on the "REPORT" and "ACCIDENT DESCRIPTION" tabs of this template. Select from the tabs appearing near the bottom margin of this page to access those worksheets. Return to this page by selecting the "INSTRUCTIONS" tab.

The following file naming convention MUST be observed, submittals that are not identified in the following manner may not be accepted. The file name shall start with the calendar year of the reporting period, followed by the company designator, and end with "HAA". For example: a company with designator AB3D, reporting for calendar year (CY) 2021 would name their submittal file: "CY2021AB3D.XLS". Make submittals via e-mail attachment and send your email to: [email protected]>.

NOTE: If a response to a section on the form is zero, enter "0". Do not leave any of the sections on the GENERAL + Base Locations page blank.

SECTION

DETAILED INSTRUCTIONS, BY SECTION

REPORTING PERIOD

Enter the reporting period as follows: Enter first date of reporting period, inclusive, in BEGINS cell. Enter last date of reporting period, inclusive, in ENDS cell. Normally, this will be 1/1/XXXX to 12/31/XXXX. If, however, the certificate holder was issued OpSpec A021 during the mid-year during the reporting period, the date A021 was issued should be entered in the BEGINS block. Likewise, if HAA operations ceased during the reporting year, enter the date those operations ceased (the date OpSpec A021 was removed from the operator's OpSpecs) in the ENDS cell

COMPANY IDENTITY

Enter Operator Name in NAME cell, enter FAA designator code (first 4 characters of the Air Carrier Certificate number) in DESIGNATOR cell.

TOTAL HAA HOURS FLOWN

Enter the total number of hours flown in HAA operations. Do not include flights for public relations events, maintenance, training, etc.

IFR HOURS FLOWN

Enter the total number of IFR hours flown in HAA operations. This includes IFR flights to pick-up patients/donor organs or tissue, flights to transport patients, and repositioning flights after patient/donor drop-off.

PATIENTS TRANSPORTED

Enter the number of patients transported during HAA operations.

HAA HOURS FLOWN AT NIGHT

Enter the total number of HAA hours flown at night.

TRANSPORT REQUESTS-

Enter the number of requests, either accepted or declined, in the appropriate category.

NUMBER OF ACCIDENTS-

Enter the total number, if any, the certificate holder suffered during the reporting period. Details of the accident(s) are to be entered on page 7 of the Report. Only report accidents that occurred during HAA Operations.

THE NUMBER OF TIMES ...

Enter the number of times, if any, in which a helicopter was not directly dispatched and arrived to transport patients but was not utilized for patient transport.

THE NUMBER OF HELICOPTERS

Enter the total number of helicopters used throughout the reporting period. Include all helicopters that were available for HAA operations even if no HAA operations were conducted during the reporting period.

BASE LOCATIONS-

Use the space on page 1 to list each base by FACILITY identifier if available, or Base name, and CITY, and STATE. If additional space is needed, use the optional pages, beginning on page 3 to continue listing bases.

ADDITIONAL ACCIDENT INFORMATION

List all accidents suffered during HAA operations for the reporting period on Page 7. In the BRIEF DESCRIPTION SECTION, Describe the circumstances leading to the accident. Include the approximate time of day, adverse weather, terrain or obstructions, apparent mechanical failures, pilot flight and time on duty since reporting that day, whether or not NVIS was in use, number of persons on board, whether or not a patient was on board, and any other pertinent information. If no accidents were suffered during the reporting period, enter "NONE" in the first BRIEF DESCRIPTION SECTION.

Unless otherwise specified, your reporting period will be the calendar year beginning January 1st and ending December 31st of the same year. Submit your report within the 30 day period following the end of the reporting period.

The following file naming convention MUST be observed, submittals that are not identified in the following manner may not be accepted. The file name shall start with the calendar year of the reporting period, followed by the company designator, and end with "HAA". The company designator is the first four characters of the Air Carrier/Operator Crtificate number. For example: a company with designator AB3D, reporting for calendar year (CY) 2021 would name their submittal file: "CY2021AB3DHAA.XLS". Make submittals via e-mail attachment and send your email to:

[email protected].

Sheet 2: Pg1 GENERAL + BASE LOCATIONS

22	50	150		73	73	30	50	150	73	73	30	50	150	73	73	22
				HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

					SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													OMB EXPIRATION DATE:		4/30/2023


	REPORTING PERIOD						TRANSPORT REQUESTS					THE NUMBER OF TIMES
	BEGINS		ENDS						ACCEPTED	DECLINED		if any, in which a helicopter was not directly dispatched and arrived to transport patients but was not utilized for patient transport.
								SCENE RESPONSE
	COMPANY IDENTITY							INTER-FACILITY TRANSFER
	NAME							ORGAN TRANSFER
	DESIGNATOR
							NUMBER OF HAA ACCIDENTS					THE NUMBER OF HELICOPTERS
	TOTAL HAA HOURS FLOWN						For each accident, complete the accident summary information listed on page 7 of this report. Include additional pages if needed.					the certificate holder used during the reporting period to provide helicopter air ambulance services
	IFR HOURS FLOWN
				PATIENTS TRANSPORTED
	HAA HOURS FLOWN AT NIGHT

	BASE LOCATIONS OF HELICOPTERS
		CITY		STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID
	1						51					101
	2						52					102
	3						53					103
	4						54					104
	5						55					105
	6						56					106
	7						57					107
	8						58					108
	9						59					109
	10						60					110
	11						61					111
	12						62					112
	13						63					113
	14						64					114
	15						65					115
	16						66					116
	17						67					117
	18						68					118
	19						69					119
	20						70					120
	21						71					121
	22						72					122
	23						73					123
	24						74					124
	25						75					125
	26						76					126
	27						77					127
	28						78					128
	29						79					129
	30						80					130
	31						81					131
	32						82					132
	33						83					133
	34						84					134
	35						85					135
	36						86					136
	37						87					137
	38						88					138
	39						89					139
	40						90					140
	41						91					141
	42						92					142
	43						93					143
	44						94					144
	45						95					145
	46						96					146
	47						97					147
	48						98					148
	49						99					149
	50						100					150

Sheet 3: Pg2 BASE LOCATIONS (optional)

22	50	150	73	73	30	50	150	73	73	30	50	150	73	73	22
			HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

				SUBMIT TO:		[email protected]							OMB CONTROL #	2120-0756
													EXPIRATION DATE:	4/30/2023
						OPERATOR					DESIGNATOR

	BASE LOCATIONS OF HELICOPTERS (Continued)
		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID			CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID
	151					211					271
	152					212					272
	153					213					273
	154					214					274
	155					215					275
	156					216					276
	157					217					277
	158					218					278
	159					219					279
	160					220					280
	161					221					281
	162					222					282
	163					223					283
	164					224					284
	165					225					285
	166					226					286
	167					227					287
	168					228					288
	169					229					289
	170					230					290
	171					231					291
	172					232					292
	173					233					293
	174					234					294
	175					235					295
	176					236					296
	177					237					297
	178					238					298
	179					239					299
	180					240					300
	181					241					301
	182					242					302
	183					243					303
	184					244					304
	185					245					305
	186					246					306
	187					247					307
	188					248					308
	189					249					309
	190					250					310
	191					251					311
	192					252					312
	193					253					313
	194					254					314
	195					255					315
	196					256					316
	197					257					317
	198					258					318
	199					259					319
	200					260					320
	201					261					321
	202					262					322
	203					263					323
	204					264					324
	205					265					325
	206					266					326
	207					267					327
	208					268					328
	209					269					329
	210					270					330

Sheet 4: Pg 3 BASE LOCATIONS (optional)

		HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

			SUBMIT TO:	[email protected]						OMB CONTROL #	2120-0756
										EXPIRATION DATE:	4/30/2023
				OPERATOR				DESIGNATOR

BASE LOCATIONS OF HELICOPTERS (Continued)
	CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available,leave blank.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID
331				391				p
332				392				452
333				393				453
334				394				454
335				395				455
336				396				456
337				397				457
338				398				458
339				399				459
340				400				460
341				401				461
342				402				462
343				403				463
344				404				464
345				405				465
346				406				466
347				407				467
348				408				468
349				409				469
350				410				470
351				411				471
352				412				472
353				413				473
354				414				474
355				415				475
356				416				476
357				417				477
358				418				478
359				419				479
360				420				480
361				421				481
362				422				482
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364				424				484
365				425				485
366				426				486
367				427				487
368				428				488
369				429				489
370				430				490
371				431				491
372				432				492
373				433				493
374				434				494
375				435				495
376				436				496
377				437				497
378				438				498
379				439				499
380				440				500
381				441				501
382				442				502
383				443				503
384				444				504
385				445				505
386				446				506
387				447				507
388				448				508
389				449				509
390				450				510

Sheet 5: Pg 4 BASE LOCATIONS (optional)

		HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

			SUBMIT TO:	[email protected]						OMB CONTROL #	2120-0756
										EXPIRATION DATE:	4/30/2023
				OPERATOR				DESIGNATOR

BASE LOCATIONS OF HELICOPTERS (Continued)
	CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, leave blank.) LOCID
511				571				631
512				572				632
513				573				633
514				574				634
515				575				635
516				576				636
517				577				637
518				578				638
519				579				639
520				580				640
521				581				641
522				582				642
523				583				643
524				584				644
525				585				645
526				586				646
527				587				647
528				588				648
529				589				649
530				590				650
531				591				651
532				592				652
533				593				653
534				594				654
535				595				655
536				596				656
537				597				657
538				598				658
539				599				659
540				600				660
541				601				661
542				602				662
543				603				663
544				604				664
545				605				665
546				606				666
547				607				667
548				608				668
549				609				669
550				610				670
551				611				671
552				612				672
553				613				673
554				614				674
555				615				675
556				616				676
557				617				677
558				618				678
559				619				679
560				620				680
561				621				681
562				622				682
563				623				683
564				624				684
565				625				685
566				626				686
567				627				687
568				628				688
569				629				689
570				630				690

Sheet 6: Pg 5 BASE LOCATIONS (optional

		HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

			SUBMIT TO:	[email protected]						OMB CONTROL #	2120-0756
										EXPIRATION DATE:	4/30/2023
				OPERATOR				DESIGNATOR

BASE LOCATIONS OF HELICOPTERS (Continued)
	CITY	STATE	LOCID		CITY	STATE	LOCID		CITY	STATE	LOCID
691				751				811
692				752				812
693				753				813
694				754				814
695				755				815
696				756				816
697				757				817
698				758				818
699				759				819
700				760				820
701				761				821
702				762				822
703				763				823
704				764				824
705				765				825
706				766				826
707				767				827
708				768				828
709				769				829
710				770				830
711				771				831
712				772				832
713				773				833
714				774				834
715				775				835
716				776				836
717				777				837
718				778				838
719				779				839
720				780				840
721				781				841
722				782				842
723				783				843
724				784				844
725				785				845
726				786				846
727				787				847
728				788				848
729				789				849
730				790				850
731				791				851
732				792				852
733				793				853
734				794				854
735				795				855
736				796				856
737				797				857
738				798				858
739				799				859
740				800				860
741				801				861
742				802				862
743				803				863
744				804				864
745				805				865
746				806				866
747				807				867
748				808				868
749				809				869
750				810				870

Sheet 7: Pg 6 BASE LOCATIONS (optional)

		HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

			SUBMIT TO:	[email protected]						OMB CONTROL #	2120-0756
										EXPIRATION DATE:	4/30/2023
				OPERATOR				DESIGNATOR

BASE LOCATIONS OF HELICOPTERS (Continued)
	CITY	STATE	LOCID		CITY	STATE	LOCID		CITY	STATE	LOCID
871				931				991
872				932				992
873				933				993
874				934				994
875				935				995
876				936				996
877				937				997
878				938				998
879				939				999
880				940				1000
881				941				1001
882				942				1002
883				943				1003
884				944				1004
885				945				1005
886				946				1006
887				947				1007
888				948				1008
889				949				1009
890				950				1010
891				951				1011
892				952				1012
893				953				1013
894				954				1014
895				955				1015
896				956				1016
897				957				1017
898				958				1018
899				959				1019
900				960				1020
901				961				1021
902				962				1022
903				963				1023
904				964				1024
905				965				1025
906				966				1026
907				967				1027
908				968				1028
909				969				1029
910				970				1030
911				971				1031
912				972				1032
913				973				1033
914				974				1034
915				975				1035
916				976				1036
917				977				1037
918				978				1038
919				979				1039
920				980				1040
921				981				1041
922				982				1042
923				983				1043
924				984				1044
925				985				1045
926				986				1046
927				987				1047
928				988				1048
929				989				1049
930				990				1050

Sheet 8: Pg7 ACCIDENT SUMMARY

HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT

SUBMIT TO:

[email protected]

OMB CONTROL #

2120-0756

EXPIRATION DATE:

4/30/2023

OPERATOR

DESIGNATOR

ACCIDENT SUMMARY-

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

NTSB NUMBER:

BRIEF DESCRIPTION OF EVENT:

DATE:

REGISTRATION NUMBER:

MAKE / MODEL:

EVENT SEVERITY:

LOCATION:

Sheet 9: Sheet1



HELICOPTER AIR AMBULANCE MANDATORY FLIGHT INFORMATION REPORT




BASE LOCATIONS OF HELICOPTERS (Continued)
	CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID		CITY	STATE	Enter Location Identifier as provided in Airport Master Record Form 5010. (If no LOCID is available, enter NA.) LOCID
151				211				271
152				212				272
153				213				273
154				214				274
155				215				275
156				216				276
157				217				277
158				218				278
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160				220				280
161				221				281
162				222				282
163				223				283
164				224				284
165				225				285
166				226				286
167				227				287
168				228				288
169				229				289
170				230				290
171				231				291
172				232				292
173				233				293
174				234				294
175				235				295
176				236				296
177				237				297
178				238				298
179				239				299
180				240				300
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182				242				302
183				243				303
184				244				304
185				245				305
186				246				306
187				247				307
188				248				308
189				249				309
190				250				310
191				251				311
192				252				312
193				253				313
194				254				314
195				255				315
196				256				316
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199				259				319
200				260				320
201				261				321
202				262				322
203				263				323
204				264				324
205				265				325
206				266				326
207				267				327
208				268				328
209				269				329
210				270				330

File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified	0000-00-00
File Created	0000-00-00