NTSB 6120.1 Form

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

^NATIONAL TRANSPORTATION SAFETY BOARD (NTSB) Form 6120.1

PILOT/OPERATOR AIRCRAFT ACCIDENT/INCIDENT REPORT

A blank version of this form, instructions for when to complete it, and information for how to return it are available at https://www.ntsb.gov/Pages/aviationreport.aspx. Forms may be returned via e-mail to [email protected] or via post mail  to NTSB, Office of Aviation Safety, 490 L'Enfant Plaza, S.W., Washington, D.C. 20594. Completed forms should be returned within 10 days after an accident for which notification is required by 49 CFR § 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.

The NTSB uses this form for aircraft accident prevention activities and for statistical purposes. NTSB regulations 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. Accordingly, the information provided herein may be subject to public release. You need not complete this form unless it displays a valid OMB control number. See 5 C.F.R. § 1320.5(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. The definition of “aircraft accident” includes “unmanned aircraft accident,” as defined at 49 CFR

§ 830.2.

2. "Substantial Damage" means damage or failure that 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 fairings 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.

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 30 days of the accident.

5. "Serious Injury" means any injury that (1) requires hospitalization or 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

ALL questions must be answered completely and accurately.

If more space is needed, continue on a blank sheet of paper.

Nearest City/Place: Use the name of the nearest community in the state where the accident/incident occurred.

Date/Time: Indicate the date, local time of the event, and time zone.

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.

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.

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

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.

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.

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.

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.

Purpose of Flight: 14 CFR Parts 91, 103, 133, 136, and 137: Indicate the type of operation that was being conducted at the time of the occurrence using the following definitions:

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.

AERIAL OBSERVATION--These flights include 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.

AIR RACE/SHOW—Includes any flight operations conducted as part 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 flying with a paid professional crew.

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.

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.

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.

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.

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.

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.

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 Chart Supplement or other official source for airport information.

Airport Identifier: 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.

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.

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.

Sky/Lowest Cloud Condition: Indicate the height above ground level of the lowest cloud condition present at the time of the accident/incident 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/incident (reported as broken or overcast).

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

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.

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.

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.

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.

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

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."

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.

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.

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

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

BASIC INFORMATION

Accident/Incident Location Nearest City/Place: State: ZIP: Country: Latitude: Longitude: (Enter in decimal degrees or degrees:minutes:seconds)

Accident/Incident Date/Time Date: Local Time: mm/dd/yyyy Time Zone: Collision with Other Aircraft: ○ Midair ○ On-ground ○ None

AIRCRAFT INFORMATION

Registration Number: Manufacturer: Model: Serial Number: Year of Manufacture:

□ IFR-Equipped and Certified □ Commercial Space Flight □ Unmanned Aircraft Maximum Gross Weight: lbs. Weight at Time of Accident/Incident: lbs. Number of Seats: Flight Crew Seats: ___________ Cabin Crew Seats: Passenger Seats: _____________ Number of Engines: ___________

Amateur-Built:

○ Yes

If yes:

○ Original Design

○ No

○ Kit/Plans

Make:

Category of Aircraft (Select one)

Type of Airworthiness Certificate (Check all that apply)

Landing Gear (Check all that apply)

Engine Type (Select one)

○ Airplane ○ Balloon ○ Blimp/Dirigible ○ Glider ○ Gyroplane ○ Helicopter ○ Powered Lift ○ Rocket ○ Ultralight ○ Unknown

Standard □ Normal □ Acrobatic □ Balloon □ Commuter □ Transport □ Utility

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

□ Retractable □ Tricycle □ Tailwheel □ Emergency Float □ Float □ Amphibian

□ High Skid □ Skid □ Ski/Wheel □ Hull □ Ski

○ Reciprocating ○ Turbo Shaft ○ Turbo Prop ○ Turbo Jet ○ Turbo Fan ○ Electric

○ Liquid Rocket ○ Solid Rocket ○ Hybrid Rocket ○ None ○ Unknown

□ Other Launch/Recovery System

Fuel System Type (Reciprocating) ○ Carburetor ○ Fuel Injected

□ None

□ Unknown

□ Certificate of Waiver or Authorization (COA)

□ None

□ Unknown

Engine

Engine Manufacturer

Engine Model/Series

Engine Serial Number

Date of Mfg. (mm/dd/yyyy)

Rated Power ○ Horsepower or ○ Lbs. of Thrust

Total Time (hours)

Time Since:

Inspection (hours)

Overhaul (hours)

Eng 1

Eng 2

Eng 3

Eng 4

Last Inspection Type ○ 100-Hour ○ AAIP ○ Annual ○ Continuous Airworthiness ○ Condition Inspection ○ Unknown Date of Last Inspection: (mm/dd/yyyy) Airframe Total Time: hours Hours measured at (Select one) ○ Last Inspection ○ Time of Accident/Incident

Additional Equipment

□ ADS-B □ Airframe Parachute □ Angle of Attack Indicator □ Autopilot □ Autopilot/FMS, Model__________ □ Coupled Flight Director □ Data Recorder □ Device Stall Warning System □ Electronic Flight Bag or Handheld Device □ Electronic Multifunction Display □ Electronic Primary Flight Display □ Flight Management System

□ Handheld GPS □ Heads Up Display □ Night Vision Goggles □ Onboard Weather □ Primary Flight Display □ SAS, Axis (circle one): 2, 3, 4, Model: _______ □ Satellite Tracking Device □ Stall Warning System □ Video Recording Device □ Wire Strike Detection □ Wire Strike Protection □ Other, Specify:

ELT Installed ○ Yes ○ No If yes: ELT Manufacturer: Model or Part No.:

Propeller 1 ○ Fixed Pitch ○ Controllable Pitch ○ Ground Adjustable Manufacturer: ________________________ Model: Propeller 2 ○ Fixed Pitch ○ Controllable Pitch ○ Ground Adjustable Manufacturer: _________________________ Model:

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

TSO No.:

○ C91 (121.5 MHz) ○ C126 (406 MHz)

○ C91a (121.5 MHz)

Was ELT still mounted in aircraft? ○ Yes ○ No Was ELT still connected to antenna? ○ Yes ○ No Did ELT activate? ○ Yes ○ No If activated: Did ELT aid in locating aircraft? ○ Yes ○ No If not activated: Indicate Reason: □ Impact Damage □ Fire Damage □ Battery □ Expired/Damaged □ Unknown

OWNER/OPERATOR INFORMATION

Registered Aircraft Owner Name: City: State: ZIP: Country:

Fractional Ownership Aircraft: ○ Yes ○ No

Operator of Aircraft □ The Operator is also the Registered Owner Name: City: State: ZIP: Country:

□ Same address as Registered Owner Doing Business As: Air Carrier/Operator Designator (4-character code):

Operating Certificates Held (Check all that apply)

Regulation Flight Conducted Under

Revenue Operation for FAR 121, 125, 129, 135 (Select one for each group)

□ 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 Waiver or Authorization (COA) □ Commercial Space Transportation Experimental Permit □ Commercial Space Transportation License □ Other Operator of Large Aircraft

○ FAR 91 ○ FAR 103 ○ FAR 121 ○ FAR 125

○ FAR 129 ○ FAR 133 ○ FAR 133 ○ FAR 137

○ FAR 415 ○ FAR 431 ○ FAR 435 ○ FAR 437 ○ FAR 450

○ Scheduled or Commuter ○ Non-Scheduled or Air Taxi ○ Passenger ○ Cargo ○ Mail Contract Only

○ Domestic ○ International

○ FAR 91 Special Flight ○ Non-US, Commercial ○ Non-US, Non-Commercial ○ Public Aircraft (Select one) ○ Armed Forces ○ Federal ○ State ○ Local ○ Unknown

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

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

Revenue Sightseeing Flight? ○ Yes ○ No

Air Medical Flight? ○ Yes ○ No

AIRPORT INFORMATION (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

Distance from Airport Center: sm. Direction from Airport: degrees true Airport Elevation: ft. MSL

Runway Information Runway ID: Length: ft. Width: ft.

Condition of Runway/Landing Surface (Check all that apply) □ Dry □ Slow Compacted □ Water-Calm □ Holes □ Snow-Crusted □ Water-Choppy □ Ice Covered □ Snow-Dry □ Water-Glassy □ Rough □ Snow-Wet □ Wet □ Rubber Deposits □ Soft □ Slush-Covered □ Vegetation □ Unknown

Runway/Landing Surface (Check all that apply)

□ Asphalt □ Concrete □ Dirt □ Elevated Heliport

□ Grass/Turf □ Gravel □ Helideck □ Helistop

□ Ice □ Macadam □ Metal/Wood □ Off-site landing area

□ Snow □ Water □ Unknown

Approach/Departure Segment (Select one) ○ Taxi ○ VFR Departure ○ On Instrument Approach ○ Downwind ○ Low Approach ○ Takeoff ○ IFR Departure Procedure/Clearance ○ Landing ○ Base ○ Go Around ○ Initial Climb ○ Final ○ Aborted Landing (after touchdown) ○ Crosswind ○ Unknown

IFR Approach (Check all that apply) □ None □ ADF/NDB □ PAR □ MLS □ Practice □ SDF □ Sidestep □ LDA □ GPS □ VOR/TVOR □ ILS □ ASR □ Unknown □ VOR/DME □ Localizer Only □ Visual □ TACAN □ LOC-back course □ Contact □ RNAV □ Circling

VFR Approach (Check all that apply) □ None □ Traffic pattern □ Stop and Go □ Straight-In □ Touch and Go □ Valley/Terrain Following □ Simulated Forced Landing □ Go Around □ Forced landing □ Full Stop □ Precautionary Landing □ Unknown

“FLIGHT CREWMEMBER 1” INFORMATION

“Flight Crewmember 1” Responsibilities at the Time of Accident/Incident ○ Captain ○ First Officer ○ Pilot ○ Co-Pilot ○ Student Pilot ○ Flight Instructor ○ Check Pilot ○ Flight Engineer ○ Other Flight Crew “Flight Crewmember 1” was pilot flying □Yes □No “Flight Crewmember 1” Identification: First Name: City of Residence: Middle Initial: State: Zip: Last Name: Country: Age at time of Accident/Incident: Date of Birth: (mm/dd/yyyy) Certificate Number:

Degree of Injury ○ None ○ Unknown ○ Minor ○ Serious ○ Fatal

Seat Occupied ○ Left ○ Front ○ Unknown ○ Right ○ Rear ○ Center ○ Single

Restraint Type Available Used ○ None ○ None ○ Lap only ○ Lap only ○ 3-point ○ 3-point ○ 4-point ○ 4-point ○ 5- point ○ 5-point ○ Unknown ○ Unknown ○ Supplemental. Restraint type:

Inflatable Restraints □ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

Pilot Certificate(s) (Check all that apply) □ None □ Flight Instructor □ Commercial □ US Military □ Private □ Recreational □ Airline Transport □ Foreign □ Sport □ Student □ Flight Engineer

Principle Occupation ○ Pilot ○ Other ○ Unknown

Medical Certificate ○ None ○ BasicMed ○ Class 1 ○ Driver’s License (Sport Pilot only) ○ Class 2 ○ Class 3 ○ Unknown

Medical Certificate Validity ○ Without limitations/waivers ○ Unknown ○ With limitations/waivers ○ N/A ○ Special Issuance

Date of Last Medical mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Special Limitations

Personal Flight Equipment (Check all that apply) □ Fire resistant flight suit □ Helmet □ Laser protective visor/glasses □ Personal locator beacon(s) (PLB) □ Fire resistant gloves □ Helmet visor □ Night vision goggles □ Personal flotation □ Other:

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

Flight Review Aircraft Make: Model:

Airplane Rating(s) (Check all that apply) □ Single-Engine Land □ Single-Engine Sea □ Multiengine Land □ Multiengine Sea

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

Instrument Rating(s) (Check all that apply) □ None □ Airplane □ Helicopter □ Powered Lift

Instructor Rating(s) (Check all that apply) □ None □ Airplane Single-Engine □ Airplane Multiengine □ Gyroplane □ Powered lift

□ Instrument Airplane □ Instrument Helicopter □ Helicopter □ Glider □ Sport

Type Ratings and Applicable Logbook Endorsements

Student Endorsements (Include dates)

Flight Time (Enter hours for each box)

All Aircraft

This Make & Model

Airplane Single Engine

Airplane Multi- engine

Night

Instrument

Rotorcraft

Glider

Lighter Than Air

Multi- engine Rotocraft

Tail- wheel

Actual

Simulated

Total Time

Pilot-in-Command

Time as Instructor

This Make/Model

Last 90 Days

Last 30 Days

Last 24 Hrs.

“FLIGHT CREWMEMBER 2” INFORMATION

“Flight Crewmember 2 Responsibilities at the Time of Accident/Incident ○ Captain ○ First Officer ○ Pilot ○ Co-Pilot ○ Student Pilot ○ Flight Instructor ○ Check Pilot ○ Flight Engineer ○ Other Flight Crew “Flight Crewmember 2” was pilot flying □Yes □No “Flight Crewmember 2” Identification: First Name: City of Residence: Middle Initial: State: Zip: Last Name: Country: Age at time of Accident/Incident: Date of Birth: (mm/dd/yyyy) Certificate Number:

Degree of Injury ○ None ○ Unknown ○ Minor ○ Serious ○ Fatal

Seat Occupied ○ Left ○ Front ○ Unknown ○ Right ○ Rear ○ Center ○ Single

Restraint Type Available Used ○ None ○ None ○ Lap only ○ Lap only ○ 3-point ○ 3-point ○ 4-point ○ 4-point ○ 5- point ○ 5-point ○ Unknown ○ Unknown ○ Supplemental. Restraint type:

Inflatable Restraints □ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

Pilot Certificate(s) (Check all that apply) □ None □ Flight Instructor □ Commercial □ US Military □ Private □ Recreational □ Airline Transport □ Foreign □ Sport □ Student □ Flight Engineer

Principle Occupation ○ Pilot ○ Other ○ Unknown

Medical Certificate ○ None ○ BasicMed ○ Class 1 ○ Driver’s License (Sport Pilot only) ○ Class 2 ○ Class 3 ○ Unknown

Medical Certificate Validity ○ Without limitations/waivers ○ Unknown ○ With limitations/waivers ○ N/A ○ Special Issuance

Date of Last Medical mm/dd/yyyy

Medical Certificate Limitations

Medical Certificate Special Limitations

Personal Flight Equipment (Check all that apply) □ Fire resistant flight suit □ Helmet □ Laser protective visor/glasses □ Personal Locator Beacon(s) (PLB) □ Fire resistant gloves □ Helmet visor □ Night vision goggles □ Personal flotation □ Other:

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

Flight Review Aircraft Make: Model:

Airplane Rating(s) (Check all that apply) □ Single-Engine Land □ Single-Engine Sea □ Multiengine Land □ Multiengine Sea

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

Instrument Rating(s) (Check all that apply) □ None □ Airplane □ Helicopter □ Powered Lift

Instructor Rating(s) (Check all that apply) □ None □ Airplane Single-Engine □ Airplane Multiengine □ Gyroplane □ Powered lift

□ Instrument Airplane □ Instrument Helicopter □ Helicopter □ Glider □ Sport

Type Ratings and Applicable Logbook Endorsements

Student Endorsements (Include dates)

Flight Time (Enter hours for each box)

All Aircraft

This Make & Model

Airplane Single Engine

Airplane Multi- engine

Night

Instrument

Rotorcraft

Glider

Lighter Than Air

Multi- engine Rotocraft

Tail- wheel

Actual

Simulated

Total Time

Pilot-in-Command

Time as Instructor

This Make/Model

Last 90 Days

Last 30 Days

Last 24 Hrs.

ADDITIONAL FLIGHT CREWMEMBERS (Exclusive of cabin crew, complete the following information.)

Additional Crewmember Information First Name: City of Residence: Middle Initial: State: Zip: Last Name: Country:

Seat Occupied

Injury

○ Left ○ Rear ○ Center ○ Single ○ Right ○ Unknown ○ Front

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Personal Flight Equipment (Check all that apply) □ Fire resistant flight suit □ Helmet □ Laser protective visor/glasses □ Personal locator beacon(s) (PLB) □ Fire resistant gloves □ Helmet visor □ Night vision goggles □ Personal flotation □ Other: __________________________________________

Pilot Certificate(s) (Check all the apply)

Restraint Type

Inflatable Restraints □ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ None □ Private □ Student

□ Flight Instructor □ Recreational □ Sport

□ Commercial □ Airline Transport □ Flight Engineer

□ US Military □ Foreign

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

Type Rating/Endorsement for Accident/Incident Aircraft? □ Yes □ No

Total Flight Time at the Time of this Accident/Incident: hrs.

Additional Crewmember Information First Name: City of Residence: Middle Initial: State: Zip: Last Name: Country:

Seat Occupied

Injury

○ Left ○ Rear ○ Center ○ Single ○ Right ○ Unknown ○ Front

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Personal Flight Equipment (Check all that apply) □ Fire resistant flight suit □ Helmet □ Laser protective visor/glasses □ Personal Locator Beacon(s) (PLB) □ Fire resistant gloves □ Helmet visor □ Night vision goggles □ Personal flotation □ Other: __________________________________________

Pilot Certificate(s) (Check all the apply)

Restraint Type

Inflatable Restraints □ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ None □ Private □ Student

□ Flight Instructor □ Recreational □ Sport

□ Commercial □ Airline Transport □ Flight Engineer

□ US Military □ Foreign

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

Type Rating/Endorsement for Accident/Incident Aircraft? □ Yes □ No

Total Flight Time at the Time of this Accident/Incident: hrs.

PASSENGER(S) / OTHER PERSONNEL (Include cabin crew; continue on separate sheet, if necessary.)

Number of Passengers ____________

Passenger Information

Seat

Injury

Restraint Type

Inflatable Restraints

Age

First Name: City: Middle Initial: State: Zip: Last name: Country: ○ Crew ○ Passenger ○ Other Personal Flight Equipment (Check all that apply) □ Fire resistant flights □ Helmet □ Laser protective visor/glasses □ PLB □ Fire resistant gloves □ Night vision goggles □ Helmet visor □ Personal flotation □ Other: ______________________

○ Left ○ Center ○ Right ○Unknown Row:

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

□ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ Under 5 years If under 5 years, ○ Child Restraint ○ Lap-Held ○ Unknown

First Name: City: Middle Initial: State: Zip: Last name: Country: ○ Crew ○ Passenger ○ Other Personal Flight Equipment (Check all that apply) □ Fire resistant flights □ Helmet □ Laser protective visor/glasses □ PLB □ Fire resistant gloves □ Night vision goggles □ Helmet visor □ Personal flotation □ Other: ______________________

○ Left ○ Center ○ Right ○ Unknown Row:

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

□ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ Under 5 years If under 5 years, ○ Child Restraint ○ Lap-Held ○ Unknown

First Name: City: Middle Initial: State: Zip: Last name: Country: ○ Crew ○ Passenger ○ Other Personal Flight Equipment (Check all that apply) □ Fire resistant flights □ Helmet □ Laser protective visor/glasses □ PLB □ Fire resistant gloves □ Night vision goggles □ Helmet visor □ Personal flotation □ Other: ______________________

○ Left ○ Center ○ Right ○ Unknown Row:

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

□ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ Under 5 years If under 5 years, ○ Child Restraint ○ Lap-Held ○ Unknown

First Name: City: Middle Initial: State: Zip: Last name: Country: ○ Crew ○ Passenger ○ Other Personal Flight Equipment (Check all that apply) □ Fire resistant flights □ Helmet □ Laser protective visor/glasses □ PLB □ Fire resistant gloves □ Night vision goggles □ Helmet visor □ Personal flotation □ Other: ______________________

○ Left ○ Center ○ Right ○ Unknown Row:

○ None ○ Minor ○ Serious ○ Fatal ○ Unknown

Available ○ None ○ Lap Only ○ 3-point ○ 4-point ○ 5-point ○ Unknown ○ Supplemental. Restraint type:

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

□ Not Installed □ Installed □ Not Deployed □ Deployed □ Unknown

□ Under 5 years If under 5 years, ○ Child Restraint ○ Lap-Held ○ Unknown

FLIGHT ITINERARY INFORMATION

Last Departure Point

Airport ID:

City:

State:

Country:

Time of Departure

Time:

Time Zone:

Flight Information

Destination

Airport ID:

City:

State:

Country:

Type Flight Plan Filed

Flight Number:

Operating as Flight _____________

○ None

○ Company

VFR

○ Military

VFR

○ VFR

○ VFR/IFR

○ IFR

○ Unknown

Activated? ○ Yes ○ No

○ Unknown

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

□ Certificate of Authorization

□ VFR

□ Special VFR

□ IFR

□ Special IFR

□ VFR On Top

□ VFR Flight Following

□ Traffic Advisory

□ Cruise

□ Unknown / NA

Type of ATC Clearance/Service (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

□ Special

□ Air Traffic

Control Area

□ Unknown

Altitude of In-Flight Occurrence:

ft. MSL

WEATHER INFORMATION AT THE ACCIDENT/INCIDENT SITE

Source of Pilot Weather Information

(Check all that apply)

Weather Observation Facility

Facility ID:

Observation Time:

Time Zone:

Distance from Accident Site: nm

Direction from Accident Site: degrees true

□ National Weather Service

□ Flight Service Station

□ TV/Radio

□ Automated Report

□ Electronic Flight Bag-Application: ________

□ On-Board Weather

□ Company

□ Military

□ Internet

□ None

□ Unknown

Basic Conditions

○ VMC

○ IMC

○ Unknown

Lowest Cloud Condition Height

Light Condition

_____________ ft. AGL

○ Dawn

○ Day

○ Dusk

○ Night

○ Dark Night

○ Bright Night

○ Unknown

Sky/Lowest Cloud Condition

Ceiling

Ceiling Height

ft. AGL

Temperature: (˚C) or (˚F)

Dewpoint: (˚C) or (˚F)

○ Clear

○ Few

○ Partial Obscuration

○ Scattered

○ Thin Broken

○ Thin Overcast

○ Unknown

○ None (Clear)

○ Broken

○ Overcast○ Obscured ○ Indefinite ○ Unknown

○ None (Clear) ○ Broken ○ Overcast

○ None (Clear) ○ Broken ○ Overcast

○ Obscured ○ Indefinite ○ Unknown

Altimeter Setting:

Hg

or

mb

Wind Direction

□ Variable

or

Direction: degrees true

Wind Speed

□ Calm

□ Light and Variable

or

Speed: kts

Wind Gusts

□ Not Gusting

or

Speed: kts

Visibility

miles

RVR: feet

RVV: miles

Destiny Altitude: ft.

Type of Precipitation (Check all that apply)

Restriction to Visibility (Check all that apply)

□ None

□ Rain

□ Snow

□ Hail

□ Rain Showers

□ Drizzle

□ Ice Pellets

□ Snow Pellets

□ Snow Grains

□ Ice Crystals

□ Freezing Rain

□ Snow Shower

□ Ice Pellets Shower

□ Freezing Drizzle

□ None

□ Blowing Dust

□ Blowing Sand

□ Blowing Snow

□ Blowing Spray

□ Dust

□ Fog

□ Ground Fog

□ Haze

□ Ice Fog

□ Smoke

□ Unknown

Icing Forecast

Intensity of Precipitation

Icing Actual

Turbulence (Check all that apply)

Amount

○ None

○ Trace

○ Light

○ Moderate

○ Severe

○ Unknown

Type

○ N/A

○ Rime

○ Clear

○ Mixed

○ Unknown

○ Light

○ Moderate

○ Heavy

○ N/A

○ Unknown

Amount

○ None

○ Trace

○ Light

○ Moderate

○ Severe

○ Unknown

Type

○ N/A

○ Rime

○ Clear

○ Mixed

○ Unknown

Type

□ None

□ Clean Air

□ Terrain-Induced

□ Convective Turbulence

Severity

□ Light

□ Moderate

□ Severe

□ Extreme

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

DAMAGE TO AIRCRAFT AND OTHER PROPERTY

Aircraft Damage

Aircraft Fire

Aircraft Explosion

○ None ○ Minor

○ Substantial ○ Destroyed ○ Unknown

○ None ○ In-Flight ○ On-Ground

○ Both Ground and In-Flight ○ Fire at Unknown Time ○ Unknown

○ None ○ In-Flight ○ On-Ground

○ Both Ground and In-Flight ○ Fire 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 location, services obtained, and intended destination. Provide as much detail as possible.

OPERATOR/OWNER SAFETY RECOMMENDATION (How could this accident/incident have been prevented?)

MECHANICAL MALFUNCTION/FAILURE (If more space is needed, continue on a separate sheet.)

Was there Mechanical Malfunction/Failure? □ Yes □ No (If yes, list the name of the part, manufacturer, part no., serial no., and describe the failure.)

Total Time/ Cycles On Part Hours Cycles

Time Since This Part Inspected/Overhauled Hours

FUEL & SERVICES INFORMATION

Fuel on Board at Last Takeoff (Convert from pounds, as necessary) Gallons

Fuel Type ○ 100 Low Lead ○ Automotive

○ Jet A ○ Jet A-1

○ Unleaded AV ○ 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 Name: City: State: ZIP: Country:

Pilot of Other Aircraft Name: City: State: ZIP: Country:

ADDITIONAL INFORMATION (Additional space for answers to any question.)

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. By signing this form, I am consenting to the public release of the information provided herein.

Date of this report: mm/dd/yyyy

Name of Pilot/Operator: Signature: -or- □ Check here to electronically sign this document

If a person other than Pilot/Operator is filing this report Name: Title: Signature: -or- □ Check here to electronically sign this document

FOR NTSB USE ONLY

NTSB Accident/Incident No.

Reviewed by NTSB AS Division

Name of Investigator

Date Report Received

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