Revised Form 6120.1 with Non-Substantive Changes

Form 6120.1 - Approved - April 2024.docx

Pilot/Operator Aircraft Accident/Incident Report

Revised Form 6120.1 with Non-Substantive Changes

OMB: 3147-0001

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FORM APPROVED FOR USE THROUGH 04-30-2027 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.

    1. "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.

    2. "Operator" means any person who causes or authorizes the operation of an aircraft, such as the owner, lessee, or bailee of an aircraft.

    3. "Fatal Injury" means any injury that results in death within 30 days of the accident.

    4. "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:

Shape1

IFR-Equipped and Certified

Commercial Space Flight

Unmanned Aircraft

Maximum Gross Weight: lbs.

Weight at Time of Accident/Incident: lbs.

Shape2

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 DamageBattery Expired/DamagedUnknown

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

Shape3

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:


Shape11 Age at time of Accident/Incident: Date of Birth: (mm/dd/yyyy)

Shape13 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:


Shape26 Age at time of Accident/Incident: Date of Birth: (mm/dd/yyyy)

Shape28 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


Shape88 Airport ID:


Shape89 City:


State:


Country:

Time of Departure



Time:


Time Zone:

Flight Information

Destination


Shape94 Airport ID:


Shape95 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:


Shape98 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)


Shape107 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

Shape113 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


12

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title71221
AuthorBenjamin Allen
File Modified0000-00-00
File Created2024-07-23

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