Original Submission Resubmission

Please e-mail me back a copy: NO YES

What is your full name?  (REQUIRED)

What is your address?   (street number and street name)

                                   (Mainly for P.O. Box or non-USA addresses)

                                   (Mainly for non-USA addresses)

Which Country are you from? U.S.      Other: 

What city do you live in?     (REQUIRED)

Which State, Province or Region?    (REQUIRED)

What is your full telephone number?  (include local area code)

What is the current date -- Month/date/year? (REQUIRED)

What is your e-mail address?  (REQUIRED)

1. Categorize event (Click on only one): (REQUIRED)

Accident (Serious to fatal injuries; and/or major damage or total destruction of rotorcraft) Incident: (none to minor injuries; and/or none to minor damages to rotorcraft) Safety Item (if not caught, may have caused incident or accident)

2. You are (check all that apply):

Pilot in command    Other occupant of aircraft    Witness to the incident/accident    

Investigator            PRA Safety Reporter            Other

If you chose "other" please tell us who you are:

Were involved in it    Interviewed witnesses    Saw the wreckage   Photographed the wreckage

Measured suspect parts    

Got information by:

            Phone        E-mail       NTSB Report        FAA or Aviation Authority        Newspaper

Other         If "other" what was your source:

EVENT INFORMATION

4. Basic Facts: (check or fill in all that you know, some are required)

Date of Occurrence (use xx/xx/xxxx format)    Month      Day      Year    (REQUIRED)

    Location (such as "in a pond" or "in the rocks" or "on a road")  (REQUIRED)

Nearest city/town/village:   (REQUIRED)

State/Province/Region:   (REQUIRED)

Country:  USA     Other:

Time:   2400 style local time Local time AM Local time PM GMT (Greenwich Mean Time) or UCT (Universal Coordinated Time)  

MSL (Mean Sea Level) altitude of terrain: Feet Meters

Altitude of incident (on the ground would be 0 or the MSL terrain altitude) Feet Meters

                                                   MSL (Mean Sea Level) AGL (Above Ground Level)     

Portion of day:     Dawn (legal daybreak) Day Dusk (legal twilight) Night

Temperature: Degrees F Degrees C

5. Flight Phase: (check all that apply) (Explain further, if you wish, in the Comments section)

Hover    Taxi    High-speed taxi    Take-off    Climb    Cruise    Descent    Approach    Landing    Go-Around    Slow flight    High Performance maneuvers or aerobatics

6. Wind/Weather: (check all that apply) (Explain further, if you wish, in the Comments section)

No information on wind    Calm, no wind     Light wind    Turbulence    Thunderstorm

Crosswind    Headwind    Tailwind

Estimated wind speed:    Miles per hour Knots per hour Kilometers per hour          Gusty wind to: Miles per hour Knots per hour Kilometers per hour

Visual flight conditions (good visibility)    Sunny    Reduced visibility    Rain    Fog    Ice    Sleet    Snow    

        Other:    

7. If collision, type of vehicle: (check all that apply) (Explain further, if you wish, in the Comments section)

Conventional airplane    Ultralight airplane    Powered parachute or Trike    Rotorcraft    

Mid-air collision with the above    Ground    Ground vehicle    Other:

8. Safety Equipment/Procedures: (check all that apply) (Explain further, if you wish, in the Comments section)

Pilot Weather briefing: NO YES     Weather briefing source:

Pre-flight inspection done? NO YES     Seatbelt? NO YES      Shoulder harness? NO YES     

Helmet?   NO YES         Eye protection?   NO YES                

Ballistic parachute present? NO YES   Ballistic parachute used? Not Used Used/deployed Used/deployed and aided in incident  

Emergency Locator Transmitter (ELT) present?    NO YES   

If present, the Emergency Locator Transmitter was:  Not turned on or triggered Turned on or triggered  

9. Rotorcraft Type

Make/model:   Make:   (REQUIRED)         Model:   

Check all that apply: Ultralight gyro    Ultralight helicopter    Tractor gyro    Pusher gyro    Helicopter    Single seat    Tandem two-place    Side-by-side two-place    Three or more seats    Horizontal stabilizer    Tall tail    Drop keel (like a Dominator)    Prop thrustline thru CG    Prop thrustline above CG    Prop thrustline below CG    

Estimate thrustline above/below CG: Inches Centimeters

10. Rotorcraft Registration

Registered with:  Not registered    FAA    ASC (Aero Sports Connection)    USUA (U.S. Ultralight Association)     EAA    Other: 

11. Rotorcraft Engine

One       Two or more     Displacement:    Cubic inches Cubic Centimeters      Estimated power at prop in HP::

12. Rotorcraft Engine Reduction Drive

Make/Model:    None    Belt    Chain    Gear    Planetary

13. Rotorcraft Propeller

Make/Model:     Diameter: Inches Centimeters     Prop Blades: 2 3 4 5 or more

14. Rotorblades

Make/Model: Number of rotor blades: 2 3 4

Diameter of blades (actually diameter of blade-tip path)  Feet Meters

Chord (width) of rotor blades:  Inches Centimeters    

PILOT IN COMMAND

15. Pilot was (check all that apply)

Owner    Student    Student taking instruction   ASC/USUA/EAA Pilot  Certificated pilot  Instructor    Other: Gender  Male Female     

Pilot's age: years old

16. Pilot experience 

A. Fixed Wing (conventional or ultralight [ultralight with the U.S. definition as under 254 lbs empty])

B. Gyroplane

C. Helicopter

D. Trike/Powered Parachute

17. Pilot certificates/ratings (check all that apply) [ultralight with the U.S. definition]

Student    Ultralight Pilot    Ultralight Instructor    FAA Recreational    Private    Commercial    Airline Transport    FAA Instructor    Multi-engine    Instrument Rating    Other:

INJURIES/DAMAGE

18. Injuries to Pilot (Explain further, if you wish, in the Comments section) (REQUIRED)

No injuries Minor injuries (treated or untreated) Serious injuries (hospitalized) Fatal injuries (immediate or soon after)

19. Injuries to passenger(s) (Explain further, if you wish, in the Comments section) (REQUIRED)

20. Rotorcraft damage (Describe further, if you wish, in the Comments section) (REQUIRED)

None Minor Substantial Substantial, pieces missing Rotorcraft destroyed

21. Primary Cause of  damage (Describe further, if you wish, in the Comments section) (REQUIRED)

Inflight fire Inflight explosion Impact Impact fire Impact explosion Possible mechanical failure Unknown

22. Other damage (check all that apply) (Describe further, if you wish, in the Comments section)

People, other than rotorcraft occupant(s)       Property, other than rotorcraft

23. Possible event cause indicators (check all that apply) 

Empty fuel tank    Propeller blade damage    Rotorblade damage    Rotor/propeller strike   Rotor blade separation/delamination    Rotor/tail strike    Mast separation    Rotorhead will not turn    Engine will not start or restart    Bent/broken controls    Damage to rudder

24. Suggested factors in event (check all that apply) (Describe further, if you wish, in the Comments section)

Fuel starvation    Fuel contamination    Rough terrain    Roll-over while taxiing    Ran off runway    Misjudged flare    Downwind turn    Rotorblade(s) struck ground    Rotorblade flap    Observed PIO (Pilot Induced Oscillation)    Possible power push-over    Loss or partial loss of engine power    Crosswind    High winds    High flight speeds    Mechanical problems with rotorcraft controls   Ground resonance    Helicopter: Tail rotor failure    Helicopter: Rotor speed decay    Helicopter: Hover, ground contact, dynamic roll-over  

COMMENTS

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