FAA ACCIDENT / INCIDENT REPORT AMENDED DATE MO …

1 FAA ACCIDENT / INCIDENT REPORT 1. ACCIDENT INCIDENT 3. DATE OF EVENT 4. FAA OFFICE 5. NTSB ID 6. LOCATION-CITY/STATE/ZIP 7. OPERATOR NAME FOUR LETTER IDENTIFIER 8. AIRPORT (IF APPLICABLE) 3- OR 4- LETTER ID 9. LOCAL TIME 24- HOUR CLOCK 10A. LATITUDE 10B. LONGITUDE REGISTRATION MAKE/MODEL SERIAL NO. YEAR OF MANUFACTURE TOTAL AIRFRAME HRS. (WHOLE HOURS) AIR FRAME CYCLES (AIR CARRIER ONLY) 16. POWER PLANT 17. PROPELLER MAKE/MODEL/SERIES (IF APPLICABLE) 18. BIOHAZARD AREA YES NO 913310135 ON DEMAND 10135 COMMUTER 12137 12 12 AIRPLANE HELICOPTER GLIDER BALLOON DIRIGIBLE GYROPLANE HOMEBUILT ULTRALIGHT CONVENTIONALSKIS TRICYCLE AMPHIBIOUS FLOATS NONE MINOR SUBSTANTIAL DESTROYED YES AIR NO GROUND REGISTRATION NUMBER SECOND AIRCRAFT PASSENGEOTHERTOTALNONE MINOR SERIOUS FATAL TOTAL GEAR COLLAPSE FIRE AFTER LANDING FUEL DEPLETION SABOTAGE GEAR UP LANDING SYSTEM FAILURE PILOT INDUCED PILOT INCAPACITATED FIRE OR EXPLOSION COMPONENT GROUND CREW FUEL CONTAMINATION LOST POWER OTHER THAN PILOT BLADE/ROTOR FAILURE FOD PARACHUTE INCIDENT DESIGN OF AIRCRAFT AUTO/IMPROPER OVER GROSS WEIGHT METAL FATIGUE CORROSION CG OUT OF LIMITS IMPROPER INFLIGHT FIRE STRUCK ANIMAL IMPROPER SMOKE/FUMES BIRD STRIKE AD NON-COMPLIANCE INFLIGHT BREAKUP PAX DISTURBANCE DECOMPRESSION IMPROPER PART STOLEN AIRCRAFT PERSONAL COMMERCIAL CARGO INSTRUCTION

2 DOWNWIND TAKEOFF CORPORATE CARBURETOR ICE FERRY HIT KNOWN OBJECT EMERGENCY LANDING HARD LANDING OVERSHOT RUNWAY UNDERSHOT RUNWAY LOSS OF CONTROL STALL/SPIN MISMANAGED GEAR MISMANAGED ABORTED TAKEOFF AIRFRAME ICE/FROST WAKE TURBULENCE NATIONAL WEATHER SERVICE RAIN FLIGHT SERVICE STATION HAIL AERIAL APPLICATION AMBULANCE FIREFIGHTING BANNER TOW AIR SHOW SIGHTSEEING SKYDIVING FAR 141 PILOT SCHOOL MILITARY FOREIGN PUBLIC USE COMPANY FREEZING DRIZZLECOMMERCIAL WX. SERVICE FREEZING RAINTV/RADIO WEATHER DRIZZLE MILITARY OTHER COMPUTER BRIEFING GROUND CRUISE MANEUVER TAXI DESCENT HOVER TAKEOFF APPROACH OTHER CLIMB LANDING NONE / NOT APPLICABLE THUNDERSTORMHAZE CROSSWIND,DUST TURBULENCE/WINDSTORMSMOKE DENSITY ALTITUDEFOG LIGHTNING STRIKEBLOWING DUST BLOWING SNOWBLOWING SMOKE WHITE OUT ICING CONDITIONS WIND SHEARGUSTY WINDS OTHER 27. ACTUAL WEATHER IMCVMC NOT AVAILABLE28, RUNWAY CONDITIONS NOT APPLICABLE DRY SNOW WET SLUSH ICE STANDING WATER - DATEMO FAR PART NUMBER15.

3 TYPE OF AIRCRAFT19. TYPE OF LANDING GEAR20. INJURY SUMMARYUNKNOWN11. AIRCRAFT DAMAGE 12. COLLISION - BETWEEN TWO AIRCRAFT21. FACTORS - IDENTIFY PRIMARY FACTOR AS A. IDENTIFY SECONDARY FACTORS, IF ANY, AS X. CHECKING OF FACTORS IS THE OPINION OF THE INVESTIGATOR/INSPECTOR BASED ON THE INVESTIGATION 22. TYPE OF OPERATIONSTECHNICAL FACTORS OPERATIONAL FACTORS21A. 21 INCP. ALCOHOL 21F. ATA CODE OTHER HIJACK21C. PART NAME 21D. MANUFACTURER 21E. PART NUMBER23WX. BRIEFING SOURCE 24 PRECIPITATIONNOT APPLICABLE/NOT AVAILABLE NOT APPLICABLE/NOT AVAILABLEVOICE RESP. SYSTEM SNOW OF FLIGHTWEATHER FACTORS 25. FAA Form 8020-23 (12-99) SUPERSEDES FAA FORMS 8020-5 and 8020-16 INFORMATION IS PRELIMINARY AND SUBJECT TO CHANGE NSN: 0052-00-923-1000 DID PILOT ATTEND SAFETY SEMINAR OR clinic WITHIN PAST 3 YEARS? YES NO UNKNOWN DID PILOT PARTICIPATE IN WINGS PROGRAM WITHIN PAST 3 YEARS? YES N0 UNKNOWN DID PILOT ATTEND ANY OTHER RECURRENT TRAINING WITHIN THE PAST 3 YEARS? YES N0 UNKNOWN NAME DATE OF BIRTH MODAYRDATE HIRED (AIR CARRIER ONLY) MODAYRDOMICILE ZIP CODE HOURS MAKE AND MODEL HOURS LAST 90 DAYS TOTAL HOURS CERTIFICATE NO.

4 RECREATIONAL STUDENT PRIVATE COMMERCIAL FLIGHT MST. ATP MODAYR MODAYR 1. FAA FACILITIES YES NO4. AIRMAN/AIR AGENCY COMPETENCE YES NO7. SECURITY YES NO 2. NON FAA FACILITIES YES NO5. FAR CHANGE NEEDED YES NO 8. AIRMAN MEDICAL QUALIF. YES NO 3. AIRWORTHINESS YES NO6. AIRPORT CERTIFICATION YES NO 9. FAR VIOLATIONS YES NO 44709 REXAM EIR SDR COUNSELING M or D OTHER LIMITED SCENE NOT ACCESSIBLE - 29. GENERAL AVIATION ACCIDENTS ONLY 30. EVACUATION OVERVIEW (AIR CARRIER ONLY) EVACUATIONEVACUATIONINITIATEDINJURIESYES NOYES NO 31. PILOT INFORMATION NOT APPLICABLECERTIFICATE TYPESECOND PILOTREGULATORY CHECK RIDE NON-PILOTMO DA YRMO DAYR32. CORRECTIVE ACTION(S) PLANNED OR INITIATED NONE33. NARRATIVE (ATTACH ADDITIONAL SHEETS AS NECESSARY)(ONLY STATE THE FACTS THAT ARE CAUSAL TO THE ACCIDENT / INCIDENT ) CONDUCT OF INVESTIGATION34.

5 NTSB PARTICIPATION ON-SCENE 35. FAA PARTICIPATIONON-SCENENOT ON-SCENE 36. FAA INITIAL NOTIFICATION DATE AND LOCAL TIME 37. FSDO NOTIFICATIONDATE AND LOCAL TIME IIC ARRIVAL ON SCENEDATE AND LOCAL TIME MO DA YR MODAYRMO DAYR24 - HOUR CLOCK 24 - HOUR CLOCK24-HR CLOCK39.. FAA HOURS USED FOR 40. FAA HOURS USED HOURS USED FORTOTAL INVESTIGATION .TOTAL INVESTIGATION. TOTAL INVESTIGATION42, FAA NINE RESPONSIBILITIES IDENTIFICATION OF RESPONSIBILITIES IS THE INVESTIGATORS OPINION BASED ON HIS/HER INVESTIGATION 43. BRIEF EXPLANATION OF ISSUES INVOLVED 44. FAA IIC NAME DATEREGIONDISTRICT OFFICEFAA Form 8020-23 (12-99) SUPERSEDES FAA FORMS 8020-5 and 8020-16 INFORMATION IS PRELIMINARY AND SUBJECT TO CHANGE NSN: 0052-00-923-1000 INSTRUCTIONS FOR ACCIDENT / INCIDENT REPORT 1. OCCURRENCE INFORMATION: 21C. PART NAME:THIS FORM IS TO BE FILLED OUT FOR EACH ACCIDENT / INCIDENT AND FORWARDED TO THE REGIONAL FS DIVISION WITHIN 30 FS DIVISION WILL FORWARD ORIGINAL FAA ACCIDENT / INCIDENT REPORT TO AFS-620 AND A COPY OF ACCIDENT REPORTS IDENTIFY THE PART NAME THAT FAILED OR IS SUSPECTED OFFAILURE BY THE PROPER NOMENCLATURE THAT IS DEPICTEDIN THE MANUFACTURERS PARTS CATALOGUE.

6 21D. MANUFACTURER:ONLY TO AAI-220. IDENTIFY THE MANUFACTURER OF THE PART, IF AMENDED DATE: 2IE. PART NUMBER:FOR AMENDED REPORTS FILL IN ITEMS 1,2,3,5, AND 13, REGISTRATIONNUMBER ONLY, AND NEW OR CHANGED INFORMATION PERTAINING TOACCIDENT INVESTIGATION. IDENTIFY THE MANUFACTURER PART NUMBER. THIS WOULD BE THESAME NUMBER NEEDED TO REQUISITION A REPLACEMENT F. ATA CODE:3. DATE OF THE OCCURRENCE: MONTH/DAY/YEAR. REFER TO THE CODE TABLE IN THE FLIGHT STANDARDS GUIDE TITLED: JOINT AIRCRAFT SYSTEM AND COMPONENT CODE TABLE4. FAA (INVESTIGATING OFFICE): AND DEFINITIONS DATED JANUARY 1996. THE FIRST TWO BLOCKS ARE THE REGION. THE SECOND TWO 22. TYPE OF OPERATIONS:BLOCKS ARE THE NUMERICAL OF THE FSDO. EA 21. CHECK APPROPRIATE NTSB ID: 23. WEATHER BRIEFING SOURCE:FOR ACCIDENTS ONLY AND SUPPLIED BY THE NTSB OFFICE WITHSAME AS 2 RESPONSIBILITY. 24. PRECIPITATION:6. LOCATION: SAME AS : NEAREST CITY OR TOWN. STATE: 2 LETTER IDENTIFIER. 25. WEATHER FACTORS:SAME AS 21 CODE: SELF- EXPLANATORY.

7 26. PHASE OF FLIGHT:7. OPERATOR: FOR AIR CARRIER OCCURRENCES ONLY. PROVIDE THE NAME OF THE OPERATOR THAT HAS OPERATIONAL CONTROL. THE 4-LETTER WHERE ACCIDENT AND INCIDENT SEQUENCE STARTED. CHECK APPLICABLE PHASE. 27. ACTUAL WEATHER CONDITIONS: DESIGNATOR IS FROM PTRS. CHECK APPROPRIATE AIRPORT: 29. RUNWAY CONDITIONS:NAME OF AIRPORT IF OCCURRENCE TOOK PLACE ON AN CHECK APPROPRIATE AIRPORT DESIGNATOR ACCORDING TO ORDER 73 1 0. GENERAL AVIATION ACCIDENTS ONLY: 9. TIME: SELF- 24 HOUR CLOCK. 30. EVACUATION OVERVIEW (AIR CARRIER ONLY): 10. LATITUDE/ LONGITUDE: EVACUATION INITIATED ALASKA ACCIDENTS ONLY. INJURIES: CHECK YES IF INJURIES ATTRIBUTABLE TO AIRCRAFT DAMAGE: 31. PILOT INFORMATION:CHECK THE MOST SEVERE DAMAGE. 12. COLLISION: MEANS TWO AIRCRAFT COLLIDED IN THE AIR OR ON THE GROUND. BOTH WERE FLYING OR HAD THE INTENT TO FLY. TWO FORMS REQUIRED IF BOTH AIRCRAFT WERE FLYING ORSELF- EXPLANATORY. CHECK THE HIGHEST CERTIFICATE THAT THE PILOT HAS. PIC NAME NOT APPLICABLE IF THE PILOTS ACTIONS OR LACK OF ACTIONS DID NOT CONTRIBUTE TO THE ACCIDENT / INCIDENT .

8 HOWEVER, FORAIR CARRIER ACCIDENTS, PLEASE PROVIDE PIC DOB, HOURS MAKE AND MODEL, AND TOTAL THE INTENT TO FLY. 32. CORRECTIVE ACTION:13. AIRCRAFT REGISTRATION NUMBER: SELF- N1234M. MAKE/MODEL: MANUFACTURER/MODEL/SERIES, ,DC-9-10. SERIAL NUMBER: SELF EXPLANATORY. YEAR OF MANUFACTURE: 1994 AIRFRAME CYCLES, AIRFRAME HOURS 33. NARRATIVE:SELF- NTSB PARTICIPATION ( ACCIDENT ONLY): SELF-EXPLANATORY. SELF- FAR PART NUMBER: 35. FAA PARTICIPATION:CHECK THE REGULATION THAT THE AIRCRAFT WAS OPERATING UNDER. AN AIR CARRIER DOING POSITIONING, TRAINING, ETC., IS PART 9 1. PART 135 AIR TAXI OR AIR AMBULANCE IS PART 91 UNTIL PASSENGER PICKUP. MEDICAL PERSONNEL ARE CONSIDEREDSELF- EXPLANATORY. ON-SCENE CAN BE CHECKED IF THE INSPECTOR/ INVESTIGATOR PARTICIPATES IN THE INVESTIGATION BEYOND USE OF THETELEPHONE, , ENGINE TEARDOWN, INTERVIEW,OR WRECKAGE INVESTIGATION NOT AT THE SCENE OF THE ACCIDENT , OF THE CREW. 36. FAA INITIAL NOTIFICATION:15. TYPE OF AIRCRAFT: THIS IS THE TIME THE FIRST FAA PERSON WHO DISCOVERS OR IS NOTIFIED OFSELF- EXPLANATORY (MORE THAN ONE MAY BE CHECKED).

9 THE OCCURRENCE. THIS IS USUALLY AIR TRAFFIC. 16. POWERPLANT INFORMATION: 37. FSDO NOTIFICATION:(ONLY IF CAUSAL TO THE ACCIDENT / INCIDENT ): THIS IS THE FIRST CALL THAT THE FSDO RECEIVES. LIST MAKE/MODEI/SERIES OF ENGINE. 39. FAA IIC ARRIVAL ON SCENE:17. PROPELLER INFORMATION: SELF-EXPLANATORY.(ONLY IF CAUSAL TO THE ACCIDENT / INCIDENT ); 39. FAA HOURS USED FOR TOTAL INVESTIGATION: LIST MAKE/MODEL/SERIES OF PROPELLER. INCLUDES ON-SCENE, TRAVEL HOURS, AND NON-SCENE BIOHAZARD AREA: WHOLE HOURS YES IF BODY FLUIDS WERE PRESENT. USE OR NONUSE OF PERSONAL PROTECTIVE EQUIPMENT DOES NOT 40. TOTAL HOURS USED AT ACCIDENT / INCIDENT SCENE:WHOLE HOURS THIS QUESTION. 41. TOTAL TRAVEL HOURS TO & FROM SCENE: 19. TYPE OF LANDING GEAR: WHOLE HOURS -EXPLANATORY. 20. INJURY SUMMARY: ENTER THE NUMBERS INVOLVED AND ACCOUNT FOR ALL ONBOARD THE AIRCRAFT, AND ACCOUNT FOR THE PERSONNEL INJURED THAT WERE NOT ON THE AIRCRAFT. 21. FACTORS: CHECK THE PRIMARY FACTOR FROM EITHER TECHNICAL OROPERATIONAL FACTORS BLOCK WHICHEVER IS MOST FAA NINE RESPONSIBILITIES ( ACCIDENT MANDATORY/INCIDENTS OPTIONAL): CHECK WHICH OF THE AREAS OF RESPONSIBILITY WERE INVOLVED.

10 THE DETERMINATION OF RESPONSIBILITIES IS THE OPINION OF THE INSPECTOR/ INVESTIGATOR BASED ON HIS/HER BACKGROUND, TRAINING, SKILL, AND EXPERIENCE. THE ANNOTATION OF ONE OR MORE RESPONSIBILITIES DOES NOT HAVE TO BE JUSTIFIED OR PROVEN. AN AIRMAN WHO MAKES A MISTAKE WHICH RESULTS IN AN ACCIDENT IS ANNOTATED UNDER AIRMAN/AIR AGENCY COMPETENCE. IT IS NOT NECESSARY TO SUBMIT AN EIR BECAUSE OF 21A. TECHNICAL FACTORS: ANNOTATION OF APPLICABLE BOXES. MORE THAN ONE MAY BE IS THE INSPECTOR/INVESTIGATOR OPINION BASED ON 43. BRIEF EXPLANATION OF ISSUES INVOLVED FOR EACH OF THE NINERESPONSIBILITIES INVESTIGATION. IF NONE INVOLVED, EXPLAIN WHY. OPERATIONAL FACTORS: 44. FAA IIC NAME:SAME AS 21 A. PRINT, SIGN, AND Form 8020-23 (12-99) SUPERSEDES FAA FORMS 8020-5 and 8020-16 INFORMATION IS PRELIMINARY AND SUBJECT TO CHANGE NSN: 0052-00-923-1000