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NTSB Pilot/Operator Aircraft Accident/Incident ReportFORM APPROVED FOR USE THROUGH 03/31/2006 BY OMB NO. 3147-0001 NATIONAL fi . ., ON SAFETY BOARD NTSB Form 6120.1 Pilot/operator accident/incident report may be filed by mailing in this form or by entering information in the online reporting system on the NTSB Web site at <http://vv vv.ntsb.gov>. Paper copies of this form may be obtained from the Web site, the National Transportation Safety Board Regional Offices, and the Federal Aviation Administration Flight Standards District Offices. Rules pertaining to aircraft accidents/incidents, overdue aircraft, and safety issues are contained in Part 830 of the National Transportation Safety Board's Regulations, 49CFR. These rules state the authority of the Board, define accidents, incidents, injuries, and other terms, and provide procedures for initial and immediate notification by aircraft pilots/operators. A. APPLICABILITY The pilottoperator of an aircraft shall file a report with the Regional Office of the National Transportation Safety Board nearest the accident or incident for which immediate notification is required by section 830.5(a) The report shall be filed within ten (10) days after an accident for which notification is required by Section 830.5 or when, after seven (7) days, an overdue aircraft is still missing. An aircraft accident, as defined in 49CFR 830.2, is determined as an occurrence that involves a fatality, serious injury, or substantial damage. 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, National Transportation Safety Board, 490 L'Enfant Plaza, S.W., Washington, D.C. 20594. The Pilot/Operator Aircraft Accidentlincident Report Form is used in determining the facts, conditions, and circumstances for aircraft accident prevention activities and for statistical purposes. It is necessary that ALL questions be answered completely and accurately to serve the above purposes. 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. 2. "Substantial Damage" means damage or failure which 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 fairing 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 thirty (30) days of the accident. 5. "Serious Injury" means any injury that (1) requires hospitalization for 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. If more space is needed, continue on a blank sheet. Nearest CitylPlace: Use the name of the nearest community that has a Post Office in the state where the accident occurred. Date & Time: Indicate the date and local time of the event. Be sure to indicate the time zone. Phase of Operation: Indicate the phase of operation during which the accident/incident occurred. Weather Information at the Accident4ricident 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 site, indicate the reported conditions at the nearest reporting site. Specify the weather reporting site identifier, the observation time, and distance from the accident site. SkylLowest Cloud Condition: Indicate the height above ground level of the lowest cloud condition present at the time of the accident 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 (reported as broken or overcast). NOTAMs ((D), (L) and FDC), AiRMETs, SIGMETs, PiREPs. Describe all NOTAMs, AIRMETs, SIGMETs, PIREPs in effect near the NTSB Form 6120.1(rev. 11/2005). This form replaces 6120.1/2. accident/incident. For NOTAMs, state if they were distant (D), local (L), or Flight Data Center (FDC), if known. 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 manufacturer of the kit or plans when appropriate. Enter engine make and model information as indicated on the engine data plate. Max Gross Weight. Enter the certificated max 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. 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. OwnerlOperator 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. Public Use Flight. 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. Military operations should not be included under public use. If public use, also indicate whether the flight was conducted by Federal, State, or Local government. Revenue Sightseeing Flight Indicate whether the accident aircraft was conducting revenue sightseeing operations under FAR 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. Purpose of Flight (FAR 91, 103, 133, 137): Indicate the type of operation that was being conducted at the time of the occurrence using the following definitions: Airport Information: Complete this section if the accident/incident occurred on approach, takeoff, or within 3 miles of an airport. Please refer to the FAA Airport/Facility Directory or other official source for airport information. Airport Identification. Provide the official 3 or 4 character airport identifier. 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. Pilot informadon. Indicate the category that best describes the capacity PERSONAL —Flying for personal reasons (excludes business served by this flight crew member at the time of the accident. The transportation) including pleasure or personal transportation. This also designators "Pilot A" and "Pilot B" do not refer to a specific pilot position or includes practice or proficiency flights performed under flight instructor responsibility. If more than one pilot is aboard, they may be entered in any supervision and not part of an approved flight training program. order and their capacity entered as appropriate. BUSINESS —Includes all personal flying without a paid, professional Degree of injury.• See Definitions on the top half of Page 1 of the crew for reasons associated with furthering a business, including Instructions. Minor injury is not defined. If an injury does not meet the transportation to and from business meetings or work. This does not criteria for another injury category, select Minor. include corporate/executive operations, air taxi, or commuter operations. Date of Last Flight Review or Equivalent Enter the date of the most recent EXECUTIVEICORPORATE—Company flying with a paid, professional flight review, or equivalent, completed by this pilot. Refer to 14 CFR 61.56 crew for accepted equivalents. OTHER WORK USE —Miscellaneous flight operations conducted for compensation or hire such as construction work (not FAR Part 135 operation), parachuting, aerial advertising, towing gliders, etc. 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. FERRY —Non -revenue flight under a special flight or "ferryy" permit. Refer to 14 CFR 21.197 for details of special flight permit issuance. POSITIONING —Non -revenue flight conducted for the primary purpose of moving the aircraft to a maintenance facility or to load passengers or cargo, etc. 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 —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. 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. UNKNOWN —Use only if the primary purpose of flight is not known. Collision Accident 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 2 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 Crew Members. Complete this section if there were more than two required flight crew members 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. • Please enter identification and injury severity information for all passengers and other personnel involved in the accident. See page 1 of the instructions for the official definition of injury levels. Occupants are considered "Revenue" passengers if they were being carried for compensation or hire. The option "FAA" refers to any FAA personnel performing a flight related function, including flight check, airman practical test, etc. Several questions throughout the form allow for multiple responses; when appropriate choose all responses that apply. These instructions only pertain to major issue areas covered by the NTSB Form 6120.1 PilotfOperator Aircraft AccidentRncident Report. For more specific definitions of questions and answers not included above, please refer to <http://www.ntsb.gov>. §830.2 49 CFR Ch. VIII (10-1-98 Edition) (a) Initial notification and later re- porting of aircraft incidents and acci- dents and certain other occurrences in the operation of aircraft, wherever they occur, when they involve civil air- craft of the United States; when they involve certain public aircraft, as spec- ified in this part, wherever they occur; and when they involve foreign civil air- craft where the events occur in the United States, its territories, or its possessions. (b) Preservation of aircraft wreckage, mail, cargo, and records involving all civil and certain public aircraft acci- dents, as specified in this part, in the United States and its territories or possessions. [60 FR 40112, Aug. 7, 19951 § 830.2 Definitions. As used in this part the following words or phrases are defined as follows: Aircraft accident means an occurrence associated with the operation of an air- craft which 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 seri- ous injury, or in which the aircraft re- ceives substantial damage. Civil aircraft means any aircraft other than a public aircraft. Fatal injury means any injury which results in death within 30 days of the accident. Incident means- an occurrence 'other, than an accident; associated with the operation of an aircraft, which affects: or could affect the safety of operations_ Operator means any person who causes or authorizes the operation of an aircraft, such as the owner, lessee, or bailee of an aircraft. Public aircraft means an aircraft used only for the United States Govern- ment, or an aircraft owned and oper- ated (except for commercial purposes) or exclusively leased for at least 90 continuous days by a government other than the United States Government, including a State, the District of Co- lumbia, a territory or possession of the United States, or a political subdivi- sion of that government. "Public air- craft" does not include a government - owned aircraft transporting property for commercial purposes and does not include a government -owned aircraft transporting passengers other than: transporting (for other than commer- cial purposes) crewmembers or other persons aboard the aircraft whose pres- ence is required to perform, or is asso- ciated with the performance of, a gov- ernmental function such as firefight- ing, search and rescue, law enforce- ment, aeronautical research, or bio- logical or geological resource manage- ment; or transporting (for other than commercial purposes) persons aboard the aircraft if the aircraft is operated by the Armed Forces or an intelligence agency of the United States. Notwith- standing any limitation relating to use of the aircraft for commercial pur- poses, an aircraft shall be considered to be a public aircraft without regard to whether it is operated by a unit of gov- ernment on behalf of another unit of government pursuant to a cost reim- bursement agreement, if the unit of government on whose behalf the oper- ation is conducted certifies to the Ad- ministrator of the Federal Aviation Administration that the operation was necessary to respond to a significant and imminent threat to life or property (including natural resources) and that no service by a private operator was reasonably available to meet the threat. Serious injury means any injury which: (1) Requires hospitalization for more than 48 hours, commencing with- in 7 days from the date of the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third- degree burns, or any burns affecting more than 5 percent of the body sur- face. Substantial damage means damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the af- fected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller 1100 National Transportation Safety Board blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered "substantial damage" for the purpose of this part. [53 FR 36982, Sept. 23, 1988, as amended at 60 FR 40112, Aug. 7, 19951 § 830.5 Immediate notification. The operator of any civil aircraft, or any public aircraft not operated by the Armed Forces or an intelligence agen- cy of the United States, or any foreign aircraft shall immediately, and by the most expeditious means available, no- tify the nearest National Transpor- tation Safety Board (Board) field of- fice 1 when: (a) An aircraft accident or any of the following listed incidents occur: (1) Flight control system malfunc- tion or failure; (2) Inability of any required flight crewmember to perform normal flight duties as a result of injury or illness; (3) Failure of structural components of a turbine engine excluding compres- sor and turbine blades and vanes; (4) In-flight fire; or (5) Aircraft collide in flight. (6) Damage to property, other than the aircraft, estimated to exceed $25,000 for repair (including materials and labor) or fair market value in the event of total loss, whichever is less. (7) For large multiengine aircraft (more than 12,500 pounds maximum certificated takeoff weight): (1) In-flight failure of electrical sys- tems which requires the sustained use of an emergency bus powered by a back-up source such as a battery, aux- iliary power unit, or air -driven genera- tor to retain flight control or essential instruments; I The Board field offices are listed under U.S. Government in the telephone direc- tories of the following cities: Anchorage, AK, Atlanta, GA, West Chicago, IL, Denver, CO, Arlington, TX, Gardena (Los Angeles), CA, Miami, FL, Parsippany, NJ (metropolitan New York, NY), Seattle, WA, and Washing- ton, DC. § 830.10 (ii) In-flight failure of hydraulic sys- tems that results in sustained reliance on the sole remaining hydraulic or me- chanical system for movement of flight control surfaces; (III) Sustained loss of the power or thrust produced by two or more en- gines; and (iv) An evacuation of an aircraft in which an emergency egress system is utilized. (b) An aircraft is overdue and is be- lieved to have been involved in an acci- dent. [53 FR 36982, Sept. 23, 1988, as amended at 60 FR 40113, Aug. 7, 1995] § 830.6 Information to be given in noti- fication. The notification required in §830.5 shall contain the following informa- tion, if available: (a) Type, nationality, and registra- tion marks of the aircraft; (b) Name of owner, and operator of the aircraft; (c) Name of the pilot -in -command; (d) Date and time of the accident; (e) Last point of departure and point of intended landing of the aircraft; (f) Position of the aircraft with ref- erence to some easily defined geo- graphical point; (g) Number of persons aboard, num- ber killed, and number seriously in- jured; (h) Nature of the accident, the weath- er and the extent of damage to the air- craft, so far as is known; and (i) A description of any explosives, radioactive materials, or other dan- gerous articles carried. Subpart C—Preservation of Air- craft Wreckage, Mail, Cargo, and Records §830.10 Preservation of aircraft wreckage, mail, cargo, and records. (a) The operator of an aircraft in- volved in an accident or incident for which notification must be given is re- sponsible for preserving to the extent possible any aircraft wreckage, cargo, and mail aboard the aircraft, and all records, including all recording medi- ums of flight, maintenance, and voice recorders, pertaining to the operation and maintenance of the aircraft and to 1101 § 830.15 the airmen until the Board takes cus- tody thereof or a release is granted pursuant to §831.12(b) of this chapter. (b) Prior to the time the Board or its authorized representative takes cus- tody of aircraft wreckage, mail, or cargo, such wreckage, mail, or cargo may not be disturbed or moved except to the extent necessary: (1) To remove persons injured or trapped; (2) To protect the wreckage from fur- ther damage; or (3) To protect the public from injury. (c) Where it is necessary to move air- craft wreckage, mail or cargo, sketches, descriptive notes, and photo- graphs shall be made, if possible, of the original positions and condition of the wreckage and any significant impact marks. (d) The operator of an aircraft in- volved in an accident or incident shall retain all records, reports, internal documents, and memoranda dealing with the accident or incident, until au- thorized by the Board to the contrary. Subpart D—Reporting of Aircraft Accidents, Incidents,d Overdue Aircraft § 830.15 Reports and statements to be filed. (a) Reports. The operator of a civil, public (as specified in §830.5), or foreign aircraft shall file a report on Board Form 6120.1h (OMB No. 3147-0001) Z with- in 10 days after an accident, or after 7 days if an overdue aircraft is still miss- ing. A report on an incident for which immediate notification is required by §830.5(a) shall be filed only as requested by an authorized representative of the Board. (b) Crewmember statement. Each crew - member, if physically able at the time the report is submitted, shall attach a statement setting forth the facts, con- ditions, and circumstances relating to the accident or incident as they appear to him. If the crewmember is incapaci- 2Forms are available from the Board field offices (see footnote 1), from Board head- quarters in Washington, DC, and from the Federal Aviation Administration Flight Standards District Offices. 49 CFR Ch. VIII (10-1-98 Edition) tated, he shall submit the statement as soon as he is physically able. (c) Where to file the reports. The opera- tor of an aircraft shall file any report with the field office of the Board near- est the accident or incident. [53 FR 36982, Sept. 23, 1988, as amended at 60 FR 40113, Aug. 7, 19951 Sec. 831.1 Applicability of part. 831.2 Responsibility of Board. 831.3 Authority of Directors. 831.4 Nature of investigation. 831.5 Priority of Board investigations. 831.6 Request to withhold information. 831.7 Right to representation. 831.8 Investigator -in -charge. 831.9 Authority of Board representatives. 831.10 Autopsies. 831.11 Parties to the investigation. 831.12 Access to and release of wreckage, records, mail, and cargo. 831.13 Flow and dissemination of accident or incident information. 831.14 Proposed findings. AUTHORITY: Independent Safety Board Act of 1974, as amended (49 U.S.C. 1101 et seq.); Federal Aviation Act of 1958, as amended (49 U.S.C. 40101 et seq.). SOURCE: 53 FR 15847, May 4, 1988, unless otherwise noted. § 831.1 Applicability of part. Unless otherwise specifically ordered by the National Transportation Safety Board (Board), the provisions of this part shall govern all accident or inci- dent investigations, conducted under the authority of title VII of the Fed- eral Aviation Act of 1958, as amended, and the Independent Safety Board Act of 1974. Rules applicable to accident hearings and reports are set forth in part 845. § 831.2 Responsibility of Board. (a) Aviation. (1) The Board is respon- sible for the organization, conduct, and control of all accident and incident in- vestigations (see §830.2 of this chapter) within the Untied States, its terri- tories and possessions, where the acci- dent or incident involves any civil air- craft or certain public aircraft (as spec- ified in §830.5 of this chapter), includ- ing an investigation involving civil or 1102