Accident/Incident Report

Office of Aviation Safety · Accident Investigation & Prevention

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Case & Investigator

Shared by all four formats

Incident Number

Investigation Class

Date of This Report

Investigator / Report Made By

Badge Number

Basic Information

Accident/Incident Location

Location

Coordinates (X, Y)

Date & Time

Date

Time (UTC)

Phase of Operation

Altitude of In-flight Occurrence

Altitude

Fatalities / Injuries

Fatalities

Serious

Minor

None

Unknown

Collision with Other Aircraft

Aircraft Information

Basic Info

Registration Number

Manufacturer

Model

Amateur-built

Model Year

Category, Type & Weight

Category of Aircraft

Number of Seats

Number of Engine & Type

Max Gross Weight (lbs)

Actual Weight (lbs)

Narrative History of Flight

Describe what occurred in chronological order, including circumstances leading to and nature of the accident/incident. Describe terrain, state departure time and location, services obtained, and intended destination.

Owner / Operator Information

Registered Aircraft Owner

Name

Address

Operator of Aircraft

Same as registered owner

Purpose of Flight

If other, specify

Flight Crewmember Information

Passenger / Other Personnel

Flight Itinerary Information

Last Departure Point

Airport / Location

Time (UTC)

Destination

Airport / Location

Type Flight Plan Filed

Weather Information

Basic Conditions

Wind Direction

Light Conditions

Wind Speed

Sky / Lowest Cloud Condition

Wind Gusts

Temperature

Intensity of Precipitation

Visibility

Turbulence

NOTAMs, AIRMETs, SIGMETs, PIREPs in effect

Damage to Aircraft & Other Property

Aircraft Damage

Aircraft Fire

Aircraft Explosion

Description of Damage to Aircraft and Other Property

Accident/Incident Report

Case & Investigator

Basic Information

Aircraft Information

Narrative History of Flight

Owner / Operator Information

Flight Crewmember Information

Passenger / Other Personnel

Flight Itinerary Information

Weather Information

Damage to Aircraft & Other Property

Recommendations

Additional Information

Follow-up Sections

Witness Information

Witness Statement

Signatory Information

Acknowledgement

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