National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type: Most Critical Injury: Investigated By: 

### Location/Time State Zip Code Local Time Time Zone

Model/Series Aircraft Manufacturer 

### Aircraft Information Summary Revenue Sightseeing Flight: Air Medical Transport Flight: Narrative Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident:

Page 1 

### FACTUAL REPORT - AVIATION Nearest City/Place Distance From Landing Facility: Airport Proximity: Type of Aircraft Aircraft Registration Number: This space for bindingThis space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 

### Narrative (Continued)This space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 

### Narrative (Continued)This space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 

### Narrative (Continued)This space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 

### Narrative (Continued)This space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 

### Narrative (Continued)National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 2 This space for binding



### Landing Facility/Approach Information Airport Name Runway Surface Type: Runway Surface Condition: Airport ID:

Approach/Arrival Flown: VFR Approach/Landing: 

### Aircraft Information Aircraft Manufacturer Airworthiness Certificate(s): Landing Gear Type: Amateur Built Acft? Number of Seats: Engine Type: 

### - Aircraft Inspection Information Type of Last Inspection 

### - Emergency Locator Transmitter (ELT) Information ELT Installed?/Type 

### Owner/Operator Information Registered Aircraft Owner
Operator of Aircraft Operator Does Business As: 

### - Type of U.S. Certificate(s) Held: Air Carrier Operating Certificate(s): Operating Certificate: Regulation Flight Conducted Under: Type of Flight Operation Conducted: Operator Certificate: Operator Designator Code: Street Address City Street Address City ELT Aided in Locating Accident Site? Time Since Last Inspection Hours

Model/Series: Engine Manufacturer: Date of Last Inspection Model/Series

Certified Max Gross Wt. Number of Engines: LBS Serial Number Airport Elevation

Ft. MSL Runway Used Runway Length Runway Width

Rated Power: Airframe Total Time

Hours

State Zip Code
State Zip CodeThis space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 3 

### First Pilot Information Name Sex: Seat Occupied: City Occupational Pilot? Certificate Number: State Date of Birth Age
Certificate(s): Airplane Rating(s): Rotorcraft/Glider/LTA: Instrument Rating(s): Instructor Rating(s): Current Biennial Flight Review? Medical Cert. Status: 

### - Flight Time Matrix Medical Cert.: Date of Last Medical Exam:

Glider Lighter Than Air Rotorcraft Instrument Actual Simulated Airplane Mult-Engine Night Airplane Single Engine This Make and Model All A/C Total Time Pilot In Command(PIC) Instructor Instruction Received Last 9 0 Days Last 30 Days

Departure Time Time Zone State Airport Identifier State Airport Identifier Type of Flight Plan Filed: 

### Departure Point Destination 

### Flight Plan/Itinerary

Type of Clearance: Type of Airspace: 

### Weather Information 3LORW
V Source of Wx Information :This space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 4 

### Weather Information WOF ID Observation Time Sky/Lowest Cloud Condition: Time Zone WOF Elevation Ft. MSL WOF Distance From Accident Site NM Ft. AGL Condition of Light: Direction From Accident Site Deg. Mag. Altimeter: "Hg Visibility: SM Weather Conditions at Accident Site : Ft. AGL W ind Gusts : 

### ° C 

### ° C Dew P oint:

Wind Speed : Lowest Ceiling: Temperature: Wind Direction : Visibility (RVR): Ft. Precip and/or Obscuration :



### Accident Information Aircraft Damage: Visibility (RVV) SM

Aircraft Fire: Aircraft Explosion 

### - Injury Summary Matrix First Pilot Second Pilot Student Pilot Check Pilot Flight Engineer Cabin Attendants Other Crew Passengers - TOTAL ABOARD - Other Ground - GRAND TOTAL - Fatal Serious Minor None TOTAL

Flight InstructorThis space for binding National Transportation Safety Board 

## FACTUAL REPORT AVIATION NTSB ID: Occurrence Date: Occurrence Type:



### FACTUAL REPORT - AVIATION Page 5 

### Administrative Information Investigator-In-Charge (IIC) Additional Persons Participating in This Accident/Incident Investigation: