Safety/Irregularity Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of occurance
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Time of Day
*
Day
Night
Type of Error
*
Please Select
Aborted Takeoff
Aircraft Damage
ATC Incident
Bird Strike
Comm/Nav Failure
Crew Illness/Injury
Electrical System
Emergency
Engine Shutdown
Engine System
FOD
Fuel Quantity
Fuel System
Gear System
Handling Difficulty
Icing Encounter
Loss of Braking
Lost/Disoriented
Near MidAir Collision
Operating Procedures
Propeller Strike
Property Damage
Runway Excursion
Tail Strike
Wake Turbulence
Weather
Wing Strike
Other Safety Concern
Other Maintenance Concern
Phase of Flight
Pre Flight
Taxi
Takeoff
Cruise Flight
Shutdown
Post Flight
Other
Weather Conditions
*
VMC
IMC
N/A
Other
Persons Involved
*
Student
Instructor
Renter
Other
Name of Person Involved
*
First Name
Last Name
Aircraft Identification (N Number)
Describe the situation/event/incident
*
Root Cause:
How could it be prevented?
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