7#)yC'yBBBBB"B=B=B=B=B= BG BQBQBQBQBQ BBqBqBqCoBCqCuBqGCyC{CCCCPRA ROTORCRAFT ACCIDENT/INCIDENT/SAFETY ITEM REPORT Note: For computer reporting purposes type size is 9-10 points and use Atypeover@ (usually set by pressing the INSERT key) INSTRUCTIONS: 1. Your personal details are required only to enable us to contact you for further details about any part of your report. 2. You=ll get an acknowledgement that this report was received, ASAP. 3. This section of the Report Form will be returned to you. No record of your name and address will be retained. Name: Address: City, State, ZIP: Country: Telephone: Today=s date: Email: FILL IN AS MUCH AS YOU CAN C IF MORE SPACE IS NEEDED, USE MORE SHEETS AND REFERENCE BY ITEM NUMBER FOR COMPUTER USE UPPERCASE X TO FILL BETWEEN ( ) x out parameter not used e.g. xx / C REPORT TYPE: 1. Categorize event: ( ) Accident [serious to fatal injuries; and/or major damage to destruction of rotorcraft] ( ) Incident [none to minor injuries; and/or none to minor damage to rotorcraft] ( ) Safety item [if not caught, could have caused incident or accident] ABOUT THE PERSON COMPLETING THIS FORM: 2. You are (check all that apply): ( ) Pilot in command ( ) Other occupant in aircraft ( ) Witness to it ( ) Investigator ( ) PRA Safety Reporter ( ) Other:_ 3. In relation to this accident/incident, safety item you (check all that apply): ( ) Were involved in it ( ) Interviewed witnesses ( ) Saw the wreckage ( ) Photographed the wreckage ( ) Measured suspect parts ( ) Got info by: ( ) phone ( ) NTSB report ( ) email ( ) FAA report ( ) newspaper ( ) other: EVENT INFORMATION: 4. Basic facts: ( ) Date of Occurrence Day Mo Yr Location: ( ) Nearest City: State/Province/Region: ( ) Country: ( )USA ( )Other: ( ) Time: (LOCAL/GMT) ( ) Height/Alt/FL (Feet / meters) ( ) Dawn ( ) Day ( ) Dusk ( ) Night ( ) Temperature: ( F / C) 5. Flight Phase (Check all that apply) (Describe in Comments Section): ( ) Hover ( ) Taxi ( ) Highspeed taxi ( ) Takeoff ( ) Climb ( ) Cruise ( ) Descent ( ) Approach ( ) Landing ( ) GoAround ( ) Slow flight ( ) High performance maneuvers or aerobatics 6. Wind/Weather (Check all that apply) (Describe in Comments Section): ( ) No information on wind ( ) Calm, no wind ( ) Headwind ( ) Light wind ( ) Tailwind ( ) Turbulence ( ) Thunderstorm ( ) Estimated wind speed, mph/kph ( ) Gusty winds to mph/kph: ______ ( ) Visual flight conditions (good visibility) ( ) Sunny ( ) Reduced visibility ( ) Rain ( ) Fog ( ) Ice ( ) Snow ( ) Other: 7. If collision, type (check all that apply): ( ) Airplane ( ) Ultralight ( ) Rotorcraft ( ) Midair collision w/above ( ) Ground ( ) Ground vehicle  8. Safety Equipment/Procedures (check all that apply): ( ) Pilot weather briefing ( )Yes ( )No ( ) Weather briefing source: ( ) Preflight inspection done ( )Yes ( )No ( ) Seat belt ( )Used ( )Not used ( ) Shoulder harness ( )Used ( )Not used ( ) Helmet ( )Used ( )Not used ( ) Eye protection ( )Used ( )Not used ( ) Ballistic parachute ( ) Used ( )Not used ( ) Emergency Locator Transmitter ( ) Used ( )Not used ( ) Used, and aided in accident location 9. Rotorcraft make/model: Check all that apply: ( ) Ultralight gyro ( ) Ultralight helicopter( ) Tractor gyro ( ) Pusher gyro ( ) Helicopter ( ) Single seat ( ) Tandem twoplace ( ) Sidebyside twoplace ( ) 3 or more seats ( ) Horizontal stabilizer ( ) Tall tail ( ) Drop keel (like Dominator) ( ) Prop thrustline thru CG ( ) Prop thrustline above CG ( ) Prop thrustline below CG ( ) Estimate thrustline above/below CG in inches/cm) : PLEASE GO TO THE SECOND PAGE FOR COMPUTER USE UPPERCASE X TO FILL BETWEEN ( ) x out parameter not used e.g. xx / C ROTORCRAFT INFO 10. Registered with: ( ) Not registered ( ) FAA ( ) Aero Sports Connection ( ) US Ultralight Assn ( ) EAA ( ) Other: 11. Engine(s) (describe in Comments Section): ( ) One ( ) Two or more Make/model: Displacement: ( )cc ( )cu. inches Estimated power at prop: HP 12. Reduction drive (describe in Comments): Make/model: ( ) None ( ) Belt ( ) Chain ( ) Gear ( ) Planetary 13. Propeller (describe in Comments): Make/model: ____________________ Diameter: (inches / cm ) Number of blades: ( )2 ( )3 ( )4 ( ) 14. Rotorblades (describe in Comments}: Make/model: ____________________ Diameter: (feet / meters) Chord (width) (inches / cm) Number of blades: ( )2 ( )3 ( )4 PILOT IN COMMAND 15. Pilot was (check all that apply): ( ) Owner ( ) Student ( ) Student taking instruction ( ) Certificated pilot ( ) ASC/USUA/EAA pilot ( ) Instructor ( ) Other (describe in Comments Section) ( ) Male ( ) Female ( ) Pilot=s age: yrs. 16. Pilot Experience A. Fixed wing (regular or ultralight) ( ) Total hours: ( ) Instruction received: ( ) Ground Instruction received: Hours ( ) Hours in last 30 days:  B. Gyroplane ( ) Total Hours: ( ) Hours in this make/model: ( ) Dual instruction received Hours ( ) Ground Instruction received: Hours ( ) Instruction this make/model Hours ( ) In this make/model last 30 days: ( ) Boom training hours: ( ) Gyroglider training hours: C. Helicopter ( ) Total Hours: ( ) Hours in this make/model: ( ) Dual instruction received Hours ( ) Ground Instruction received: Hours ( ) Instruction this make/model Hours ( ) In this make/model last 30 days: D. Trike/Powered Parachute ( ) Total Hours: ( ) Hours in this make/model: ( ) Dual instruction received Hours ( ) Ground Instruction received: Hours ( ) Instruction this make/model Hours ( ) In this make/model last 30 days: 17. Pilot Certificates/Ratings (check all that apply): ( ) Student ( ) Ultralight Pilot ( ) Ultralight Instructor ( ) FAA Recreational ( ) FAA Private ( ) FAA Commercial ( ) FAA Airline Transport ( ) FAA Instructor ( ) FAA Multiengine ( ) FAA Inst Rating ( ) Other: INJURIES/DAMAGE 18. Injuries to pilot (describe in Comments): ( ) No injuries ( ) Minor (treated or untreated) ( ) Serious (hospitalized) ( ) Fatal 19. Injuries to other occupant (describe in Comments Section): ( ) No other occupant ( ) No injuries ( ) Minor (treated or untreated) ( ) Serious (hospitalized) ( ) Fatal 20. Rotorcraft damage (describe in Comments Section):( ) None - GO TO QUESTION #24 ( ) None ( ) Minor ( ) Substantial ( ) Substantial, pieces missing ( ) Destroyed  21. Primary cause of damage if known (describe in Comments Section): ( ) Inflight fire ( ) Inflight explosion ( ) Impact ( ) Impact fire ( ) Impact explosion ( ) Possible mechanical failure ( ) Unknown 22. Other damage (describe in Comments Section) ( ) People, other than rotorcraft occupant(s) ( ) Property, other than rotorcraft 23. Possible event cause indicators (check all that apply) ( ) Empty fuel tank ( ) Propeller blade damage ( ) Rotorblade damage ( ) Rotor/propeller strike ( ) Rotorblade separation/delamination ( ) Rotor/tail strike ( ) Mast separation ( ) Rotorhead will not turn ( ) Engine will not start or restart ( ) Bent/Broken controls ( ) Damage to rudder 24. Suggested factors in event (Check all that apply) (Describe in Comments Section): ( ) Fuel starvation ( ) Fuel contamination ( ) Rough terrain ( ) Rollover while taxiing ( ) Ran off runway ( ) Misjudged flare ( ) Downwind turn ( ) Rotorblade(s) struck the ground ( ) Rotorblade flap ( ) Observed PIO (Pilot Induced Oscillation) ( ) Possible Power Push Over ( ) Loss or partial loss of engine power ( ) Crosswind ( ) High winds ( ) High flight speeds ( ) Mechanical problems with rotorcraft controls ( ) Ground resonance ( ) Helicopter: Tail rotor failure ( ) Helicopter: Rotor speed decay ( ) Helicopter: Hover, ground contact, dynamic rollover 25. Written comments are: ( ) Attached >SEE NEXT COLUMN> 25. COMMENTS SECTION NARRATIVE ACCOUNT OF EVENT Please write your narrative account on additional pages. If cause of accident/incident is known, please give accurate and objective details.  ADDITIONAL COMMENTS: (Note that APilot error@ is not included above since that is a value judgement deduced after an examination of the facts. If you think Pilot error is the cause you may indicate it here along with your reasons) Please place the completed report form, with additional pages, in a sealed, stamped envelope and mail to: PRA Safety Net P.O. Box 303 Red Oak, TX 75154 OR . . . 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