HAI OPERATOR SAFETY AWARD APPLICATION FORM (2004)

PART 1

To recognize the safe operation of helicopters by its Regular members, HAI provides the “Operator Safety Award” to those whose safety statistics for the just-concluded year of 2004 are less than half the total of: the median accident rate of HAI operator members added to the median accident rate for U. S. civil helicopters. This qualifying criteria is determined once all applications are received.

Please answer all questions completely, accurately and legibly. Information provided in the Helicopter Operating Statistics (Part 2) will be used to determine eligibility for the Operator Safety Award. Plaques will be engraved with the Operator name specified on this application. For first time recipients and for members whose plaques are filled with past-year medallions, one new plaque will be provided by HAI. Year-date medallions will be provided only for the operational year currently being considered (2004); past year medallions will not be provided unless an application was made in that year and is on record.

Company Name:

(Print or type the name as it is to appear on the award. It must be the same as the HAI membership name.)

Attention of:

(Specify to whom the award is to be sent.)

Mailing Address:

(To allow UPS or FEDEX delivery, please indicate street address rather than P.O. Box number.)

City: ______State: _____ ZIP:______Country:

Telephone: FAX: Email:

Chief Executive Officer:

Chief of Operations/Safety Officer:

Based on the qualifying safety statistics, operators who qualify for the HAI Operator Safety Award will be awarded a Year-date medallion for 2004 to update previously provided award plaques.

·  Does your organization now have an HAI Operator Safety Award Plaque? Y____ N____

·  Number of HAI Operator Safety Award Plaques for which Year-date medallion needed:

·  Will this year’s Year-date medallion (2004) complete all the spaces on your plaque(s)? Y____ N____

(HAI will provide one new plaque per member, at no cost, for initial award and after a sixth award fills the current plaque.)

Additional plaques may be ordered for $40.00, plus $5.00 shipping and handling each. Please send _____ additional plaques. (Payment must be enclosed.)

SIGNATURE: DATE:

NAME & TITLE:

(Please print or type)

PLEASE RETURN PARTS 1 & 2 OF THIS APPLICATION NO LATER THAN MARCH 31, 2005

(Applications received after March 31, 2005 may not be processed.)

Dedicated to the advancement of the civil helicopter industry

2004 HELICOPTER

OPERATING STATISTICS

PART 2

COMPANY NAME: ______

(Must be the same as HAI Membership name)

Please complete the following information as accurately as possible:

1. Total helicopter flying hours in 2004 for the company. ______

2. Total helicopter accidents in 2004 for the company. ______

3. Was a safety audit conducted during 2004? Y____ N____

National Transportation Safety Board Accident Definitions

The United States National Transportation Safety Board defines accidents/incidents in title 49, Part 830, “Notification and Reporting of Aircraft Accidents or Incidents and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail, Cargo, and Records.”

“Aircraft Accident” is an occurrence associated with the operation of the 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.

“Fatal Injury” means any injury that results in death within thirty (30) days of the accident.

“Serious Injury” means any injury which:

(1) requires hospitalization for more than forty-eight (48) hours commencing within seven (7) days from the date the injury was received;

(2) results in a fracture of any bone (except simple fractures of fingers, toes or nose);

(3) causes severe hemorrhaging, nerve, muscle or tendon damage;

(4) involves any internal organ; or

(5) involves second or third degree burns, or any burns affecting more than five (5) percent of the body surface.

“Substantial Damage” means damage or failure which adversely affects the structural strength, performance or flight characteristics of the aircraft and which normally require major repair or replacement of the affected 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 blades, damage to landing gear, wheels, tires, flaps, engine accessories, brakes or wingtips are not considered substantial damage for the purpose of this part.

PLEASE RETURN PARTS 1 & 2 OF THIS APPLICATION NO LATER THAN

MARCH 31, 2005

TO:

Helicopter Association International

Attn: Operations Department

1635 Prince Street

Alexandria, VA 22314-2818

FAX: (703) 683-4745

Email:

Dedicated to the advancement of the civil helicopter industry