FM COMTRAWING FOUR CORPUS CHRISTI TX//
TO CNO WASHINGTON DC//N78F//
CMC WASHINGTON DC//A/SD//
COMNAVSAFECEN NORFOLK VA//00/10/11/FILE//
CNATRA CORPUS CHRISTI TX
COMTRAWING ONE MERIDIAN MS
ALL SUPERKINGAIR AIRCRAFT ACTIVITIES
COMNAVAIRFOR SAN DIEGO CA//
COMNAVAIRSYSCOM PATUXENT RIVER MD//PMA 273//
NAVAVSCOLSCOM PENSACOLA FL//N3E//
NAS CORPUS CHRISTI TX// or appropriate USN/USMC base
ARMED FORCES INSTITUTE OF PATHOLOGY WASHINGTON DC// only if a fatality
ALL AEROMEDICAL ACTIVITIES//
BUMED WASHINGTON DC//23/23A/231//
NAVOPMEDINST DET NAVAEROMEDINST PENSACOLA FL//
COMNAVAIRWARCENWPNDIV CHINA LAKE CA//
COMNAVAIRWARCENACDIV PATUXENT RIVER MD//
NAVSURFWARCENDIV INDIAN HEAD MD// if ejection involved
LSO SCHOOL NAS OCEANA VA if mishap involves a carrier landing
NAVY JAG WASHINGTON DC non-DOD aircraft personnel or property involved
MATSG-22 CORPUS CHRISTI TX// if USMC aircrew involvement
TRARON NINE MERIDIAN MS//
BT
UNCLAS FOUO//N03750//THIS IS AN INITIAL GENERAL USE NAVAL AVIATION MISHAP DATA REPORT CTW-4, CLASS A FM, 01-10, 17 XXX 10, T-XXX, 160982/ REPORT SYMBOL OPNAV 3750-20
MSGID/GENADMIN/CTW-4//
SUBJ/AVIATION MDR CTW-4 CLASS A FM 01-10//
REF/A/DOC/OPNAVINST/3750.6R/-//
REF/B/DOC/JAGINST/5800.7C/-//
NARR/REF A IS THE NAVAL AVIATION SAFETY PROGRAM.REF B IS THE NAVY JAG MANUAL.//
POC/ I. M. DUTYOFFICER/LCDR/CDO/CTW-4 NAS CORPUS CHRISTI TX/TEL: COMM: 361-961-XXXX DSN: 637-XXXX /E-MAIL: //
RMKS/1.SUMMARY.T-XX CRASHED AFTER TAKEOFF.TWO FATALITIES.Short sweet description of what happened, not why it happened.
2.DATA.
A.REPORTING ACTIVITY.
(1)TW-4
(2)09177
(3)NA
(4)NA
B.AIRCRAFT.
(1)T-34C
(2)160982
(3)A123
(4)CTW-4
(5)09251
(6)NA
(7)NA
(8)F405-RR-401
(9)TBD
(10)GPWS: NOT INSTALLED
COLLISION AVOIDANCE SYSTEM:NOT INSTALLED
PREDICTIVE MATERIAL FAILURE WARNING SYSTEM: NOT INSTALLED
SURVIVABLE FLIGHT INFORMATION COLLECTION SYSTEM: INSTALLED/OPERATIVE
NAVIGATION SYSTEM INTEGRATED GPS: INSTALLED/OPERATIVE
(11)NA
(12)NA
C.INVOLVED EQUIPMENT. TBD
D.ENVIRONMENT.
(1)DATE:17 OCT 09
(2)TIME:1919L
(3)ZONE:SIERRA Local time zone (spell out)
(4)CONDN:DAY or NIGHT
(5)LOCN:CORPUS CHRISTI, TX Geographic location - state name of geographic area, body of water, nearest town or city, or a significant landmark.
(A)LATD: XXXXXX N (DDMMSS N/S format; fill leftmost digits with zeros as appropriate and rightmost digits with X's if required due to an imprecise location.) or TBD
(B)LONG: XXXXXXX W DDDMMSS E/W format or TBD
(C)STATE:TEXAS
(D)COUNTRY:USA
(E)FACILITY: NAS CORPUS CHRISTI, TX State name of shore facility.If facility is a ship, include name, followed by a slash and class - hull number, i.e., USS NIMITZ/CVN-68.If mishap did not occur in the vicinity of an identifiable facility, state NA.
(F)NAVAID: KNMM ICAO identifier of nearest named airfield or NAVAID or TBD
(G)BRG: 360 Magnetic bearing from NAVAID or TBD
(H)DIST: 001.0 distance from NAVAID or TBD
(I) AIRSPACE: CLASS DSelect from: CLASS A, CLASS B, CLASS C, CLASS D, CLASS E, CLASS G, VICTOR AIRWAY, JET ROUTE, IR, VR, ALERT AREA, MOA, WARNING AREA, RESTRICTED AREA, CARRIER CONTROL AREA, CARRIER CONTROL ZONE, N/A, ON DECK, UNKNOWNor TBD
(J)MISHAP SITE ELEVATION: 317 in MSL or TBD
(K)MISHAP/EMERGENCY ALTITUDE: 600 State altitudes as appropriate for mishaps occurring above the surface, or altitude of initial emergency onset or TBD
(6)WX AS BRIEFED. Provides forecasted weather and briefing data.For major mishaps where speed of release of the MDR is critical, it is better to submit the MDR with "TBD" on all weather lines.
(A)BRIEFED BY: FORECASTER Select one:FORECASTER; BRIEFER; PILOT; OTHER: (Describe); UNKNOWN; NOT APPLICABLE (Applies only when a briefing was not available and for events for which no wx brf was expected or required.) or TBD
(B)BRIEFING UTILIZATION: USED Select one: USED; NOT USED; NOT AVAILABLE; UNKNOWN; NOT APPLICABLE. (not applicable only applies to events for which a weather briefing would not normally be required.) or TBD
(C)AIR TEMP: 59 In degrees Fahrenheit or TBD
(D)RELATIVE HUMIDITY: 68 Forecast percentage of relative humidity or TBD
(E)DEWPOINT:52 In degrees Fahrenheit or TBD
(F)WATER TEMP: 52 In degrees Fahrenheit, or state "NA" or TBD
(G)WIND DIRECTION: 190 In degrees; if light and variable, state "0" or TBD
(H)WIND VELOCITY: 15 In knots; if light and variable, state "99" or TBD
(I)WIND GUSTS: 25 Velocity or "NONE FORECAST" or TBD
(J)CEILING: 20 In hundreds of feet AGL, first cloud layer classified as broken or overcast. If none is forecast state "NONE FORECAST" or TBD
(K)SKY CONDITION: 20 BKN 50 OVC 250 SCT In weather sequence format, forecast altitude/type of cloud layers or TBD
(L)HORIZON: VISIBLE Forecast horizon from one from the following: VISIBLE; OBSCURED; PARTIALLY OBSCURED; UNKNOWN or TBD
(M)VISIBILITY:10 In statute miles.If CAVU or unrestricted, state "99" or TBD
(N)OBSTRUCTIONS TO VISION: HAZE Select from the following all that apply: DUST; FOG; ICE FOG; GROUND FOG; HAZE; SMOKE; PRECIPITATION; BLOWING DUST; BLOWING SAND; BLOWING SPRAY; BLOWING SNOW; CLOUDS; OTHER: (specify) or TBD
(O)ALTIMETER SETTING: 29.92 Forecast altimeter setting in inches of mercury for the time and location of the mishap or nearest official weather facility or TBD
(P)ICING: LIGHT RIME Forecast icing conditions or state "NONE FORECAST" or TBD
(Q)PRECIPITATION: LIGHT RAIN Forecast/briefed precipitation: select all that apply from the following: DRIZZLE; LIGHT RAIN; HEAVY RAIN; HAIL; SLEET; LIGHT SNOW; HEAVY SNOW; FREEZING RAIN; FREEZING DRIZZLE; OTHER:(specify) or TBD
(R)EXTREME WX: THUNDERSTORM Forecast/briefed extreme weather conditions select all that apply from the following: TURBULENCE (IMC); CLEAR AIR TURBULENCE; GUSTY WINDS; TORNADO/WATERSPOUT; WIND SHEAR; HURRICANE/TYPHOON; THUNDERSTORM; SEVERE THUNDERSTORM; LIGHTNING; OTHER:(specify) or TBD
(S) BRIEFING ACCURACY: SUBSTANTIALLY CORRECT Select one of the following: SUBSTANTIALLY CORRECT; CONSIDERABLY BETTER THAN FORECAST; CONSIDERABLY WORSE THAN FORECAST; UNKNOWN; NOT APPLICABLE or TBD
(7)WX - PREVAILING. Provides weather data.For major mishaps where speed of release of the MDR is critical, it is better to submit the MDR with "TBD" on all weather lines.
(A)AIR TEMP: 59 In degrees Fahrenheit or TBD
(B)RELATIVE HUMIDITY: 68 Forecast percentage of relative humidity or TBD
(C)DEWPOINT: 52 In degrees Fahrenheit or TBD
(D)WATER TEMP: 52 In degrees Fahrenheit, or state "NA" or TBD
(E)WIND DIRECTION:190 In degrees; if light and variable, state "0" or TBD
(F)WIND VELOCITY:15 In knots; if light and variable, state "99" or TBD
(G)WIND GUSTS: 25 Velocity or "NONE FORECAST" or TBD
(H)CEILING: 20 In hundreds of feet AGL, first cloud layer classified as broken or overcast.If none exists, state "NONE PRESENT" or TBD
(I) SKY CONDITION: 20 BKN 50 OVC 250 SCT Altitude and type of all cloud layers or TBD
(J)HORIZON: VISIBLE Select one: VISIBLE; PARTIALLY OBSCURED; OBSCURED; UNKNOWN or TBD
(K)VISIBILITY: 10 In statute miles.If CAVU or unrestricted, state "99" or TBD
(L)OBSTRUCTIONS TO VISION: HAZE Select all that apply: DUST; FOG; ICE FOG; GROUND FOG; HAZE; SMOKE; PRECIPITATION; BLOWING DUST; BLOWING SAND; BLOWING SPRAY; BLOWING SNOW; CLOUDS; OTHER: (specify) or TBD
(M)ALTIMETER SETTING: 29.92 Barometric pressure in inches of mercury or TBD
(N)ICING: LIGHT RIME Provide any icing conditions present or state "NONE PRESENT" or TBD
(O)PRECIPITATION: LIGHT RAIN Select all that apply from the following: DRIZZLE; LIGHT RAIN; HEAVY RAIN; HAIL; SLEET; LIGHT SNOW; HEAVY SNOW; FREEZING RAIN; FREEZING DRIZZLE; OTHER:(specify) or TBD
(P)EXTREME WX: THUNDERSTORM Describe by selecting all that apply from the following: TURBULENCE (IMC); CLEAR AIR TURBULENCE; GUSTY WINDS; TORNADO/WATERSPOUT; WIND SHEAR; HURRICANE/TYPHOON; THUNDERSTORM; SEVERE THUNDERSTORM; LIGHTNING; OTHER: (specify) or TBD
(Q)RUNWAY CONDITION: WET Describe the condition by selecting from the following all that apply:NOT APPLICABLE (implies event not in the runway environment); DRY; WET; SLUSH; LOOSE SNOW; PACKED SNOW; ICE; PATCHY; SANDED; OILY; UNPREPARED; OTHER:(specify); UNKNOWN or TBD
(R)METEOROLOGICAL COMMENTS: LINE OF THUNDERSTOMRS RAPIDLY APPROACHING THE AIRFIELD Briefly describe any additional environmental/meteorological information deemed pertinent to the mishap or NA or TBD
E.SAFETY PROGRAMS.
(1)CO MAY 07
(2)ASO SEP 08
(3)SURVEY APR 09
3.CIRCUMSTANCES.
A.ORIGIN. NAS CORPUS CHRISTI, TX Name of the departure airfield.
B.MISSION. DAY FAM In plain language (cross country, Day Fam, inst training)
C.TOTAL MISSION REQUIREMENT CODE. 1D1
D.TYPE OF FLIGHT PLAN. VFR IN VMC State VFR, IFR, DVFR, etc., and (if known) if the pilot was or was not in instrument meteorological conditions at the time of mishap.
E.DESTINATION. NAS CORPUS CHRISTI, TX Next intended point of landing same manner as 3A above.
F.AIRCRAFT EVOLUTION. TAKE OFF Activity in which the aircraft was involved, i.e., climb, cruise, 30-degree dive, maintenance, etc.
4.MISHAP CLASSIFICATION.CLASS A FLIGHT MISHAP.INTENT FOR FLIGHT DID EXIST.AIRCRAFT DAMAGE ESTIMATED MORE THAN $2,000,000.NO INJURIES. or something like CLASS A FLIGHT MISHAP.AIRCRAFT DESTROYED.2 FATALITIES.
5.DAMAGE AND COSTS.
A.AIRCRAFT.DESTROYED IF AN AIRCRAFT WAS DESTROYED OR IF NOT, TBD
B.DOD PROPERTY DAMAGE.TBD
C.NON-DOD PROPERTY DAMAGE.TBD
6.PERSONNEL INFORMATION, INJURIES, AND COSTS.
A.SOULS ON BOARD.2 or whatever the number was
B.CREW.
(1) CREW DUTY: INSTRUCTOR PILOT, PILOT AT CONTROLS
RANK:LT
DESIG:1310
SERVICE:USN
PARENT ORG:CTW-4
DUTY STATUS:ON DUTY
INJURIES:FATAL or TBD
GENDER:MALE
NVD:NOT USED
TOTAL HOURS:TBD
HOURS IN MODEL:TBD
HOURS LAST 30 DAYS:TBD
HOURS LAST 60 DAYS:TBD
HOURS LAST 90 DAYS:TBD
(2) CREW DUTY: STUDENT NAVAL AVIATOR, PILOT NOT AT CONTROLS
RANK:ENS
DESIG:1395
SERVICE:USN
PARENT ORG:VT-28
DUTY STATUS:ON DUTY
INJURIES:FATAL or TBD
GENDER:MALE
NVD:NOT USED
TOTAL HOURS:TBD
HOURS IN MODEL:TBD
HOURS LAST 30 DAYS:TBD
HOURS LAST 60 DAYS:TBD
HOURS LAST 90 DAYS:TBD
C.TOTAL NUMBER OF PASSENGERS.NONE
(1)INJURED PASSENGERS.NONE
(2)UNINJURED PASSENGERS.NONE
D.INJURED NONOCCUPANTS.NONE or appropriate number or TBD
E.AEROMEDICAL ANALYSIS WILL BE SENT.
7.MISHAP INVESTIGATION. If any special requests, state here, otherwise NA.State the nature of help needed, when and where, and the source of the aid, if known.Requests for help from activities subordinate to the controlling custodian should be similarly addressed.Be sure the activity from whom you are requesting aid is an action addressee on the message. i.e
FOR CNATRA:REQUEST SALVAGE OF SUBMERGED WRECKAGE.
- LOCATION OF WRECKAGE, IF DIFFERENT FROM MISHAP LOCATION.
8.JAG MANUAL INVESTIGATION.THIS MISHAP DOES MEET THE REQUIREMENTS IN REF B FOR A JAG MANUAL INVESTIGATION.
9.AVIATION MISHAP BOARD.
SENIOR MEMBER:TBD unless already assigned by the Commodore or Skipper then CDR I. M. PILOT VT-XX.DSN: 637-XXXX, COMM: 601-679-XXXX, CELL: XXX-XXX-XXXX, FAX: 601-679-XXXX
AIRCRAFT OPERATIONS:LT O. SKEDSMAN, CTW-4 if any members are not yet confirmed then use TBD
AIRCRAFT MAINTENANCE:LT M. MAINTMAN, CTW-4 or TBD
AVIATION SAFETY:LT A. GREER, CTW-4 or TBD
FLIGHT SURGEON:LT D. FATFINGER, CTW-4 or TBD
BT
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