Wess Aviation Hazard Report - Additional Aircraft Worksheet

WESS AVIATION HAZARD REPORT - ADDITIONAL AIRCRAFT WORKSHEET

INVOLVED AIRCRAFT (May have more than one - but enter only one at a time in application)

63. Branch of Service (i.e., USN, USMC, USAF, etc)

64. Controlling Custodian (i.e., CNAL, CNAP, CMFP, 4th MAW, Other, etc)

64A. If other US Government (Specify)

64B. If other (Specify)

65. Intent for flight? (Circle one) YES NO

66. Aircraft UIC

67. Aircraft Model/Series

68. Aircraft BUNO

69. Aircraft Tail Code & Side No.

70. Activity Status (Circle one) Embarked Ashore

71. Type of Operations (Circle one) Extended Deployment Short Term Ops/Detachment

Home Based/Local Ops X-Country/RON N/A Not yet reported Unknown

72. Pre-Deployment Work-ups (Circle one) YES NO

73. Readiness Cycle (IDRC) Phase

74. Airway/Operating Area (For this specific Aircraft - may be different from event location)

75. Emergency Landing (Circle one) Precautionary Immediate Forced Simulated Forced

N/A

76. Flight Demo (Circle one) Air show Practice Simulated Emergency TYCOM Demo CNO/CMC Approved Show N/A

77. FCF? (Circle one) YES NO

78. TFOA? (Circle one) YES NO

79. Destination (i.e., NAS Oceana, USS Nimitz, etc)

80. Flight Duration (HH:MM)

81. TFOA (What Fell off, if applicable)

82. Engine Involved: (Circle one) YES NO Unknown

83. FOD to Engine? (Circle one) Internal Source External Source N/A

84. FOD not to Engine: (Circle one) YES NO

85. NVD Used? (Circle one) YES NO

86. Landing Lights (Circle one) On Off Unknown N/A

87. External Lights (Circle one) On Off Unknown N/A

88. Safety Locking Devices (i.e., Ejection seat pins, Landing gear pins, etc. Circle one)

Misused Used Correctly N/A

89. Engine Power Loss (Required if Engine involved = Yes. Circle all that apply)

Complete Loss (not Pilot induced, not result of precautionary securing)

Complete Loss (Pilot induced, result of precautionary securing)

Fuel Exhaustion / Starvation Oil Starvation Partial Loss Unknown or N/A

90. Hazardous Foreign Object (Required if FOD = anything other than NO or N/A. Provide all that apply)

91. Landing Quals (Circle one) FCLP CQ DLQ N/A

92. Aircraft Fire (Circle one) Fire in Flight Fire on Deck No Fire Unknown

93. Shipboard Landing (Circle one) YES NO

94. Aircraft Diverted (Circle one): Ship to Shore Shore to Ship Ship to Ship Shore to Shore

N/A

95. ATC Agency

96. Heading (Degree Magnetic)

97. Airspeed (KIAS)

98. Altitude MSL AGL (Circle one)

99. Altimeter Setting and Source (i.e., Tower, Approach, By rule)

100. Type of Flight Plan (i.e., IFR, VFR, Combo, etc)

101. FPR/TMR Code (i.e., 1A1, 2L6, etc)

102. Actual Meteorological Conditions (Circle one) IMC VMC

102A. Estimated Continuous IMC time as it relates to event (if applicable)

103. Aircraft Mission Remarks:

104. Tape Load (OFP) Tape Load (FCS)

105. Take-off Location (Circle one) Shore Ship at Sea Ship Pierside

105A. CONUS? (Circle one) YES NO

105B. Country (If take off location = shore or ship pierside)

105C. State / Province (If Country = US/Canada)

105D. Ship is (Circle one If take off location = ship at sea) Anchored Underway Pierside

Underway Not Yet Reported

105E. Body of Water

105F. Latitude N / S Longitude E / W