Reporting form

With the exclusive aim of preventing future incidents or limiting the consequences thereof, the Board has the task to investigate and establish the causes or probable causes of individual incidents or categories of incidents and of the extent of the consequences thereof and, if necessary, to make recommendations accordingly. The investigation will in no way target blame or liability.

The issued data are protected by the Kingdom act concerning the Dutch Safety Board and will not be forwarded to third parties, unless the person who issued the data gives his or her explicit permission to do so.

After evaluation of the gathered information the Dutch Safety Board will decide if the occurrence will be further investigated. If the Board decides to draw up a report the involved parties will be given the opportunity to view, and give their comments on the draft report

Personal information

M F

Experience (in hours)

Occurrence:

Aircraft Information

Yes No

VFR IFR

PURPOSE OF FLIGHT

Event phase

Consequences

No consequences
Rejected take-off
Engine(s) shutdown
Diversion
Turn back
Precaution landing
Flight delayed/cancelled
Fuel dump

Configuration at event

ENVIRONMENTAL DETAILS

Wind

Cloud

Percipitation

Other meteorological conditions

IMC VMC

Bird strike

1 2 - 10 11 - 100 More

1 2 - 10 11 - 100 More

Ground found (failures found during pre - and postflight inspection)

TYPE OF OCCURRENCE/FINDING

Significant Damage/Deterioration
A/C Docs out of Compliance
Spilling Causing Hazard to A/C
Significant System Failure
Parts missing in flight
Transit Damage
Incorrect Parts Supplied
Incorrect Parts / Fluids used
Incorrect Assembly / Installation
U/S on Fit
Other

Description

Describe the event in your own words
(If necessary please clarify with a drawing of the situation and/or (digital) photographs)

What in your opinion caused the event?

Have you got any further remarks regarding this event?

If necessary please clarify with a drawing of the situation and/or (digital) photographs

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