Initial Notification Form

Instructions

Please fill in the Initial Notification / Preliminary Report form. This form must be completed for all aircraft with a maximum certificated take-off weight above 2,250kg involved in an accident or serious incident (see Annex 13 for definition).

Fields with titles in bold are mandatory and fields with titles in italics are optional. Please note that the form cannot be submitted until all mandatory fields are filled. If you have left any mandatory fields blank when submitting the form, they will be filled in red.

Administrative Information

Report Type:

Reference/State File Number: Reporter's Organization:

Reporter Name: Reporter Position: Reporter Telephone: Reporter Email:

Organization Conducting Investigation: Scope of Investigation: Delegated To (if applicable):

Investigator Name: Investigator Position: Investigator Telephone: Investigator Email:

Classification

Occurrence Class: Accident Serious Incident Incident

Occurrence Categories:

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Dangerous Goods on Flight? Yes No Unknown

If Yes, UN Number:

Occurrence Details

Local Date: Local Time:

UTC Date: UTC Time:

State / Area of Occurrence:

Location of Occurrence:

Map

Click on the map below to mark the exact location of the event. You can move the marker by clicking in another spot. Click OK when done.

Latitude:	The latitude and longitude must be entered in decimal format. After entering the state/area of occurrence and location, click below to use the:
Longitude:

Weather Conditions:

Light Conditions:

Event Narrative:

Crew, Passengers and Injuries

Nationality of Pilot-In-Command: Pilot-In-Command Qualifications: Nationality of Co-Pilot: Co-Pilot Qualifications:

Injury Level: Persons On Board and Injuries:

	Crew	Passengers	Others
On Board
Fatal
Serious
Minor

Aircraft Information

Aircraft Remove

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Aircraft Type: Registration: State of Registry: Serial Number: Year of Build: Aircraft Manufacturer: Aircraft Model: Mass Group: Engine Manufacturer / Model:

Operator or Owner: Operation Type:

Damage Level: Destroyed Substantial Damage Minor Damage None Unknown

Departed From: Intended Destination: Phase of Flight: Aircraft Supplemental Narrative:

Occurrence Type:
Injury Level:
Local Date:
Local Time:
State/area of occurrence:
Location of occurrence:
Latitude of occurrence:
Longitude of occurrence:
Occurrence Categories:
Dangerous Goods on board:
Meteorological conditions:
Light conditions:

Nationality of Pilot-in-command:
Pilot-in-command qualifications:
Co-pilot nationality:
Co-pilot qualifications:

Aircraft type:
Damage level:
State of registry:
Registration number:
Manufacturer:
Type or model:
Serial number:
Year of construction:
Mass group:
Engines:
Operator:
Operation type:
Departed from:
Intended destination:
Flight phase:
Aircraft note:

Instructions

Map

Remove Aircraft

INITIAL NOTIFICATION / PRELIMINARY REPORT

Filing Information

Investigation Details

Occurrence

Injuries to Persons

Crew

Aircraft

EVENT NARRATIVE

Investigating Organization:
This investigation has been delegated to:
Investigator Contact: