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OMB No. 2120-0003
1. Submitter Information
(a) Unique Control #
(b) Difficulty Date
(mm/dd/yyyy)
(c) Registration #
(d) Submitter Type
A - CARRIER PART 121
B - REPAIR STATION PART 145
C - OPERATOR PART 91
D - MECHANIC
E - CARRIER PART 135
F - MANUFACTURER
G - FEDERAL AVIATION ADMIN
H - OTHER
I - AIR TAXI PART 125
L - EXTERNAL LOAD PART 133
M - MILITARY
P - PILOT
S - LIGHT SPORT ACFT
W - FOREIGN PART 129
Z - NON CERT INTERNATIOAL
2. Codes
(a) Operator Designator
(b) Operator Type
--Choose Type--
Air Carrier
General Aviation
(c) JASC/ATA Code
(d) Stage of Operation
AA - AIR AMBULANCE
AB - AEROBATIC
AG - AGRICULTURE
AP - APPROACH
CL - CLIMB
CR - CRUISE
DE - DESCENT
EX - EXTERNAL LOAD
FF - FIRE FIGHTING
HO - HOVERING
IN - INSP/MAINT
LD - LANDING
MS - MAPPING/SURVEY
NR - NOT REPORTED
TO - TAKEOFF
TX - TAXI/GRND HDL
UK - UNKNOWN
(e) How Discovered
9 - Unknown
B - Boroscope
C - Functional Check
D - Dye Penetrant
E - Eddy Current
L - Light Source
M - Magnetic Particle
O - Other
T - Thermal
U - Ultrasonic
V - Visual
W - Magnified Visual
X - X-Ray
(f) Nature of Condition
A - FLAME/FIRE
B - SMOKE/FUMES/ODORS/SPARKS
C - F.O.D.
D - INFLIGHT SEPARATION
E - VIBRATION/BUFFET
F - FLT CONT AFFECTED
G - MULTIPLE FAILURE
H - ELECT. POWER LOSS-50 PC
I - FLT. ATTITUDE INST.
J - WARNING INDICATION
K - FLUID LOSS
L - NO TEST
M - OVER TEMP
N - FALSE WARNING
O - OTHER
P - NO WARNING INDICATION
R - PARTIAL RPM/PWR LOSS
S - AFFECT SYSTEMS
T - ENGINE CASE PENETRATION
W - INADEQUATE Q C
X - ENGINE FLAMEOUT
Y - ENGINE STOPPAGE
Z - SIGNIFICANT FAILURE REPORT
A - FLAME/FIRE
B - SMOKE/FUMES/ODORS/SPARKS
C - F.O.D.
D - INFLIGHT SEPARATION
E - VIBRATION/BUFFET
F - FLT CONT AFFECTED
G - MULTIPLE FAILURE
H - ELECT. POWER LOSS-50 PC
I - FLT. ATTITUDE INST.
J - WARNING INDICATION
K - FLUID LOSS
L - NO TEST
M - OVER TEMP
N - FALSE WARNING
O - OTHER
P - NO WARNING INDICATION
R - PARTIAL RPM/PWR LOSS
S - AFFECT SYSTEMS
T - ENGINE CASE PENETRATION
W - INADEQUATE Q C
X - ENGINE FLAMEOUT
Y - ENGINE STOPPAGE
Z - SIGNIFICANT FAILURE REPORT
A - FLAME/FIRE
B - SMOKE/FUMES/ODORS/SPARKS
C - F.O.D.
D - INFLIGHT SEPARATION
E - VIBRATION/BUFFET
F - FLT CONT AFFECTED
G - MULTIPLE FAILURE
H - ELECT. POWER LOSS-50 PC
I - FLT. ATTITUDE INST.
J - WARNING INDICATION
K - FLUID LOSS
L - NO TEST
M - OVER TEMP
N - FALSE WARNING
O - OTHER
P - NO WARNING INDICATION
R - PARTIAL RPM/PWR LOSS
S - AFFECT SYSTEMS
T - ENGINE CASE PENETRATION
W - INADEQUATE Q C
X - ENGINE FLAMEOUT
Y - ENGINE STOPPAGE
Z - SIGNIFICANT FAILURE REPORT
(g) Precautionary Procedures
A - UNSCHED LANDING
B - EMER. DESCENT
C - ABORTED TAKEOFF
D - RETURN TO BLOCK
E - ENGINE SHUTDOWN
F - ACTIVATE FIRE EXT.
G - O2 MASK DEPLOYED
H - DEACTIVATE SYST/CIRCUITS
I - CABIN DEPRESSURIZATION
J - DUMP FUEL
K - NONE
L - ABORTED APPROACH
O - OTHER
R - AUTOROTATION
A - UNSCHED LANDING
B - EMER. DESCENT
C - ABORTED TAKEOFF
D - RETURN TO BLOCK
E - ENGINE SHUTDOWN
F - ACTIVATE FIRE EXT.
G - O2 MASK DEPLOYED
H - DEACTIVATE SYST/CIRCUITS
I - CABIN DEPRESSURIZATION
J - DUMP FUEL
K - NONE
L - ABORTED APPROACH
O - OTHER
R - AUTOROTATION
A - UNSCHED LANDING
B - EMER. DESCENT
C - ABORTED TAKEOFF
D - RETURN TO BLOCK
E - ENGINE SHUTDOWN
F - ACTIVATE FIRE EXT.
G - O2 MASK DEPLOYED
H - DEACTIVATE SYST/CIRCUITS
I - CABIN DEPRESSURIZATION
J - DUMP FUEL
K - NONE
L - ABORTED APPROACH
O - OTHER
R - AUTOROTATION
A - UNSCHED LANDING
B - EMER. DESCENT
C - ABORTED TAKEOFF
D - RETURN TO BLOCK
E - ENGINE SHUTDOWN
F - ACTIVATE FIRE EXT.
G - O2 MASK DEPLOYED
H - DEACTIVATE SYST/CIRCUITS
I - CABIN DEPRESSURIZATION
J - DUMP FUEL
K - NONE
L - ABORTED APPROACH
O - OTHER
R - AUTOROTATION
(h) FAA Region
(i) District Office
(j) Flight Number
3. Major Equipment Identity
Manufacturer
Model
Serial Number
Total Time
(hours)
Total Cycles
(a) Aircraft
(b) Engine
(c) Propeller
4. Problem Description
(Note: Please limit your description to 1500 characters.)
Your description is
0
characters in length.
5. Specific Part or Structure Causing Difficulty
(a) Part Name
(b) Manufacturer's Name
(c) Part Number
(d) Serial Number
(e) Part Condition
(f) Part/Defect Location
(g) Total Time
(hours)
(h) Total Cycles
(i) Time Since
(hours)
--Choose Location--
Zone 100 - Fuselage Lower
Zone 200 - Fuselage Top
Zone 300 - Stabilizers
Zone 400 - Nacelles/Pylons
Zone 500 - Left Wing
Zone 600 - Right Wing
Zone 700 - Landing Gear
Zone 800 - Doors
Zone 900 - Lavatories & Galleys
OR
Overhaul
Repair
Inspection
Reset
6. Component/Assembly That Includes Defective Part
(a) Component Name
(b) Manufacturer's Name
(c) Part Number
(d) Serial Number
(e) Model Number
(f) Location
(g) Total Time
(hours)
(h) Total Cycles
(i) Time Since
(hours)
Overhaul
Repair
Inspection
Reset
7. Submitted By
(This Information is used by the FAA to contact you, only if additional information about the submission is needed and then is removed.)
Name
Telephone
Email Address
Paperwork Reduction Act Statement:
The information collected is used to evaluate certification standards, maintenance programs, regulatory requirements. The information is required to ensure safety in air transportation. We estimate that it will take 9 minutes to complete. Use of this form is mandatory. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with this collection is 2120-0003.
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