FORM APPROVED FOR USE THROUGH 7131 /96 BY OMB N0.3147-0001. NATONAL TRANSPORTATON SAFETY BOARD PLOT/OPERATOR ARCRAFT ACCDENT REPORT This form To Be Used For Reporting Civil Aircraft Accidents nvolving Commercial and General Aviation Aircraft Nearest Cityplace, State, Zip Code Date of Accident Local Time Zone (24 HOUR CLOCK) 1-13._ Elevation At Accident Site 2.0 FeetMSL Feet MSL Airport Name 251 i p Airport ldent Runway/Landing Surface Conditions: S F 2.a Length: 4.Q Surface: 1.a Direction: 3.Q Width: 5.0 Condition: Registration Mark Aircraft Manufacturer Aircraft Typehlodel Serial Number Cerl Max Gross WT Type Of Aircraft 1.0 Airplane 5.0 Blimp/Dirigible % Helicopter 6.m Ultralight 3.0 Glider 7.0 Gyroplane 4.m Balloon 8.m Specify Landing Gear 1.a Tricycle-fixed 4.0 Tailwheel-Retractable 7- Skid 2.m Tricycle-Retractable 5.m Tailwheel-Retractable Mains 8.0 Limited 3.0 Tailwheel-f-ixed 6.0 Amphibian 9.0 Specify Stall Warning System nstalled FR Equipped Engine Type yes 2.m No Engine Manufacturer Engineis) Engine No. 1 Engine No. 2 sh~n - 1.a Annual 2.0 Manufacturer's nspection Program 3.a Other Approved nspection Program(AAP) 4.0 Continuous Airworthiness 5.Q Specify Emergency Locator Engine ModelBeries _. :%;tlrs 3.0 AAlP 4.a Continuous Airworthiness Type Of Airworthiness Certificate Amateur Built lkl Normal 5.0 Restricted 1.a Yes 2.U Utility 6.0 Limited 2- No 3.Q Acrobatic 7.0 Experimental 4.0 Transport 8.0 Specify Engine Rated Power p17a d;kc-. 1. /h Horsepower 2. Lbs Thrust Type Of Fire Extinguishing System 1. None "7 2.Specify No. Of Seats 2 FlighVCabin Crew Pax 1 date of Mfg. Mfg. Serial No. Total Time Time Since nspection Time Since Overhaul ocray dv L i5-9iy-394 3y0bll. Hours 77, y Hours /?J?-/ Hours Hours Hours Hours Engine No. 3 Hours Hours Hours /p:/2-06 (MDN) Time Since Last nspection Airframe Total Time 7 3' Y Hours ELT Manufacturer ModelEeries Serial Number Battery Date (MDN) Operated 7 Hours perator Of Aircraft Same As Reaistered Owner 1 2. Name 3. DBS: TS6 Form 6120.1/2 (11/87)Thls Form replaces NTSB Forms6120.1 (re'#. 10177) and 6120.2 (Rev.lOn7) ddress Same As Registered Owner
lperator (Certificate Number) Operator Designator (4 Letter Designator) 3e ulation Flight Conductor Under Operator Authority FAR121 FAR 133!b d FAR91 (only) 4.0 FAR 121 7.0 FAR 133 1.0 Domestic 6.0 Rotorcraft FAR9lD 5.0 FAR 125 8.0 FAR 135 External Load 1.0 FAR 103 6.0 FAR 129 9.0 FAR 137 2.0 Flag 3.0 Supplemental Jurpose of Flight FAR1 25 1.0 Personal 6.0 Aerial Observation FAR 135 7.0 Large Aircraft 2.0 Business 7.0 Other Work Use 4.0 On Demand 3.d Educational 8.0 Public Use 5.0 Commuter FAR 129 4.0 Executive/Corporate 9.0 Ferry 8.0 Foreign 5.0 Aerial Application 10.0 Positioning FAR 121,125,127,129,135 Revenue Operations 1.0 Scheduled 2.0 Non Scheduled 3.0 Domestic 4.0 nternational 5.0 Passenger 6.0 Cargo 7. Specify Pilot Name Pilot Certificate No. Address 209 P,? AKk4 Nationality Rating (s) nstrument Rating (s) 1.0 None 6.dHelicopter 1.0 None 2.0 Single Engine Land 7.0 Glider 3.0 Single Engine Sea 8.0 Free Balloon 4.0 Multiengine Land 9.0 Airship 5.0 Multiengine Sea 10.0 Gyroplane Type Ratings/Student Endorsements Medical Certificate 1.0 None ivone 3& JW Class uass L 2 2.0 Class 1 4.0 Class 3 Date Of Biennial Flight Review or Equivalent (MDN) ':., 4 -m) Date Of Last Medical Limitation; A - (MDN) Waivers 1 gr"~",,",' Wry 4.0 Front 2.0 Minor 2.0 Right 5.0 Rear 3.0 Serious 3.0 Center 4.0 Fatal l0fi-c. nstructor Rating (s) 1.0 None 6.3 nstrument Airplane 2.0 Airplane S.E. 7. nstrument Helicopter 3.ZAirplane M.E 8.0 Ground nstructor 4. Helicopter 5.0 Glider 9.0 Specify BFR Aircraft Person At Controls At Time Of Accident Date Of Birth (MDN) 1.0 Pilot n Control 2.d Second Pilot 4.0 Non-Pilot 5.0 No One 2.a No 3.0 Both Pilots This Make & Model Last 90 Days Last 30 Days Last 24 Hours 1 S 17'5 O 75 LO Go 5 0 4 t 4 Pilot Name Pilot Certificate No. Address PNrG;- k\l ow c\w. Nationality k Page 2
Medical Certificate.d None 3.Q Class 2!.Q Class 1 4.Q Class 3 Date Of Last Medical (M Limitations Waivers Date Of Birth (M/D/Y) 3.Q Serious 2.0 Minor 4.Q Fatal Seat Occupied 1.Q Left 3.Q Center 5.a Rear 2.dRight 4.Q Front Seat Belt Available 1.d Yes 2.a No 1. 2. 3. 4. 5. Non- Name Seat Address (City 81 State) Crew Revenue Revenue 6. Flight tinerary nformation Last Departure Point Time Of Departure Destination Flight Plan Filed Non- Occupant FAA Fatal Serious Minor None 1. Airport D 1. Time PM,%&\ 1. Airport D 1.dNone 4.Q VFRllFR 2. City/Place 2.a VFR 5.a Company (VFR) 2. Time Zone 3. State 3.Q FR 6.Q Military (VFR) f Weather Was nvolved, State f Weather Briefing Was Obtained or f Weather Reports Were Checked And How t Was Accomplished or Pounds Fuel Type 1.0 80/87 4.Q 1151145 7.Specify 2.a 100 Low Lead 5.a Jet A 3.Q 100/130 6.Q Automotive Source Of Weather nformation (Pilot/Operator, Weather Observation) Light Condition Visibility Temp (OF) 3.m Dusk 5.a Dark Night %;iht 4.a Bright Night 7 Miles Page 3
Weather nformation At The Accident Site (cont.) lew Point 1 Altimeter SkyAowest Cloud Condition find nformation.direction. Velocity Kts. Gusts Kts Restriction To Visibility 4 0 Overcast Feet AGL 5.a Partial Obscuration 6.a Obscured Type Precipitation ntensity Of Precipitation 1.a Light 3.a Heavy 2.0 Moderate 4.Specify Jrbulerice (Multiple Entry) R None 2.a Light 3.a Moderate 4.0 Severe 5.0 Extreme 6.a Clean Air 7.Q n Clouds Damage To Aircraft And Other Property -0 None 4.a Destroyed lescription Of Damage To Aircraft And Other Property Fire 3.a n-flight 4.a On Ground At Overhaul Hours :olliiion Accident 1 Collision Accident Occurred, Complete The nformation For Other Aircraft 4ssistance Received 1.0 Outside Person (s) 2.0 Auxiliary Lighting 3.0 Slide 4.0 Rope 5.a Ladder 6.Q Specify Vlethod Of Exit (Stat Wroximate Number Of Persons Using Each Of The Following 1. Main Door 2. Auxiliary Door 3. Emergency Exit Recommendation (How Could This Accident Have Been Prevented) )perator/owner Safety Recommendation (Optional Entry) Page 4
Certificate@) 1.m Student 3.Q Commercial 5.Q Flight nstructor 7.0 Foreign 2.Q Private 4.0 Airline Transport 6.0 Flight Engineer &Specify RetingsEndorsements Total Flight Time Flight Time This Accident Name FAA Certificate No. Address Title RatingdEndorsements Total Flight Time Flight Time This Accident lname Certificate@) 1.0 Student 2.Q Private 1 FAA Certificate NO. Address 3.Q Commercial 5.0 Flight nstructor 4.0 Airline Transport 6.m Flight Engineer 7.m Foreign &Specify Title Ratings/Endorsements Total Flight Time Flight Time This Accident Page 5
escribe What Occurred n Chronological Order, The Circumstances Leading To The Accident And The Nature Of The Accident. Describe The errain and nclude a Sketch Of Wreckage Distribution f Pertinent. Attach Extra Sheets f Needed. State Point Of Departure, Time f Departure, ntended Destination And Services Obtained. Signature Of Person Filing Report Other Than PilotlOperator \- 1. Signature 2.Type Or Print Name 3. Title NTSB Accident No. Reviewed By NTSB Office Located At
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