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Aviation Safety Incident/Hazard Report

This is a confidential reporting system to alert the Safety Coordinator of incidents or hazards associated with our airport and flight program. This program is completely voluntary and although you are not required to give your name and contact information, if you wish for the safety coordinator to contact you in regards to your report then please submit with your information.

The information obtained through this system will allow the Safety Coordinator to ensure that our airport and flight operations are being conducted in a safe manner and that all hazards are identified and fixed. No attempt will be made to identify the reporter as long as the incident was unintentional and no crimes or violations were willfully committed.

Questions marked with an * are required information.

Date*
Time of incident*
Location*
Reporter CFI
Student Pilot
Pilot
Passenger
Dispatcher
Air Traffic Control
Line Service
Maintenance
Transient Pilot
Certificates/Ratings Student Pilot
Private Pilot
Intrument Rating
Commerical Pilot
Multi-Engine Rating
CFI
CFII
MEI
ATP
A & P
Weather Conditions* VMC
IMC
Marginal
Rain
Snow
Sleet
Ice
Mixed
Turbulence
Fog
Airport Type* Controlled
Uncontrolled
Airspace that incident occurred in* Class A
Class B
Class C
Class D
Class E
Class G
Not Applicable
Phase of Flight* Taxi
Takeoff
Climb
Cruise
Manuevering
Descent
Approach
Landing
Missed Approach
Visual Approach
Instrument Approach
Non-Flight
Name:
Phone Number:
Email Address:
In as much detail as possible, please describe the incident to include altitude, directon of flight, practice area. If more than one aircraft was involved please include information on other aircraft to include relation to other aircraft.*