APPENDIX 3
Incident Reporting Form
Incident Reporting
AutoGyro Form AG-F-AIR-V2.A
This form is supplied to enable the owner/operator to inform (anonymously, if needed) AutoGyro
GmbH of any incident, accident, or other field or service failure that they feel appropriate. The owner
must also, of course, inform the relevant authorities if that is appropriate, e.g. Air Accident
Investigation Branch etc.
Depending on the incident information supplied, a corrective action is investigated and, if needed,
supplied back to the customer(s).
The information is stored in a database and is only used within AutoGyro GmbH for the above
purpose.
Return this form to:
AutoGyro GmbH
Dornierstraße 14
31137 Hildesheim or E-Mail to [email protected]
Aircraft Type:
Serial Number (Werk-Nr.):
Registered at:
(Airworthiness authority)
Registration / Call Sign:
Year of manufacture:
Engine Type:
Airframe S/N:
Rotor System S/N:
Engine S/N:
Airframe hours:
Rotor System hours:
Engine hours:
Description of incident (be as precise as possible and use extra sheets if needed)
Incident reported by (information is only stored for further inquiry and deleted after investigation)
Signature and Date
Below fields are used for AutoGyro internal processing – do not fill in!
Investigation completed
Corrective action
Internal reference
