Bailey Moyes 912 Dragonfly, Maintenance Manual

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Appendix A -- Safety of Flight Reporting Form & Comment Form
(make copies of this page as needed)
Safety of Flight & Service Difficulty Report Form
Mail to: Pitman Air, 1840 Airport Blvd., Red Bluff, CA 96080 and/or Online at: www.pitmanair.com/dragonfly/
Check One
Item of
Concern Safety of Flight
Service
Difficulty
Reporting Party Contact
Information
Name
Address
City
ST
Zip Code
Day Phone #
FAX #
email
address
Check
Appropriate
Owner Operator LSRI LSRM A&P
Other Explain:
Aircraft Specific Information
Aircraft Information
Engine
Information
Make Make
Model Model
Serial
Number
Serial Number
N-Number Gearbox Ratio
Date of Mfg. Propeller Mfg
Propeller Serial #
Date of Problem Discovery dd/mm/yyyy
Description:
Comments
End Appendix A