Ultralight Accident Report

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Reporter:

Name:
E-mail Address:
Address:
City:
State:	Zip Code:
Phone:

Note: This information is kept confidential. It is only used, in case we want to contact you for clarifications on this form.

A. General Information:

1. Type:

2. Injuries:

3. Damage:

4. Date Of Occurence:

(mm/dd/yyyy)

5. Time:

(local)

6. Location (city or town, state, and site name):

7. Brief Description:

B. Operator:

1. Name And Address:

2. Registered With USUA?:

3. Age:

4. Sex:

5. Weight:

6. Operator's Ultralight Experience:

Total hours of instruction:		Hours in make/model:
Hours flown last 6 months:		Time since last flight:
Total UL hours:		Months of UL experience:
Other:

7. FAA Rating(s)?:

8. Condition: Other:

C. Vehicle:

1. Make And Model:

2. Serial Number: 3. Engine:

4. Registered With USUA?: 5. USUA Registration Number: (if applicable)

6. Modifications:

7. Hours On Vehicle: 8. Persons On Board:

9. Equipment:

ASI	Parachute
Helmet	Other:

10. Ownership: Other:

11. Storage: Other:

D. Location:

1. Area: Other:

2. Site/Terrain:

3. Airspace: Other:

4. Elevation: (MSL)

E. Flight History:

1. Source of Flight: Other:

2. Purpose Of Flight: Other:

3. Phase Of Flight: Other:

4. Length Of This Flight: (hh:mm)

5. Altitude: (above ground level)

F. Weather:

1. Sky Conditions:

2. Light:

3. Turbulence:

4. Visibility: (miles)

5. Temperature: (F)

6. Wind Velocity: (mph) Gusting to: (mph)

G. Additional Information:

1. Third Party Injuries:

2. Third Party Damage: Other:

3. Components Damaged:

4. Cause Factors:

Unknown:		Ultralight Design:
Inadequate Instruction:		Unauthorized Operations:
Unauthorized Modifications:		Weather
Pilot Induced Oscillations:		Structural:
Improper Power Management:		Aerobatics:
Improper Use Of Controls:		Power Lines:
Collision With Ground Object:		Medically Impaired:
Buzzing/Flying Too Low:		Inadequate Preflight:
Fuel Starvation:		Control System Failure:
Fuel Exhaustion:		Flying Under The Influence:
Inadequate Operating Site:		Midair Collision:
Vortex Turbulence:		Pilot Error:
Darkness:		Engine Failure:
Foreign Object In Prop:		Inadequate Maintenance:
Failure To Maintain Flight Speed:		Manufacturer Defect:
Drive Train Failure:

Other:

Note: If you want to save a copy of this report, please print this screen before pressing the Submit button.

Thank you!

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