Free Suspected Unapproved Parts Report - Federal

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OMB Approved 2120-0552 06/30/2009

SUSPECTED UNAPPROVED PARTS REPORT
Refer to page 2 for instructions on how to complete this form. 1. Date the Part Was Discovered: 2. Part Name: 3. Part Number: 5. Quantity: 6. Assembly Name: 4. Part Serial Number: 7. Aircraft Make & Model:

Assembly Number: 8. Name, Address, and Description of the Company or Person Who Supplied or Repaired the Part: Name: City: Country: State: Phone Number: Street Address: ZIP Code:

Check One of the Following Applicable to the Company or Person Who Supplied or Repaired the Part: Air Carrier ­ Certificate # Supplier Mechanic ­ Certificate # Production Approval Holder Repair Station ­ Certificate # Manufacturer Distributor Owner/Operator 9. Description of the Issue: Other Unknown

10. Name and Address of (the Company or Person) Where the Part Was Discovered: Name: City: Country: State: Phone Number: Street Address: ZIP Code:

Check One of the Following Applicable to the Company or Person Who Discovered the Part: Air Carrier - Certificate # Mechanic - Certificate # Repair Station - Certificate # Distributor Supplier Production Approval Holder Unknown 11. Date of This Report: 12. Check this box if you request anonymity - Do not complete blocks 13-15. FAA Inspector DOT/Office of Inspector General Defense Criminal Investigation Service Other Government Agency Foreign Civil Aviation Authority Owner/Operator Other

13. Name and Address of the Reporter: Name: City: Country: 14. 15. 16. Check this box if you request confidentiality. Check this box if you do not wish to receive an acknowledgment letter. Check this box if you have attached additional information.
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Street Address: State: Phone Number: ZIP Code:

FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition

Instructions for Completing FAA Form 8120-11, Suspected Unapproved Parts Report
1. 2. 3. 4. 5. 6. Record the date the part was discovered. Record the part name (or a description of the part). Record the part number or identification number of the part. Record the serial number on the part, if applicable. Record the quantity of parts. Record the assembly name and assembly number (where the part was or could be installed). Part Name: Strut Part Number: PN 12345 Serial Number: 678 Assembly Name: Main Landing Gear Assembly Number: PN 90101112 Quantity: 1

Example:

Note: Record additional part numbers on page 3 or a blank sheet of paper with the following column headers: Part Name -- Part Number -- Serial Number -- Quantity -- Assembly Name -- Assembly Number 7. Record the type of aircraft the part was (or could be) installed on. 8. Record the complete name and address of the company or person who produced, repaired, and/or sold the part. Do not list a P.O. Box address unless a street address is not available. Check the box that describes the company or person. Provide the certificate number, if known. Air Carrier - An FAA-certificated company or person who undertakes directly by lease, or other arrangement, to engage in air transportation. Mechanic - A person holding an FAA mechanic certificate with airframe and/or powerplant ratings. Supplier - A company or person who furnishes aircraft parts or related services, at any tier, to the producer of a product or part thereof. Production Approval Holder - A company or person holding one of the following four types of FAA production approvals: production certificate, approved production inspection system, parts manufacturer approval, or technical standard order authorization. Manufacturer ­ The original equipment manufacturer (OEM.) Other-Record other type of business. Unknown

Repair Station - An FAA-certificated repair station. Distributor - A broker, dealer, reseller or other person or agency engaged in the sale of parts. Owner/Operator - The owner or operator of an aircraft.

9. Record a brief narrative stating why you believe the part is not approved. Include a description of the part (improper configuration, suspect marking, different material, etc.), where it was obtained, and what type of documentation was supplied with it. 10. Record the complete name and address of the location where the part was found. Check the appropriate block to reflect the affiliation of the company or person who discovered the part. 11. Record the date the FAA Form 8120-11 is being submitted. 12. Check this box if you request anonymity (do not wish to provide your identity), and do not complete 13, 14 or 15. 13. Record your name, address and phone number, if desired. This information will enable the FAA to contact you for additional information, if necessary. 14. Check this box if you request confidentiality of your personal information recorded in block 13. 15. Check this box if you do not wish to receive a letter acknowledging the FAA's receipt of FAA Form 8120-11. 16. Check this box if you have provided additional information (photos, invoices, certification statements, etc.) Forward the completed FAA Form 8120-11, Suspected Unapproved Parts Report, to: Federal Aviation Administration Office of Accident Investigation, Aviation Safety Hotline, Rm 840 800 Independence Avenue, SW, Washington, DC 20591 An electronic copy of FAA Form 8120-11, Suspected Unapproved Parts Report, is available on the FAA website at http://www.faa.gov/aircraft/safety/programs/sups. You may complete the electronic FAA Form 8120-11 and send it to the Aviation Safety Hotline e-mail: [email protected]. The Hotline phone number is (800) 255-1111. Privacy Act and Paperwork Reduction Act Statement:
An agency may not conduct or sponsor, and a person is not required to respond, to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this form is 2120-0552. This information is collected by the FAA's Suspected Unapproved Parts (SUP) Program, under the authority of 49 USC 44701. The information will be used to support SUP investigations and management reports. Submission of this information is voluntary, with questions limited to reduce any burden on the reporter. Completion of this form is estimated to take 30 minutes. Information collected is not available elsewhere and necessary to support the FAA's commitment to promote safety. Information is routinely shared with law enforcement agencies for use in civil and criminal investigations. Information developed from this form is covered under the Privacy Act system of records DOT/FAA 852 and the routine uses of that system will apply. A reporter may request confidentiality of personal information to the extent permitted by the Freedom of Information Act (5 USC 552) and the Privacy Act (5 USC 552a).

FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition

Local Reproduction Authorized

Page 2

FAA Form 8120-11, Suspected Unapproved Parts Report Continuation Sheet Page ( ) of ( ) Part Name Part Number Serial Number Quantity Assembly Name Assembly Number

FAA Form 8120-11 (10/16/2003) Supersedes Previous Edition

Local Reproduction Authorized