Free BIRD / OTHER WILDLIFE STRIKE REPORT - Federal

Form Approved OMB NO. 2120-0045 09/30/2006

BIRD / OTHER WILDLIFE STRIKE REPORT
U S. Department of Transportation Federal Aviation Administration

1. Name of Operator

2. Aircraft Make/Model

3. Engine Make/Model

4. Aircraft Registration

5. Date of Incident /
Month Day

6. Local Time of Incident /
Year Dawn Day Dusk Night HR AM MIN PM

7. Airport Name

8. Runway Used

9. Location if En Route (Nearest Town/Reference & State)

10. Height (AGL) 12. Phase of Flight A. Parked B. Taxi C. Take-off Run D. Climb E. En Route F. Descent G. Approach H. Landing Roll

11. Speed (IAS) 13. Part(s) of Aircraft Struck or Damaged Struck A. Radome B. Windshield C. Nose D. Engine No. 1 E. Engine No. 2 F. Engine No. 3 G. Engine No. 4 Damaged H. Propeller I. Wing/Rotor J. Fuselage K. Landing Gear L. Tail M. Lights N. Other: (Specify) Struck Damaged

14. Effect on Flight None Aborted Take-Off Precautionary Landing Engines Shut Down Other: (Specify) 17. Bird/Other Wildlife Species

15. Sky Condition No Cloud Some Cloud Overcast

16. Precipitation Fog Rain Snow None

18. Number of birds seen and/or struck Number of Birds Seen Struck 1 2-10 11-100 more than 100

19. Size of Bird(s) Small Medium Large

20. Pilot Warned of Birds

Yes

No

21. Remarks (Describe damage, injuries and other pertinent information)

22. Aircraft time out of service: hours Reported by (Optional)

DAMAGE / COST INFORMATION 23. Estimated cost of repairs or replacement (U.S. $):
$

24. Estimated other Cost (U.S. $) (e.g. loss of revenue, fuel, hotels):
$

Title

Date

Paperwork Reduction Act Statement: The information collected on this form is necessary to allow the Federal Aviation Administration to assess the magnitude and severity of the wildlifeaircraft strike problem in the U.S. The information is used in determining the best management practices for reducing the hazard to aviation safety caused by wildlife-aircraft strikes. We estimate that it will take approximately 6 minutes to complete the form. The information collected is voluntary. Please note that 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 associated with this collection is 2120-0045. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20

FAA Form 5200-7 (11-97) Supersedes Previous Edition

Electronic Version (Adobe)

* U.S. GPU:1997-432-349/74201

NSN: 0052-00-651-9005

U.S. Department of Transportation

Federal Aviation Administration
800 Independence Ave. S.W. Washington, D.C. 20561 Official Business Penalty for Private Use, $300

NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES

BUSINESS REPLY MAIL
FIRST CLASS PERMIT NO. 12438 WASHINGTON D.C. POSTAGE WILL BE PAID BY FEDERAL AVIATION ADMINISTRATION

Federal Aviation Administration Office of Airport Safety and Standards, AAS-310 800 Independence Avenue, SW WASHINGTON, DC 20591

FOLD AND TAPE HERE


Directions for FAA Form 5200-7
Bird/Other Wildlife Strike Report
1. Name of Operator - This can be an airline (abbreviations okay - UAL, AAL, etc.), business (Coca Cola), government agency (Police Dept., FAA) or if a private pilot, his/her name. 2. Aircraft Make/Model - Abbreviations are okay, but to include the model (e.g. B737-200). 3. Engine Make/Model - Abbreviations are allowed (e.g., PW 4060, GECT7, LYC 580). 4. Aircraft Registration - This means the N# (for USA registered aircraft). 5. Date of Incident - Give the local date, not the ZULU or GMT date. 6. Local Time of Incident - Check the appropriate light conditions and fill in the hour and minute local time and check AM or PM or use the 24 clock and skip AM/PM. 7. Airport Name - Use the airport name or 3 letter code if a US airport. If a foreign airport, use the full name or 3 letter code and location (city/country). 8. Runway used - Self explanatory. 9. Location if En Route - Put the name of the nearest city and state. 10. Height AGL - Put the feet above ground level at the time of the strike (if you don't know, use MSL and indicate this). For take-off run and landing roll, it must be 0. 11. Speed (IAS) - Speed at which the aircraft was traveling when the strike occurred. 12. Phase of Flight - Phase of flight during which the strike occurred. Take-off run and landing roll should both be 0 AGL. 13. Part(s) of Aircraft Struck or Damaged - Check which parts were struck and damaged. If a part was damaged but not struck indicate this with a check on the damaged column only and indicate in comments (#21) why this happened (e.g., the landing gear might be damaged by deer strike, causing the aircraft to flip over and damage parts not struck by deer). 14. Effect on Flight - You can check more than one and if you check (Other", please explain in Comments (#21). 15. Sky condition - Check the one that applies. 16. Precipitation - You may check more than one. 17. Bird/Other Wildlife Species - Try to be accurate. If you don't know, put unknown and some description. Collect feathers or remains for identification for damaging strikes. 18. Number of birds seen and/or struck - check the box in the Seen column with the correct number if you saw the birds/other wildlife before the strike and check the box in the Struck column to show how many were hit. The exact number, can be written next to the box. 19. Size of Bird(s) - Check what you think is the correct size (e.g. sparrow = small, gull = medium and geese = large). 20. Pilot Warned of Birds - Check the correct box (even if it was an ATIS warning or NOTAM). 21. Remarks - Be as specific as you can. Include information about the extent of the damage, injuries, anything you think would be helpful to know. (e.g., number of birds ingested). 22. Aircraft time out of service - Record how many hours the aircraft was out of service. 23. Estimated cost of repairs or replacement - This may not be known immediately, but the data can be sent at a later date or put down a contact name and number for this data. 24. Estimated other cost - Include loss of revenue, fuel, hotels, etc. (see directions for #23). 25. Reported by - Although this is optional, it is helpful if questions arise about the information on the form (a phone number could also be included). 26. Title - This can be Pilot, Tower, Airport Operations, Airline Operations, Flight Safety, etc. 27. Date - Date the form was filled out.