Free Malfunction or Defect Report - Federal

OMB No. 2120-0003
08/31/2008 DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION ATA Code OPER. Control No.
DISTRICT OFFICE

8. Comments (Describe the malfunction or defect and the circumstances under which it occurred. State probable cause and recommendations to prevent recurrence.)

Enter pertinent data 2.

MANUFACTURER

MODEL/SERIES

SERIAL NUMBER

AIRCRAFT
3.

POWERPLANT
4.

PROPELLER
5. SPECIFIC PART (of component) CAUSING TROUBLE Part Name MFG. Model or Part No. Serial No. Part/Defect Location.
AIR TAXI MFG.

FAA

COMMUTER

OTHER

MALFUNCTION OR DEFECT REPORT

1.

A/C Reg. No.

N-

OPERATOR DESIGNATION

Comp/Appl Name

Manufacturer

Model or Part No.

Serial Number

MECH.

6. APPLIANCE/COMPONENT (Assembly that Includes part)

Part TT

Part TSO

Part Condition

7. Date Sub.

Accident; Date
FAA FORM 8010-4 (10-92) SUPERSEDES PREVIOUS EDITIONS

Incident; Date

Use this space for continuation of Block 8 (if required).

PAPERWORK REDUCTION ACT STATEMENT: The information collected on this form is used to evaluate certification standards, maintenance programs, and regulatory requirements. The information is required to ensure safety in air transportation. It is estimated that it will take approximately 9 minutes to complete the form. Providing this information is mandatory. No assurance of confidentiality is given. 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 control number for this collection of information is 2120-0003. 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

REP.STA.

Check a box below, if this report is related to an aircraft

SUBMITTED BY:

Optional Information:

TELEPHONE NUMBER

OPER.

(

)

U.S. Department of Transportation Federal Aviation Administration
Flight Standards Service Aviation Data Systems Branch P.O. Box 25082 Oklahoma City, OK 73125-5029

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