Safety Event / Incident / Accident Report

This form is part of Mitiguy Aviation’s Safety Management System (SMS). The purpose of this report is to identify hazards, improve safety, and prevent future incidents or accidents.

This is a non-punitive reporting system. Honest reporting is encouraged and expected. Reports may be submitted anonymously.

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Full Name (optional)
Your information does not appear on the report.
Email Address (optional, for follow-up)
Your information does not appear on the report.
Phone Number (Optional)
Your information does not appear on the report.
Are you submitting this report anonymously? *
Type of Safety Event *
Did this event result in aircraft damage? *
Did this event result in injury? *
Date of Event *
MM
/
DD
/
YYYY
Local Time of Event *
Time
:
Airport or Location of Event *
Example: 6B6, practice area, ramp, runway, off-airport location
Aircraft Registration (N-Number) *
Type of Operation *
Phase of Flight *
Weather Conditions at the Time *
Wind Conditions (if known) *
Runway / Surface Conditions *
Describe what happened *
Please describe the sequence of events in your own words.
What factors do you believe contributed to this event? *
Examples: weather, aircraft performance, human factors, workload, training, maintenance, communications, procedures.
What actions were taken after the event? *
Examples: aircraft grounded, maintenance notified, instructor or management notified, flight terminated.
Do you believe this event could happen again? *
What could help prevent a similar event in the future? *
Training, procedures, briefings, equipment, policy changes, or other suggestions.
Are there any immediate safety hazards that should be addressed? *
May Mitiguy Aviation contact you for follow-up or clarification? *
Additional comments or information *
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