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Accident/Inciden t Dateffime
Accident/Inciden t Location
Nearest City/Place:
ZIP: 2_0(, lq
Latitude:
~8
CA L I r:=t> R
flit A
Country:
v~A
tiJ
5f)
State:
Longitude:
fr1 Q
1b
3~
..... :..' ,\
.AIRCRAFtINEGRM~116N'
Registration Number: .A/ 4 3 2. j-L.
PtPcll... f} I R...C..R..Y-\~ T
Manufacturer:
PA ?...R-
Serial Number:
Amateur-Built: CYes
@No
Category of Aircraft
8Airplane
CBalloon
C Blimp/Dirigible
CGiider
CGyroplane
CHelicopter
C Powered Lift
CRocket
Ultralight
CUnknown
Time Zone:
' ; '<
.... .. : ;.
;
Number of Seats:
JLV o
2.0 - f:-2A
ONe.
Engine Type (Select one)
CLiquid Rocket
0 Reciprocating
CSolid Rocket
CTurbo Shaft
CHybrid Rocket
CTurbo Prop
CNone
CTurboJet
CUnknown
CTurboFan
CElectric
Landing Gear
(Check all that apply)
0Retractable
II!!ITricycle
OTailwheel
DAmphibian
DEmergency Float
OF Ioat
OHull
DHighSkid
0Skid
0Ski
0Ski!Wheel
0Unknown
0None
Manufacturer's
Serial Number
Number of Engines:
p-~
Date
of Mfg.
mmlddlyyyy
Total
Rated Power
@) Horsepower or Time
l(honrs)
C lbs of Thrust
I So
ti'-ID
Time Since:
Inspection Overhaul
I (boors) I (boors)
(D
Eng.2
Eng.3
Eng. 4
Propeller 1
Ccontinuous Airworthiness
C Conditional Inspection
CUnknown
l iD
2.c>i 5
mmlddlyyyy
hrs
Airframe Total Time: (0 .Oe>l:>
one)
(Select
at
measured
hours
t>Time of Accident/Incident
CLast Inspection
'
lbs
Engine
Model/Series
<~iI
lbs
Enl!ine Manufacturer
!:.; . .
Make:
C Original Design
Ly.vc..o---n .. iV'I
.. , <
EST'
If Yes: CKit/Plans
Eng. I
. :
8 oo (2m
COn-ground Iii} None
I q II
Enl!ine
Local Time:
oo_"j
Lt 1)
28-712.. 52.\ '1
Year of Manufacture:
[01_(!)()
mmlddlyyyy
Model:
t2..
Date:
ti)Fixed Pitch
CControllable Pitch
CGround Adjustable
Propeller 2
Manufacturer:
Manufacturer:
Model:
Model:
C Fixed Pitch
C Controllable Pitch
CGround Adjustable
City: \7(~\u
Name: Pr.rT'-")(e,.v\
R_,v:zt<
Yes
{llfW'-(
clvb
e'-{liV9
State:
0
0
OFAR415
0FAR431
0FAR435
0FAR437
QDomestic
International
Scheduled or Commuter
Non-Scheduled or Air Taxi
0Passenger
QCargo
0 Mail Contract Only
(Select one)
0
0
Aerial Application
Aerial Observation
OAirDrop
0 Air Race/Show
OBannerTow
QBusiness
0 Executive/Corporate
0 External Load
QFerry
OUnknown
OFAR 129
0FAR 133
QFAR 135
OFAR 137
@)FAR91
QFAR 103
OFAR 121
0FAR 125
ZIP:------ --
State: - - - - - - -
OAirCargo
0Foreign Air Carriers (FAR 129)
ORotorcraft External Load (FAR 133)
0Commuter Air Carrier (FAR 135)
Don-Demand Air Taxi (FAR 135)
0Commercial Air Tour (FAR 136)
0Agricultural Aircraft (FAR 137)
0Pilot School (FAR 141)
0Certificate of Authorization or Waiver
0Commercial Space Transportation
Experimental Permit
0Commercial Space Transportation License
0 Other Operator of Large Aircraft
ZIP:
HI None
ft1 j)
Country:_u__s_~------------------------
No
t--e;T Rw'e(L...-
QYes
@)No
QUnknown
Firefighting
0Fiight Test
OGiiderTow
8 Instructional
00ther Work Use
0Personal
0Positioning
0Skydiving
f)No
ij2'sm
Distance F rom Airport Center: --'----------
___<..________ __________
Airport Identifier: __..._!.N-=----=z_=-w
@On Airport/Airstrip
ON!A
Runway Information
Runway ID:
(LIR/C) Length:
{ (
L( i " 0
ft
ft Width:
Dirt
0
0
0
Grass/Turf
Gravel
Ice
0
0
0
Macadam
Metal/Wood
Snow
Dry
0 Holes
0
0
0
&!it Asphalt
O Concrete
111!1
Ice Covered
Rough
Rubber Deposits
0Slush-Covered
OWater
OUnknown
D Snow-Compacted
D Snow-Crusted
0
0
0
0
0
0
Snow-Dry
Snow-Wet
Soft
Vegetation
Water-Calm
Water-Choppy
0 Water-Glassy
OWet
Unknown
0VFR Departure
OIFR Departure Procedure/Clearance
0Downwind
OBase
Q)Final
0Crosswind
0 Low Approach
OGoAround
0Aborted Landing (after touchdown)
OUnknown
J!!!INone
ONone
OADF/NDB
0SDF
OVOR!TVOR
OVOR!DME
0TACAN
OPAR
0Sidestep
OILS
OLocalizer Only
OLOC-back course
ORNAV
OMLS
0LDA
OASR
0Visual
0Contact
0Circling
OPractice
0GPS
OUnknown
OStopandGo
0 Touch and Go
0 Simulated Forced Landing
OForced Landing
0 Precautionary Landing
0Unknown
0 Pilot
eFlight Instructor
0 Student Pilot
DYes
0 Check Pilot
0 Flight Engineer
No
State:
0 Z..\ ~ UJ ' . -
Last Name:
f? P R ~
SA
8D
mm/dd/yyyy
Date of Birth:
Certificate Number:
Degree oflnjury
Seat Occupied
0 None
O Minor
0 Serious
0 Left
@) Right
0 Center
0 Fatal
0 Unknown
0 Front
ORear
0 Single
OUnknown
li!tCommercial
0 Airline Transport
0 Flight Engineer
Used
Available
ONone
OLaponly
f>3-point
04--point
05-point
OUnknown
Inflatable Restraints
Restraint Type
0 us Military
OForeign
Principal Occupation
Medical Certificate
0 Pilot
@) Other
Unknown
t'tClass 3
Driver's License (Sport Pilot only)
Unknown
None
Class l
Class 2
L.V e..A
II Not Installed
ONone
OLap only
83-point
04--point
05-point
OUnknown
Without limitations/waivers
@J With limitations/waivers
0 Special Issuance
0 Installed
D Not Deployed
ODeployed
QUnknown
en
02. Lol<-t
mmldd/yyyy
L e> R Ree-ll ve
3i
Model:
mm/dd/yyyy
Airplane Rating(s)
Instrument Rating(s)
Instructor Rating(s)
ONone
liiJ Single-Engine Land
0 Single-Engine Sea
11!1 Multiengine Land
0 Multiengine Sea
0None
0 Airship
0 Balloon
0 Glider
0 Gyroplane
D Helicopter
0 Powered Lift
ONone
li!!l Airplane
0 Helicopter
0 Powered Lift
ONone
I!!IJ Airplane Single-Engine
0 Airplane Multi-Engine
0 Gyroplane
0 Powered Lift
0
0
0
0
Instrument Airplane
Instrument Helicopter
Helicopter
Glider
Sport
Type Ratings
All
This Make
Glider
Lighter
Than Air
~Y.lo:'i
'"';2:':- 1
..
'-~Vid_::~.i~'"f.-_c/. .; -, . . . .
- t;:'r,'
.:,::.<i'';c'_J~<:.>>-.:,:;;.,_, ~r
...
OPilot
0Fiight Instructor
Q) Student Pilot
DYes
0Check Pilot
Last Name:
~[!GL~"'~
--A
2.:2
.. I
Date of Birth:
Certificate Number:
0Front
ORear
Osingle
8'Left
0Right
Ocenter
0Unknown
D Commercial
0 Airline Transport
D Flight Engineer
0 Flight Instructor
D Recreational
0 Sport
Z.DlO lq
mmlddlyyyy
Principal Occupation
Medical Certificate
0 Pilot
0 Other
0 Unknown
ONone
0 Class I
0 Class2
Inflatable Restraints
Used
Available
D us Military
OForeign
,i!)'Not Installed
Oinstalled
0 Not Deployed
0Deployed
OUnknown
0 None
0 Lap only
@I)> 3-point
0 4-point
0 5-point
0 Unknown
ONone
OLaponly
03-point
04-point
0 5-point
0Unknown
ZIP:
Restraint Type
Seat Occupied
0 Fatal
0 Unknown
HI
0
/'\'1 D
State:
Degree oflnjury
eNone
0 Minor
0 Serious
OFlightEngineer
ONo
0Ciass 3
0 Driver's License (Sport Pilot only)
OUnknown
0 Unknown
ON/A
mmlddlyyyy
Make:
Model:
mmlddlyyyy
Airplane Rating(s)
Instrument Rating(s)
Instructor Rating(s)
1!1
0
If!! None
@None
DAirplane
OHelicopter
D Powered Lift
None
Single-Engine Land
D Single-Engine Sea
0 Multiengine Land
0 Multiengine Sea
Airship
0 Balloon
0 Glider
0 Gyroplane
0 Helicopter
0 Powered Lift
0
D
D
D
D
None
Airplane Single-Engine
Airplane Multi-Engine
Gyroplane
Powered Lift
Instrument Airplane
D Instrument Helicopter
D Helicopter
D Glider
0 Sport
Type Ratings
Airplane
_Total Time
Pilot in Comm~n<\ (PIC)
All
Aircraft
i'5
0
This Make
&Model
Airplane
Multiengine
15'
1>"
"'
'
'}
Last90 Days
_Las! 30 Days
Night
Time as Instructor
This
Englue
').1.
.z
CZ.
' ~
2.'i
Last 24 Hours
Actual
Shn1tlatPol
Rotorcraft
Glider
Lighter
Than Air
ktv H
Time of Departure
\o(.
Time: ( .. 3,0
a...
Time Zone:
State: MV
Country:
Destination
(?'"""
KJV' H l<.
State: M 1)
0 None
0 Company VFR
0 Military VFR
@JVFR
Country: V S. f.:t-
Activated?
Airport ID:
f:S r
tJ S P.
0 VFRIIFR
0 IFR
0 Unknown
iff
0 Special IFR
OVFROnTop
0 Special VFR
0 IFR
None
0 VFR
0 Cruise
0 Unknown INA
0Class G
ODemo Area
0Waming Area
0Prohibited Area
0Restricted Area
Class A
Class B
Class C
Class D
1!!!!1 Class E
0
0
0
0
Facility ID: - - - - - - - - - - - - - -
0Company
0Military
0Intemet
ONone
OUnknown
Basic Conditions
Light Condition
8VMC
0IMC
OUnknown
0Dawn
ODay
Ceiling
0 Few
0 Partial Obscuration
0 Scattered
0 Thin Overcast
0 Unknown
@Dark Night
OBright Night
0Dusk
ONight
OObscured
0 Indefinite
OUnknown
0 Broken
0 Overcast
_ _ _ _ _ _ _ _ _ _ _ ft agl
_ _ _ _ _ _ _ _ _ _ _ ft agl
Wind Direction
Wind Speed
Wind Gusts
lil!l Variable
Sl
degrees true
~ None
Rain
Snow
Hail
Rain Showers
0Light
0Moderate
OHeavy
ON!A
OUnknown
0
0
0
0
0 Drizzle
0 Ice Pellets
0 Snow Pellets
0 Snow Grains
0 Ice Crystals
Visibility
0
0
0
0
Type
ON/A
0Rime
Oclear
0Mixed
Ounknown
Amount
@None
OTrace
OLight
OModerate
0Severe
OUnknown
(F)
or
MB
_ _ _ _ _ miles
RVR: ----~feet
RVV: _ _ _ ____,miles
kts
Speed:
Density Altitude:
ft
Freezing Rain
Snow Shower
Ice Pellets Shower
Freezing Drizzle
J!ljNone
Blowing Dust
Blowing Sand
Blowing Snow
O Blowing Spray
0 Dust
0
0
0
0Fog
0 Ground Fog
0 Haze
0 Ice Fog
0 Smoke
0 Unknown
Turbulence
Icing Actual
Icing Forecast
(C)
Intensity of Precipitation
Amount
t!J None
0Trace
OLight
OModerate
OSevere
0Unknown
Dew Point:
-orkts
OUnknown
or
Ceiling Height
Calm
0 Light and Variable
-orSpeed:
degrees true
f) None (Clear)
-orDirection:
_ _ _ _ _ ftmsl
Altitude of In-Flight
Occurrence:
OSpecial
0Air Traffic Control Area
OUnknown
Type
ON/A
ORime
Oclear
0Mixed
0Unknown
NOTAMs (D and FDC), AIRMETs, SIGMETs, PIREPs in effect at the time of the accident/incident:
;vo,ve..
Severity
0Light
0Moderate
0Severe
OExtreme
Aircraft Damage
Aircraft Fire
8
0
0
@None
0 In-Flight
0 On-Ground
0
0
None
Minor
Substantial
Destroyed
Unknown
Aircraft Explosion
0
0
&None
0 In-Flight
0 On-Ground
0
0
Description of Damage to Aircraft and Other Property (Use additional sheet if necessary)
Of\(Y'Acre
re>
f~o peL-Le(l.-
eN d1
tv"t::.
A' R F 6ZI'l,...
Describe what occurred in chronological order, including circumstances leading to and nature of accident/incident. Describe terrain and include
wreckage distribution sketch if pertinent. Attach extra sheets if needed. State departure time and and location, seJVices obtained, and intended
destination. Provide as much detail as possible.
Total Time/Cycles
On Part
0 Yes !I No
_ _ _ _ _ _ Hours
_ _ _ _ _ _ Cycles
Fuel Type
Gallons
e
0
80/87
100 Low Lead
100/130
0
0
0
1151145
OJetB
Jet A
Jet A-I
0JP8
0 Automotive
0 Other, s p e c i f y - - - - - - - - - -
1!1 No
0 Yes
Was an emerge ncy evacua tion ofthe aircraf t perform ed?
occupants evacuated each location
Method of Exit - Describe how the occupants exited and how many
2.. oc. c:;.......- i? A tv T' 5
D ~ C> R.
I j) e..
10
- or-
---------------
aocument
Name: ------------------------ ------------------------ ----Signature:----------- ------------------------ ----------0 Check here to electronically sign this document
- or -
GAA16CA077
Title:---------------- ---------
Name oflnvestigator
BIGELOW
GAA
11
12/30/2015