OMB No. 2120-0663

1. Submitter Information

(a) Unique Control #		(b) Difficulty Date	(mm/dd/yyyy)
(c) Registration #		(d) Submitter Type	A - CARRIER PART 121 B - REPAIR STATION PART 145 C - OPERATOR PART 91 D - MECHANIC E - CARRIER PART 135 F - MANUFACTURER G - FEDERAL AVIATION ADMIN H - OTHER I - AIR TAXI PART 125 L - EXTERNAL LOAD PART 133 M - MILITARY P - PILOT S - LIGHT SPORT ACFT W - FOREIGN PART 129 Z - NON CERT INTERNATIOAL

2. Codes

(a) Operator Designator		(b) Operator Type	--Choose Type-- Air Carrier General Aviation
(c) JASC/ATA Code
(d) Stage of Operation	AA - AIR AMBULANCE AB - AEROBATIC AG - AGRICULTURE AP - APPROACH CL - CLIMB CR - CRUISE DE - DESCENT EX - EXTERNAL LOAD FF - FIRE FIGHTING HO - HOVERING IN - INSP/MAINT LD - LANDING MS - MAPPING/SURVEY NR - NOT REPORTED TO - TAKEOFF TX - TAXI/GRND HDL UK - UNKNOWN	(e) How Discovered	9 - Unknown B - Boroscope C - Functional Check D - Dye Penetrant E - Eddy Current L - Light Source M - Magnetic Particle O - Other T - Thermal U - Ultrasonic V - Visual W - Magnified Visual X - X-Ray
(f) Nature of Condition	A - FLAME/FIRE B - SMOKE/FUMES/ODORS/SPARKS C - F.O.D. D - INFLIGHT SEPARATION E - VIBRATION/BUFFET F - FLT CONT AFFECTED G - MULTIPLE FAILURE H - ELECT. POWER LOSS-50 PC I - FLT. ATTITUDE INST. J - WARNING INDICATION K - FLUID LOSS L - NO TEST M - OVER TEMP N - FALSE WARNING O - OTHER P - NO WARNING INDICATION R - PARTIAL RPM/PWR LOSS S - AFFECT SYSTEMS T - ENGINE CASE PENETRATION W - INADEQUATE Q C X - ENGINE FLAMEOUT Y - ENGINE STOPPAGE Z - SIGNIFICANT FAILURE REPORT A - FLAME/FIRE B - SMOKE/FUMES/ODORS/SPARKS C - F.O.D. D - INFLIGHT SEPARATION E - VIBRATION/BUFFET F - FLT CONT AFFECTED G - MULTIPLE FAILURE H - ELECT. POWER LOSS-50 PC I - FLT. ATTITUDE INST. J - WARNING INDICATION K - FLUID LOSS L - NO TEST M - OVER TEMP N - FALSE WARNING O - OTHER P - NO WARNING INDICATION R - PARTIAL RPM/PWR LOSS S - AFFECT SYSTEMS T - ENGINE CASE PENETRATION W - INADEQUATE Q C X - ENGINE FLAMEOUT Y - ENGINE STOPPAGE Z - SIGNIFICANT FAILURE REPORT A - FLAME/FIRE B - SMOKE/FUMES/ODORS/SPARKS C - F.O.D. D - INFLIGHT SEPARATION E - VIBRATION/BUFFET F - FLT CONT AFFECTED G - MULTIPLE FAILURE H - ELECT. POWER LOSS-50 PC I - FLT. ATTITUDE INST. J - WARNING INDICATION K - FLUID LOSS L - NO TEST M - OVER TEMP N - FALSE WARNING O - OTHER P - NO WARNING INDICATION R - PARTIAL RPM/PWR LOSS S - AFFECT SYSTEMS T - ENGINE CASE PENETRATION W - INADEQUATE Q C X - ENGINE FLAMEOUT Y - ENGINE STOPPAGE Z - SIGNIFICANT FAILURE REPORT	(g) Precautionary Procedures	A - UNSCHED LANDING B - EMER. DESCENT C - ABORTED TAKEOFF D - RETURN TO BLOCK E - ENGINE SHUTDOWN F - ACTIVATE FIRE EXT. G - O2 MASK DEPLOYED H - DEACTIVATE SYST/CIRCUITS I - CABIN DEPRESSURIZATION J - DUMP FUEL K - NONE L - ABORTED APPROACH O - OTHER R - AUTOROTATION A - UNSCHED LANDING B - EMER. DESCENT C - ABORTED TAKEOFF D - RETURN TO BLOCK E - ENGINE SHUTDOWN F - ACTIVATE FIRE EXT. G - O2 MASK DEPLOYED H - DEACTIVATE SYST/CIRCUITS I - CABIN DEPRESSURIZATION J - DUMP FUEL K - NONE L - ABORTED APPROACH O - OTHER R - AUTOROTATION A - UNSCHED LANDING B - EMER. DESCENT C - ABORTED TAKEOFF D - RETURN TO BLOCK E - ENGINE SHUTDOWN F - ACTIVATE FIRE EXT. G - O2 MASK DEPLOYED H - DEACTIVATE SYST/CIRCUITS I - CABIN DEPRESSURIZATION J - DUMP FUEL K - NONE L - ABORTED APPROACH O - OTHER R - AUTOROTATION A - UNSCHED LANDING B - EMER. DESCENT C - ABORTED TAKEOFF D - RETURN TO BLOCK E - ENGINE SHUTDOWN F - ACTIVATE FIRE EXT. G - O2 MASK DEPLOYED H - DEACTIVATE SYST/CIRCUITS I - CABIN DEPRESSURIZATION J - DUMP FUEL K - NONE L - ABORTED APPROACH O - OTHER R - AUTOROTATION
(h) FAA Region		(i) District Office
(j) Flight Number

3. Major Equipment Identity

	Manufacturer	Model	Serial Number	Total Time   (hours)	Total Cycles
(a) Aircraft
(b) Engine
(c) Propeller

4. Problem Description  (Note: Please limit your description to 1500 characters.)

Your description is 0 characters in length.

5. Specific Part or Structure Causing Difficulty

(a) Part Name	(b) Manufacturer's Name	(c) Part Number	(d) Serial Number
(e) Part Condition	(f) Part/Defect Location	(g) Total Time (hours)	(h) Total Cycles	(i) Time Since (hours)
	--Choose Location-- Zone 100 - Fuselage Lower Zone 200 - Fuselage Top Zone 300 - Stabilizers Zone 400 - Nacelles/Pylons Zone 500 - Left Wing Zone 600 - Right Wing Zone 700 - Landing Gear Zone 800 - Doors Zone 900 - Lavatories & Galleys OR				Overhaul Repair Inspection Reset

6. Component/Assembly That Includes Defective Part

(a) Component Name	(b) Manufacturer's Name	(c) Part Number	(d) Serial Number	(e) Model Number
(f) Location	(g) Total Time (hours)	(h) Total Cycles	(i) Time Since (hours)
				Overhaul Repair Inspection Reset

7. Submitted By (This Information is used by the FAA to contact you, only if additional information about the submission is needed and then is removed.)

Name	Telephone	Email Address

Paperwork Reduction Act Statement:

Per 14 CFR Part 121.703, the information on this report can be submitted on this form or in another format acceptable to the Administrator. The information collected is used to evaluate certification standards, maintenance programs, regulatory requirements. The information is required to ensure safety in air transportation. We estimate that it will take 9 minutes to complete. Use of this form is mandatory. 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 2120-0663. 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, AES-200.