USDA Forest Service FS-5700-14 (08/97)

SAFECOM: AVIATION SAFETY COMMUNIQUE

(Ref. FSM 5720)
1.	REPORTED BY (OPTIONAL)
Name: Phone: ( ) -

Organization: Date (mm/dd/yyyy)

Address:

E- Mail Address:

2.	EVENT
Date: Local time: Injuries? Y N Damage? Y N

24 hour clock

Location: State:

Airport, City, Lat/Long, or Fire Name

3.	MISSION

Type: Procurement

Pax, Cargo, Recon, Sling, Longline, etc. Contract, CWN, Rental, Fleet, etc.

Number of Persons: Special Use? Hazardous Material Onboard?

Departure Point: Destination:

4.	AIRCRAFT

(Reg.)N#: Manufacturer: Model:

Owner/Operator: Pilot:
5.	NARRATIVE	Provide a brief explanation of the event.
6.	CORRECTIVE ACTION
SEND TO:
USDA Forest Service	-	Local Forest and Regional Aviation Safety Office in which the event took place.

U.S. Department of the Interior	-	Through Bureau channels to OAS safety Manager, P.O. Box 15428, Boise,

ID 83715-5428 or Electronically through SAFETYNET at (208) 387-5823 (8-1-N)
This form is used to report any condition, observance, maintenance problem, act or circumstance which has potential to cause an aviation-related mishap.
Coding: For use of Regional Aviation safety Manager.

CAUSE PHASE OCCURRENCE TYPE
Data Tracking #:

Microsoft Word 2000

ax31922u.aw

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lbeckman

2005-08-17

KeatorM

USDA Forest Service