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MANUFACTURER
1.
A/C Reg. No.
MODEL/SERIES
N-
OTHER
MALFUNCTION OR DEFECT REPORT
OPERATOR
DESIGNATION
8. Comments (Describe the malfunction or defect and the circumstances under which it
occurred. State probable cause and recommendations to prevent recurrence.)
OPER. Control No.
DEPARTMENT OF TRANSPORTATION
DISTRICT
OFFICE
OMB No. 2120-0003
08/31/2008
SERIAL NUMBER
COMMUTER
2.
AIRCRAFT
3.
FAA
POWERPLANT
4.
MFG.
PROPELLER
5. SPECIFIC PART (of component) CAUSING TROUBLE
Serial No.
Part/Defect Location.
)
MFG. Model or Part No.
(
AIR TAXI
Part Name
Optional Information:
Part TT
Part TSO
Part Condition
7. Date Sub.
Check a box below, if this report is related to an aircraft
Accident; Date
FAA FORM 8010-4
Incident; Date
TELEPHONE NUMBER
Serial Number
SUBMITTED BY:
Model or Part No.
OPER.
Manufacturer
REP.STA.
Comp/Appl Name
MECH.
6. APPLIANCE/COMPONENT (Assembly that Includes part)
(10-92) SUPERSEDES PREVIOUS EDITIONS
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
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
U.S. Department
of Transportation
Federal Aviation
Administration
Flight Standards Service
Aviation Data Systems Branch
P.O. Box 25082
Oklahoma City, OK 73125-5029
AFS-620
Official Business
Penalty for Private Use $300
BUSINESS REPLY MAIL
FIRST CLASS PERMIT NO. 12438 WASHINGTON, D. C.
Federal Aviation Administration
AFS-620 (Alerts)
P.O. Box 25082
Oklahoma City, OK 73125-5029
File Type | application/pdf |
File Title | Malfunction or Defect Report |
File Modified | 2017-06-27 |
File Created | 2004-04-14 |