Attachment-3 USAF MISHAP REPORT af711b.pdf

USAF MISHAP REPORT

(Fill in all spaces applicable. If additional space is needed, use additional sheet(s).)

(When filled in)FOR OFFICIAL USE ONLY

2. VEHICLES(S) OR MATERIEL INVOLVED1. DATE OF

OCCURRENCE

3. MISHAP EVENT NUMBER

(Mission Design Series and serial number if applicable)

(Year, Month, Day)

5. LOCAL AND

ZULU TIME

6.4. LOCATION OF OCCURRENCE

DAY NIGHT

DUSKDAWN

7. ORGANIZATIONS OWNING VEHICLE OR MATERIEL AT TIME OF MISHAP

MAJOR

COMMAND

SQUADRON

OR UNIT

WING GROUPNAF/CENTER

8. (List of organizations of second vehicle or materiel, if they differ from item 7 above)

MAJOR

COMMAND

SQUADRON

OR UNIT

NAF/CENTER WING GROUP

(Do not abbreviate)9. ORGANIZATION AND BASE SUBMITTING REPORT

10. LIST OF PERSONNEL DIRECTLY INVOLVED

LAST NAME, FIRST NAME,

MIDDLE INITIAL

ASSIGNED

DUTY

AERO

RATING

DEGREE

INJURY*GRADE SSN

*Enter applicable letters in DEGREE INJURY column:

No Lost Time-NL; Lost Time-LT; Permanent Partial-PP; Permanent Total-PT; Fatal-FT

11. FACTUAL SUMMARY OF CIRCUMSTANCES

12. AUTHENTICATION

CERTIFIED BY (Title) TYPED NAME AND GRADE SIGNATURE DATE

PREVIOUS EDITIONS ARE OBSOLETE(V1)AF IMT 711B, 20031101

BASE AND ICAO

OR SORTS CODE

BASE AND ICAO

OR SORTS CODE

Item 6. Day, Night, Dawn, Dusk. Using the Air Almanac, dusk begins at official sunset and lasts 30 minutes. Dawn begins 30 minutes before sunrise and lasts until sunrise.

Item 7. Organization Owning Vehicle or Materiel at Time of Mishap. Substitute proper units and organizations if the structure of the organization possessing the vehicle or materiel is not the same as the headings of the boxes in item 7. For federalized ANG units, show the gaining command, Numbered Air Force, and the applicable ANG wing, group and squadron. For ANG units not federalized, show the ANG organizations and ANG as the MAJCOM. Enter the base name and ICAO code. If an ICAO code is not available, use Home Locaiton Code from SORTS

Item 8. If a second vehicle or materiel is involved list it here. Continue on plain white paper if more than two vehicles or materiels are involved.

Aero Rating. Use the current rating held. Leave blank if not rated.

To meet these objectives, present the summary in sequence. List the facts, conditions, and circumstances just as the safety investigators discovered them, without reference to attachments. State how the mishap occurred, not why. Do not discuss the importance of facts or how they relate to investigative conclusions. Provide as complete a factual summary as possible. Many requests under the Freedom of Information Act are for an account of the mishap, but not for the report itself. In these cases, only the factual summary of circumstances is released.

AF IMT 711B, 20031101 (V1) PREVIOUS EDITIONS ARE OBSOLETE

Item 2. Vehicles (s) or Materiel Involved. List the nuclear weapon or system, space system, aircraft/UAV, guided missile, explosives or chemical agents item, directed energy system, automotive vehicle, ground equipment, or any other item involved. Provide MDS and serial number, or other item number if they have numbers. If the report is on injuries only and no equipment is involved, enter "NA" in this block. If more than one vehicle or materiel is involved, list the one most heavily damaged first followed by the others. Continue on plain white paper if more space is needed.

Item 3. Mishap Event Number. (AFI 91-204, Chapter 6)

Item 4. Place of Occurrence. Give the location of the mishap and not the location where trouble first developed. Identify state, county and distance/ direction from nearest town. Indicate distances in nautical miles (NM) or statute miles (SM) and points of the compass for direction. Also list latitude and longitude. For an on-base mishap, give the exact location (e.g., Bldg. T-465, Aircraft Hangar, Luke AFB AZ).

Item 10. List of Personnel Directly Involved. List the information for all DoD personnel involved in the mishap. Include all persons injured on the ground as a result of the mishap. List the operator or person most directly involved first. Army and Navy personnel assigned to the Air Force are shown as Army or Navy. List all passengers aboard a mishap aircraft. List mission controller and flight safety officer for launch mishaps and list mission controller and the individual on console during an orbit mishap. Identify civilian employees by their employment agency or department (e.g., Civ-USAF, Civ-Army, Civ-FAA, and so forth). This list may also include personnel such as maintainers when maintenance is a factor in the mishap.

Assigned Duty: Use duty title abbreviations. For crewmembers involved in aviation mishaps use the duty symbol shown on the AFTO Form 781, Arms Aircrew/Mission Flight Data Document.

Item 11. Factual Summary of Circumstances. This summary of the mishap may be disclosed under the Freedom of Information Act. Therefore, there are two main considerations for completing this item. First, the summary must be completely factual. It must not draw on privileged sources. Do not use any information in Part 2 of the report not found in the exhibits in Part 1. For example, do not include statements indicating what the operator heard, felt, or saw. Second, the Factual Summary of Circumstances must lead the reader through the sequence of events involved in this mishap.

Fill out AF Form 711b on each vehicle or materiel involved in the mishap. Vehicle or materiel includes assets and property (AFI 91-204, Chapter 4). See guidance below for completing items that are not self-explanatory.

USAF MISHAP REPORT

(Fill in all spaces applicable. If additional space is needed, use additional sheet(s).)

(When filled in)

FOR OFFICIAL USE ONLY

2. VEHICLES(S) OR MATERIEL INVOLVED

1. DATE OF

OCCURRENCE

3. MISHAP EVENT NUMBER

(Mission Design Series and serial number if applicable) (Year, Month, Day)

5. LOCAL AND ZULU TIME

6.

4. LOCATION OF OCCURRENCE

DAY

NIGHT

DUSK

DAWN

7. ORGANIZATIONS OWNING VEHICLE OR MATERIEL AT TIME OF MISHAP

MAJOR

COMMAND

SQUADRON

OR UNIT

WING

GROUP

NAF/CENTER

8. (List of organizations of second vehicle or materiel, if they differ from item 7 above)

MAJOR

COMMAND

SQUADRON

OR UNIT

NAF/CENTER

WING

GROUP

(Do not abbreviate)

9. ORGANIZATION AND BASE SUBMITTING REPORT

10. LIST OF PERSONNEL DIRECTLY INVOLVED

LAST NAME, FIRST NAME, MIDDLE INITIAL

ASSIGNED

DUTY

AERO

RATING

DEGREE

INJURY*

GRADE

SSN

*Enter applicable letters in DEGREE INJURY column:

No Lost Time-NL; Lost Time-LT; Permanent Partial-PP; Permanent Total-PT; Fatal-FT

11. FACTUAL SUMMARY OF CIRCUMSTANCES

12. AUTHENTICATION

CERTIFIED BY (Title)

TYPED NAME AND GRADE

SIGNATURE

DATE

PREVIOUS EDITIONS ARE OBSOLETE

(V1)

AF IMT 711B, 20031101

BASE AND ICAO

OR SORTS CODE

BASE AND ICAO

OR SORTS CODE

Item 6. Day, Night, Dawn, Dusk. Using the Air Almanac, dusk begins at official sunset and lasts 30 minutes. Dawn begins 30 minutes before sunrise and lasts until sunrise.

Item 7. Organization Owning Vehicle or Materiel at Time of Mishap. Substitute proper units and organizations if the structure of the organization possessing the vehicle or materiel is not the same as the headings of the boxes in item 7. For federalized ANG units, show the gaining command, Numbered Air Force, and the applicable ANG wing, group and squadron. For ANG units not federalized, show the ANG organizations and ANG as the MAJCOM. Enter the base name and ICAO code. If an ICAO code is not available, use Home Locaiton Code from SORTS Item 8. If a second vehicle or materiel is involved list it here. Continue on plain white paper if more than two vehicles or materiels are involved.

Aero Rating. Use the current rating held. Leave blank if not rated.

To meet these objectives, present the summary in sequence. List the facts, conditions, and circumstances just as the safety investigators discovered them, without reference to attachments. State how the mishap occurred, not why. Do not discuss the importance of facts or how they relate to investigative conclusions. Provide as complete a factual summary as possible. Many requests under the Freedom of Information Act are for an account of the mishap, but not for the report itself. In these cases, only the factual summary of circumstances is released.

AF IMT 711B, 20031101 (V1)

PREVIOUS EDITIONS ARE OBSOLETE

Item 2. Vehicles (s) or Materiel Involved. List the nuclear weapon or system, space system, aircraft/UAV, guided missile, explosives or chemical agents item, directed energy system, automotive vehicle, ground equipment, or any other item involved. Provide MDS and serial number, or other item number if they have numbers. If the report is on injuries only and no equipment is involved, enter "NA" in this block. If more than one vehicle or materiel is involved, list the one most heavily damaged first followed by the others. Continue on plain white paper if more space is needed.

Item 3. Mishap Event Number. (AFI 91-204, Chapter 6) Item 4. Place of Occurrence. Give the location of the mishap and not the location where trouble first developed. Identify state, county and distance/ direction from nearest town. Indicate distances in nautical miles (NM) or statute miles (SM) and points of the compass for direction. Also list latitude and longitude. For an on-base mishap, give the exact location (e.g., Bldg. T-465, Aircraft Hangar, Luke AFB AZ).

Item 10. List of Personnel Directly Involved. List the information for all DoD personnel involved in the mishap. Include all persons injured on the ground as a result of the mishap. List the operator or person most directly involved first. Army and Navy personnel assigned to the Air Force are shown as Army or Navy. List all passengers aboard a mishap aircraft. List mission controller and flight safety officer for launch mishaps and list mission controller and the individual on console during an orbit mishap. Identify civilian employees by their employment agency or department (e.g., Civ-USAF, Civ-Army, Civ-FAA, and so forth). This list may also include personnel such as maintainers when maintenance is a factor in the mishap.

Assigned Duty: Use duty title abbreviations. For crewmembers involved in aviation mishaps use the duty symbol shown on the AFTO Form 781, Arms Aircrew/Mission Flight Data Document.

Item 11. Factual Summary of Circumstances. This summary of the mishap may be disclosed under the Freedom of Information Act. Therefore, there are two main considerations for completing this item. First, the summary must be completely factual. It must not draw on privileged sources. Do not use any information in Part 2 of the report not found in the exhibits in Part 1. For example, do not include statements indicating what the operator heard, felt, or saw. Second, the Factual Summary of Circumstances must lead the reader through the sequence of events involved in this mishap.

Fill out AF Form 711b on each vehicle or materiel involved in the mishap. Vehicle or materiel includes assets and property (AFI 91-204, Chapter 4). See guidance below for completing items that are not self-explanatory.

8.2.1.3158.1.475346.466429