ࡱ> !` bjbj\\ >>P 4t`^`^`^h^t_$ajjjjekun!p$h vpekekppjjtttpjjtpttjttja {4`^qtt 0tqtthtpppspppppppd.|I|IP$t, MISHAP REPORT FORMDATE OF REPORTTHIS REPORT MUST BE COMPLETED IN ACCORDANCE  FORMTEXT      WITH CAPR 62-2 FOR ALL CAP MISHAPSINSTRUCTIONS: This report must be completed by the unit commander or designee and forwarded within 48 hours following each accident which results in injury to any person and/or damage to any property during CAP activities. See CAPR 62-2, paragraph 5, for distribution.DATE OF MISHAPTIME OF MISHAPREGIONWINGPLACE OF MISHAP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      TYPE MISHAP (Check one or more) FORMCHECKBOX  Bodily Injury FORMCHECKBOX  Vehicle FORMCHECKBOX  Aircraft FORMCHECKBOX  Flight FORMCHECKBOX  GroundAIRCRAFT OR VEHICLEA/C OR VEH NO.A/C N-NUMBER OR VEH IDENTIFICATION NO.YEAR/MAKE/MODELAPPARENT DAMAGE SUSTAINEDEST REPAIR COSTS (OR MARKET VALUE IF TOTAL LOSS)1  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2  FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      PRIVATE PROPERTY DAMAGE OTHER THAN AIRCRAFT OF VEHICLE (OBJECT DAMAGED AND EXTENT OF DAMAGE):EST REPAIR COSTS FORMTEXT       FORMTEXT      PERSON AT CONTROLSINJURYA/C OR VEH NO.GRADE AND NAMEAGEPHONE NUMBERCAP UNIT NO.FATALNONFATAL1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX 2 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX CAP Operator's License No. Veh 1: FORMTEXT      CAP Operator's License No. Veh 2: FORMTEXT      B. CODE: W-WITNESS P-PASSENGER S-SCANNER O-OBSERVER Z-OTHER (SPECIFY BELOW))INJURYA/C OR VEH NO.GRADE AND NAMEAGEPHONE NUMBER.CODECAP UNIT NO.FATALNONFATAL1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX 2 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Code Z (Specify Here): FORMTEXT      C. OWNER OF AIRCRAFT OR VEHICLEINJURYA/C OR VEH NO.GRADE AND NAMEAGEPHONE NUMBERCAP UNIT NO.FATALNONFATAL1 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX 2 FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX D. PERSON(S) INJURED NOT AS A RESULT OF AIRCRAFT OR VEHICLE MISHAPINJURYGRADE AND NAMEAGEPHONE NUMBERCAP UNIT NO.FATALNONFATAL FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  PURPOSE OF ACTIVITY:  FORMTEXT      MOVEMENT OF AIRCRAFT OR VEHICLE WAS REQUESTED BY: FORMTEXT       CAP Form 78, Sep 99PREVIOUS EDIT&D      " 6 8 : D F H J ^ ` b l n ߻߰񨤙ƨ񨤎ƨ񨤃ƨjyh yUjh yUjh yUhDMjhDMUjh yUjh yUjhGUmHnHujh yUhGjhGU h"&@h"&h"&5CJ\aJ0&D $IfXkd$$IflF 'D     4 lax$If  0 2 P n | }s@:::$If2kdK$$Ifl'&(4 la <<$Ifkd=$$IflF 'D 0    4 la| H p z~kd$$Iflrjz'tb8 @ 4 la$Ifp r * b WOOOOOO<$Ifkd$$Iflrjz'tb8 @ 04 la     ( * , H J L P ` b d "$8:<FHJL`jhGUmHnHuj h yUhDMjhDMUh"&CJ aJ jh yUjh yUjh yUjh yUh"&CJaJj)h yUjh"&Uh"& h"&6]0 F= $$Ifa$kdm $$Iflֈ t"' F04 la bE~kd $$Iflr* dJ'p p4 la<$If2kd $$Ifl'&(4 la "Jrokd $$Ifl r* dJ'p p4 la$If $$Ifa$ `bdnprt  "68:DFHJ^`blnr.TVֵ֪֟֔ڎچh"&CJ aJ h"&@jh yUjh yUj2h yUjh yUjY h yUj h yUhDMh"&jhGUmHnHujhDMUjm h yU4 Hpr0Rxpp<$Ifkdp$$Ifl r* dJ'p p4 la$IfRT|B8 & F$Ifnkd$$Ifl0J'p04 la$IfGkd[$$Ifl)0J'p4 laVjlnxz|~Vrz|  8:<>@\אׅאjh yUjh"&UjQh yUjh yUjqh yUjh yUh"&CJ aJ jlh yUh"&jhGUmHnHujhDMUjh yUhDM2"<Vbt$IfZkd$$IflF^!'b    4 la $<$Ifa$<$If tvz3( <$If $<$Ifa$kd$$Ifl֞*:d^!6$'*bv04 la>b $<$Ifa$<$If\^`hj~ &(*,.JLNܸܭܢ܁j7h yUjMh yUjh yUj[h yUjh yUjh yUjhGUmHnHujh yUhDMjhDMUh"&jh"&UjOh yU2bdh1&<$If $<$Ifa$kd$$Ifl֞*:d^!6$'*bv04 la,P $<$Ifa$<$IfPRT1''' <<$Ifkd$$Ifl֞*:d^!6$'*bv04 la,.0a[N $<<$Ifa$$Ifkd#$$Iflֈ@ dJ&' $  b4 la <<$If(*0@\f  246@BDFZ\^hjl쵪쵟쵔쵉~j$h yUj#h yUj=#h yUj"h yUji"h yUhDMh"&CJ aJ h"&@h"&6CJ]aJh"&CJaJh"&jhGUmHnHujhDMUjh yU18@\f<$IfZkd@ $$IflF!'@    4 la   $<$Ifa$kd !$$Iflִ*:d^!6$'*vv0    4 laDl $<$Ifa$<$Ifln   "$.024HJLVXZ\prt~ոѭոѢոїոьոjA)h yUj(h yUj[(h yUj'h yUj'h yUjhGUmHnHuj'h yUhDMjhDMUj%h yUj$h yUh"&jh"&U2 $<$Ifa$kd%$$Iflִ*:d^!6$'*vv0    4 la 2Z $<$Ifa$<$If  *,.8:<>RTV`bdfz|~󸴩ȸ󸴞ȸ󸴓ȸ󸴈ȸ}j0h yUjG0h yUj/h yUjs/h yUj /h yUhDMjhDMUh"&CJ aJ jhGUmHnHuj+h yU h"&6]j)h yUh"&jh"&U1 <<$Ifkd-*$$Iflִ*:d^!6$'*vv0    4 la"$fhvx?Zkd,$$IflF.!'    4 la $<<$Ifa$$IfGkd?,$$Ifl0't 4 la <<$If<$If<3( <$If $<$Ifa$kd-$$Ifl֞*:d^!6$'*bv04 la<d $<$Ifa$<$If&(*,@BDNPRThjlvxz|ܸܭ󥡖åxxh"&CJ aJ j75h yUj4h yUjE4h yUhDMjhDMUj3h yUjq3h yUjhGUmHnHuj3h yUhJukjhJukUj91h yUh"&jh"&U/*1&<$If $<$Ifa$kd1$$Ifl֞*:d^!6$'*bv04 la*Rz $<$Ifa$<$Iftv1++$Ifkd5$$Ifl֞*:d^!6$'*bv04 lav$IfZkd6$$IflF !'!    4 la $<<$Ifa$(PxF>>>><$Ifkd7$$Iflֈ:d^!6$'*bv04 la$&(*>@BLNPRfhjtvxz*ָڸ֖֡֡֋j=h yUj@;h yUj:h yUjh"&UjN:h yUhDMjhDMUj9h yUjz9h yUh"&jhGUmHnHuj9h yUhJukjhJukU/1kd;$$Iflֈ:d^!6$'*bv04 la<$If $<$Ifa$*,.8:<>RTV`bdfz|~(*.ÿڬڡڬږ֋ڃxjNBh yUh"&CJaJj@h yUj6?h yUj>h yUjh"&UjD>h yUhDMjhDMUj=h yUhJukh"&jhGUmHnHujhJukUjp=h yU,<d $<$Ifa$<$If,D:: <<$Ifkd?$$Iflֈ:d^!6$'*bv04 la,.>:<GkdB$$Ifl0&'4 la <<$IfnkdrA$$Ifl0 'D 04 la,PRTVZ<Xkd_C$$IflF <'D d     4 la $<$Ifa$<$If  ,TZƂȂʂ 2ȃ"$@BDfh|~ÿvq hB>*jhGUmHnHujvFh yU hBhBjhBhBUjFh yUjEh yUjhBUhB hB5\jHDh yUjCh yUjh"&U h"&5\Uh"&h"&5CJ\aJ+IONS WILL NOT BE USEDOPR/ROUTING: DOR For Ground Vehicle. Seat belt used?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoFor Pilot. Has PIC participated in FAA Pilot Proficiency Programs? For Aircraft. Shoulder harness used? FORMCHECKBOX  Yes FORMCHECKBOX  NoWhich phase? FORMTEXT       FORMCHECKBOX  Yes FORMCHECKBOX  No(Enter last phase completed)PERSON AUTHORIZING MOVEMENT OF A/C OR VEH OPERATED BY CAP PERSONNEL:  FORMTEXT      GRADE AND NAMEPOSITIONADDRESSPHONE NUMBER  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      ACCOUNT OF MISHAP: (Be brief and do not include statement or comments about fault or liability. Include sketches, diagrams, or additional pages if appropriate). (Refer to CAPR 62-2 before completing).  FORMTEXT      WEATHER CONDITIONS AT TIME OF MISHAP: FORMCHECKBOX  Fog FORMCHECKBOX  Rain FORMCHECKBOX  Snow FORMCHECKBOX  Sleet FORMCHECKBOX  Ice FORMCHECKBOX  TornadoTemperature: FORMTEXT    DegreesVisibility: FORMTEXT      MilesA/C MISHAPS ONLYDewpoint: FORMTEXT      DegreesCeiling: FORMTEXT      FeetWind: FORMTEXT      KtsWind Dir: FORMTEXT      PILOT INFORMATIONFOR PILOT IN COMMANDFOR COPILOT OR STUDENT PILOTTOTAL TIME FORMTEXT       FORMTEXT      TIME LAST 6 MONTHS FORMTEXT       FORMTEXT      TIME LAST 3 MONTHS FORMTEXT       FORMTEXT      TIME THIS MODEL FORMTEXT       FORMTEXT      NO. OF LANDINGS LAST 90 DAYS FORMTEXT       FORMTEXT      NO. OF FLIGHTS LAST 90 DAYS FORMTEXT       FORMTEXT      DATE OF LAST FORM 5 CHECKFLIGHT FORMTEXT       FORMTEXT      DATE OF LAST FORM 91 CHECKFLIGHT FORMTEXT       FORMTEXT      TIME IN RETRACTABLE GEAR IF APPLICABLE FORMTEXT       FORMTEXT      DATE OF FAA MEDICAL FORMTEXT       FORMTEXT      FAA RATING/CERTIFICATES/EXPIRATION DATES FORMTEXT       FORMTEXT      ANY PREVIOUS MISHAPS (EXPLAIN ABOVE) FORMTEXT       FORMTEXT      GENERAL (Check Yes, No, or Not Applicable)YesNoN/AYesNoN/ATrip Authorized by CAP Orders/Form 99? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Mishap Resulted from CAP Activities? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Photographs Taken? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX DATE NTSB NOTIFIED AND LOCATION:CHECK ONE: (IAW NTSB PART 830) FORMTEXT       FORMCHECKBOX  Accident  FORMCHECKBOX  IncidentPHONE NUMBER OF PERSON COMPLETING THIS REPORT :UNIT AND CHARTER NUMBER:  FORMTEXT       FORMTEXT      GRADE, NAME, AND CAPSN OF PERSON COMPLETING THIS REPORT:SIGNATURE: FORMTEXT       FORMTEXT      CAP Form 78, Sep 99REVERSE     "Lft <<$IfgdB <<$IfskdD$$Ifl0'04 la"?555 <<$IfkdF$$Iflֈ4 &' 04 la܄ބƅȅʅԅօ:<PRT^`bdxz|Ȇʆ̆ֆ؆xz輸ļ輸ļ輸ļ輸ļ輸ļjOh yUjMh yUj(Mh yUjLh yUjJLhjlxzƉȉʉԉ։"$8:<BDnp󧢕|wj|jTh y>*U hB>*jhB>*UjhG>*UmHnHuj^Th y>*U h"&>*jh"&>*UjSh yUjrSh yUjRh yUjRh yUjRh yUjQh yUh"&jh"&U)ڊ܊$&:<>HJbdxz|ʋ̋prݶݩ□}j`h yUjhGUmHnHuj.`h yUjh"&UjZh y>*Uj$Zh y>*UjYh y>*UjPYh y>*U hB>*h"&jhB>*UjhG>*UmHnHu/Ɗڊ$LVb΋ЋX$IfFf\ <<$IfXZpxnhh$If <<$Ifkd._$$IflF'>  0    4 laŒ8xnhh$If <<$Ifkd>a$$IflF'>  0    4 la &(*46`bvxzҍԍ ^`tvxڹڮڣژڍjhh yUjnhh yUjfh yUj^fh yUjdh yUjNdh yUjbh yUh"&jhGUmHnHujh"&Uj>bh yU78:`xnhh$If <<$IfkdNc$$IflF'>  0    4 laҍ"xnhh$If 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