Protoplane Form 939 – Date: 05/15/2015 – Issue: 01
Aircraft concerned
TC Holder:
Model:
S/N:
Registration:
Name of the operator:
Phone (including country code):
E-mail:
Adress:
Protoplane product (modification, repair or appliance) concerned
Name:
EASA approval number:
Date of approval:
Description of the unsafe condition or potentially unsafe condition
Date:
Time:
Location:
Pilot name:
Pilot experience (total):
Pilot experience (on aircraft):
Co-pilot name:
Co-pilot experience (total):
Co-pilot experience (on aircraft):
Engineer name:
Engineer experience (total):
Engineer experience (on aircraft):
Detailed description of the occurence:
Other relevant information:
Signatory.
Please be advised that Protoplane will not be able to answer your request if the information provided is incomplete or inaccurate.
