BIRD / OTHER WILDLIFE STRIKE NOTIFICATION

Operator: Effect of flight

Aircraft Make/Model : None
Engine Make/Model : Aborted take-off
Aircraft Registration: Precautionary landing
Date: day Month Year Engines shutdown
Local Time: Other (specify)
Dawn A day B dusk C night D Sky Condition
Aerodrome Name : No cloud
Runway Used : Some cloud
Location If En Route : Overcast
Height AGL : ft Precipitation
Speed of Flight : kts Fog
Phase of Flight : Rain
Parked A En route E Snow
Taxi B Descent F Bird Species

Take- off run C Approach G Number of Birds Struck

Seen
Climb D Landing Roll H 1 A A
Part(s) of Aircraft 2 -10 B B
Struck Damage 11-100 C C
Radome more D D
Windshield
Nose (excluding above) Size of Bird
Engine No 1 Small S
2 Medium M
3 Large L
4
Propeller Pilot Warned of Birds
Wing/ Rotor Yes No
Fuselage Remark (describe damage, injuries and
Landing Gear Other pertinent information).
Tail
……………………………………………………………………………………..
Lights
Other (specify) ……………………………………………………………………………………..

…………………………………………………………………………………….. ……………………………………………………………………………………..

…………………………………………………………………………………….. ……………………………………………………………………………………..

Completed form to be sent to :

Reported by GM - Safety & Risk, SS&AT Sector
General Authority of Civil Aviation
……………………………………………………. sd@gaca.gov.sa I fax: (012) 685 5507
P.O. Box 887, Jeddah, 21421
Kingdom of Saudi Arabia
THIS INFORMATION IS REQUIRED FOR GACA SAFETY & RISK

SS&AT_S&R_F-004_V1.0 (01-02-2016) Page 1 of 2

 A. BASIC DATA
Operator……………………………………………………………………………………………………………………………………………………………
Aircraft Make/Model……………………………………………………………………………..………………………………….………………………
Engine Make/Model…………………………………………………………………………………………..……………………………………………..
Aircraft Registration………………………………………………………….…….………………….……………………………………………….……
Date of Strike: Day …………………..………. Month …………….…………... Year..………………..…….
Aerodrome/Location if known ………………………………………………………………………………………..………………………………..

B. COST INFORMATION
Aircraft time out of service ……………………………………………………………………………………………………………………………….
Estimated cost of repairs or replacement U.S.$ (in thousands) ………………………………………………………………
Estimated other costs
(E.g. loss of revenue, fuel, hotels) U.S.$ (in thousands) …………………………………………………………

C. SPECIAL INFORMATION ON ENGINCE DAMAGE STRIKES

Engine Position No. 1 2 3 4

Reason for failure/shutdown
Uncontained failure A A A A
Fire B B B B
Shutdown-vibration C C C C
Shutdown-temperature D D D D
Shutdown-fire warning E E E E
Shutdown-other (specify) Y Y Y Y
Shutdown-unknown Z Z Z Z
Estimated % of thrust loss* .
Estimated number of birds ingested .
Bird species ……………………………………………………………………………………………………………………………………………………...

* These may be difficult to determine but even estimates are useful

Completed form to be sent to :

GM - Safety & Risk, SS&AT Sector
Reported by
General Authority of Civil Aviation
……………………………………………………. sd@gaca.gov.sa I fax: (012) 685 5507
P.O. Box 887, Jeddah, 21421
Kingdom of Saudi Arabia
THIS INFORMATION IS REQUIRED FOR GACA SAFETY & RISK

SS&AT_S&R_F-004_V1.0 (01-02-2016) Page 2 of 2