Da Form 2397 Ab R – Fill Out and Use This PDF

1. DATE/CASE NO.

a.

(YYMMDD)

b. Time(Lcl)

c. Acft Ser No.

2.

a. Classification

A

B

C

D

E

F

OF ACCIDENT

b. Category

Flight

Flight Related

Acft Ground

3. TYPE OF ACFT (MTDS)

4

PERIOD

Daw n

Day

5. NO. ACFT

6. NEAREST MIL

.

INVOLVED

INSTALLATION

Dusk

Night

9.

ORGANIZATION DEEMED ACCOUNTABLE (If same as block 8 leave blank)

a. Name of Unit

b. UIC(6 Digit Unit Id Code)

c. Home Station

10. ESTIMATED ACCIDENT COST

a. Acft Total Loss

Yes

No

b. Acft Damage (Excl man

c. No. Man

d. Man Hr

e. Other Damage Mil

f . Civilian

g. Injury

h. Total (This acft)

i. Total (All acft)

hr)

Hrs

Damage

$

$

$

$

$

$

11. GEN.

a. Msn

(1) Type (Tng, Svc,

(2)

b. Flight Plan

c. Flight Data Recorder

d. Night Vision Device/System In use

DATA

etc.)

Single-ship

NA

VFR

Installed

Yes

Yes

No

If " Yes" Specify

Multi-ship

IFR

No

type

e. Fire

None

Inflight

f . Flammable Fluid Spillage (If " Yes" for Class A, B,

g. Field Training Exercise (FTX)

and C acdts, attach DA Form 2397-6)

Postcrash

Other

Yes

No

Yes

No

If " Yes" Name of FTX

12. FLIGHT

Flight

Phase of Operation (Enter max of 3

Altitude

Airspeed

Aircraf t

Overgross for

13. TYPE EVENTS

(Enter max 3 codes from

codes from fig 3-5 DA Pam 385-40 or

Conditions

fig 3-4 DA Pam 385-40 or specify type event

DATA

Duration

AGL

KIAS

Weight

specify phase (e.g., hover, NOE, etc.)

w hich best describes the acdt/incdt, e.g.,

a. At

Hours

tree strike, generator failure, eng overspeed,

hard landing fuel exhaustion, dropped cargo,

Emergency

Tenths

oil cooler bearing failure, etc.)

b. At

Hours

Impact/Acdt

Tenths

or Termination

14. ACCIDENT CAUSE FACTORS (Enter

a. Human Error

(If D or

b. Materiel Failure/Malfunction

c. Environmental

D, S, or U to identify Definite, Suspected, or

S complete blks 21, 23, &

(Includes mfg/design induced

(If D or S Complete blk 17)

Undetermined causes)

24)

failures)(If D or S complete blk 16)

16. COMPONENT AND PART FAILURE/MALFUNCTION DATA (part that initiated failure/malfunction.)

17. ENVIRONMENTAL

(Chk conditions at time of acdt .)

Identification

Major Component

Part

a. General (1)

IMC

(2)

VMC (3)

Unknow n

a. Nomenclature

b. Environmental Conditions

(1) Weather Conditions

(2) Other Conditions

b.Type, Design,

(a) Hail

(a) Animals

and series

(b) Sleet

(b) Fow l

c. Part Number

(c) Fog

(c) Surface

(d) Drizzle

(d) Noise

d. NSN

(e) Rain

(e) Chemicals

(f) Snow

(f) Radiation

e.Manufac-

(g) Lightning

(g) Glare

turer' s

Code

(h) Thunderstorm

(h) FOD

f . Part Serial

(i) Gusty Winds

(i) Temperature

No.

(j) Freezing Rain

(j) Vibration

g.Cause

(1)

Materiel (2)

Maintenance

FGCODE

(USASC)

TYPEFL

CAUFL

(k) Other

(k) Dust

Failure/

(4)

c. Acft Icing

No

Yes

d. Turbulence

No Yes

Malfunction

(3)

Design

Manufacture

18. BOARD PRESIDENT/ASO/POC

(Name, Signature, and Date) SSN

Address and Tel No. (DSN and Com)

19

. MOON ILLUMINATION DATA (For night Class A, B, or C acdts.

If blk a is " no" , no other entry is required.)

a. Moon Above Horizon

b. Moon Visible

c. Moon (Degrees

d. Percent of

%

e. Moon (Clock Position from

Yes

No

Yes

No

Above Horizon)

Moon

Flight Path/Nose of Acft)

20

. WIRE STRIKE DATA (If " no" in blk a, no other entry is required)

a. Wire Strike

b. WSPS

c. WSPS Engaged Wire

d. WSPS Cut Wire

e. WSPS Functioned as

f . Wires

Installed

Designed

Stuck

Yes

Yes

Yes

Yes

Yes

No.

Dia (inches)

No

No

No

No

No

21

. PERSONNEL DATA (Complete for each crew member w ith access to fit controls or other personnel injured or having a contributing role in the accident; use additional forms as needed)

(8) On Flt

(9) Lab Test (Blood/urine; for pos

(10)Activity

(a)Hrs Slept

(c) Hrs

(11) (a)RL

(12)Injury (If " yes"

(13)Tot Flt

Controls

attach AFIP report)

(Last 24 Hrs)

Flow n

1

2

3

complete DA Form

Yes

Hrs (acdt

(b)FAC

1

2

3

2397-9-R)

MTDS)

(b)Hrs Worked

No

Yes

No

Pos

Neg

b. Name (last, first, MI)

(1) SSN

(2) Grade

(3)Sex

(4)Duty

(5)SVC

(6)UIC (Assigned)

(7)Contributing Role

D

S

N

U

(8) On Flt

(9) Lab Test (Blood/urine; for pos

(10)Activity

(a)Hrs Slept

(c) Hrs

(11) (a)RL

(12)Injury (If " yes"

(13)Tot Flt

Controls

attach AFIP report)

(Last 24 Hrs)

Flow n

1

2

3

complete DA Form

Yes

Hrs (acdt

(b)FAC

1

2

3

2397-9-R)

MTDS)

(b)Hrs Worked

No

Yes

No

Pos

Neg

c. Name (last, first, MI)

(1) SSN

(2) Grade

(3)Sex

(4)Duty

(5)SVC

(6)UIC (Assigned)

(7)Contributing Role

D

S

N

U

(8) On Flt

(9) Lab Test (Blood/urine; for pos

(10)Activity

(a)Hrs Slept

(c) Hrs

(11) (a)RL

(12)Injury (If " yes"

(13)Tot Flt

Controls

attach AFIP report)

(Last 24 Hrs)

Flow n

1

2

3

complete DA Form

Yes

Hrs (acdt

(b)FAC

1

2

3

2397-9-R)

MTDS)

(b)Hrs Worked

No

Yes

No

Pos

Neg

22. IMPACT/PROTECTIVE/ESCAPES/SURVIVAL/RESCUE DATA (For Class A, B, and C acdts)

a. Acft Occupiable Space Compromised (If " yes"

b. Escape/Survival Difficulties (If " yes" DA Form

c. Protective/Restraint Equip Functioned as designed

Yes

DA Form 2397-6-R required)

2397-10-R required for the individual)

(If " no" DA Form 2397-10-R required for the individual)

Yes

No

Yes

No

No

a.

Training Failure (Stds exist but not

b.

Standards Failure (Stds not

c.

Leader Failure (Stds

d.

Individual Failure

e.

Support Failure (Inadequate equip/

know n or w ays to achieve them not know n)

clear,

practical, or do not exist)

are

know n but not enforced)

(Stds know n but not follow ed)

facilities/svcs/no or type personnel)

USASC

Duty

Role

Failure/error Code

SI 1

RM 1

RM 2

RM 3

use only

Phase of OP

Task/part no.

SI 2

RM 1

RM 2

RM 3

REVIEWER

Organization

Name (Typed/Printed)

Rank

Signature

Comments

a.

Unit

Concur

Non-concur

Commander

b.

Review ing

Concur

Non-concur

Official

c.

Approving

Approved

Disapproved

Authority

d. DA

Approved for entry into

Review

US Army Safety Center

ASMIS (YYMMDD)