During the last 24 months, how many times have you experienced each
of these events.
[Please note that the default value for each event is zero. Don't skip
items just because
the zero button is selected. Think about each item and choose the response
that applies
to you.]
| 1 |
Run so low on fuel that you were seriously
concerned about making it to an airfield/heliport or refueling point
before you ran out? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 2 |
Made a precautionary or forced landing at an airfield/heliport
other than your original destination? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 3 |
Made a precautionary or forced landing away from
an airfield/heliport? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 4 |
Been forced to perform an abrupt maneuver to avoid
an obstacle? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 5 |
Had a mechanical failure that jeopardized the
safety of your flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 6 |
Flown into areas of instrument meteorological
conditions, when you were not on an instrument flight plan? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 7 |
Turned back or diverted to another airport because
of bad weather while on a VFR flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 8 |
Experienced vertigo so severe that you had to
pass control of the aircraft to the other pilot? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 9 |
Had a crewmember become ill or incapacitated during
flight, to the extent that they could not fully perform their duties?
|
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 10 |
Lost visual contact with the ground because of
dust or snow while landing or taking off (brown-out)? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 11 |
Drifted more than two dots to the left or right
of course while inside the outer marker on an ILS approach? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 12 |
Lost one or more of your primary flight instruments
(gyro failure, altimeter failure, etc.) during instrument flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 13 |
Attempted to hover out of ground effect, and discovered
you had insufficient power? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 14 |
Experienced a near mid-air collision? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 15 |
Nearly collided with the ground or some object
while flying? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 16 |
Had your aircraft slide after landing on a slope
or smooth rocks? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 17 |
Executed a go-around after encountering
brown-out or white-out conditions during the last portion of your
approach to landing? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 18 |
Made a zero-visibility take-off in which you immediately
lost visual contact with the ground while pulling pitch because
of brown-out or white-out? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 19 |
Narrowly avoided a wire-strike? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 20 |
Became so fatigued while flying that you had difficulty
remaining alert and performing your duties? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 21 |
Were asked by a ranking passenger to perform an
action that you believed was contrary to the safety of flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 22 |
Struck a large bird while in flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 23 |
Experienced much worse weather enroute or at your
destination than was forecast? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 24 |
Experienced a failure of your night vision device
during a critical phase of flight (for example, while on approach
to an LZ or while maneuvering low-level)? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 25 |
Had a significant dispute with the other pilot
regarding what course of action should be taken? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 26 |
Found that you and the other pilot had a very
different mental picture of what was going on in or around the aircraft
(for example, your position relative to friendly and enemy forces,
the location of the next navigation fix)? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 27 |
Flown with a pilot, outside of a training situation,
who did not seem to have the skills needed to fly the aircraft and
accomplish your mission? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 28 |
Had the other pilot perform some action that was
completely unexpected and might have jeopardized the safety of your
flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 29 |
Had a radio communications failure that jeopardized
the safety of your flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 30 |
Discovered during a flight that you did not have
the correct frequencies and/or callsigns required for communication
with ground personnel? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 31 |
Lost communications with another member of the
crew during some critical phase of flight? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 32 |
Misinterpreted some statement or request by the
other pilot or a crewmember leading to an unsafe condition? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 33 |
Had the other pilot misunderstand some statement
or request that you made, leading to an unsafe condition? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 34 |
Inadvertently moved the control (cyclic, collective,
or control wheel) when you were not the pilot flying the aircraft?
|
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 35 |
Performed unauthorized aerobatics, return to target
maneuvers, or buzzed ground vehicles? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
| 36 |
Performed a terrain (low-level) flight without
having documented all the hazards on your maps? |
0 (None) |
1 time |
2 times |
3 times |
4 or more times |
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