Fill and Sign the Hmrc Form 5003 En

Tel 0116 289 4316 8 Merus Court Meridian Business Park 24 hour answering Fax 0116 281 4949 Leicester LE19 1RJ British Hang Gliding and Paragliding Association Ltd Serial No. (Office use only) Incident Report Form It is a legal requirement and your duty as a BHPA member to report air incidents. Fatal or potentially fatal incidents must be reported to the BHPA, Air Accident Investigation Branch (AAIB) and Police immediately. Serious incidents should be reported to the BHPA as soon as possible and in all cases an Incident Report Form should be sent to the BHPA within 48 hours. BHPA Technical Officers: 0116 289 4316 BHPA Office: 0116 289 4316, office@bhpa.co.uk, www.bhpa.co.uk AAIB (24 hours): 01252 512299 Report incidents if any of the following apply: • Involve injury, whether to participants or others. • Involve damage to property, third party or not. • May give rise to an insurance or legal claim. • Involve non-standard equipment or techniques. • Involve failed or malfunctioned equipment. • Highlight safety points or were unusual. • You feel the sport may learn from. Person involved BHPA c BMAA c Membership / Intro. Cert. No. Name Address Post code Email Telephone Home Nationality Mobile Gender M/F ____ Age ____ Weight (kg) ____ Clip in weight (kg) ____ Ratings: None c Under training c CP c P c AP c Dual c Instructor c Date last rating attained IPPI levels: Safepro ___ Parapro ___ Time since last flown Experience: Years ________ Flying hours ______________ Hours on type ________ Total flights ________ Trained by: BHPA Instructor c BMAA Instructor c Other Instructor ________________ Training School c Friend c Self c Current club Incident details Discipline: HG c PG c PA c Country Date Time Name of site Wind direction: Best for site _________ On the day _________ Launch: Hill: Assisted Wind speed mph: 0-7 Weather: c Forward c Reverse c Tow: Winch c Vehicle c Aerotow c Power c 8-12 c 13-17 c 18-21 c 22-25 c 26-30 c 30+ c c Variable c Gusts c Thermic c Turbulent c Smooth/steady Incident during: Take-off c Tow c Free flight c Powered flight c Thermalling c SIV c Acro c Approach c Landing c Injuries Person/s injured: Pilot 1 c Pilot 2 c 2nd pilot (dual) c Ground crew c Course member c Third party c Injuries sustained Medical: c Casualty dept. c Hospital admission c Name of hospital and town: Equipment c PG c Glider/canopy: HG Bought: New Certified by: Manufacturer Model DHV c Secondhand c Size Total flying hours Date of manufacture c LTF c CEN c Certification grade (e.g. A, B, 1, 2/3, etc.) ________ BHPA c HGMA c Registered Prototype c Registered Grandfathered c Not certified c Modifications (list) Accessories Power unit: Manufacturer Harness: Manufacturer Helmet type: None Model Age ____ Modifications Type Padding type c Open face c Full face c CE966 approved? _______ Emergency parachute: Manufacturer Model Deployment at height agl _______ metres Successful deployment Age ________ Size ________ c Failed deployment c Accidental deployment c Narrative report • Please write clearly, preferably in black ink. • Provide as much factual information as possible. • Provide sketches opposite. • Continue on a separate sheet if necessary. What led up to the incident? What was the student/pilot briefed to do (or what did he say he would do)? Describe the incident: What happened after the incident? (Include medical diagnosis.) Contributory factors Tick the box/es for any factors Major Minor Inexperience c c High wind c c Low wind c c which you think may have contributed. Major Minor Major Minor Major Minor Turbulence Overconfidence c c c c Traffic density c c Stall/tuck c c Equipment c c Other ___________________ Confusion/froze c c Insufficient lookout c c ________________________ Sketch of incident Side and/or plan view sketches as appropriate SCHool-BASEd INCIdENTS oNly For any incident or accident at a BHPA registered school this section is to be completed. Serious incidents/accidents are to be reported by telephone immediately. This report form must be posted to the BHPA office within 48 hours. At the time of the incident Who was the duty Instructor/Instructor in charge? Who was supervising the ‘incident’ group? What ratings are held? Who was driving/operating the tow unit? What ratings are held? Was a separate tensiometer reader carried? Separate observer carried? What length tow line was used? Anchor man used? What line material? What type of communications were used? What training aids were used? How many students were being trained? What training exercise was the student attempting? How many students were in the ‘incident’ group? No. of flights on this exercise? Student’s training history Type of course student was on: Intro c EP c CP c Refresher c Soaring c XC c SIV c Acro c Other c Previous School attended (if any) No. of days on this course Total no. of training days What was the student’s previous training exercise? No. of flights on the previous exercise? On what date? Details of the student’s two most recent theory sessions: Date Subject Duration Venue (outdoor, vehicle, clubroom, etc) 1 2 Name of tutor Additional contact information WITNESSES 1: Name Telephone Address Postcode 2: Name Telephone Address THIRd PARTIES Postcode 1: Name . Telephone Address Postcode Desciption of injury/damage 2: Name Telephone Address Postcode Desciption of injury/damage . Signature • Completed the report as fully as possible? • Print your name, sign and date it. • Post to the BHPA Office in the reply paid envelope. Name Signed Date If different person from front page: Membership No. Address Postcode Telephone The PdF version of this form may be downloaded from: www.bhpa.co.uk/members/forms BHPA oFFICE uSE oNly I.O. assessment: Injury category: Nil c Minor c Serious c Fatal c Cause: Received: Acknowledged: Serial No.: BHPA - IR 04/09