Reference
Modification no.
- 5 -
Page
272
Date
2003 03 01
Main
914 F
d03052
CUSTOMER
SERVICE INFORMATION REPORT
OPER. Control No.
ATA Code
A/C Reg. No.
Enter pertinent data
MANUFACTURER MODEL/SERIES SERIAL NUMBER
AIRCRAFT
POWERPLANT
PROPELLER
5. SPECIFIC PART
(of component)
CAUSING TROUBLE
Part Name MFG. Model or Part No. Serial No. Part/Defect Location
4.
3.
2.
6. ENGINE COMPONENT
(Assembly that includes part)
Engine
/
Comp. Name Manufacturer Model or Part No. Serial Number
Engine TSN Engine TSO Engine Condition 7. Date Sub.
8. Comments
(Describe the malfunction or defect and the circumstances under which
it occurred. State probable cause and recommendations to prevent recurrence.)
Optional Information:
Check a box below, if this report is related to an aircraft
Accident; Date Incident; Date
TELEPHONE NUMBER: ( ) ———
REP. STA
SUBMITTED BY:
1.
Muster
0
ROTAX
A-Z L1.V R
DISTRICT
OFFICE
OPER
MECH AIR TAXI MFG ACG COMMUTER OTHER
OPERATOR
DESIGNATOR
AIRCRAFT ENGINES
05478
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