404 Notification

Defect report

This form can be completed online. We recommend using Adobe Acrobat

Go to CASA Defect Reporting Portal. to complete this form to ensure your
information is saved correctly
Purpose of this form
Use this form to report a defect discovered in an aircraft. Filling in this form
This form can be completed as a fillable form:
Who is this form for? • Adobe Reader is available free of charge from the Adobe website
This form is for aircraft maintainers, aircraft owners and operators. • use ‘tab’ or ‘mouse click’ to navigate through the form
If printing this form:
Information needed to complete this form • use black or blue pen and print in BLOCK LETTERS
Even though all questions are not mandatory, provide as much • mark check boxes with a  or a 
detail is necessary to properly describe the defect.
Aviation Reference Number (ARN)
An ARN is an identifier that is similar to an account or customer
number. You may need an ARN to complete this form.
If you do not have an ARN, apply for an ARN.

Contact details
CASA will use the currently held contact details linked to your ARN profile.
If your address, contact or other details have changed, you must update
them online using changing your details prior to lodging this form.

Privacy
Any personal information you provide to CASA is protected by the
Privacy Act 1988 (Cth). CASA can only collect, use and disclose
that information in accordance with that Act.
CASA will use the information collected in this form for purposes
associated with performing its functions under civil aviation legislation
and other Australian laws.
For full details on how CASA collects, protects and uses personal
information, please refer to CASA Privacy Policy.

For more information

Go to the CASA website or call us on 131 757.

Civil Aviation Safety Authority

Defect report | Form 404 | V 1 | CASA-04-1028 | 03/2020 Page 1 of 5
Reporter General details
1 What are the reporters details? 3 Provide a short summary of the defect. (Max 200 characters)
Provide the details of the individual or contact person who is
submitting this application.

Full name

ARN (Leave blank if you do not have an ARN)

4 What type of defect report are you submitting?
Defect Report with complete investigation
City
Initial report with additional information to be provided
Follow up to an existing Defect Report

Contact number Defect Report number

Email address
5 When was the defect discovered?
Date (DD/MM/YYYY)
Reference number (If applicable) / /

Notifier/reporter type 6 What type of registration is it?

Operator Australian VH aircraft
Maintenance provider Australian non-VH aircraft
Both Military aircraft
Non-Australian aircraft
Operator details Component

2 What are the operators details?

Operator name 7 Has the Type Certificate Holder been notified?
No/unsure
Yes
Operator ARN (if known)

Air Transport
Aerial Work
Aerial Application
General Aviation
Charter
Other (specify)

Civil Aviation Safety Authority

Defect report | Form 404 | V 1 | CASA-04-1028 | 03/2020 Page 2 of 5
Aircraft details 9 Continued
Time since new
8 What are the aircraft details?
Hours Cycles
Registration mark

Time since last maintenance check

Manufacturer
Hours Cycles

Model
Time since overhaul
Hours Cycles
Serial number

Time since last shop visit

Time in service since new Hours Cycles
Hours Cycles

Time since last maintenance check Propeller details

Hours Cycles
10 What are the details of the propeller(s) fitted to the aircraft
(if relevant)?
Manufacturer
Aircraft system of maintenance
Manufacturer’s Maintenance Schedule (reg 42A of the CAR)
CASA Maintenance Schedule 5 (reg 42B of the CAR) Model

Approved System of Maintenance (reg 42C of the CAR)

Approved Maintenance Program (Subpart 42.J of the CASR)
Serial number

Engine details
Time since new (Hours)
9 What are the details of the engine(s) fitted to the aircraft (if
relevant)?
Turbine Shaft
Time since last maintenance check (Hours)
Jet
Piston
Other (specify) Time since overhaul
Hours Cycles

Manufacturer

Model

Serial number

Civil Aviation Safety Authority

Defect report | Form 404 | V 1 | CASA-04-1028 | 03/2020 Page 3 of 5
Part details Causal factors
11 What are the details of the defective part(s)? 13 Were there any causal factors (Select all that apply)?
Name of the part Design
Manufacture
Operational
Part number Human factors
Inadequate maintenance
Other (specify)
Condition

Location on aircraft
14 When was the defect found (Select all that apply)?
Take off
Climb
Time since new (Select one)
Cruise
Hours Months Cycles Landings
Landing
Accident

Time since overhaul (Select one) Scheduled maintenance

Hours Months Cycles Landings Descent
Other (specify)

JASC code level 1

Airworthiness directive reference

JASC code level 2

Service bulletin reference

Available for CASA inspection

Available for destructive testing Investigation summary
15 What were the results of the investigation?
Contributing factors Provide a summary of the defect. If relevant, include:

12 Were there any contributing factors (Select all that apply)? • Circumstances under which it was discovered
• Indications or warnings
Corrosion
• Hidden consequences
Fatigue • Probable cause
Inadequate data • Action taken to rectify the defect
• Recommendations to prevent recurrence
Accident/heavy landing
Material failure What were the symptoms?

Age
Lightning Strike
Environment
High Hours
Other (specify)

Attach additional pages if required

Civil Aviation Safety Authority

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15 Continued Declaration
What was the cause?
16 I declare that:
• All statements in this notice are true and correct in every
particular and that I have read and understood all provisions
of the Civil Aviation Safety Regulations 1998 which are
relevant to this notice.
• I understand CASA will use the currently held details to
process this notice and it is my responsibility to ensure my
details are correct prior to lodgment.
• I consent to CASA using and disclosing my personal
information in accordance with CASA Privacy Policy
including exchanging the information with Commonwealth,
State and Territory government agencies.
• I acknowledge that to knowingly make a false or misleading
statement in this notice is an offence against the
Criminal Code Act 1995 (Cth).
I grant CASA a licence to use, adapt, modify and
communicate images attached to this report.
Full name

Organisation name

Attach additional pages if required

What was the result of the investigation/remedy?

Date (DD/MM/YYYY)
/ /

Returning your form

By email – attach this form and all supporting documents.
Send them to [email protected]

By post – return this form and all supporting documents to:

Civil Aviation Safety Authority
Defect Report
Replay Paid 2005
Canberra ACT 2601
Alternatively fax completed form to (02) 6217 1920.

Attach additional pages if required

Civil Aviation Safety Authority

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