I, (name), am employed as a pilot by (airline and location of main offices). I am based in (location). I am making this statement only for the safety investigation with the understanding that it will only be used for that purpose.

I served as the (Capt/F.O./S.O.) on aircraft registration (registration), which operated as (airline name) Flight (number) between (airport name) and (airport name), and which departed (airport name) on or about (UTC, day, month and year). The other crew members were (list both flight crew and cabin crew, giving position and crew base).

I am fully qualified and current to serve as a (Capt/F.O./S.O.) by (airline), and I am certified by the Australian Civil Aviation Safety Authority, licence number (number), with the following ratings: (ratings). I possess a valid medical certificate dated (date).

I am a citizen of (country), residing at (address). My passport number is (number), issued by (country), on (date), which expires on (date).

Option 1 (preferred)

There appears to be an occurrence involving Flight (number). This occurrence is currently under investigation by (airline) and the appropriate government authorities. I intend to cooperate fully in this investigation. I am not in a position to provide specific factual information at this time. I will provide any facts relating to the occurrence as soon as I can confirm them.

Option 2

At approximately (time of event), (factually describe occurrence, i.e., “we lost no. 2 engine” or “smoke filled the cabin” or “we made a precautionary landing at (airport name) and evacuated the aircraft”). I have no information as to what caused the problem. I will fully cooperate in any investigation to determine what led to this occurrence. I will provide further facts relating to this occurrence as soon as I can obtain and confirm them.

(signature and date)