Wess Aviation Hazard Report Worksheet

WESS AVIATION HAZARD REPORT - EVENT/AIRCRAFT WORKSHEET

NOTE

Use this worksheet and others that follow or are linked as a guide to make your WESS entry easier. Fill out as much information as possible - not all fields are required in WESS - particularly "remarks" fields. Information in red is there to help guide you to the specific type data the application requires.

EVENT INFORMATION

1. Type of Hazard (Circle one) GeneralBASH PHYS EP NMAC OOCF

ATC UAV EMI Embarked Landing

2. Intent for flight (circle one)YESNO

2A. Does this report need endorsement (Circle one):YESNO

3. Brief Description (Limit to 70 characters)

4. Operation Name (i.e., Iraqi Freedom)

5. Material Damage Cost (in dollars)

6. Reporting UIC

7. Detachment (circle one, if YES, need parent UIC)YESNO(parent UIC )

8. Event Information: (circle one)DayNight DuskDawn

Event Date: Local Time: Time Zone __

(MM/DD/YYYY)(HH:MM)

Hazard No Abnormal Egress (circle one)YESNO

Injuries from the event (circle one)YESNO

9. Narrative (Recommend creating in Word and using copy/paste function)

10. Egress Narrative (if applicable)

11. Damage Narrative (if applicable)

12. Injury Narrative (if applicable)

13. Type of Airspace (i.e., Class D, AR, VR, MOA, Warning area, etc)

14. Event occurred in CONUS? (circle one)YESNO

15. General location (circle one)Shore Over Water Ship Pierside Ship at Sea

16. Country Location State/Province Location (If US/Canada)

17. Fleet (circle one, if applicable)2nd3rd5th6th7thN/A

18. Body of Water (If applicable)

19. Latitude N / SLongitude E / W

(XX:XX:XX)(circle one)(XXX:XX:XX)(circle one)

20. NAVAID IDBearing From Distance

(i.e., KNTU)

21. Shore Location (If applicable - i.e., NAS Whidbey Island)

21A. Locations comments

21B. Ship Involved? (circle one) YESNO

INVOLVED SHIP (Applicable if ship involved = YES, otherwise, skip)

22. Was the ship the event location? (Circle one)YES NO

23. Aircraft under positive control of ship? (Circle one)YES NO

24. Was this ship damaged? (Circle one)YES NO

25. Person aboard ship received injuries? (Circle one)YES NO

26. Vessel Type

26A. Class

26B. Hull number

26C. Name

27. Foreign or Commercial Vessel Name (if applicable)

ENVIRONMENT / METRO (if applicable. Info not required if 28 = NO)

28. Is there pertinent meteorological information to report for the event? (Circle one)YES NO

29. Did this event involve a takeoff, departure or other operation where surface/runway/flight deck information is relevant? (Circle one) YES NO

30. Was an embarked landing environment pertinent to this report? (Circle one) YESNO

31. Air temperature (-150 to 180) Fahrenheit Celsius(Circle one)

32. Dewpoint temperature (in whole numbers) Fahrenheit Celsius (Circle one)

33. Water temperature (in whole numbers) Fahrenheit Celsius(Circle one)

34. Percent relative humidity (0 to 100)

35. Wind direction degrees (001 to 360)

36. Wind velocity knots (in whole numbers)

37. Velocity of gusts in knots (in whole numbers)

38. Altimeter setting mercury (inches Hg., eg. 29.98)

39. Visibility statute miles (enter 99 if CAVU)

40. Weather briefed by: (Circle one) Briefer, Forecaster, N/A, other, Pilot, unknown

40A. Utilization of briefing: (Circle one) Not Applicable, Not Available, not used, unknown, used

40B. Forecast accuracy: (Circle one) N/A, substantially correct, unknown, weather considerably better than forecast, weather considerably worse than forecast

41. Ceiling AGL (100's ft)(EG: 15 = 1500 FT) - OR - Check if No ceiling

39A. Sky condition remarks (EG: 10SCT 15BKN 350VC)

42. Horizon (Circle one): visible, partially obscured, obscured, unknown

43. Icing present? (Circle one)YES NO

43A. Icing comments

44. Environment/weather remarks

45. Obstruction to Vision – (Circle all that apply): no obstructions, ice fog, ground fog, haze, precipitation, blowing dust, blowing sand, blowing snow, blowing spray, clouds, dust, fog, unknown, other (specify)

46. Type of Precipitation- (Circle all that apply): No Precipitation, freezing rain, freezing drizzle, light rain, heavy rain, hail, sleet, light snow, heavy snow, drizzle, unknown, other (specify)

47. Extreme Weather- (Circle all that apply): none, hail, wind shear, gusty winds, lightning, thunderstorm, severe thunderstorm, microburst, earthquake, flood, mudslide, hurricane/typhoon, tornado/waterspout, turbulence (CAT), turbulence (IMC), unknown, other (specify)

INVOLVED RUNWAYS (if applicable. Info not required if 29 = NO)

48. AIRFIELD

48A. Departure/Landing Surface ID (i.e., KNTU)

48B. Runway (00-35) (Circle one) Right Left CenterSingle

48C. Helo Pad (5 character limit)

49. AFLOAT (If applicable)

49A. Helo/VSTOL Spot

49B. Ship Base Recovery Course

50. N/A (LZ, Heliport, etc)

51. UNKNOWN

52. Relative Wind Direction (0-180) Left Right

53. Velocity (whole numbers)

51A. Light & Variable

54. Runway Surface Conditions (Circle one)DryWetSlush Loose Snow

Packed Snow Ice Sanded Oil slicked Unprepared Unknown

Other

55. Braking Action (Circle one) Good Fair Poor Nil Unknown N/A

EMBARKED LANDING INFORMATION (if applicable. Info not required if 30 = NO. Same special data as that contained in EMBLAND worksheet)

56. Visual Landing Aid: (Circle one)IFLOLS FLOLS MOVLAS HSSL HRS SGSI UNK N/A Other

57. VLA Information (If 56 = IFLOLS or FLOLS only)

57A. VLA aircraft setting:______(Hornet 360, Prowler 460, etc…)

57B. VLA Glideslope:______(2.5-4.5 degrees)

57C. VLA hook to ramp:______(5 to 50)

57D. VLA Roll Degrees:______(0 to 20)

57E. VLA Cal setting:______(-6 to 6)

57F. VLA Cal Mode (Circle One) Line Inertial Unknown N/A

58. Case Recovery (Circle One)VFR IFR VFR / IFR Combo

59. CCA Mode (Circle One) Coupled Coupled to 100' GCA ILS Non-Precision Unknown N/A

60. SPN Radar (Circle all that apply) SPN-41 SPN-42 SPN-43 SPN-46 SPN-49 SPN-67

61. Arresting Gear Information

61A. Gear Setting:______61B. Target wire:______

61CA-gear remarks:______

61D. Deck motion (feet):______61E. Ship trim (degrees):______(If applicable)

62. Embarked Landing Remarks

62A. LSO console status: (If applicable)

62B. Lighting Comments: (If applicable)

62C. Communications Comments: (If applicable)

62D. LSO / LSE Qualifications Comments: (If applicable)

INVOLVED AIRCRAFT (May have more than one - but enter only one at a time in application. Use link at bottom to download additional aircraft worksheets)

63. Branch of Service (i.e., USN, USMC, USAF, etc)

64. Controlling Custodian (i.e., CNAL, CNAP, CMFP, 4th MAW, Other, etc)

64A. If other US Government (Specify)

64B. If other (Specify)

65. Intent for flight? (Circle one)YESNO

66. Aircraft UIC

67. Aircraft Model/Series

68. Aircraft BUNO

69. Aircraft Tail Code & Side No.

70. Activity Status (Circle one)EmbarkedAshore

71. Type of Operations (Circle one)Extended DeploymentShort Term Ops/Detachment

Home Based/Local Ops X-Country/RON N/A Not yet reported Unknown

72. Pre-Deployment Work-ups (Circle one)YESNO

73. Readiness Cycle (IDRC) Phase

74. Airway/Operating Area (For this specific Aircraft - may be different from event location)

75. Emergency Landing (Circle one)Precautionary Immediate ForcedSimulated Forced

N/A

76. Flight Demo (Circle one)Air show Practice Simulated Emergency TYCOM Demo CNO/CMC Approved Show N/A

77. FCF?(Circle one)YESNO

78. TFOA? (Circle one)YESNO

79. Destination (i.e., NAS Oceana, USS Nimitz, etc)

80. Flight Duration (HH:MM)

81. TFOA (What Fell off, if applicable)

82. Engine Involved: (Circle one)YESNOUnknown

83. FOD to Engine? (Circle one)Internal SourceExternal SourceN/A

84. FOD not to Engine: (Circle one)YESNO

85. NVD Used? (Circle one)YESNO

86. Landing Lights (Circle one)OnOffUnknownN/A

87. External Lights (Circle one)OnOffUnknownN/A

88. Safety Locking Devices (i.e., Ejection seat pins, Landing gear pins, etc. Circle one)

MisusedUsed CorrectlyN/A

89. Engine Power Loss (Required if Engine involved = Yes. Circle all that apply)

Complete Loss (not Pilot induced, not result of precautionary securing)

Complete Loss (Pilot induced, result of precautionary securing)

Fuel Exhaustion / StarvationOil StarvationPartial Loss Unknown or N/A

90. Hazardous Foreign Object (Required if FOD = anything other than NO or N/A. Provide all that apply)

91. Landing Quals (Circle one)FCLP CQ DLQ N/A

92. Aircraft Fire (Circle one)Fire in Flight Fire on Deck No Fire Unknown

93. Shipboard Landing (Circle one)YESNO

94. Aircraft Diverted (Circle one):Ship to Shore Shore to Ship Ship to Ship Shore to Shore

N/A

95. ATC Agency

96. Heading (Degree Magnetic)

97. Airspeed (KIAS)

98. Altitude MSLAGL (Circle one)

99. Altimeter Setting and Source (i.e., Tower, Approach, By rule)

100. Type of Flight Plan (i.e., IFR, VFR, Combo, etc)

101. FPR/TMR Code (i.e., 1A1, 2L6, etc)

102. Actual Meteorological Conditions (Circle one)IMCVMC

102A. Estimated Continuous IMC time as it relates to event (if applicable)

103. Aircraft Mission Remarks:

104. Tape Load (OFP) Tape Load (FCS)

105. Take-off Location (Circle one) Shore Ship at Sea Ship Pierside

105A. CONUS?(Circle one)YESNO

105B. Country (If take off location = shore or ship pierside)

105C. State / Province (If Country = US/Canada)

105D. Ship is (Circle one If take off location = ship at sea) AnchoredUnderwayPierside

UnderwayNot Yet Reported

105E. Body of Water

105F. Latitude N / SLongitude E / W

------WHO SHOULD BE NOTIFIED OF THIS HAZARD REPORT? ------

COMMUNITIES OF INTEREST(i.e., All Hornet Aircraft Activities, All Rotary Wing Aircraft Activities, etc):

INDIVIDUAL COMMAND(i.e., Chief of Naval Operations, Naval Safety Center, NAVAIR, etc):

--- IF THIS HAZARD REPORT NEEDS ENDORSEMENT, THEN WHOM? ---

ENDORSING CHAIN (if question 2A = YES)

First endorser

Second endorser (if required)

Third endorser (if required)

Fourth endorser (if required)

Fifth endorser (if required)

Sixth endorser (if required)