Agence Nationale de l’Aviation
Civile et de la Météorologie / FORM / SN-ALL-DGN-FORM-45-A
OCCURRENCE REPORT
Detected in air navigation / Application date:
01/08/2016 / Page
1 sur 4

INITIAL REPORT SECTION

Accountable manager name / Phone number / E-mail
Contact
ANACIM[1] / Operator / Aircraft owner
Report sent to: / BEA[2] / State of Registry / State of the operator
Occurrence’s title
Date (jj/mm/aaaa) / / / / / UTC Time (hh: mm) / :
Airspace class / FIR
Detail on occurrence location(FL, coordinates, QFU, procedure item, radial, distance, Taxiway,…)
Aircraft 1 (Reporting)
Aircraft type / Registration
Operator / Call sign
Operation type / Flight phase
ICAO code of the last departure terrain, if aplicable
ICAO code of the planned arrival terrain, if aplicable
Aircraft 2 / Aircraft type / Registration
Operator / Call sign
Operation type / Flight phase
ICAO code of the last departure terrain, if aplicable
ICAO code of the planned arrival terrain, if aplicable
Instructions:
1. / The section «Initial report » must be filled in the most precise manner by the reporting agent based on available information.
2. / In case of accident or serious incident, a copy of this report must be sent to BEA without delay [2].
3. / The four pages of this form are inseparable and they must be sent during the initial report and during the analysis report.
4. / During the analysis report, the missing information of the section « Initial report » may be added, if necessary.
5. / In any case, once the analysis completed, the operator must send back this updated form. The field « Occurrence status » must then be closed (Brief or detailed analysis, as appropriate).
6. / Attach complete transcription of radio and telephone communication
[1] / ou
[2] / ou

*If the occurrence involves a second aircraft

INITIAL REPORT SECTION

Description of the occurrence and its context
Describe the scenario of the occurrence, weather conditions, flight type, phases and conditions, triggered alarms or not, the consequences on flight, theground/flight interfaces … and all considerations that would help to understand the occurrence.

ANALYSIS SECTION

Occurrence class: / Incident / Serious incident / Accident
Occurrence status: / Open, analysisinprogress / Closedwith detailed analysis* / Closedwith brief analysis
*If the analysis contains non textual information (ex : photos), join the documents to this form during the report of the analysis
AIS Contribution to occurence: / Directement impliqué / Indirectement impliqué / Aucune / Inconnue
*If the analysis contains non textual information (ex : photos), join the documents to this form during the report of the analysis
Effect on ATS: / Total inability to provide ATS in good conditions of safety
Major inability to provide ATS in good conditions of safety
Partial inability to provide ATS in good conditions of safety
Ability to provide ATS in good conditions of safety but in degraded mode
Non determined
No immediate incidence on providing ATS
To which catégory(ies) of accident(s) this occurrence has or could have led ?
In-flight loss of control
Mid-air collision
Controlled flight into terrain
Runway excursion
Collision with the ground
Touchdown off the runway
Abnormal touchdown on the runway
Other, specify :
Type (s) of occurrence(s) :
Insufficientseparation
Runway incursion / FATO (aéronef, véhicule ou personne)
Airspace or Aerodrome traffic intrusion
Non respect of ATSapplicable regulation
Non-stabilized or non-compliant approach
Animal hazard including bird hazards (observations and impact)
Occurrence related to work/maintenance on or next of a runway
Inability to provideall or several ATS
Disruption or failure of ground/onboard communications or with another ATS unit
Misunderstanding of ground/onboard communications or with another ATS unit
Occurrence related to the airport conditions (state of the runway and meteorological/aerological informations), including wrong or missing informations
Important workload on ATS positions
Technical failure of radionavigation means
ATS frequencies jamming (communications or navigation) ou loss of RNAV capability
Failure of ATS security system
Emergency situation declaration
Autre, précisez :
Results of the analysis and taken actions
Following the analysis of the occurrence, describe the causes of the occurrence and the takenactions, if applicable,toreduceorsuppresstherisk.

SN-ALL-DGN-FORM-45-A Compte-rendu d’événement de sécurité – Navigation Aérienne