Please Fill in As Much As You Can. Leave Blank Any Areas That You Are Unsure Of. Some

Occurrence Report Form

Please note: Any shaded areas are to be filled out by the designated company personnel or his/her delegate.
Company File # / NAA File #: / Safety Board File #:

Please fill in as much as you can. Leave blank any areas that you are unsure of. Some information will be filled in by the Safety Officer, such as aircraft historical information.

Location and date:

Date of Occurrence: / Time:
Location: / Latitude: / Longitude:
Last Departure Airport: / Airport of Intended Landing:
Please indicate location in relation to an airport or Navigation aid. If on the ground please indicate location on the airport itself.

Aircraft Information:

Aircraft Type: / Registration:
TTSN: / Time since last Inspection:
Engine type: / TTSO:

Flight Crew Information

Experience

Name and Certificate Number / Total Flight Time / Total on Type / Total last 90 Days / Total last 30 Days
Pilot in Command
Student’s Name
Observers

Fatigue Management Information

Hours on Duty / Hours of rest in last 24: / Last full day of rest: / Last uninterrupted rest period of 8 hours was:
Pilot in Command
Student’s Name
Observers

Maintenance Staff Information

AME’s or Apprentice Name
Job Tasking
Reported for duty at:
Last uninterrupted rest period of 8 hours was:
Have you had previous experience with this type of job tasking? / Yes No / Yes No / Yes No
If no, were you under supervision during the occurrence? / Yes No / Yes No / Yes No

Hazard Description

Please describe the hazard
What would you recommend be done to better manage this hazard?:

Occurrence Description (Air Event)

Type of Occurrence / Air miss
q / Bird strike
q / Wake Turbulence
q / Technical
q / Ground Occ.
q
Aircraft / A/C Type / Engine Type / Registration
Flight or / Parked
q / Towing
q / Taxi
q / T/O
q / Climb
q / Cruise
q / Descent
q / Holding
q / Approach
q / Landing
q
A/C Config. / Speed / Altitude / Heading / Flaps / Power / Gear / Pilot controlling
Kts. / Ft. / º M / º / Up Down
q q / Inst.
q / Student
q
Weather / IMC / VMC / Wind / Vis. / Clouds / Temp. / Alt. / Precipitation
q / q / Nil
q / <4/8
q / >4/8
q / __ºC / __._ / Fg
q / Dz
q / Rn
q / Sn
q / Nil
q
Emergency Response / Was an Emergency declared? / Emergency declared with who? / Were the Emergency Vehicles called out? / Was the Emergency Response satisfactory?
Yes / No
r r / Yes / No
r r / Yes / No
r r
Emergency Equipment Used / First Aid Kit r
Fire Extinguisher r
Description of Occurrence: (Please use extra sheets as required)

Occurrence Description (Ground Event)

Type of Occurrence / During Aircraft Maintenance / Office work / Other / If other please list
q / q / q
Type of Work / Snag Rectification / Scheduled Inspection / Aircraft Modification
q / q / q
Area of Work / Airframe / Engine / Avionics / Electrical
q / q / q / q
Location of Work / Hangar Floor / Specialty area / Outside
q / q / q
Environmental / Temperature / __ºC / Wind
Lighting / Daylight / Hangar Lights / Extra lights / Flashlight
q / q / q / q
Emergency Response / Was an emergency declared?
Yes / No / Emergency Declared with Who?
Airport / City / Were the Emergency Vehicles Called Out?
Yes / No / Was the Emergency Response Satisfactory?
Yes / No
Emergency Equipment Used? / First Aid Kit
Yes/ No / Fire Extinguisher
Yes/ No / Eye Wash
Yes/ No / Other (Please List)
Detailed Description of Occurrence: (Please use extra sheets as required)

Air Miss

Air Miss Plot position of other aircraft relative to you assuming that you are at the centre of the square at the time of passage. Please write the estimated distance from the other aircraft in feet for both horizontal and vertical separation
.
Avoiding action / By whom / Under ATC Control / ATC avoidance inst. given / Flight Rules / Under Radar / Reported. To ATC / Risk Assessment:
Yes/No
r r / You/Him
r r / Yes/No
r r / Yes/No
r r / VFR/IFR
r r / Yes/No
r r / Yes/No
r r / High
r / Med.
r / Low
r / Nil
r
Other Aircraft / Type / Color / Lights
On / Off / Call Sign/ Reg. / Strobe lights
On / Off

Bird Strike

Bird Strike
Bird Species:
______/ Size of Bird(s)
r Small
r Med.
r Large / No. of Birds
1 2-10 11-100 More
Seen r r r r
Struck r r r r / Parts of Aircraft:
Windshield Nose Eng. Wing Gear Other
Struck r r r r r r
Damaged r r r r r r

Wake Turbulence

Position in relation to airport: / Position in relation to lead aircraft / Rolling / Buffet / Stall Warning / Change in Attitude / Change in Altitude / Alerted by:
Yes/No
r r / Yes/No
r r / Yes/No
r r / Yes/No
r r / ______ft. / ATC
r / Traffic
r / Not
r

Technical

Electrical
r / Mechanical
r / Instrument
r / Avionics
r / Airframe
r / Engine L/R
r / Hydraulic
r
Snag Description:

Ground Occurrence

Collision with another aircraft/vehicle / Propstrike / Collision with pedestrian / Engine running?
Yes / No / Aircraft moving?
Yes / No / Rotating beacon/ nav lights on?
Yes / No
r / r / r / r r / r r / r r
Occurrence Description:

Note:

The purpose of this report is to help improve the safety of operations in our company. We have anon disciplinary policy for any occurrence unless one of the following conditions applies:

·  Gross negligence on the part of the individuals involved.

·  Criminal Intent on the part of the individuals involved.

·  Use of illicit substances on the part of the individuals involved.

Do you wish to this report classified as a confidential report? Yes No

Do you wish to receive feedback on the progress of this report? Yes No

Reporting person’s signature:______Date: ______

Address: ______Contact Number: ______

______

______

Thank you for your report.

This document has been prepared by Doiron Aviation Consulting ()