WESS AVIATION HAZARD REPORT - INVOLVED FACTORS AND RECOMMENDATIONS WORKSHEET
INVOLVED FACTORS
Involved Factors of aHazard Report
Complete this worksheet for each Human Factor
Human Factors
Select from list: ______(Aircrew, Supervisory Personnel, Facilities Supervisory, Facilities Non-Supervisory, Maintenance Supervisory, Maintenance Non-Supervisory)
Factor Statement: ______
______(70 characters free text)
Factor analysis and amplifying remarks: ______
______(free text)
ProbabilitySeverity / A / B / C / D
I / 1 / 1 / 2 / 3
II / 1 / 2 / 3 / 4
III / 2 / 3 / 4 / 5
IV / 3 / 4 / 5 / 5
Risk assessment code: ______
Probability:
A - Likely to occur immediately or within a short period of time
B - Probably will occur in time
C - May occur in time
D - Unlikely to occur
Severity:
I - May cause death or loss of facility/asset
II - May cause severe injury, illness, property damage
III - May cause minor injury, illness, property damage
IV - Minimal threat)
Who: ______(Select from: aircrew/PAX, supervisory, facilities personnel, or maintenance)
Who (specific): ______(Reference 3750 Appendix L - hyperlink
Who (fine): ______(Reference 3750 Appendix L - hyperlink
What: ______(Select from: aircrew/PAX, supervisory, facilities personnel, or maintenance)
What (specific): ______(Reference 3750 Appendix L - hyperlink
What (fine): ______(Reference 3750 Appendix L - hyperlink
For this section, multiple “Why” items may be listed:
1st Why: ______(Communication/coordination, psychosocial, environment, performance, human engineering, medical physiological, or undetermined)
1st Why (specific): ______(Reference 3750 Appendix L - hyperlink
1st Why (fine): ______(Reference 3750 Appendix L - hyperlink
2nd Why (if applicable): ______(Communication/coordination, psychosocial, environment, performance, human engineering, medical physiological, or undetermined)
2nd Why (specific): ______(Internal to the aircraft, external, or other)
2nd Why (fine): ______(Be prepared to select from lengthy list of sub-categories)
Any additional “Why” items may be entered in the same way
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Complete this worksheet for each Material Factor
Material Factors
Select from list: ______(Aircraft Systems, Aircrew Equipment, Support Equipment, Facility Equipment)
Factor Statement: ______
______(70 characters free text)
Factor analysis and amplifying remarks: ______
______(free text)
ProbabilitySeverity / A / B / C / D
I / 1 / 1 / 2 / 3
II / 1 / 2 / 3 / 4
III / 2 / 3 / 4 / 5
IV / 3 / 4 / 5 / 5
Risk assessment code: ______
Probability:
A - Likely to occur immediately or within a short period of time
B - Probably will occur in time
C - May occur in time
D - Unlikely to occur
Severity:
I - May cause death or loss of facility/asset
II - May cause severe injury, illness, property damage
III - May cause minor injury, illness, property damage
IV - Minimal threat)
Component Involved is: ______(Engine/Prop or Other)
Nomenclature: ______(30 characters free text)
Make/Manufacturer: ______(50 characters free text)
Model: ______(30 characters free text)
Serial Number: ______(20 characters free text)
Manufacturer Part Number: ______(20 characters free text)
Type Equipment Code: ______(4 characters)
Work Unit Code (WUC): ______(7characters)
Naval Ammunition Logistics Code (NALC): ______(7 characters)
Failure or Malfunction Mode: ______(30 characters free text)
Failure or Malfunction Agent(s): ______(40 characters free text)
2nd Failure or Malfunction Agent (if applicable): ______(40 characters free text)
Any additional “Agent” items may be entered in the same way
Amplifying remarks: ______
______(free text)
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RECOMMENDATIONS
Type of action agency to add: (individual command or community of interest)
a) Individual CommandRecommendations:
Action Agency: ______(UIC or Name)
Recommendation Statement: ______
Remarks: ______
Recommendation Status:______(Circle one)OPEN COMPLETED
Associate Recommendation to which Involved (cause) Factor:
1.
2.
3.
4.
Note: Any additional “individual command" recommendations may be entered in the same way
b) Community of Interest (COI) Recommendations:
Action Agency: ______(UIC or Name)
Recommendation Statement: ______
Remarks: ______
Recommendation Status:______(Circle one)OPEN COMPLETED
Associate Recommendation to which Involved (cause) Factor:
1.
2.
3.
4.
Note: Any additional “COI" recommendations may be entered in the same way
Commanding Officers Comments: (Recommend creating in Word and using copy/paste function)
______