ATS OCCURRENCE REPORTING FORM

for ATS personnel to report an occurrence caused by an aircraft or vehicle, by your own or another Unit, an allege violation of ATS provisions or clearances, equipment/ATC Procedures shortcomings, etc.

1. DATE / TIME OF OCCURRENCE (IN UTC) 2. DAY OR NIGHT 3. GEOLOCATION OF OCCURRENCE
YY
MM
DD
hh
mm

4. AIRCRAFT INVOLVED
OPERATOR CALL SIGN AND REGISTRATION TYPE ADEP ADES FLT ALTITUDE OR HEIGHT
ACTUAL DEARED
SSR CODE MODE C RELEVANT ROUTE SEGMENT FLT RULES




IFR VFR Spec
5. RTF FREQUENCY / COMMUNICATION AND SURVEILLANCE EQUIPMENT USED 6. CLASS OF ATC AIRSPACE 7. TYPE OF AIRCRAFT SERVICE
A
B
C
D
E
F
G
8. ESTIMATED VERTICAL DISTANCE (METERS/FEET) 10. AUTOMATED WARNING SYSTEM
9. ESTIMATED HORIZONTAL DISTANCE (NM/KM/MINUTES) 11. TRAFFIC INFORMATION GIVEN
13. WAS WEATHER CONSIDERED RELEVANT? (IF YES, INCLUDE DETAILS IN BOX 14) 12. HAVE YOU REVIEWED RELEVANT RTF AND/OR SURVEILLANCE
14. DESCRIPTION OF OCCURRENCE WITH DIAGRAM, IF NECESSARY; CAUSES AND FACTORS BELIEVED RELEVANT TO OCCURRENCE; SUGGESTED CHANGES AND IMPROVEMENTS, IF APPROPRIATE
USE ADDITIONAL FORMS IF NECESSARY
15. ASSESSMENT OF WORKLOAD 16. TIME SINCE LAST BREAK 17. START TIME OF SHIFT 18. NAME OF YOUR
UTC LT ATS/UNIT ANS SECTOR
UTC
LT
19. ON DUTY AS: FOR OFFICE USE ONLY:

When completed, please send to: Azerbaijan State Civil Aviation Authority Flight Safety Division (FSD)

Fax: +99412 5984947; +99412 5984209
Tel: +99412 5984947; +99412 5984209
20. YOUR NAME AND LOCAL DATE