ATS ENGINEERING OCCURRENCE REPORT

NOTES:
(i) See Instructions and Expanatory Notes;
(ii) When completed please send to : Azerbaijan State Cvil Aviation Auhority, Flight Safety Division (FSD),

Fax: +99412 5984947; +99412 5984209

Tel: +99412 5984947; +99412 5984209

(iii) Complete and /or check boxes/fields 1-25 as appropriate.

Original to FSD

Make additional photocopies as required

1. CATEGORIES OF OCCURRENCE
ACCIDENT INCIDENT PROCEDURAL FAILURE HAZARD
2. OCCURRENCE LOCATION 3. DATE 5. DURATION ON 6. ATS FACILTY 7. SERVICE AFFECTED

4. Time

8. EQUIPMENT TYPE/MANUFACTURER 9. FREQUENCY 10. CALLSIGN 11. EQUIPMENT LOCATION
12.FACILITY CONFIGURATION 13. EQUIPMENT STATUS 14. PREVIOUS DEFECTS /OCCURRENCES? 15.RTF FREQUENCIES/RADAR SOURCE
16. NARRATIVE 17.Recordings impounded 18. Can the information be disseminated in the interest of flight safety? 19. Other fault report action

use a diagram if necessary (attach copies of all relevant information)

Yes
No
20. Name 21. Organization/ Position continue on additional forms if necessary 22. Start time and duration of shift 23. Address Phone (if reporter wishes to be contacted privately)
24. Signature 25. Date

See the reverse side for the explanation of terms and use

ADVICE ON THE COMPLETION OF THE CAA ATS ENGINEERING MOR FORM

USE AND EXPLANATION OF TERMS IN BOXES
BOX 1:
Check one or more category of occurrence.
ACCIDENT / INCIDENT: A reportable occurrence
PROCEDURAL: A reportable occurrence attributed to procedural aspects including operation and maintenance of any facility on the ground.


FAILURE: A reportable occurrence attributed to any defect in or malfunctioning of any facility on the ground.
HAZARD: A potential accident, incident or failure.

EXPLANATORY NOTES
GENERAL: Complete all boxes. If NOT APPLICABLE use N/A, or if NOT KNOWN use N/K. Jargon and uncommon abbreviations must be avoided.
BOX 5: The period over which the Occurrence condition existed. Instantaneous, indefinite or unknown classifications must be identified
BOX 6: The facility type must be marked.
BOX 7: More than one element could be selected.

DETAILS OF THE EQUIPMENT ATTRIBUTING TO THE OCCURRENCE
BOX 9: Frequency (Radio) appropriate to equipment and occurrence, if applicable
BOX 10: Callsign - Navaid identification, SSR code or RTF callsign.
BOX 11: Location - Identify station or other physical location of equipment

BOX 12: More than one element could be identified. Additional channels, diversity, etc. must be stated where applicable. External information source completed with equipment and/or the station/location.
BOX 13: More than one element could be selected. The categories apply to the subject equipment at the time of the Occurrence
BOX 15: Identification of appropriate RTF frequencies/radar source is necessary to secure recordings which may be vital to subsequent investigations
BOX 17: If records impounded, state source, effective date and retaining station.
BOX 19: Other fault reporting action, including contact with agencies, must be stated. It is important to ensure that any involved agency is informed of the reporting action. Normal, immediate fault action takes precedence over MOR reporting action.

CONFIDENTIAL REPORTS
A report may be submitted confidentially. Please clearly annotate the top of the form "CONFIDENTIAL". The second copy need not be forwarded to local management. BOXES 20 to 25 should be completed. The SCAA will respect the confidentiality and the Head of FSD will contact you personally.