FLIGHT CREW AIR SAFETY REPORT

1. EVENT AIRPROX ATC PROCEDURAL TCAS RA WAKE TURB BIRD STRIKE SECURITY
ASR (BOX 31/32) (BOX 31/32) (BOX 31/32) (BOX 33) (BOX 34) (BOX 35)
2. CAPT I / D doc. NO. CO-PILOT I/D NO. OTHER CREW
3. DATE OF OCCURRENCE 4. UTC / LT 5. FLT NO. / CALLSIGN 6. SECTOR 7. TRANSPONDER
-
8.A/C TYPE 9.REGISTRATION 10. PAX / CREW 11. FUEL JETTISONED 12. ETOPS
Kg
13. ALTITUDE/Flt level 14.SPEED/MACH NR 15. A/C WEIGHT 16. TECH LOG REF
17. FLIGHT PHASE 18. AIRPORT AND STAND
19. GOEG POSITION / CO-ORDS FIR/Way Point
20. MET 21. WX ACTUAL 22. SIGNIFICANT WX
IMC M
VMC Km
WIND VIS CLOUD
TEMP QNH
23. RUNWAY 24. RUNWAY STATE 25. CONFIGURATION
A.PILOT A.THRUST GEAR FLAP SLAT SPOILERS
26. SUMMARY (CONCISE DESCRIPTION OF THE EVENTS INCLUDING OTHER A/C DETAILS IF APPLICABLE e.g. A/C TYPE, MARKINGS, COLOUR, LIGHTING etc. MOR
If you consider this event to be a Mandatory Occurrence please tick the box and it will be forwarded to the CAA
Yes No
27. DELAY IF ANY 28. OTHER INFORMATION AND SUGGESTIONS FOR PREVENTIVE ACTION
29. ACTIONS AND RESULTS (ACTION TAKEN, THEIR RESULTS AND ANY SUBSEQUENT EVENT)
30. STATION ENGINEER'S STATION MANAGERS REPORT
31. AIRPROX* / ATC PROCEDURAL* and/or TCAS RA* (*Delete as applicable)
Mark passage of other aircraft relative to you in plan on the left and in elevation on the right assuming YOU are at the center of each diagram. Indicate appropriate scale.
SEVERITY OF THE RISK TO A/C MINIMUM VERTICAL SEPARATION _ FT
AVOIDING ACTION TAKEN Yes No MNIMUM HORIZONTAL SEPARATION _ M /MM*
REPORTED TO ATC _ UNIT TCAS ALERT
ATC INSTRUCTIONS ISSUED FQ IN USE _ TYPE OF RA
HEADING _ DEG WAS RA FOLLOWED        Yes No (VERTIC. DEV. _ FT)
CLEARED ALTITUDE / FL* WAS TCAS ALERT        Yes No
32. AIRCRAFT POSITION DIAGRAM




View from above (horizontal plane: meters* or NM* View from astern (vertical plane: ft)
33. WAKE TURBULENCE 34. BIRD STRIKE
HEADING DEG TYPE OF BIRDS
TURNING NUMBER SEEN
POSITION ON GLIDESLOPE NUMBER STRUCK
POSITION ON EXTENDED CENTERLINE TIME
CHANGE IN ATTITDE PITCH ROLL YAW DEG DESCRIBE IMPACT POINTS AND DAMAGE
CHANGE IN ALTITUDE
WAS THERE BUFFET Yes No
WHAT MADE YOU SUSPECT WAKE TURBULENCE? 35. SECRITY RELATED OCURRENCES
DESCRIBE ANY VERTICAL ACCELERATION
GIVE DETAILS OF PRECEDING A/C (TYPE/CALLSIGN etc)
WERE YOU AWARE OF OTHER A/C BEFORE THE INCIDENT Yes No
NARRATVE:
SIGNATURE RANK
FILING INSTRUCTIONS
FLIGHT CREW           Immediatelly after landing hand to :
At "BAKU"
CONTROLLER:           DUTY OPERATIONS
REPORTING OFFICIAL           on receipt forward immediately to:
Azerbaijan State Civil Aviation Authorty, Flight Safey Division (FSD).
Fax: +99412 5984947; +99412 5984209
Tel: +99412 5984947; +99412 5984209
ORIGINAL TO SCAA           CHIEF SAFETY DEPARTMENT