ANNEXURES

Annexure A
CONFIDENTIAL AVIATION HAZARD REPORT

If you have encountered an aviation situation or incident that you deem hazardous or potentially so, please describe it in the space below, mark “CONFIDENTIAL” and mail to:

(Postal address of designated

body or institution.)

Information in reports may appear in future publications or AICs to encourage aviation safety. Be as specific as you wish. Please include the type of licence held, if any, and type of aircraft applicable. Whatever your involvement in aviation we want your reports, be it aerodrome management, air traffic services, cabin crew, amateur home-building, aircraft maintenance, flight safety officer, etc. You do not need to include your name and telephone number, although this would assist our Aviation Hazard Report analysts if more information is needed. No criminal account should be reported.

No names of individuals, companies or aircraft registrations involved in a report will ever be published or passed onto any other organisation, agency, company or individual.

Please note:

This form does not replace any mandatory accident/incident reporting that is required by the Commissioner.

The filing of a hazard report could save many lives. If in doubt, report it. Together we can make flying in Southern Africa much safer.


1.	Hazard identified (write overleaf or attach separate paper if necessary)
	Date of hazard:			Type of licence/aviation involvement:
	Type of aircraft involved:		Time of day:			Duration:












Optional information (this will be discarded once received) Reported by (please print) ..................................................... Phone:
2.	Suggested remedy by person reporting the hazard
3.	For office use only Assessment of hazard level Hazard severity (S) .............. Hazard probability (P).............. Hazard exposure (E)
	Risk assessment (S × P × E) = %
Risk value		Risk level			Action
0		None			None
1 – 17		Slight			Possibly acceptable
18 – 39		Possible			Attention needed
40 – 59		Substantial			Correction needed
60 – 79		High			Immediate correction
80 – 100		Very high			Discontinue stop
Possible cause
Suggested remedy ................................................................................ Refer to Signature of analyst.............................................. Date

Annexure B

Leave this space clear as it will be discarded if name appears on reverse.


AIR TRAFFIC SERVICE INCIDENT REPORT FORM (PROCEDURAL AND FACILITY)
ZCZC
Priority indicator >	FAHQYQQQ			FA		FA

Date/Time >						Originator
SECTION 1: GENERAL INFORMATION
Type of incident					(A) Incident: Procedural/Facility
Name of pilot-in-command					(B)
Operator					(C)
Identification markings of aircraft (Reg or Tail No.)					(D)
Aircraft type					(E)
Radio call sign – In communication with – Frequency at time of incident					(F)
Aerodrome of departure					(G)
Aerodrome of first intended landing and destination, if different					(H)
Type of flight plan					(I) *IFR/VFR/NONE
Position at time of incident - Heading or route – True airspeed					(J)
FL, altitude or height – Altimeter setting – Altitude					(K) *Levelflight/climbing/descending/ turning
Flight weather conditions at time of incident					(L) IMC/VMC above/below cloud/fog/haze horizontally from cloud Between cloud layers In cloud/rain/snow/sleet/fog/haze Flying into/out of sun flight visibility
Date and time of incident in UTC e.g. 29050700					(M) Reported to (ATSU)
SECTION 2: DETAILED INFORMATION
Description of aircraft, if relevant: Type, high/low wing, number of engines Radio call sign, registration Markings, colour, lighting Other available details					(N)
Description of incident, and contact details of persons concerned with filing of report. If desired add comment or suggestion, including your opinion on the probable cause of the incident. (In case of airprox or internationally related incident, please complete appropriate form.)					(O) (Continue overleaf if necessary)
SECTION 3: SUPPLEMENTARY INFORMATION BY ATS UNIT CONCERNED
How report received					(P) Radio/telephone/teleprinter at ARO/AFIS/TWR/APP/ACC/FIC -NNNN (Continue overleaf if necessary)
Details of ATS action Clearance, incident observed on radar, warning given, result of local enquiry, etc.					(Q) -NNNN (Continue overleaf if necessary)
Date Time Place – of completion of form		Function and signature of person submitting report					Function and signature of person receiving report
*Delete as appropriate			Name and signature of ATS Officer Date/time UTC

Annexure C
AIR TRAFFIC SERVICE INCIDENT REPORT FORM

(INTERNATIONAL AND AIRPROX)

For use when submitting and receiving reports on air traffic service incidents. In an initial report by radio, shaded items should be included

AIRCRAFT IDENTIFICATION

B: TYPE OF INCIDENT

Airprox/Procedure/Facility*

THE INCIDENT

General

(a)

Date/time of incident

UTC

(b)

Position

Own aircraft

(a)

Heading and route

(b)

True airspeed

measured in ( ) kt

( ) km/h

(c)

Level and altimeter setting

(d)

Aircraft climbing or descending

( ) Level flight

( ) Climbing

( ) Descending

(e)

Aircraft bank angle

( ) Wings level

( ) Slight bank

( ) Moderate bank

( ) Steep bank

( ) Inverted

( ) Unknown

(f)

Aircraft direction of bank

( ) Left

( ) Right

( ) Unknown

(g)

Restrictions to visibility (select as many as required)

( ) Sunglare

( ) Windscreen pillar

( ) Dirty windscreen

( ) Other cockpit structure

( ) None

(h)

Use of aircraft lighting (select as many as required)

( ) Navigation lights

( ) Strobe lights

( ) Cabin lights

( ) Red anti-collision lights

( ) Landing taxi lights

( ) Logo (tail fin) lights

( ) Other

( ) None

(i)

Traffic avoidance advice issued by ATSU

( ) Yes, based on radar

( ) Yes, based on visual sighting

( ) Yes, based on other

( ) No

information

(j)

Traffic information issued

( ) Yes, based on radar

( ) Yes, based on visual sighting

( ) Yes, based on other

( ) No

information

(k)

Airborne collision avoidance system – ACAS

( ) Not carried

( ) Type

( ) Traffic advisory issued

( ) Resolution advisory issued

( ) Traffic advisory or

resolution advisory

not issued

(l)

Radar identification

( ) No radar available

( ) Radar identification

( ) No radar identification

(m)

Other aircraft sighted

( ) Yes

( ) No

( ) Wrong aircraft sighted

(n)

Avoiding action taken

( ) Yes

( ) No

(o)

Type of flight plan

IFR/VFR/None*

Other aircraft

(a)

Type and call sign/registration (if known)

(b)

If (a) above not known, describe below

( ) High wing

( ) Mid wing

( ) Low wing

( ) Rotocraft

( ) 1 Engine

( ) 2Engines

( ) 3 Engines

( ) 4 Engines

( ) More than 4 engines

Marking, colour or other available details

(c)

Aircraft climbing or descending

( ) Level flight

( ) Climbing

( ) Descending

( ) Unknown

(d)

Aircraft bank angle

( ) Wings level

( ) Slight bank

( ) Moderate bank

( ) Steep bank

( ) Inverted

( ) Unknown\

(e)

Aircraft direction of bank

( ) Left

( ) Right

( ) Unknown

(f)

Lights displayed

( ) Navigation lights

( ) Strobe lights

( ) Cabin lights

( ) Red anti-collision

( ) Landing/taxi lights

( ) Logo (tail fin) lights

( ) lights

( ) Other

( ) None

( ) Unknown

(g)

Traffic avoidance advice issued by ATSU

( ) Yes, based on

( ) Yes, based on other

( ) radar

( ) visual sightings

( ) information

( ) No

( ) Unknown

(h)

Traffic information issued

( ) Yes, based on

( ) Yes, based on other

( ) radar

( ) visual sightings

( ) information

( ) No

( ) Unknown

(i)

Avoiding action taken

( ) Yes

( ) No

( ) Unknown

Distance

(a)

Closest horizontal distance

(b)

Closest vertical distance

* Delete as appropriate

Flight weather conditions

(a)

IMC?VMC*

(b)

Above/below* clouds/fog/haze or between layers*

(c)

Distance vertically from cloud

m/ft* below

m/ft* above

(d)

In cloud/rain/snow/sleet/fog/haze*

(e)

Flying into/out of *sun

(f)

Flight visibility

m/km*

Any information considered important by the pilot-in-command

MISCELLANEOUS

Information regarding reporting aircraft

(a)

Aircraft registration

(b)

Aircraft type

(c)

Operator

(d)

Airport of departure

(e)

Airport of first landing

destination

(f)

Reported by radio or other means to

(name of ATSU)

at time UTC

(g)

Date/time/place of completion form

Function, address and signature of person submitting report

(a)

Function

(b)

Address

(c)

Signature

(d)

Telephone number

Function and signature of person receiving report

(a)

Function

(b)

Signature

SUPPLEMENTARY INFORMATION BY ATSU CONCERNED

Receipt of report

(a)

Report received via AFTN/radio/telephone/other (specify)*

(b)

Report received by

(name of ATSU)

* Delete as appropriate

Details of ATS action

Clearance, incident seen (radar/visually, warning given, result of local inquiry, etc.)

DIAGRAMS OF AIRPROX

Mark passage of other aircraft relative to you, in plan on the left and in elevation on the right, assuming you are at the centre of the diagram, including first sighting and passing distance.

Instructions for the completion of the Air Traffic Service Incident Report Form


Item
A	Aircraft identification of the aircraft filing the report
B	An AIRPROX report should be filed immediately by radio
C1	Date/time UTC and position in bearing and distance from a navigation aid or in LAT/LONG
C2	Information regarding aircraft filing the report, tick as necessary
C2 (c)	e.g. FL 350/1 013 HPA or 2 500 FT/QNH 1 007 HPA or 1 200 FT/QFE 998 HPA
C3	Information regarding the other aircraft involved
C4	Passing distance – state units used
C6	Attach additional papers as required. The diagrams may be used to show aircraft’s positions
D1 (f)	State name of ATSU and date/time in UTC
D1 (g)	Date and time in UTC


E2	Include details of ATS unit such as service provided, radiotelephony frequency, SSR codes assigned and altimeter setting. Use diagram to show aircraft’s position and attach additional papers as required.

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