Exhibit C_19_JUN_09 Contract Carrier Incident Form.pdf
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- Attached to
- J&A: FAR 52. 217-8, Extension of Services
- Solicitation number
- (HTC711-09-R-0022)
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Exhibit C Incident Report Form
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Contract Carrier Safety/Procedural Incident Worksheet This worksheet is used to document safety and procedural incidents involving contract commercial carriers working under the Theater Express program. All statements contained herein are not protected under the promise of confidentiality. Fill out all areas of the worksheet that apply to the incident. Completed form will be submitted by the Assistant Contracting Officer Representative (A COR) to the Air Mobility Division (AMD), DSN: 318-436-4062 for further action.
Contact the USTC Contracting Officer, DSN: 312-779-2462 if you have any questions.
SECTION II. FOR REPORTING AND DOCUMENTATION USE
1. DATE
2. TIME (ZULU)
3. LOCATION
4. REPORTING BASE
(ICAO)
5. MISSION NUMBER
6. TYPE AIRCRAFT
7. CARRIER NAME
8. PHONE NO.
9. ALTITUDE (MSL)
10. WEATHER (VFR, IFR, THUNDERSTORMS, HAIL, LIGHTNING, TURBULENCE, RAIN,
ICING, ETC.)
11. PHASE OF FLIGHT:
TAXI TAKEOFF CLIMB CRUISE DESCENT LOW LEVEL FINAL APPROACH MISSED APPROACH
TRAFFIC PATTERN TOUCH & GO LANDING GROUND SAFETY PPR OTHER
12. TAKEOFF TIME
(ZULU)
13. TAKEOFF TIME
(LOCAL)
14. AIRCRAFT SYSTEM(S) INVOLVED
15. STATEMENT: (A CONCISE, CHRONOLOGICAL DESCRIPTION OF THE FACTS AND CIRCUMSTANCES LEADING TO THE OCCURRENCE, ACTIONS TAKEN AND RESULTS. ATTACH EXTRA SHEETS IF ADDITIONAL SPACE IS REQUIRED.)
16. PERSONNEL INVOLVED (INCLUDE NAME, ASSIGNED DUTY, PHONE NUMBER, AND A DESCRIPTION OF ANY INJURY OR ILLNESS.
tcgoulta Typewritten Text tcgoulta Typewritten Text tcgoulta Typewritten Text PERFORMANCE WORK STATEMENT - EXHIBIT C Page 1 of 2 19 JUN 09 tcgoulta Typewritten Text tcgoulta Typewritten Text tcgoulta
SOLICITATION HTC711-09-R-0022
SECTION II. FOR AMD/APCT USE
17. MISHAP COST/IF APPLICABLE
18. AMD/APCT NOTES AND RECOMMENDATION (ATTACH SEPARATE SHEET OF PAPER IF ADDITIONAL SPACE IS NECESSARY)
19. AMD/APCT CONTACT INFORMATION (PHONE, ADDRESS, EMAIL)
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PERFORMANCE WORK STATEMENT - EXHIBIT C PAGE 2 OF 2 19 JUN 09
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SOLICITATION HTC711-09-R-0022
| 18 AMDAPCT NOTES AND RECOMMENDATION ATTACH SEPARATE SHEET OF PAPER IF ADDITIONAL SPACE IS NECESSARY: |
| 1 DATE: |
| 2 TIME ZULU: |
| 3 LOCATION: |
| 7 CARRIER NAME: |
| 6 TYPE AIRCRAFT: |
| 5 MISSION NUMBER: |
| ICAO: |
| 9 ALTITUDE MSL: |
| ICING ETC: |
| ZULU: |
| LOCAL: |
| 14 AIRCRAFT SYSTEMS INVOLVED: |
| Check Box3: Off |
| Check Box4: Off |
| Check Box11: Off |
| Check Box5: Off |
| Check Box12: Off |
| Check Box6: Off |
| Check Box13: Off |
| Check Box7: Off |
| Check Box14: Off |
| Check Box8: Off |
| Check Box15: Off |
| Check Box2: Off |
| Check Box9: Off |
| Check Box10: Off |
| ACTIONS TAKEN AND RESULTS ATTACH EXTRA SHEETS IF ADDITIONAL SPACE IS REQUIRED: |
| 8 PHONE NO: |
| 16 PERSONNEL INVOLVED INCLUDE NAME ASSIGNED DUTY PHONE NUMBER AND A DESCRIPTION OF ANY INJURY OR ILLNESS: |
| 17 MISHAP COSTIF APPLICABLE: |
| 19 AMDAPCT CONTACT INFORMATION PHONE ADDRESS EMAIL: |
| Text16: |
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