Appendix 5.6 Incident Report Form - 12.29.11.pdf

HTC711‐12‐R‐C003

Appendix 5.6

Carrier Incident Report

29 Dec 2011 Page 1

CONTRACT CARRIER SAFETY/PROCEDUAL INCIDENT WORKSHEET

SECTION II. FOR REPORTING AND DOCUMENATION USE

1. DATE 2. TIME (ZULU) 3. LOCATION

4. REPORTING BASE 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.)

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.

29 Dec 2011 Page 2

16. PERSONNEL INVOLVED (INCLUDE NAME, ASSIGNED DUTY, PHONE NUMBER, AND A

DESCRIPTION OF ANY INJURY OR ILLNESS.

SECTION II. FOR AMD/APCT USE

17. MISHAP COST/IF APPLICABLE

29 Dec 2011 Page 3

18. AMD/APCT NOTES AND RECOMMENDATIONS (ATTACH EMAILS, SEPARATE SHEET OF PAPER IF

ADDITIONAL SPACE IS NECESSARY)

19. AMD/APCT CONTACT INFORMATION (PHONE, ADDRESS, EMAIL)