J09_PWS_Attachment_8_DA_FORM_2696_OCT2013.pdf
Department of the Army Form Oct 8, 2013 PDF 185 KB Posted
- Attached to
- Fort Bliss Air Traffic Control Services
- Solicitation number
- W911S826RA015
About this file
DA Form 2696 is a Department of Army Operational Hazard Report form used to document any condition or act that affects or may affect the safety of Army aircraft or associated personnel and equipment. The form is used by aviation personnel to report hazards to the Aviation Safety Officer at the local command level.
The form captures comprehensive incident details including the date, time, and location of the hazard occurrence (categorized as in-flight, airfield/heliport, field site, or obstacle); the specific hazard category pertaining to procedures, policies, facilities, maintenance, materiel, services, communications, pilot procedures, near midair collisions, air traffic control, controller actions, armament, or aviation life support equipment. For in-flight incidents, the form collects detailed aircraft information for up to two aircraft, including mission type, design, series, serial number, service branch, departure and destination points, flight plan type (IFR, VFR, DVFR, SVFR, or None), course/heading, altitude, airspeed, and phase of operation. The form also documents meteorological conditions, cloud proximity, visibility, and for near midair collision incidents, specific details about aircraft proximity, relative positioning, and detection methods. The form requires completion of a narrative describing circumstances and causes, investigation and recommendations by the Aviation Safety Officer, corrective actions by the Commander, and point of contact information for follow-up inquiries. The form is referenced in DA PAM 385-10 and has a Requirements Control Symbol of CSOCS-307.
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Text version
DA FORM 2696, OCT 2013 APD AEM v1.01
PREVIOUS EDITIONS ARE OBSOLETE.
d. TIME (LCL)
OPERATIONAL HAZARD REPORT
For use of this form, see DA PAM 385-10; the proponent agency is DAS.
Requirements Control Symbol -
CSOCS-307
An operational hazard is any condition or act that affects or may affect the safety of Army aircraft or associated personnel and equipment.
1. TO: (Include 9-Digit ZIP Code)
Aviation Safety Officer (LCL Command)
2. FROM: (Name and Address of Originator (Include 9-Digit ZIP Code))
3. Date and Time of Occurrence
e. CHECK ONE
(1) Day
(3) Dawn
(2) Night
(4) Dusk
4. Location Where Hazard Occurred (Check all applicable items.)
a. In Flight h. Airfield/Heliport
(1) Movement Area/Parking
(2) Hangar
(3) Support Area
i. Field Site
j. Obstacle
(1) Trees
(2) Wires
(3) Building
k. This hazard occurred on or near
5. This Hazard Pertains to
6. If this Hazard Occurred in Flight, Complete the Following (if additional aircraft are involved, attach supplemental sheet)
b. Airways
c. Uncontrolled Airspace
(1) NOE
(2) Low Level
d. Terminal Control Area
e. Traffic Pattern
f. Control Zone
g. On the Ground
a. Procedures/Instructions
b. Policies/Regulations
(1) Military
(2) FAA
c. Facilities
(1) Airport/Heliport
(2) NAV Aids
d. Maintenance
e. Materiel
f. Services
(1) Weather
(2) Refueling
g. Communications
h. Pilot Procedures/Tech.
i. Near Midair Collision
j. Air Traffic Control
(1) Enroute
(2) Terminal Area
(3) APP Control
(4) DEP Control
(5) Ground Control
(6) GCA
(7) ILS
(8) Tower
(9) Radar Service
(10) Publications/Flip
(11) Controlling Agency
(a) FAA
(b) Army
(c) Navy
(e) Host Nation
k. Controller
(1) Procedures
(2) Technique
l. Other
m. Armament
o. Night vision devise
n. Aviation Life Support Equipment
(d) USAF
a. Mission
b. Design
c. Series
d. Serial Number
e. Service, MACOM
f. Point of Departure
g. Destination
h. Flight Plan
i. Course/Heading in Degrees
Aircraft 1
CHECK ONE
(1) IFR
(3) DVFR
(5) None
(2) VFR
(4) SVFR
j. Mission
k. Design
l. Series
m. Serial Number
n. Service, MACOM
o. Point of Departure
p. Destination
q. Flight Plan
CHECK ONE
(1) IFR
(3) DVFR
(5) None
(2) VFR
(4) SVFR
a. YEAR b. MONTH c. DAY
f. USASC USE ONLY
(1) AIRPORT/INSTALLATION
(2) DISTANCE FROM N.M./DME
(3) DIRECTION FROM DEGREES MAG
Aircraft 2 (Aircraft 2 is other aircraft, if applicable.)
r. Course/Heading in Degrees
DA FORM 2696, OCT 2013 APD AEM v1.01
e. AIRCRAFT 2
(a) Static
(c) Take Off
(e) Level
(g) Left Turn
(i) Descent
(k) Landing
(b) Taxi
(l) Hover
(j) Approach
(h) Right Turn
(f) Acrobatics
(d) Climb
(b) Taxi
(d) Climb
(f) Acrobatics
(h) Right Turn
(j) Approach
(l) Hover
g. ORGN. (UIC)f. MACOM (UIC)e. PHONE NOS. (AV and Comm.)
b. RANKa. NAME (Last, First, MI)
12. ACTION TAKEN TO CORRECT THIS HAZARD (To be completed by Commander. Attach additional sheet, if required.)
11. INVESTIGATION AND RECOMMENDATIONS (To be completed by Aviation Safety Officer. Attach additional sheet, if required.)
7. Meteorological Conditions 8. Cloud Proximity (Check applicable blocks)
9. For Single Aircraft Hazards Complete item d. For Near Midair Collisions, Complete all Applicable Items.
ITEM AIRCRAFT 1 AIRCRAFT 2a. Clear
b. Scattered
c. Broken
d. Overcast
e. Rain
f. Snow
g. Fog
h. Haze
i. Smoke
j. Icing
k. Visibility (in miles)
a. Above
b. In/Out of Clouds
c. Between Layers
d. Below
e. In Clouds
(1) Proximity Warning Device
(2) Conspicuity Markings
(3) Lighting
(4) Aircraft Profile
(a) NAV Lights
(b) Strobe Lights
(c) Rotating Beacon
a. What first directed your attention to Aircraft 2? (5) Another Crewmember/Pax
(6) Radar Service
(7) Radio Contact
(2) Below
b. Proximity (Ft.)
c. Other (No. 2) Aircraft Sighted at (O'Clock Position)
(1) Above
(6) Aircraft Which Overtook the Other
(3) Same Altitude
(4) Diverging
(5) Converging
(a) Aircraft 1
(b) Aircraft 2
d. AIRCRAFT 1
(1) Altitude MSL
(2) Heading (Degrees Mag)
(3) Airspeed (Knots)
(4) Phase of Operation (More than one may apply)
13. Point of Contact for Further Information (To be Completed by Aviation Safety Officer)
10. NARRATIVE (Describe circumstances concerning this hazard, indicate the causes and provide corrective recommendations. Attach additional sheet, if required.)
c. DUTY d. MAILING ADDRESS (Include ZIP Code)
h. ORGN. (UIC)
(a) Static
(c) Take Off
(e) Level
(g) Left Turn
(i) Descent
(k) Landing
DA FORM 2696, OCT 2013
APD AEM v1.01
PREVIOUS EDITIONS ARE OBSOLETE.
DA FORM 2696, OCT 2013
APD AEM v1.01
d. TIME (LCL)
OPERATIONAL HAZARD REPORT
For use of this form, see DA PAM 385-10; the proponent agency is DAS.
Requirements Control Symbol -CSOCS-307 An operational hazard is any condition or act that affects or may affect the safety of Army aircraft or associated personnel and equipment.
1. TO: (Include 9-Digit ZIP Code) Aviation Safety Officer (LCL Command)
2. FROM: (Name and Address of Originator (Include 9-Digit ZIP Code))
3. Date and Time of Occurrence
e. CHECK ONE
(1) Day
(3) Dawn
(2) Night
(4) Dusk
4. Location Where Hazard Occurred (Check all applicable items.)
a. In Flight
h. Airfield/Heliport
(1) Movement Area/Parking
(2) Hangar
(3) Support Area
i. Field Site
j. Obstacle
(1) Trees
(2) Wires
(3) Building
k. This hazard occurred on or near
5. This Hazard Pertains to
6. If this Hazard Occurred in Flight, Complete the Following (if additional aircraft are involved, attach supplemental sheet)
b. Airways
c. Uncontrolled Airspace
(1) NOE
(2) Low Level
d. Terminal Control Area
e. Traffic Pattern
f. Control Zone
g. On the Ground
a. Procedures/Instructions
b. Policies/Regulations
(1) Military
(2) FAA
c. Facilities
(1) Airport/Heliport
(2) NAV Aids
d. Maintenance
e. Materiel
f. Services
(1) Weather
(2) Refueling
g. Communications
h. Pilot Procedures/Tech.
i. Near Midair Collision
j. Air Traffic Control
(1) Enroute
(2) Terminal Area
(3) APP Control
(4) DEP Control
(5) Ground Control
(6) GCA
(7) ILS
(8) Tower
(9) Radar Service
(10) Publications/Flip
(11) Controlling Agency
(a) FAA
(b) Army
(c) Navy
(e) Host Nation
k. Controller
(1) Procedures
(2) Technique
l. Other
m. Armament
o. Night vision devise
n. Aviation Life Support Equipment
(d) USAF
a. Mission
b. Design
c. Series
d. Serial Number
e. Service, MACOM
f. Point of Departure
g. Destination
h. Flight Plan
i. Course/Heading in Degrees Aircraft 1
CHECK ONE
(1) IFR
(3) DVFR
(5) None
(2) VFR
(4) SVFR
j. Mission
k. Design
l. Series
m. Serial Number
n. Service, MACOM
o. Point of Departure
p. Destination
q. Flight Plan
CHECK ONE
(1) IFR
(3) DVFR
(5) None
(2) VFR
(4) SVFR
a. YEAR
b. MONTH
c. DAY
f. USASC USE ONLY
(1) AIRPORT/INSTALLATION
(2) DISTANCE FROM N.M./DME
(3) DIRECTION FROM DEGREES MAG
Aircraft 2 (Aircraft 2 is other aircraft, if applicable.)
r. Course/Heading in Degrees
e. AIRCRAFT 2
(a) Static
(c) Take Off
(e) Level
(g) Left Turn
(i) Descent
(k) Landing
(b) Taxi
(l) Hover
(j) Approach
(h) Right Turn
(f) Acrobatics
(d) Climb
(b) Taxi
(d) Climb
(f) Acrobatics
(h) Right Turn
(j) Approach
(l) Hover
g. ORGN. (UIC)
f. MACOM (UIC)
e. PHONE NOS. (AV and Comm.)
b. RANK
a. NAME (Last, First, MI)
12. ACTION TAKEN TO CORRECT THIS HAZARD (To be completed by Commander. Attach additional sheet, if required.)
11. INVESTIGATION AND RECOMMENDATIONS (To be completed by Aviation Safety Officer. Attach additional sheet, if required.)
7. Meteorological Conditions
8. Cloud Proximity (Check applicable blocks)
9. For Single Aircraft Hazards Complete item d. For Near Midair Collisions, Complete all Applicable Items.
ITEM
AIRCRAFT 1
AIRCRAFT 2
a. Clear
b. Scattered
c. Broken
d. Overcast
e. Rain
f. Snow
g. Fog
h. Haze
i. Smoke
j. Icing
k. Visibility (in miles)
a. Above
b. In/Out of Clouds
c. Between Layers
d. Below
e. In Clouds
(1) Proximity Warning Device
(2) Conspicuity Markings
(3) Lighting
(4) Aircraft Profile
(a) NAV Lights
(b) Strobe Lights
(c) Rotating Beacon
a. What first directed your attention to Aircraft 2?
(5) Another Crewmember/Pax
(6) Radar Service
(7) Radio Contact
(2) Below
b. Proximity (Ft.)
c. Other (No. 2) Aircraft Sighted at (O'Clock Position)
(1) Above
(6) Aircraft Which Overtook the Other
(3) Same Altitude
(4) Diverging
(5) Converging
(a) Aircraft 1
(b) Aircraft 2
d. AIRCRAFT 1
(1) Altitude MSL
(2) Heading (Degrees Mag)
(3) Airspeed (Knots)
(4) Phase of Operation (More than one may apply)
13. Point of Contact for Further Information (To be Completed by Aviation Safety Officer)
10. NARRATIVE (Describe circumstances concerning this hazard, indicate the causes and provide corrective recommendations. Attach additional sheet, if required.)
c. DUTY
d. MAILING ADDRESS (Include ZIP Code)
h. ORGN. (UIC) .\arrow.jpg
(a) Static
(c) Take Off
(e) Level
(g) Left Turn
(i) Descent
(k) Landing 1.01
DA FORM 2696, OCT 2013
OPERATIONAL HAZARD REPORT
APD
| TO: |
| FROM: |
| Enter the 4 digit Year.: |
| MONTH_A: |
| DAY_A: |
| TIME: |
| USASC: |
| INSTALLAT: |
| DISTANCE: |
| DIRECT: |
| ACRAFT_A: |
| ACRAFT_A_1: |
| ACRAFT_A_2: |
| ACRAFT_A_3: |
| ACRAFT_A_4: |
| ACRAFT_A_5: |
| ACRAFT_A_6: |
| HEADING_A: |
| ACRAFT_B: |
| ACRAFT_B_1: |
| ACRAFT_B_2: |
| ACRAFT_B_3: |
| ACRAFT_B_4: |
| ACRAFT_B_5: |
| ACRAFT_B_6: |
| HEADING_B: |
| DAY: |
| NIGHT: |
| DAWN: |
| DUSK: |
| LOCAT_A: 0 |
| LOCAT_B: 0 |
| LOCAT_C: 0 |
| LOCAT_D: 0 |
| LOCAT_E: 0 |
| LOCAT_F: 0 |
| LOCAT_G: 0 |
| LOCAT_H: 0 |
| LOCAT_I: 0 |
| LOCAT_J: 0 |
| LOCAT_K: 0 |
| LOCAT_L: 0 |
| LOCAT_M: 0 |
| LOCAT_N: 0 |
| LOCAT_O: 0 |
| LOCAT_P: 0 |
| LOCAT_Q: 0 |
| LOCAT_R: 0 |
| LOCAT_S: 0 |
| PERTAIN_A: 0 |
| PERTAIN_K: 0 |
| PERTAIN_U: 0 |
| PERTAIN_AE: 0 |
| PERTAIN_B: 0 |
| PERTAIN_L: 0 |
| PERTAIN_V: 0 |
| PERTAIN_AF: 0 |
| PERTAIN_C: 0 |
| PERTAIN_M: 0 |
| PERTAIN_W: 0 |
| PERTAIN_AG: 0 |
| PERTAIN_D: 0 |
| PERTAIN_N: 0 |
| PERTAIN_X: 0 |
| PERTAIN_AH: 0 |
| PERTAIN_E: 0 |
| PERTAIN_O: 0 |
| PERTAIN_Y: 0 |
| PERTAIN_AI: 0 |
| PERTAIN_F: 0 |
| PERTAIN_P: 0 |
| PERTAIN_Z: 0 |
| PERTAIN_AJ: 0 |
| PERTAIN_G: 0 |
| PERTAIN_Q: 0 |
| PERTAIN_AA: 0 |
| PERTAIN_AK: 0 |
| PERTAIN_H: 0 |
| PERTAIN_R: 0 |
| PERTAIN_AB: 0 |
| PERTAIN_AL: 0 |
| PERTAIN_I: 0 |
| PERTAIN_S: 0 |
| PERTAIN_AC: 0 |
| PERTAIN_J: 0 |
| PERTAIN_T: 0 |
| PERTAIN_AD: 0 |
| PERTAIN_AM: 0 |
| IFR_A: |
| VFR_A: |
| DVFR_A: |
| SVFR_A: |
| NONE_A: |
| IFR_B: |
| VFR_B: |
| DVFR_B: |
| SVFR_B: |
| NONE_B: |
| VISIBILITY: |
| PROXIMITY: |
| Enter Time in the O'clock format. |
Example: 1:00, 2:00, 10:00, 12:00.:
| AIRCRT_A: |
| AIRCRT_A_1: |
| AIRCRT_A_2: |
| AIRCRT_B: |
| AIRCRT_B_1: |
| AIRCRT_B_2: |
| PHASE_B: 0 |
| PHASE_BB: 0 |
| PHASE_B_1: 0 |
| PHASE_BB_1: 0 |
| PHASE_B_2: 0 |
| PHASE_BB_2: 0 |
| PHASE_B_3: 0 |
| PHASE_BB_3: 0 |
| PHASE_B_4: 0 |
| PHASE_BB_4: 0 |
| PHASE_B_5: 0 |
| PHASE_BB_5: 0 |
| NARRATIVE: |
| INVEST_REC: |
| ACTION: |
| NAME: |
| RANK: |
| DUTY: |
| MAIL_ADD: |
| PHONE_NOS: |
| MACOM: |
| ORGN_A: |
| ORGN_B: |
| METEOR_A: 0 |
| METEOR_B: 0 |
| METEOR_A_1: 0 |
| METEOR_B_1: 0 |
| CLOUD_A: 0 |
| CLOUD_B: 0 |
| METEOR_A_2: 0 |
| METEOR_B_2: 0 |
| CLOUD_A_1: 0 |
| CLOUD_B_1: 0 |
| METEOR_A_3: 0 |
| METEOR_B_3: 0 |
| CLOUD_A_2: 0 |
| CLOUD_B_2: 0 |
| METEOR_A_4: 0 |
| METEOR_C: 0 |
| CLOUD_A_3: 0 |
| CLOUD_B_3: 0 |
| METEOR_A_5: 0 |
| CLOUD_A_4: 0 |
| CLOUD_B_4: 0 |
| HAZARD_G: 0 |
| HAZARD_E: 0 |
| HAZARD_A: 0 |
| HAZARD_E_1: 0 |
| HAZARD_G_1: 0 |
| HAZARD_A_1: 0 |
| HAZARD_E_2: 0 |
| HAZARD_G_2: 0 |
| HAZARD_B: 0 |
| HAZARD_H: 0 |
| HAZARD_C: 0 |
| HAZARD_C_1: 0 |
| HAZARD_I: 0 |
| HAZARD_C_2: 0 |
| HAZARD_F: 0 |
| HAZARD_J: 0 |
| HAZARD_D: 0 |
| HAZARD_F_1: 0 |
| PHASE_A: 0 |
| PHASE_AA: 0 |
| PHASE_A_1: 0 |
| PHASE_AA_1: 0 |
| PHASE_A_2: 0 |
| PHASE_AA_2: 0 |
| PHASE_A_3: 0 |
| PHASE_AA_3: 0 |
| PHASE_A_4: 0 |
| PHASE_AA_4: 0 |
| PHASE_A_5: 0 |
| PHASE_AA_5: 0 |
File details come from the government source that posted it. Updated .