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CAA005 Occurrence Notification Form

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CAA005 Occurrence Notification Form Powered By Docstoc
					                                                               OCC NO. |___.___/___.___.___.___| FILE NO. |___.___/ SAI /___.___.___.___|

Occurrence Report – CA005                                                                   email to: ca005@caa.govt.nz
Complete shaded areas only where applicable. Post or fax to CAA as soon as possible. Fax to (04)-560-9469
To report an accident or serious incident phone: 0508 ACCIDENT (0508 222 433) Monitored 24 hours a day, seven days a week.
To report other safety or security concerns phone: 0508 4SAFETY (0508 472 338) Available office hours (voice mail after hours).



Date of occurrence                                      Time                            NZST               NZDT           UTC      Location

Aircraft manufacturer and model                                                                                    Aircraft registration ZK -

Operator                                                                                                                              Client ID

POB                    Number of injuries - Fatal                            Serious                              Minor

                                                        Crew       Pax                  Crew         Pax                   Crew       Pax

Operational Details

Flight No./Call sign                                Altitude                  AGL              ASL           FTL           Runway used

Departure point                                    Destination point                                  Nearest reporting point (NRP)

Distance and bearing from NRP                                          NM                                         VFR          IFR               VMC             IMC

Nature of flight         scheduled       OR           non-scheduled              domestic          OR               international           ETOPS
                         Passenger A to A                                        Passenger A to B                                           Freight only
                         Agricultural                                            Other aerial work                                          Business/executive
                         Training dual                                           Training solo                                              Test or ferry/position
                         Private other                                           Parachuting                                                Air ambulance
                         Other (specify)

Flight phase             parked                                                 taxiing                                                     takeoff
                         climb                                                  hover                                                       cruise
                         circuit                                                aerobatics                                                  holding
                         descent                                                approach                                                    landing

Effect on flight         Nil                                                    Flight delayed/cancelled                                    Aborted takeoff
If weather is a          Failure to get airborne                                Emerg/precaution descent                                    Emerg/precaution ldg
significant factor       Go-around/missed app                                   Abnormal approach                                           Diversion
include in               Turnback                                               Engine(s) shutdown                                          Sig loss of control/perform
description of           Avoiding action                                        Overweight landing                                          Abnormal landing
occurrence               Runway excursion                                       Other (specify)



Description of Occurrence




Pilot in command’s name                                                                                    Licence Number

Pilot flight hours in last 90 days                                   Flight hours on type                                  Total flight hours

Last checked            IFR          BFR           6 month flight competency                               By - name

Date checked                                                                Check pilot’s ID
                                                                        OCC NO. |___.___/___.___.___.___| FILE NO. |___.___/ SAI /___.___.___.___|


Type of Occurrence

Accident/incident              Collision/strike object                          Component/system failure malfunction                Loss of control
                               Engine power loss                                Damage to aircraft                                  Airframe failure
                               Fire/explosion/fumes                             Fuel/fluids occurrence                              Flight crew illness/incapacitation
                               Injuries to persons                              Failure of emergency equip/procedures               Evacuation
                               Pax/cargo related occurrence                     Valid warning/alert system                          Invalid warning/alert system
                               Emergency declaration                            Other (specify)

Airspace incident              Airspace ID – eg AA / TMA/C

                               Near collision                                   Loss of separation                                  Unauthorised altitude penetration
                               Unauthorised airspace incursion                  Breach of other clearance                           Pilot flight planning deficiency
                               Clearance/instruction deficiency                 Flight information deficiency                       Other (specify)

                               TCAS alert                      RA               TA          Intruder relative alt in feet           Relative position         o’clock

Facility malfunction           Facility ID                                      Name                                                Facility Type

                               Failure/non availability                         Coverage/intensity deficiency                       Alignment/course deficiency
                               Excessive bends/roughness                        False overhead/distance indication                  Identification deficiency
                               Readability deficiency                           Interference                                        Other (specify)

Aerodrome Occ.                 Physical surface deficiency                      Surface marking deficiency                          Wildlife incursion
                               Physical obstruction                             Equipment/installation deficiency                   Apron management deficiency
                               Public protection deficiency                     Other (specify)

Dangerous goods                Spillage/leakage                                 Fumes/gas/smoke/fire                                Mis/non-declaration
                               Other (specify)

Bird hazard                    Strike                 Near strike            Species                                        Small              Medium              Large

                            Number seen               1          2-10         11-100         100+      Number hit           1         2-10           11-100             100+


Aircraft Defect/
Engineering Details         Major component/system affected

ATA Code                                                    Part defective

Manufacturer                                                                           Model

Part number                                                                            Serial number

TTIS                Hours                    Cycles        TSO                  Hours                  Cycles      TSI                   Hours                   Cycles


Detection phase            Unscheduled OR                   Scheduled maintenance                                   Manufacturer advised             Yes                No
Compliance with            AD           SB                                  Specify reference

Maintenance organisation                                                       Client ID                                        Telephone

Aircraft damage level         Destroyed                     Substantial           Minor                Other (specify)


Aircraft disposal             Write-off                     Repair                Unknown              Other (specify)

Engineering Description of Incident




Submitter’s Details

Name                                                      Client ID                              Telephone                                    Date

Attachments                   sketches                      reports                  photographs                    Others (specify)

Submitters investigation                  Open                          OR              Closed          Submitters reference number
                                                             OCC NO. |___.___/___.___.___.___| FILE NO. |___.___/ SAI /___.___.___.___|

Investigation Report
                                                   Complete blue shaded areas only where applicable
This section of the form is intended to be completed by the reporter or reporter’s organisation at the conclusion of their internal investigation. It
may be submitted separately to the Occurrence Report. For further assistance with this section refer to CAR Part 12 Advisory Circular.


Date of occurrence                                     Time                             NZST             NZDT               UTC    Location

Aircraft manufacturer and model                                                                                  Aircraft registration ZK -

Finding attributed to : name                                                                                 Client ID

Aviation document                                 Rule ref                                     Manual reference

    Non-compliance           Non-conformance           Observation         Safety related concern                Critical         Major       Minor

Description

Cause




Person/organisation                                            Category                                       Item

Clients Closing Action




                                                                                                    Completion date

       Estimated     OR             Actual cost of occurrence and corrective action                    $NZ

Reporters Details

Name                                                                                       Position


Organisation                                                                               Client ID

Date                                                         Telephone                              Reporters ref number
                                                         OCC NO. |___.___/___.___.___.___| FILE NO. |___.___/ SAI /___.___.___.___|


     Notification of Serious Harm                                             Health and Safety in Employment Act
    under the Health and Safety in                                                   Notification Continued
           Employment Act                                                9    Body part:
Required for section 25(1), (1A), (1B), and (3)(b) of the                □ head               □ neck              □ trunk
Health and Safety in Employment Act 1992.                                □ upper limb         □ lower limb        □ multiple locations
1    Personal data of injured person:
                                                                         □ systemic internal organs
Name
                                                                         10 Nature of injury or disease:    □ fatal
Residential Address                                                      (specify all)
                                                                         □ fracture of spine       □ puncture wound
                                                                         □ other fracture               □ poisoning or toxic effects
Date of Birth                               Sex (M/F)
                                                                         □ Dislocation                  □ multiple injuries
                                                                         □ sprain or strain             □ damage to artificial aid
2    Occupation or job title of injured person:
(Employees and self-employed persons only)                               □ head injury                  □ disease, nervous system
                                                                         □ internal injury of trunk     □ disease, musculoskeletal
                                                                                                        system
3    The Injured person is:                                              □ amputation, inc. eye         □ disease, skin
□ an employee      □ a contractor (self-employed person)                 □ open wound                   □ disease, digestive system
□ self                 □ other                                           □ superficial injury           □ disease, infectious or parasitic
                                                                         □ bruising or crushing         □ disease, respiratory system
4     Period of employment of injured person:
(employees only)                                                         □ foreign body                 □ disease, circulatory system
□ 1st week          □ 1st month     □ 1-6 months                         □ burns                        □ tumour (malignant or benign)
□ 6 months-1 year □ 1-5 years           □ Over 5 years                   □ nerves or spinal chord       □ mental disorder
□ non-employee
                                                                         Signature and Date __________________________ __/__/__
5   Treatment of injury:
□ None                              □ First aid only
□ Doctor but no hospitalisation     □ Hospitalisation                    Name and
                                                                         Position
6    Time and date of accident/serious harm                              (Capitals)
Time                 am/pm
                                                                                               Information Only
Date                     Shift    □ Day □ Afternoon □ Night
                                                                         Serious harm includes death and …
Hours worked since arrival at work
(employees and self-employed persons only)                               1.    Any of the following conditions that amounts to or
                                                                               results in permanent loss of bodily function, or
7     Mechanism of accident/serious harm:                                      temporary severe loss of bodily function: respiratory
□ fall, slip or trip   □ hitting objects with part of the body                 disease, noise-induced hearing loss, neurological
□ sound or pressure        □ being hit by moving objects                       disease, cancer, dermatalogical disease, communicable
                                                                               disease, musculoskeletal disease, illness caused by
□ body stressing           □ heat, radiation or energy                         exposure to infected material, decompression sickness,
□ biological factors       □ chemicals or other substances                     poisoning, vision impairment, chemical or hot-metal
□ mental stress                                                                burn of eye, penetrating wound of eye, bone fracture,
                                                                               laceration, crushing.
8        Agency of accident/serious harm:                                2.    Amputation of body part.
□ machinery or (mainly) fixed plant                                      3.    Burns requiring referral to a specialist registered
□ mobile plant or transport                                                    medical practitioner or specialist outpatient clinic.
□ powered equipment, tool, or appliance                                  4.    Loss of consciousness from lack of oxygen.
□ non-powered hand tool, appliance or equipment                          5.    Loss of consciousness, or acute illness requiring
□ chemical or chemical product                                                 treatment by a registered medical practitioner, from
□ material or substance                                                        absorption, inhalation, or ingestion, of any substance.
□ environmental exposure (e.g. dust, gas)                                6.    Any harm that causes the person harmed to be
□ animal, human or biological agency (other than bacteria or                   hospitalised for a period of 48 hours or more
virus)                                                                         commencing within 7 days of the harm's occurrence.
□ bacteria or virus

				
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