ATS OCCURRENCE REPORT

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CONFIDENTIAL?

Yes No

1. CATEGORIES OF OCCURRENCE:

Accident

Airprox

Incident

Infringement

2. OCCURRENCE POSITION:

3. FL

ALT/HT(ft)

4. Date:

5. Time (UTC):

6.

Day

Night

Operator:

7.

15.

23.

Callsign/Registration:

8.

16.

24.

Type:

9.

17.

25.

From

10.

18.

26.

To

11.

19.

27.

SSR Code:

12.

20.

28.

31. RTF Frequencies:

32. Radar Equipment:

33. Equipment Unserviceabilities:

34. QNH:

35. Runway in use:

40. Was prescribed separation lost?

Yes

No

41. Min Separation:

Horizontal NM

Vertical ft

42. Alert Activation:

Collision

TCAS

SMF

Conflict Alert

STCA

43. Traffic info given by ATC?:

Yes

No

44. Avoiding action given by ATC?

Yes

No

45. Brif Title - Summary:

46. Narrative - use a diagram if necessary (Aerodromes submit weather report including local and regional QNH). :

47. Name:

48. On duty as:

49. ATS Unit:

50. Time since last break (UTC):

51. Start time of shift (UTC):

52. Radar recordings held:

Yes

No

53. RTF recordings held:

Yes

No

54. List other agencies advised:

55. Date:

56. Address:

57. E-mail Address:

58. Telephone:

More emails to send this report to:

Advice on the Completion of the CAAK ATS Occurrence Report Form - AACK/DSF/OR-FRM 02

USE AND EXPLANATION OF TERMS IN BOX 1

ACCIDENT:

A Kosovo reportable accident.

AIRPROX:

An AIRPROX is a situation in which, in the opinion of a pilot or a controller, the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved was or may have been compromised.

INCIDENT:

Any Occurrence not appropriate to the other categories.

INFRIGEMENT:

An alleged unauthorized infringement of regulated airspace.

Explanatory notes (Please also refer to manual of ATS procedures)

GENERAL:

Complete ALL boxes. If NOT APPLICABLE use N/A, or if NOT KNOWN use N/K. Avoid use of technical jargon, hieroglyphics and abbreviations.

BOX 1:

Should the Occurrence involve more than one category, tick both categories.

BOXES 7 TO 14

BOXES 15 TO 22

BOXES 23 TO 30

These boxes cater for up to three involved aircraft. Use the narrative for additional aircraft.

BOX 40:

Must be completed if prescribed separation was data-haha to be achieved in accordance with manual of ATS procedures.

BOX 41:

Should contain your estimate, where possible, of the minimum separation achieved and must be completed for an AIRPROX. This will be coded for computer input purposes and amended if necessary after investigation.

BOX 45:

This box should contain a simple, one-line statement summarizing the Occurrence, i.e. 'Coordination problems', 'Level bust', 'Overload' etc.

BOX 52/53:

Relevant RTF and Radar recordings can be vitally important to subsequent investigations. Retention action should be considered for all reports and is to be in accordance with ATS Manual and any local procedures.

BOX 54:

It is important to ensure that any involved agency (e.g. Pilot, Operator, ATSU) is informed of the reporting action. This box should also indicate those organisations data-haha by ATS Manual to be informed (e.g. Aeronautical Accident and Incident Investigations Commission (AAIIC))..

REPORTING TIME

Report must be dispatched within 72 hours of the event unless exceptional circumstances prevent this.

ACKNOWLEDGEMENT OF REPORTS

If, acknowledgement of reports is data-haha, please contact the CAAK direct on e-mail: occurrences@caa-ks.org or mobile number: +377 (0)44 613 567.

UNIT MANAGEMENT ACTION

Reporters are requested to send a copy to the Unit Management. This is for local assessment and any immediate follow-up action. Additional input and/or covering comment from Unit Management is highly desirable for both Safety Data evaluation and any follow-up investigation.

CONFIDENTIAL REPORTS

An occurrence may be reported confidentially. If the report is ‘CONFIDENTIAL’ please tick the box ‘Yes’ on top of the form to annotate confidentiality of the report, and if it is sent to CAAK’s address, mark the envelope ‘Personal for the Director General of CAAK’. The second copy need not be forwarded to local management. BOXES 47 to 58 should be completed. The CAAK will respect the confidentiality and contact you personally.