121st ARW/SE Facility Inspection

• Organization Inspected

• Conducted on

  Date

• Inspection conducted by:

Finding 1

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 2

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 3

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 4

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 5

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 6

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media

Finding 7

• Date/Time

  Date

• Building

  Select 2000 911 888 887 885 883 872 846 220th Unlisted

  • 2000
  • 911
  • 888
  • 887
  • 885
  • 883
  • 872
  • 846
  • 220th
  • Unlisted

• Give description:

• Room

• Functional Area or Shop:

• Supervisor or POC:

• Phone Number:

• Hazard or Deficiency:

• Finding:

• Reference:

• Is this a hazard or deficiency?

  Hazard

  Deficiency

• RAC

• Assign RAC:

  5 (Negligible)

  4 (Minor)

  3 (Moderate)

  2 (Serious)

  1 (Imminent)

• Cause:

  Select Training Equipment Technical Data Human Error Misconduct Process Inadequate or Faulty Leadership/Supervision Other

  • Training
  • Equipment
  • Technical Data
  • Human Error
  • Misconduct
  • Process Inadequate or Faulty
  • Leadership/Supervision
  • Other

• Recommendation:

• 30 Day Follow-Up Date:

  Date

• Corrective Action:

• Supporting Picture:

  Media