Submitter Instructions - Mark a checkbox for the event or issue you want to share/report from any of the following categories:

Safety of Flight, Ground Safety, Environmental, Health or Positive Observation

Complete the Submitter's Action Items section. Feel free to share as much or as little as you deem appropriate. Finally, choose ''Mark As Complete" and export the form to the Safety Officer.

Safety of Flight

Incorrect assembly of parts or components.

Any damage or deterioration.

Any condition in which an injury or potential injury was experienced.

Loss of any part from the aircraft on ground or during flight.

Non-compliance or significant errors in compliance with req'd servicing procedures.

Other Potential safety of flight issue.

Ground Safety

PPE - Personal Protective Equipment, gloves, eye or ear protection utilized, etc.

PTP - Protect the Property, check that proper aircraft protection is being utilized and in place.

GSE - Ground Support Equipment, verify that GSE is in good operating condition and stored properly.

Lock Out / Tag Out - Ensure LO/TO is being properly used.

Slip / Trip / Fall - Any hazardous conditions that can contribute to slips, trips, or falls.

Other Safety related issue.


Hazardous Material - Haz Mat not stored correctly, not labeled correctly, leaks, expired, etc.

Energy Waste - Lights, shop air, equipment, Ground Support Equipment (GSE) left on, etc.

Water Waste - Include all water resources.

Solid Waste - Paints, adhesives, rags, etc. proper disposal or correctly utilized

Recycling - Recycling not being properly utilized, etc.

Other Environmental related issue.


Ergonomics - Proper body position, good lifting techniques, etc.

Ventilation - Check for proper ventilation, air quality, etc.

HVAC - Look for proper heating and air conditioning.

Noise Hazards - Check the high noise areas are properly identified, hearing protection available, etc.

Medical Service and First Aid - Eye wash stations clear, contact numbers available, first aid kits accessible, etc.

Other Health related issue

Positive Observation

Great Team Effort

Nice Landing

Excellent Meal Service

Great MX resolution of our issue

Do you have any positive observations you want to elaborate on about a situation, occurrence or team member?

Submitter's Action Items

Submitter's explanation/observation of safety issue

Submitter's recommendation to eliminate, correct, or minimize the issue/condition.

Submitter - 'Mark As Complete' at the bottom of the page and export this audit to the Safety Officer for coordination.

Safety Officer Action Items - the Safety Officer will fill out the section below and will notify the Director for final review

Safety Officer's investigation summary:

Tracking Number and/or Risk Code

Corrective Action Taken

Suspense Date
Corrective Action Completion Date

Corrective Action Competed by:

Director of Aviation Action Items
Director of Aviation Final Review
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.