Mishap Response & Investigation Report

• Site conducted

  Select

• Date and Time of Mishap

  Date

• Report Prepared by

• Phase of Operation (check all that apply)

  Select Aircraft Arrival Aircraft Departure Loading / Unloading Aircraft Aircraft Towing, outdoor Aircraft Towing, Hangar Fueling Lavatory Service Potable Water Service Belt Loader Operation Air Start Operation Stair Truck / Crew Stairs Operation Other

  • Aircraft Arrival
  • Aircraft Departure
  • Loading / Unloading Aircraft
  • Aircraft Towing, outdoor
  • Aircraft Towing, Hangar
  • Fueling
  • Lavatory Service
  • Potable Water Service
  • Belt Loader Operation
  • Air Start Operation
  • Stair Truck / Crew Stairs Operation
  • Other

• Impact of Mishap (check all that apply)

  Select Flight Cancelled Flight Delayed Aircraft Damaged, but flyable Aircraft damaged, not flyable Aircraft destroyed GSE damaged, but usable GSE damaged, not usable GSE destroyed Personnel injured, 1st Aid only Personnel injured, hospitalization required Personnel death

  • Flight Cancelled
  • Flight Delayed
  • Aircraft Damaged, but flyable
  • Aircraft damaged, not flyable
  • Aircraft destroyed
  • GSE damaged, but usable
  • GSE damaged, not usable
  • GSE destroyed
  • Personnel injured, 1st Aid only
  • Personnel injured, hospitalization required
  • Personnel death

• Description of Mishap

• 1. Ensure the Scene is Safe

• 2. Photos / Diagrams Take photos from far, medium, and close range to capture the entire scene. Include a measuring device (ruler, tape measure) in close range photos.

  Media

• 3. Remove Equipment Involved from Service
  
  -Conduct post-mishap equipment inspection(s)
  -Return equipment to service if safe to do so

• 4. Identify all Parties involved and Collect Statements

  Media

• 5. Resume Operations when appropriate

• Contact all of the following parties, and include names and date/time of contact:

• Emergency Services if needed

  Yes

  No

  N/A

• Department Manager (include name in notes)

• General Manager (include name in notes)

• HR Coordinator (include name in notes)

• Customer Contact (include name in notes)

• Send Preliminary email to SRTreport@millionair.com Include the following information: -Aircraft Involved -Location of Mishap -Weather Conditions -Equipment Involved -Brief description of incident

Personnel Involved

Person 1

• Name

• Position

  Select LSP LS Supervisor LSM CSR CS Supervisor CSM General Manager Operations Manager Facility Staff Other Employee Non-Employee

  • LSP
  • LS Supervisor
  • LSM
  • CSR
  • CS Supervisor
  • CSM
  • General Manager
  • Operations Manager
  • Facility Staff
  • Other Employee
  • Non-Employee

• Time in Position

  Less than 6 months

  6 months to 1 year

  1 year to 3 years

  3+ years

• Number of Hours on shift day of event

• Number of Hours on shift day prior to event

Person 2

• Name

• Position

  Select LSP LS Supervisor LSM CSR CS Supervisor CSM General Manager Operations Manager Facility Staff Other Employee Non-Employee

  • LSP
  • LS Supervisor
  • LSM
  • CSR
  • CS Supervisor
  • CSM
  • General Manager
  • Operations Manager
  • Facility Staff
  • Other Employee
  • Non-Employee

• Time in Position

  Less than 6 months

  6 months to 1 year

  1 year to 3 years

  3+ years

• Number of Hours on shift day of event

• Number of Hours on shift day prior to event

Person 3

• Name

• Position

  Select LSP LS Supervisor LSM CSR CS Supervisor CSM General Manager Operations Manager Facility Staff Other Employee Non-Employee

  • LSP
  • LS Supervisor
  • LSM
  • CSR
  • CS Supervisor
  • CSM
  • General Manager
  • Operations Manager
  • Facility Staff
  • Other Employee
  • Non-Employee

• Time in Position

  Less than 6 months

  6 months to 1 year

  1 year to 3 years

  3+ years

• Number of Hours on shift day of event

• Number of Hours on shift day prior to event

Person 4

• Name

• Position

  Select LSP LS Supervisor LSM CSR CS Supervisor CSM General Manager Operations Manager Facility Staff Other Employee Non-Employee

  • LSP
  • LS Supervisor
  • LSM
  • CSR
  • CS Supervisor
  • CSM
  • General Manager
  • Operations Manager
  • Facility Staff
  • Other Employee
  • Non-Employee

• Time in Position

  Less than 6 months

  6 months to 1 year

  1 year to 3 years

  3+ years

• Number of Hours on shift day of event

• Number of Hours on shift day prior to event

Person 5

• Name

• Position

  Select LSP LS Supervisor LSM CSR CS Supervisor CSM General Manager Operations Manager Facility Staff Other Employee Non-Employee

  • LSP
  • LS Supervisor
  • LSM
  • CSR
  • CS Supervisor
  • CSM
  • General Manager
  • Operations Manager
  • Facility Staff
  • Other Employee
  • Non-Employee

• Time in Position

  Less than 6 months

  6 months to 1 year

  1 year to 3 years

  3+ years

• Number of Hours on shift day of event

• Number of Hours on shift day prior to event

Aircraft / Equipment Involved

Aircraft 1

• Aircraft Registration

• Aircraft Type

Aircraft 2

• Aircraft Registration

• Aircraft Type

Aircraft 3

• Aircraft Registration

• Aircraft Type

GSE 1

• Select GSE Type

  Select Tug Towbar Towhead Fuel Truck GPU Lavatory Cart Potable Water Cart Golf Cart Belt Loader Air Start Stair Truck / Crew Stairs Other GSE

  • Tug
  • Towbar
  • Towhead
  • Fuel Truck
  • GPU
  • Lavatory Cart
  • Potable Water Cart
  • Golf Cart
  • Belt Loader
  • Air Start
  • Stair Truck / Crew Stairs
  • Other GSE

GSE 2

• Select GSE Type

  Select Tug Towbar Towhead Fuel Truck GPU Lavatory Cart Potable Water Cart Golf Cart Belt Loader Air Start Stair Truck / Crew Stairs Other GSE

  • Tug
  • Towbar
  • Towhead
  • Fuel Truck
  • GPU
  • Lavatory Cart
  • Potable Water Cart
  • Golf Cart
  • Belt Loader
  • Air Start
  • Stair Truck / Crew Stairs
  • Other GSE

GSE 3

• Select GSE Type

  Select Tug Towbar Towhead Fuel Truck GPU Lavatory Cart Potable Water Cart Golf Cart Belt Loader Air Start Stair Truck / Crew Stairs Other GSE

  • Tug
  • Towbar
  • Towhead
  • Fuel Truck
  • GPU
  • Lavatory Cart
  • Potable Water Cart
  • Golf Cart
  • Belt Loader
  • Air Start
  • Stair Truck / Crew Stairs
  • Other GSE

GSE 4

• Select GSE Type

  Select Tug Towbar Towhead Fuel Truck GPU Lavatory Cart Potable Water Cart Golf Cart Belt Loader Air Start Stair Truck / Crew Stairs Other GSE

  • Tug
  • Towbar
  • Towhead
  • Fuel Truck
  • GPU
  • Lavatory Cart
  • Potable Water Cart
  • Golf Cart
  • Belt Loader
  • Air Start
  • Stair Truck / Crew Stairs
  • Other GSE

Environment and Operation

• Where did the mishap occur?

  Select Indoors Outdoors (including inside a hangar)

  • Indoors
  • Outdoors (including inside a hangar)

• Lighting conditions

  Lights on

  Lights off

• Flooring conditions

  Select Dry Wet Icy Unpaved surface (grass, gravel)

  • Dry
  • Wet
  • Icy
  • Unpaved surface (grass, gravel)

• Weather conditions (select all that apply)

  Select Clear sky Cloudy Rain No Precipitation Snow Ice / Sleet / Freezing Rain Lightning

  • Clear sky
  • Cloudy
  • Rain
  • No Precipitation
  • Snow
  • Ice / Sleet / Freezing Rain
  • Lightning

• Wind Speeds

  0-5 mph

  6-15 mph

  16-25 mph

  26+ mph

• Temperature (including wind chill or heat index)

  Select -20 or lower to 0 F 0 to 32 F 32 to 60 F 60 to 75 F 75 to 95 F 95 to 105+ F

  • -20 or lower to 0 F
  • 0 to 32 F
  • 32 to 60 F
  • 60 to 75 F
  • 75 to 95 F
  • 95 to 105+ F

• Ground / Floor conditions

  Select Dry Wet Icy Unpaved surface (grass, gravel)

  • Dry
  • Wet
  • Icy
  • Unpaved surface (grass, gravel)

• Lighting Conditions

  Select Daylight / Lights On Nighttime, Exterior Lights On Nighttime, Lights off / No lights available

  • Daylight / Lights On
  • Nighttime, Exterior Lights On
  • Nighttime, Lights off / No lights available

Shift Information

• Number of Employees on shift

• In general, was the activity level busy, slow, or normal?

  Busy

  Slow

  Normal

• Review and Save Video Clips to storage devices

Drug / Alcohol Screenings

Person 1 Screening

• Screening Company / Location

• Screening Time

  Date

• Results

  Pass

  Fail

  N/A

Person 2 Screening

• Screening Company / Location

• Screening Time

  Date

• Results

  Pass

  Fail

  N/A

Person 3 Screening

• Screening Company / Location

• Screening Time

  Date

• Results

  Pass

  Fail

  N/A

Person 4 Screening

• Screening Company / Location

• Screening Time

  Date

• Results

  Pass

  Fail

  N/A

Person 5 Screening

• Screening Company / Location

• Screening Time

  Date

• Results

  Pass

  Fail

  N/A

Training Records

• Person 1 Qualified and Current on tasks involved

  Yes

  No

  N/A

• Person 2 Qualified and Current on tasks involved

  Yes

  No

  N/A

• Person 3 Qualified and Current on tasks involved

  Yes

  No

  N/A

• Person 4 Qualified and Current on tasks involved

  Yes

  No

  N/A

• Person 5 Qualified and Current on tasks involved

  Yes

  No

  N/A

Equipment Inspections

• Was the equipment inspected at the beginning of the workday?

  Yes

  No

  N/A

• Did the post-mishap inspection reveal any defects?

  Yes

  No

• Did the defect(s) contribute to the mishap?

  Yes

  No

Contributing Factors (Select all that apply)

• Organizational Factors

  Select Insufficient Staff Lack of Supervision Delegation / Workload Management

  • Insufficient Staff
  • Lack of Supervision
  • Delegation / Workload Management

• Individual Factors

  Select Physical health (hearing / sight) Fatigue Personal issue Inexperience Lack of situational awareness Memory Lapse Lack of Training

  • Physical health (hearing / sight)
  • Fatigue
  • Personal issue
  • Inexperience
  • Lack of situational awareness
  • Memory Lapse
  • Lack of Training

• Equipment / Tools

  Select Equipment malfunction Inspections / Maintenance not completed Faulty Equipment not removed from service Proper Equipment unavailable Equipment improperly used / Abuse Safety device bypassed

  • Equipment malfunction
  • Inspections / Maintenance not completed
  • Faulty Equipment not removed from service
  • Proper Equipment unavailable
  • Equipment improperly used / Abuse
  • Safety device bypassed

• Environment / Weather

  Select Lighting conditions Slippery surface Trip hazard Noise Fumes High winds Excessive Heat or Cold

  • Lighting conditions
  • Slippery surface
  • Trip hazard
  • Noise
  • Fumes
  • High winds
  • Excessive Heat or Cold

• Tasking

  Select Procedure deviation Procedure not documented Procedure not trained / reinforced Procedure insufficient for task Task communicated poorly

  • Procedure deviation
  • Procedure not documented
  • Procedure not trained / reinforced
  • Procedure insufficient for task
  • Task communicated poorly

• Human Factors

  Select Lack of Communication Complacency Lack of Knowledge Distractions Lack of Teamwork Fatigue Lack of Resources Pressure Lack of Assertiveness Stress Lack of Awareness Norms

  • Lack of Communication
  • Complacency
  • Lack of Knowledge
  • Distractions
  • Lack of Teamwork
  • Fatigue
  • Lack of Resources
  • Pressure
  • Lack of Assertiveness
  • Stress
  • Lack of Awareness
  • Norms

• Describe how these factors contributed to the mishap:

• Why did this mishap occur?

• Corrective Actions

• Lessons Learned / Process Improvement