Anonymous

Safety Report Form

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Title Page

Site conducted
Conducted on
Prepared by

Details

ASR No:
Type of Event: Tick all that apply
Captain
Total Hours
On Type Hours
In Command Hours
Student PAX
Total Hours
On Type Hours
Other Pax
Date of Occurrence (DD/MM/YYYY)
Time (Local/LUTC) Day / Night
Registration
Aircraft Type
Speed (KTS)
Altitude (Feet)
Flight Conditions
- VMC
- IMC
Rules
Flight Phase: Tick all that apply
- Parked
- Taxi Out
- Take Off
- Initial Climbing (below 1000ft in circuit)
- Circuit
- Climb
- Cruise
- Descent
- Holding
- Approach
- Landing
- Taxi In
- Overshoot
- Other
Wind (Knots)
Visibility (KM)
Cloud Base (Feet)
Temperature (C)
QNH
Significant Weather: Tick all that apply
- Moderate
- Severe
- Rain
- Snow
- Ice
- Fog
- Turbulence
- Hail
- Windshear
Runway Identification
Configuration
Runway State
Brief description of the Event
Event, Cause. Action & Results (Detailed description of the event, immediate cause, action taken)
Suggested preventative action
Review Date
Name
Signature
Date

Anonymous

Safety Report Form

Use this Template

Print as PDF

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