Formularul REAC 01

AIR SAFETY REPORT

Complete all sections where information is
relevant. For multi-choice boxes, indicate
which entry is appropiate.

Date received by I.S.Av.C. / RCAA

I.S.Av.C. / RCAA Air Safety Report No.

If you check voluntary report, the informations conteins in the Reporter identifications
fields are not mandatory. Please entry these filds olnly if you desire to receive a personal
reply or permit us to contact you for more informations!
The information on this form will only used for the porpouse for which you have provided it.
We will not use this infirmations for any other purpose, and will not disclosure it without your
consent.

Mandatory
REPORT TYPE :
Voluntary
ACCIDENT

INCIDENT

AircraftType and Series

Registration

HAZARD

Operator

Owner

Date of Occurence

FLIGHT AND WEATHER DETAILS

Flight No.:

Wind

DAY

Runway
used

Precipitation

Icing

NIGHT
From:

TWILIGHT

Kts

IMC

DRY

Time

AMP

Ht / Alt / FL

Visibility

________
C

LIGHT

MOD

MOD

HEAVY

HEAVY

MOD

SLEET

FLOODED
OAT

LIGHT
LIGHT

SNOW

WET

GMT
Geog.
Position

State
RAIN

VMC

To:

IAS

Turbulence

SEVERE

HAIL

ICE

Cloud Type

SNOW

Height / ft

SLUSH

Amount / 8 ths

FLIGHT PHASE

EXTREME

NATURE OF FLIGHT

PARKED

DESCENT

SCHED PAX

BUSINESS

TOWING

HOLDING

NON-SCHED PAX

CLUB / GROUP

TAXYING

APPROACH

SCHED FREIGHT

PRIVATE

TAKE-OFF

LANDING

NON- SCHED FREIGHT

POSITIONING

INIT CLIMB

CIRCUIT

SURVEY

FERRY

CLIMB

AEROBATICS

PLEASURE

TEST

CRUISE

HOVER

AGRICULTURAL

TRAINING

TYPE OF EVENT (TICK ALL THAT APPLY)

Aircraft Flight Operational (except B,C,D,E,F)

Complete this report on section

Technical Malfunction / Failure

Complete this report on section

Airmiss / ATC Incident

Complete this report on section

TCAS RA

Complete this report on section

Wake Turbulance / Wind Shear

Complete this report on section

Bird Strike

Complete this report on section

Dangerous Goods

Complete this report on section

AIR SAFETY REPORT

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Section A:
Aircraft Flight Operational
DESCRIPTION OF OCCURRENCE:

ORGANISATION :

NAME :

IF REPORT IS VOLUNTARY (I.E., NOT

SUBJECT TO MANDATORY
REQUIREMENTS) CAN THE
INFORMATION BE PUBLISHED IN THE
INTEREST OF SAFETY ?

YES

POSITION :

SIGNATURE :

ADDRESS AND/OR TEL.

NUMBER, IF REPORTER
WISHES TO BE
CONTACTED PRIVATELY

NOTE 1: if additional information, as below, is

available please provide.
NOTE 2: if the occurrence is related to a design
or manufacturing deficiency, the manufacturer
should be also be advised promptly.
NOTE 3: where applicable, a report of this
incident should be forwarded directly to other
agencies involved, e.g. Aerodrome Authority, ATC
Agency.

NO

DATE :

REPORTING ORGANISATION REPORT :

Reported Investigation

Organization

NIL

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

AIR SAFETY REPORT Section A

Address and Tel. No.:

Name:

page 1/2

Signature:

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AIR SAFETY REPORT Section A

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Section B:
Technical Malfunction / Failure
DESCRIPTION OF OCCURRENCE :

ENGINEERING DETAILS

Component Part

Aircraft Constructors No.

Location of aircraft

Engine Type & Series

Manual Reference

Ground
Phase

MAINTENANCE
UNATTENDED

Overhaul / Repair Agency

GROUND HANDLING
TAXING

Maintenance Program
O.C.

C.M.

Component Part

H.T.

Reability
Program Cat
A Intem
YES
NO

Manufacturer

Part No.

Serial No.

HOURS

Total

CYCLES

Since
Overhaul
Repair
Inspection

LANDINGS
Is there any published
Airworthiness Information or
control procedures (c.g.AD, SB
etc.) relevant to occurrence.
YES

Reference No. and Compliance Status of Aircraft or Equipment

REPORTING ORGANISATION REPORT :

Organization

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

AIR SAFETY REPORT Section B

Address and Tel. No.:

Name:

page 1/2

NO

NO

NO

Reported Investigation

YES

Entered in Aircraft Technical Log

YES

NIL

Manufacturer
Advised

Signature:

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AIR SAFETY REPORT Section B

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Section C:
AIRMISS / ATC, TCAS RA

10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10

Hundreds of metres
14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
300
270
240
210
180
150
120
90
60
30
0
30
60
90
120
150
180
210
240
270
300

OPERATING AIRCRAFT
Heading and route

True airspeed
AIRCRAFT
DIRECTION OF BANK

AIRCRAFT BANK ANGLE

Wings level
Slight bank
Moderate bank

Steep bank
Inverted
Unknown

Navigation
Strobe
Cabin

Red anti-collision
Landing / taxy
Logo (tail fin)

Yes, based on
other
information
No

Sunglare
Windscreen pillar
Dirty windscreen

Other
None

Not carried
Type
Trafic advisory
issued

TRAFIC INFORMATION ISSUED

Yes, based on radar
Yes, based on
visual
sighting

AIR SAFETY REPORT Section C

Radar identification

Resolution
advisory
issued
Trafic advisory or
resolution advisory
not issued
AVOIDING ACTION
TAKEN

Yes, based on
other
information
No

RADAR IDENTIFICATION
No radar available

Other cockpit
structure
None

AIRBORNE COLLISION AVOIDANCE SYSTEM

TCAS

TRAFIC AVOIDANCE ADVICE ISSUED BY

ATS
Yes, based on radar
Yes, based on visual
sighting

RESTRICTIONS TO VISIBILITY
(select as many as required)

Left
Right
Unknown

USE OF AIRCRAFT LIGHTING

(select as many as required)

Kt
Km-h

Yes
No

TYPE OF FLIGHT PLAN

No radar
identification

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IFR

VFR

METRES

14 13 12 11 10 9 8 7 6 5 4Hundreds
3 2 1 of0metres
1 2 3 4 5 6 7 8 9 10 11 12 13 14

Hundreds of FEET

10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9
10

VIEW FROM ASTERN

Hundred of metres

VIEW FROM ABOVE

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OTHER AIRCRAFT SIGHTED
Yes

No

Reported Investigation

Organization

NIL

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

none*
Wrong aircraft
sighted

( * delete as appropiate)

Address and Tel. No.:

Name:

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Signature:

AIR SAFETY REPORT Section C

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O T H E R

A I R C R A F T

Type

WING

Registration

ENGINE
Left
Right
Unknown

Rotocraft

1
2
3

4
more than 4

Marking, colour or other avaible details

AIRCRAFT CLIMBING OR DESCENDING

Level flight
Climbing

Descending

Wings level
Slight bank
Moderate bank

Unknown

Steep bank
Inverted
Unknown

Navigation

Red anti-collision

Other

Strobe

Landing / Taxy

None

Cabin

Logo (tail fin)

Unknown

Yes, based on
radar
Yes, based on
visual sighting

TRAFFIC INFORMATION ISSUED

Yes, based on
other information

Unknown

Yes

________

Unknown

No

DISTANCE

Closest vertical distance

Yes, based on
other information
No
Unknown

AVOIDING ACTION TAKEN

No

Closest horizontal distance ________

Left
Right
Unknown

TRAFFIC AVOIDANCE ADVICE ISSUED BY

ATS

LIGHTS DISPLAYED

Yes, based on
radar
Yes, based on
visual sighting

AIRCRAFT DIRECTION
OF BANK

AIRCRAFT BANK ANGLE

FLIGHT WEATHER CONDITIONS

m

ft

ft

IMC / VMC
Above / below* clouds / fog / haze or between layers*
Distance vertically from cloud ___________ m / ft* below __________ m / ft* above
In clode / rain / snow / sleet / fog / haze*
Flying into / out of* sun
Flight visibility __________ m / km*
(* Delete as appropiate)

ANY OTHER INFORMATION CONSIDERED IMPORTANT BY THE PILOT-IN COMMAND

AIR SAFETY REPORT Section C

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Section D:
Wake Turbulance / Wind Shear
HEADING

TURNING
Right

Left

___________ Deg.

POSITION ON GLIDESLOPE
No

CHANGE IN ATTITUDE

High

Low

CHANGE IN ALTITUDE

On

____________ Ft

WAS THERE BUFFET

Pitch

_______________

Roll

_______________

Yaw

_______________

Deg

_______________

Yes

No

STICK SHAKE
Yes

No

WHAT MADE YOU SUSPECT WAKE TURBULANCE ?

DESCRIBE ANY VERTICAL ACCELERATION

GIVE DETAILS OF PRECEDING AIRCRAFT

Type

_____________________

Registration

_________________

WHERE YOU AWARE OF OTHER A/C BEFORE THE INCIDENT ?

Other details
Yes

__________________________
No

NARATION

Reported Investigation

Organization

NIL

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

AIR SAFETY REPORT Section D

Address and Tel. No.:

Name:

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Signature:

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AIR SAFETY REPORT Section D

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Section E: BIRD STRIKE

Engine Make / Model

Aerodrome Name

Part(s) of Aircraft

Location if En Route

Effect on Flight
Struck

Demaged

Radome

None

Windshield

Aborted take-off

Nose (excluding above)

Precautionary landing

Engine no. 1

Engines shut down

Other (specify)

Birds Species

Number of birds

Propeller
Wing / rotor

Seen

Struk

Yes

No

Fuselage

2-10

Landing gear

11-100

Tail

More

Lights

Size of birds

Other (specify)

Small

Sky Condition

Medium
No cloud

large

Some cloud

Pilot Warned of Birds

overcast
NARATION

Reported Investigation

Organization

NIL

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

AIR SAFETY REPORT Section E

Address and Tel. No.:

Name:

page 1/2

Signature:

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AIR SAFETY REPORT Section E

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Section F: DANGEROUS GOODS

1. Flight /Truck date:

2. Flight /Truck no:

3. Departure airport:

4. Destination airport:

5. Aircraft type:

6. Aircraft registration:

7. Location of occurrence:

8. Local time of occurrence:

9. Origin of the goods:

10. Description of the occurrence, including details of injury, damage, etc.:

11. Proper shipping name (including the technical name):

12. UN/ID no (when known):

13. Class/division (when

known):

14. Subsidiary risk(s):

15. Packing group

16. Category, (class 7 only)

17. Type of packaging:

18. Packaging specification marking:

19. No of packages:

20. Quantity (or transport index, if

applicable):

21. Reference no of Air Waybill:

22. Reference no of courier pouch, baggage tag, or passenger ticket:
23. Name and address of shipper, agent, passenger, etc:

24. Other relevant information (including suspected cause, any action taken):

Reported Investigation

Organization

NIL

OPEN

CLOSE

Flight Data:

Position:

Record Held:

Date:

AIR SAFETY REPORT Section F

Address and Tel. No.:

Name:

page 1/2

Signature:

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AIR SAFETY REPORT Section F