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.

REPORT TYPE :

Mandatory

Voluntary
If you check voluntary report 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.

ACCIDENT Appropiate name of occurance (Title):

INCIDENT

HAZARD

Aircraft Type and Series

Registration

Operator

Owner

Date of Occurence

FLIGHT AND WEATHER DETAILS

Flight No.: DAY NIGHT From: TWILIGHT VMC Kts IMC To: Time GMT Geog. Position Visibility OAT ________ C Ht / Alt / FL DRY AMP WET FLOODED ICE SNOW SLUSH Cloud Type Height / ft Amount / 8 ths HAIL SNOW MOD SLEET HEAVY HEAVY EXTREME MOD SEVERE IAS Status RAIN LIGHT LIGHT MOD LIGHT Wind Runway Used Precipitation Icing Turbulence

FLIGHT PHASE
PARKED TOWING TAXYING TAKE-OFF INIT CLIMB CLIMB CRUISE DESCENT HOLDING APPROACH LANDING CIRCUIT AEROBATICS HOVER SCHED PAX NON-SCHED PAX SCHED FREIGHT

NATURE OF FLIGHT
BUSINESS CLUB / GROUP PRIVATE POSITIONING FERRY TEST TRAINING

NON- SCHED FREIGHT SURVEY PLEASURE AGRICULTURAL

TYPE OF EVENT (TICK ALL THAT APPLY)

Aircraft operation (except B,C,D,E,F) Technical Malfunction / Failure Airmiss / ATC Incident TCAS RA Wake Turbulance / Wind Shear Bird Strike Dangerous Goods
AIR SAFETY REPORT 1/1

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A B C C D E F

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AIR SAFETY REPORT

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Section A:
AIRCRAFT OPERATION
DESCRIPTION OF OCCURRENCE:

ORGANISATION :

NAME :

POSITION :

SIGNATURE :

DATE :

IF REPORT IS VOLUNTARY (I.E., NOT SUBJECT TO MANDATORY REQUIREMENTS) CAN THE INFORMATION BE PUBLISHED IN THE INTEREST OF SAFETY?

YES

ADDRESS AND/OR TEL. NUMBER, IF REPORTER WISHES TO BE CONTACTED PRIVATELY

NO

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.

REPORTING ORGANISATION REPORT :

Reported Investigation NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

AIR SAFETY REPORT Section A

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AIR SAFETY REPORT Section A

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Section B:
TECHNICAL MALFUNCTION / FAILURE
DESCRIPTION OF OCCURRENCE :

ENGINEERING DETAILS

Aircraft Constructors No.

Engine Type & Series

Ground Phase

MAINTENANCE UNATTENDED

GROUND HANDLING TAXING

Component Part

Location of aircraft

Manual Reference

Overhaul / Repair Agency

Maintenance Program O.C. C.M. H.T.

Reability Program Cat A Intem YES NO

Component Part

Manufacturer

Part No.

Serial No.

HOURS CYCLES LANDINGS

Total Overhaul Repair Inspection

Since

Manufacturer Advised YES NO

Is there any published Airworthiness Information or control procedures (c.g.AD, SB etc.) relevant to occurrence. YES NO

Reference No. and Compliance Status of Aircraft or Equipment

Entered in Aircraft Technical Log

YES

NO

REPORTING ORGANISATION REPORT :

Reported Investigation NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

AIR SAFETY REPORT Section B

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AIR SAFETY REPORT Section B

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Section C:
AIRMISS / ATC, TCAS RA
VIEW FROM ABOVE
Hundreds of metres
10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10

VIEW FROM ASTERN

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 10 300 9 270 8 240 7 210 6 180 5 150 4 120 3 90 2 60 1 30 0 0 1 30 2 60 3 90 4 120 5 150 6 180 7 210 8 240 9 270 10 300

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

Hundred of metres

OPERATING AIRCRAFT
Heading and route True airspeed Kt Km-h

AIRCRAFT BANK ANGLE Wings level Slight bank Moderate bank Steep bank Inverted Unknown

AIRCRAFT
DIRECTION OF BANK Left Right Unknown

Hundreds of FEET

RESTRICTIONS TO VISIBILITY (select as many as required) Sunglare Windscreen pillar Dirty windscreen Other cockpit structure None

USE OF AIRCRAFT LIGHTING

(select as many as required) Navigation Strobe Cabin Red anti-collision Landing / taxy Logo (tail fin) Other None

AIRBORNE COLLISION AVOIDANCE SYSTEM

TCAS
Not carried Type Trafic advisory issued Resolution advisory issued Trafic advisory or resolution advisory not issued AVOIDING ACTION TAKEN

TRAFIC AVOIDANCE ADVICE ISSUED BY

ATS Yes, based on radar Yes, based on visual sighting Yes, based on other information No

TRAFIC INFORMATION ISSUED

Yes, based on radar Yes, based on visual sighting

Yes, based on other information No

Yes No

RADAR IDENTIFICATION
No radar available Radar identification No radar identification

TYPE OF FLIGHT PLAN

IFR none
*

VFR

OTHER AIRCRAFT SIGHTED

Yes No Wrong aircraft sighted

( * delete as appropiate)

AIR SAFETY REPORT Section C

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METRES

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Type Registration Rotocraft Marking, colour or other avaible details

A I R C R A F T
WING Left Right Unknown ENGINE 1 2 3 4 more than 4

AIRCRAFT CLIMBING OR DESCENDING Level flight Climbing Descending Unknown LIGHTS DISPLAYED Navigation Strobe Cabin Red anti-collision Landing / Taxy Logo (tail fin) TRAFFIC INFORMATION ISSUED Yes, based on radar Yes, based on visual sighting DISTANCE Closest horizontal distance ________ m ft Yes, based on other information No Other None

AIRCRAFT BANK ANGLE Wings level Slight bank Moderate bank Steep bank Inverted Unknown

AIRCRAFT DIRECTION OF BANK Left Right Unknown

TRAFFIC AVOIDANCE ADVICE ISSUED BY

ATS
Yes, based on radar Yes, based on visual sighting Yes, based on other information No Unknown

Unknown

AVOIDING ACTION TAKEN Unknown Yes No FLIGHT WEATHER CONDITIONS Unknown

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

Closest vertical distance

________

ft

(* Delete as appropiate)

ANY OTHER INFORMATION CONSIDERED IMPORTANT BY THE PILOT-IN COMMAND

Reported Investigation NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

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AIR SAFETY REPORT Section C

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Section D: Wake Turbulance / Wind Shear

HEADING
___________ Deg. TURNING POSITION ON GLIDESLOPE CHANGE IN ALTITUDE On ____________ Ft

Left

Right

No

High

Low

CHANGE IN ATTITUDE
Pitch Yaw _______________ _______________ Roll Deg _______________ _______________

WAS THERE BUFFET Yes No Yes

STICK SHAKE No

WHAT MADE YOU SUSPECT WAKE TURBULANCE ?

DESCRIBE ANY VERTICAL ACCELERATION

GIVE DETAILS OF PRECEDING AIRCRAFT Type _____________________ Registration _________________ Other details __________________________

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

Yes

No

Reported Investigation NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

AIR SAFETY REPORT Section D

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AIR SAFETY REPORT Section D

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Section E: BIRD STRIKE

Engine Make / Model Aerodrome Name Location if En Route

Part(s) of Aircraft Struck Radome Windshield Nose (excluding above) Engine no. 1 2 3 4 Propeller Wing / rotor Fuselage Landing gear Tail Lights Other (specify) Sky Condition No cloud Some cloud overcast NARATION Demaged

Effect on Flight

None Aborted take-off Precautionary landing Engines shut down Other (specify) Birds Species Number of birds Seen 1 2-10 11-100 More Size of birds Small Medium large Pilot Warned of Birds Yes No Struk

Reported Investigation NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

AIR SAFETY REPORT Section E

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AIR SAFETY REPORT Section E

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Section F: DANGEROUS GOODS

1. Flight /Truck date: 3. Departure airport: 5. Aircraft type: 7. Location of occurrence: 2. Flight /Truck no: 4. Destination airport: 6. Aircraft registration: 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): 15. Packing group 16. Category, (class 7 only)

13. Class/division (when known): 17. Type of packaging:

14. Subsidiary risk(s):

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 NIL OPEN CLOSE

Organization

Address and Tel. No.:

Flight Data:

Position:

Record Held:

Date:

Name:

Signature:

AIR SAFETY REPORT Section F

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AIR SAFETY REPORT Section F

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ATS OPERATIONAL OCCURRENCE REPORT

1. Date/Time of occurrence (UTC) Data/Ora evenimentului (UTC): 2. Day Ziua or sau Night noaptea 3. Geographical location of occurrenceLocul evenimentului:

4. Aircraft involved Aeronave implicate:

Operator Call sign and/or registration Type ADEP ADES FL. altitude or height actual cleared SSR Code Mode C Relevant route Flt. Rule s

5. RTF frequency/Communication equipment and Surveillance equipment used Frecvena de comunicaii i echipamentul de supraveghere folosit: 8. Estimated vertical distance Distana verticala estimata: Estimated horizontal distance Distana orizontala estimata: 10. Traffic information given Informaii de trafic date:

6. Class of ATS airspace Clasa spaiului ATS:

A B C D

7. Type of Air Trafic Services Tipul Serviciului:

9. Automated Warning Systems - Sisteme Automate de Avertizare : Ground-based La sol (STCA, MTCD, APWS) Airborne La bord (TCAS, GPWS) 11. Have you reviewed relevant RTF and/or surveillance recordings? S-au revzut nregistrrile comunicaiilor i/sau radar?

YES

NO

YES
YES

NO
NO

12. Was Weather considered relevant? (if YES, include details in Box 13) Sunt condiiile meteo considerate relevante? (daca sunt, detaliai la pct.13)

13. Description of occurrence (use additional forms as necessary) Descrierea evenimentului (folosii coli suplimentare dac este necesar):

14. Assessment of workload Evaluarea ncarcarii a CTA:

very

heavy

medium

light

15. Time since last break Timpul de la ultima pauza:

16. Start time of shift Ora de nceput a lucrului(UTC):

17. Name of : ATS Unit Unitatea ATS: Sector:

18. On duty as - Funcia: 19. Your Name, Signature and local Date Nume, Semnatura, Data:

ATS OPERATIONAL OCCURRENCE REPORT

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REPORTING ORGANISATION REPORT :

Reported Investigation NIL Flight Data: OPEN CLOSE

Organization

Address and Tel. No.:

Position:

Record Held:

Date:

Name:

Signature:

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ATS OPERATIONAL OCCURRENCE REPORT

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ATS TECHNICAL OCCURRENCE REPORT

1. Unitatea de trafic aerian 2. Sectorul (sectoarele) afectat (afectate) 3. Anul: Luna: Data: Ora:

Incapacitate de furnizare ATS Incapacitate de furnizare servicii ASM Incapacitate de furnizare servicii ATFM Intreruperea funciei de COMUNICAII 4. Tipul de eveniment ntreruperea funciei de NAVIGAIE ntreruperea funciei de SUPRAVEGHERE ntreruperea funciilor de PROCESARE I DISTRIBUTIE A DATELOR ntreruperea funciilor SUPORT DE INFORMARE AERONAUTIC Evenimente privind securitatea/security sistemului ATM (ameninri cu bomba la bordul aeronavelor aflate n zbor i a facilitilor aeronautice aparinnd ROMATSA, deturnri de aeronave etc). 6. Durata evenimentului ore min. sec.

7. Descrierea evenimentului i a modului de remediere

8. Funcia:

9. Numele i prenumele:

10. Semntura:

Raport cercetare / investigaie intern :

Investigaie intern N/A Deschis nchis

Organizaie: Funcia: Data:

Adresa i numrul de telefon:

Nume:

Semntura:

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