If any questions, please call Flight Safety Department +7 (343)345-32-26 e-mail fs@u6.

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1. TYPE OF ASR ATC/AIRPROX TCAS RA WAKE TURB BIRD STRIKE NON MANDATORY FOR OFFICE USE
EVENT (BOX 25/26) (BOX 25/26) (BOX 27) (BOX 28) CONFIDENTIAL ❏ OCCURRENCE ASR REF

❏ ❏ ❏ ❏ ❏ REPORT (MOR)
CONFIDENTIAL ❏
 TICK ALL THAT APPLY INCLUDING RELEVANT BOXES ON REVERSE OF FORM ❏
2. CAPTAIN CODE CO-PILOT CODE OTHER CREW CODE
______ ______ ______

3. DATE OF OCCURRENCE 4. TIME LOCAL❏/UTC❏ 5. FLIGHT NR 6. SECTOR (IATA CODE)

______/______/______ ____/____/ DAY❏ / NIGHT❏ SVR-_______ From__________ To___________ Diverted________

7. A/C TYPE 8. REGISTRATION 9. CREW/PAX 10. HEIGHT ❏ / ALTITUDE ❏ / FL ❏

❏A319 ❏A320 ❏A321 ❏B737 V__ - B___ ___ / _______________ft ____________
11. FLIGHT PHASE PRE-FLIGHT ❏ / TOWING ❏ / PARKED ❏ / PUSHBACK ❏ / TAXI-OUT ❏ / TAKE-OFF ❏ / RTO ❏ / INITIAL CLIMB ❏
CLIMB ❏ / CRUISE ❏ / DESCENT ❏ / HOLDING ❏ / APPROACH ❏ / GO-AROUND ❏ / LANDING ❏ / TAXI-IN ❏ / POST-FLIGHT ❏
12. SPEED/ MACH 13. A/C WEIGHT 14. ATLB REF 15. AIRPORT/GATE 16. GEOG.POSITION
kg Page__________Block__________
17. MET / WX ACTUAL 18. SIGNIFICANT WX 20. CONFIGURATION
WIND ______º/ ______ MODERATE / SEVERE RAIN❏ / SNOW ❏ / ICING❏ / FOG❏ AUTOPILOT ❏
TURBULENCE❏ / HAIL❏ / WINDSHEAR❏
VIS (RVR) ___________km AUTOTHRUST ❏
CLOUD ____ft(m) / __ /OCT 19. RUNWAY / RUNWAY STATE SPOILERS EXTENDED❏ /ARMED❏
TEMP ____°C RWY_________ BRKN ACTN/Kсц ____________ GEAR UP❏ /DOWN❏
QNH ________ DRY ❏/ WET ❏/ STANDING WATER❏ / ICE ❏/ SNOW❏ / SLUSH❏ FLAPS 1❏ /1+F❏ /2❏ /3❏ /FULL❏
21. SUMMARY (CONCISE DESCRIPTION OF THE EVENTS INCLUDING OTHER A/C DETAILS, IF APPLICABLE, eg. A/C TYPE, MARKINGS, COLOUR, LIGHTING etc.)

22. EVENT AND PROBABLE CAUSE (DETAILED DESCRIPTION OF THE EVENT AND ITS IMMEDIATE PROBABLE CAUSE)

23. ACTIONS AND RESULTS (ACTIONS TAKEN, THEIR RESULT AND ANY SUBSEQUENT EVENTS)
24. OTHER INFORMATION (AND SUGGESTIONS FOR PREVENTIVE ACTION)

25. AIRPROX / ATC PROCEDURAL / TCAS RA

MARK PASSAGE OF OTHER AIRCRAFT RELATIVE TO YOU, IN PLAN ON THE LEFT AND IN ELEVATION ON THE RIGHT,
ASSUMING YOU ARE AT THE CENTRE OF EACH DIAGRAM. INDICATE APPROPRIATE SCALE. INDICATE APPROXIMATELY TRACK (º) OF CONFLICTING TFC.

26. TCAS RA or AIRPROX SEVERITY OF RISK TO A/C NIL❏ / LOW❏ / MED❏ / HIGH❏
MINIMUM VERTICAL SEPARATION ______________M / FT AVOIDING ACTION TAKEN YES❏ / NO❏
MINIMUM HORIZONTAL SEPARATION ______________ M / NM REPORTED TO ATC YES❏ / NO❏
TCAS ALERT RA❏ / TA❏ ATC INSTRUCTIONS ISSUED ___________________
TYPE OF RA CLIMB❏ / CRUISE❏ / DESCENT❏ FREQUENCY IN USE ____________________
RA FOLLOWED YES❏/ NO❏ HEADING ___________________DEG
VERTICAL DEVIATION _________________FT CLEARED ALTITUDE / FL __________________
27. WAKE TURBULENCE WHAT MADE YOU SUSPECT WAKE TURBULENCE?
TURBULENCE HEADING _____________DEG
TURNING LEFT ❏/ RIGHT❏ / NO❏ DESCRIBE ANY VERTICAL ACCELERATION
POSITION ON GLIDESLOPE HIGH ❏/ LOW❏ / ON❏
POSITION ON RWY TRACK LEFT❏/RIGHT ❏/ ON❏ WERE YOU AWARE OF OTHER A/C BEFORE INCIDENT?
CHANGE IN ATTITUDE PITCH_____ ROLL _____ YAW_____DEG YES❏/NO❏
CHANGE IN ALTITUDE _______________FT GIVE DETAILS OF PRECEEDING A/C (TYPE, CALLSIGN, ETC.)
LOW SPEED PROT ACTIVE YES❏/NO❏
28. BIRD STRIKE ❏ / BIRD STRIKE HAZARD ❏
TYPE OF BIRDS _________________________ EFFECT ON FLIGHT NONE❏ RTO❏ RETURN❏ DIVERTED❏
QTY SEEN 1❏ 2-10 ❏ 11-100 ❏ MORE ❏ ACFT IMPACTS RADOME ❏ WINDSHIELD ❏ FUSELAGE ❏
QTY STRUCK 1❏ 2-10 ❏ 11-100 ❏ MORE ❏ ENG#1 ❏ ENG#2 ❏ TAIL ❏ PROP ❏ WING ❏
BIRDS WARNING GIVEN BY ATC? YES❏ / NO❏ LDG-GEAR ❏ LIGHTS ❏ OTHER _______________❏
BIRDS WARNING GIVEN BY CREW TO ATC? YES❏ / NO❏

SIGNATURE RANK DATE (DD/MM/YY)