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Anonymous Incident Report Form Langley Flying School
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Use this form to report any workplace accident, injury, incident, close call or Hazard.
This is Documenting a/an
*
Lost Time / Injury
First Aid
Accident
Almost hit / Close Call
Observation
Row 1
Lost Time / Injury
First Aid
Accident
Almost hit / Close Call
Observation
Row 1
Date of Report:
MM
/
DD
/
YYYY
Time of Event
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Location of Event:
Add aircraft's Ident if applicable
Your answer
Weather Conditions:
Specify the followings: Wind Velocity, Gusting Wind, Prevailing Visibility, Ceiling Altitude
Your answer
Special Weather
If Applicable.
Choose
Fog
Mist
Drizzle
Rain
Ice Palates
Snow
Freezing Rain
Hail
Frost
Thunderstorm
Flight Rules
VFR
IFR
SVFR
Day Flight
Night Flight
Row 1
VFR
IFR
SVFR
Day Flight
Night Flight
Row 1
Description of Observation or Event:
*
What Happened? in chronological order
Your answer
Description of the Standards:
*
What Should Have Happened? (In accordance to S.O.P, Airport’s Procedures, A.T.C., C.A.R., P.O.H, Airworthiness, Checklist)
Your answer
Description of the Gap:
*
What went wrong?
Knowledge
Comprehension
Self-Discipline
Decision Making
Fatigue
Health Condition
Mechanical
Weather
Log Discrpancy
Missing Aircraft
Undefined
Other:
Required
Description of the Cause
*
Why it happened the way it did?
Your answer
Was the event / injury caused by an unsafe act (activity or movement) or an unsafe condition (machinery or weather)?
*
Your answer
Conclusions and Corrective Actions to be Taken
How can we prevent it from recurring?
Your answer
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