17 May

Mandatory Occurrence Reporting System Handbook

REPUBLIC OF AZERBAIJAN

MANDATORY OCCURRENCE REPORTING SYSTEM HANDBOOK

BAKU——2010PREFACE

The Mandatory Occurrence Reporting (MOR) System is an essential part of the SCAA's

monitoring function. The MOR System is complementary to the normal day to day procedures

and 'control' systems (e.g. Air Operator Certificate (AOC), Company Approvals, etc.) and is not

intended to duplicate or supersede them. The MOR System tries to identify those occurrences

where the routine control procedures have failed. To achieve this objective, the MOR System sets

forth the criteria for a reportable occurrence (in terms of the effects on safety), normal day-to-day

defects, and minor incidents.

The objectives of occurrence reporting and the formal definition of a reportable occurrence are

based on the definitions contained in Law of the Republic of Azerbaijan on Aviation, Chapter III,

and further amplified in this handbook. Reporters should ensure that the content of their reports

meets the criteria and guidance laid out in this handbook. Operators, inspectors, and other

reporters should pay particular attention to day-to-day operational anomalies, technical defects,

and routine reliability issues are dealt with through the normal organizational systems and

procedures.

Comments and recommendations for revision/amendment action to this publication should be

forwarded to the Director of the State Civil Aviation Administration of the Republic of

Azerbaijan.

________________________________________

Director State Civil Aviation Administration

Republic of Azerbaijan

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RECORD OF AMENDMENTS

NumberPageDateEntered byNumberPageDateEntered by affectedEnteredaffectedentered

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CHAPTER 1 GENERAL

1. 1

1.2

PURPOSE

APPLICABILITY

1.2.1Category of Aircraft Involved The following aircraft are covered by the MOR System:

In accordance with the Law of the Republic of Azerbaijan on Aviation, Chapter III, the reasons

for every aviation accident (air crash) and incident shall be investigated. The primary purpose of

accident (air crash) and incident investigations shall be prevention. The purpose of such

investigation shall not be to identify guilty parties and hold them liable.

This handbook describes the State Civil Aviation Administration of the Republic of Azerbaijan

(SCAA) Mandatory Occurrence Reporting (MOR) System and to provide guidance to SCAA

inspectors regarding occurrence reporting to ensure that aviation safety data is collected on all

occurrences, including those which do not fit the definition of incident or accident.

Operators are required under ARA-OPS 1.037 to establish the MOR System as part of the

Accident Prevention and Flight Safety Program. The MOR System enables the collection and

assessment of relevant incident and accident reports in order to identify adverse trends or to

address deficiencies in the interest of flight safety.

1.2.2

(a)Any aircraft operated under an air operator's certificate issued by the SCAA.

(b)Any turbine-powered aircraft that has a certificate of airworthiness issued by the SCAA.

(c)In the case of organizations providing a service or facility for aircraft operating over or in the Republic of Azerbaijan (e.g. Air Traffic Services, airfields, etc.) any occurrence meeting the required criteria should be reported regardless of the nationality of the aircraft involved.

Categories of Persons Required to Report

Anyone may submit an Occurrence Report to the SCAA; however, the following categories of persons (or organizations) are required to report occurrences. These persons and organizations include:

(a)the operator and the commander of a turbine-powered aircraft which has a certificate of airworthiness issued by the SCAA;

(b)the operator, the commander, and the crew members of an aircraft operated under an air operator's certificate issued by the SCAA;

(c)a person who carries on the business of maintaining or modifying a turbine-powered aircraft, which has a certificate of airworthiness issued by the SCAA, and a person who carries on the business of maintaining or

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1.3

(d)a person who carries on the business of maintaining or modifying an aircraft, operated under an air operator's certificate granted by the SCAA, and a person who carries on the business of maintaining or modifying any equipment or part of such an aircraft;

(e)a person who signs an airworthiness review certificate, or a certificate of release to service in respect of a turbine-powered aircraft, which has a certificate of airworthiness issued by the SCAA, and a person who signs an airworthiness review certificate or a certificate of release to service in respect of any equipment or part of such an aircraft;

(f)a person who signs an airworthiness review certificate, or a certificate of release to service in respect of an aircraft, operated under an air operator's certificate granted by the SCAA, and a person who signs an airworthiness review certificate or a certificate of release to service in respect of any equipment or part of such an aircraft;

(g)a person who performs a function which requires him to be authorized by the SCAA as an air traffic controller or as a flight information service officer;

(h)a licensee and a manager of a licensed aerodrome or a manager of an airport;

(i)a person who performs a function in respect of the installation, modification, maintenance, repair, overhaul, flight-checking or inspection of air navigation facilities which are utilized by a person who provides an air traffic control service under an approval issued by the SCAA; and

(j)a person who performs a function in respect of the ground-handling of aircraft, including fueling, servicing, loadsheet preparation, loading, de- icing and towing at an airport.

DEFINITIONS

1.3.1

In accordance with ARA-OPS 1.420, Occurrence reporting, the following definitions apply to the MOR System:

1.3.1.1 Incident. An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation.

1.3.1.2 Serious Incident. An incident involving circumstances indicating that an accident nearly occurred.

1.3.1.3 Accident. An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all persons have disembarked, in which:

(a)a person is fatally or seriously injured as a result of: being in the aircraft;

modifying any equipment or part of such an aircraft;

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␣ ␣

direct contact with any part of the aircraft, including parts which have become detached from the aircraft; or,

direct exposure to jet blast;

except when the injuries are from natural causes, self- inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew: or

(b)the aircraft sustains damage or structural failure which adversely affects the structural strength, performance or flight characteristics of the aircraft; and would normally require major repair or replacement of the affected component; except for engine failure or damage, when the damage is limited to the engine, its cowlings or accessories; or for damage limited to propellers, wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in the aircraft skin: or

(c)the aircraft is missing or is completely inaccessible.

1.3.1.4 Incident Reporting. An operator shall establish procedures for reporting incidents taking into account responsibilities described below and circumstances described in sub-paragraph (d) below.

(a)ARA-OPS 1.085(b) specifies the responsibilities of crew members for reporting incidents that endanger, or could endanger, the safety of operation.

(b)The commander or the operator of an aircraft shall submit a report to the SCAA of any incident that endangers or could endanger the safety of operation.

(c)Reports must be dispatched within 72 hours of the time when the incident was identified unless exceptional circumstances prevent this.

(d)A commander shall ensure that all known or suspected technical defects and all exceedances of technical limitations occurring while he was responsible for the flight are recorded in the aircraft technical log. If the deficiency or exceedance of technical limitations endangers or could endanger the safety of operation, the commander must in addition initiate the submission of a report to the SCAA.

(e)In the case of incidents arising from, or relating to, any failure, malfunction or defect in the aircraft, its equipment or any item of ground support equipment, or which cause or might cause adverse effects on the continuing airworthiness of the aircraft the operator must also inform the organization responsible for the design or the supplier or, if applicable, the organization responsible for continued airworthiness, at the same time as a report is submitted to the SCAA.

1.3.1.5 Accident and Serious Incident Reporting. An operator shall establish procedures for reporting accidents and serious incidents taking into account responsibilities described below.

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(a)A commander shall notify the operator of any accident or serious incident occurring while he was responsible for the flight. In the event that the commander is incapable of providing such notification, this task shall be undertaken by any other member of the crew if they are able to do so, note being taken of the succession of command specified by the operator.

(b)An operator shall ensure that the aviation authority (AA) in the State of the operator, and any other organizations registered in AA required to be informed, are notified by the quickest means available of any accident or serious incident.

(c)The commander or the operator of an aircraft shall submit a report to the AA in the State of the operator within 72 hours of the time when the accident or serious incident occurred.

1.3.1.6 Specific Reports. Occurrences for which specific notification and reporting methods must be used are described below:

(a)Air Traffic Incidents. A commander shall without delay notify the air traffic service unit concerned of the incident and shall inform them of his intention to submit an air traffic incident report after the flight has ended whenever an aircraft in flight has been endangered by:

(i)A near collision with any other flying device;

(ii)Faulty air traffic procedures or lack of compliance with applicable procedures by air traffic services or by the flight crew;

(iii)Failure of air traffic services facilities.

In addition, the commander shall notify the SCAA of the incident.

(b)Airborne Collision Avoidance System (ACAS) Resolution Advisory. A commander shall notify the air traffic service unit concerned and submit an ACAS report to the SCAA whenever an aircraft in flight has maneuvered in response to an ACAS Resolution Advisory.

(c)Bird Hazards and Strikes

(i)A commander shall immediately inform the local air traffic service unit whenever a potential bird hazard is observed.

(ii)If he is aware that a bird strike has occurred, a commander shall submit a written bird strike report after landing to the SCAA whenever an aircraft for which he is responsible suffers a bird strike that results in significant damage to the aircraft or the loss or malfunction of any essential service. If the bird strike is discovered when the commander is not available, the operator is responsible for submitting the report.

(d)Dangerous Goods Incidents and Accidents. ␣n case of emergency, when situation is suitable for, an operator shall notify the

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1.4

Division of Responsibilities

1.3.2

appropriate air traffic services on carriage of dangerous cargo. After landing, if dangerous goods accident or incident occurred, commander shall submit report in accordance with ARA-OPS 1.1225

(e)Unlawful Interference. Following an act of unlawful interference on board an aircraft, the commander or, in his absence, the operator shall submit a report as soon as practicable to the local AA and to the AA in the State of the operator.

(f)Encountering Potential Hazardous Conditions. A commander shall notify the appropriate air traffic services unit as soon as practicable whenever a potentially hazardous condition such as an irregularity in a ground or navigational facility, a meteorological phenomenon or a volcanic ash cloud is encountered during flight.

For purposes of the MOR System, Occurrences to be reported are those where the safety of operation was or could have been endangered or which could have led to an unsafe condition. If in the view of the reporter an occurrence did not endanger the safety of the operation but if repeated in different but likely circumstances would create a hazard, then a report should be made.

1.4.1

1.4.2

The MOR System does not replace or reduce the duties and responsibilities of all organizations and personnel within the air transport industry. The primary responsibility for safety rests with the management of the organizations involved (SCAA, Operators and Maintenance Organizations). The SCAA's responsibility is to provide the regulatory framework within which the industry must work and thereafter to monitor performance to be satisfied that required standards are set and maintained. The MOR System is an established part of the SCAA's monitoring function and is complementary to the normal day to day procedures and systems (e.g. AOC, Company approvals, etc.); it is not intended to duplicate or supersede these. Organizations are required:

(a) (b)

to record occurrences; and

in conjunction with the appropriate organization (e.g. Operator, Maintenance/Repair Organization) and when necessary the SCAA, to investigate occurrences in order to establish the cause sufficiently to devise, promulgate and implement any necessary remedial and preventative action.

In relation to all reported occurrences, including those raised by its own personnel, the SCAA will

(a)evaluate each Occurrence Report received;

(b)decide which occurrences require investigation by the SCAA in order to discharge the SCAA's functions and responsibilities;

(c)make such checks as it considers necessary to ensure that operators, manufacturers, maintenance, repair and overhaul organizations, air traffic control services and aerodrome operators are taking any necessary

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1.5 1.6

remedial and preventative action in relation to reported occurrences;

(d)take such steps as are open to it to persuade foreign aviation authorities and organizations to take any necessary remedial and preventative action in relation to reported occurrences;

(e)assess and analyze the information reported to it in order to detect safety problems which may not be apparent to individual reporters;

(f)make available the information derived from Occurrence Reports in accordance with the relevant SCAA Regulations;

(g)make available the results of studies of the data provided to those who will use them for the benefit of air safety;

(h)where appropriate, issue specific advice or instructions to particular sections of the industry;

(i)where appropriate, take action in relation to legislation, requirements or guidance, aviation regulations, amendments to Flight Manuals and Operations Manuals, introduction of mandatory modifications and inspections, amendments to maintenance schedules, terms of approval, and licenses, issue of Aeronautical Information Circulars, Airworthiness Notices, etc.

[RESERVED] LEGISLATIVE AND REGULATORY AUTHORITY

The MOR System is governed by the Law of the Republic of Azerbaijan on Aviation, Chapter

III, Investigation of Aviation Accidents (Air Crashes) and Incidents, and ARA-OPS 1.037 and

1.420 regarding occurrence reporting.

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CHAPTER 2 REPORTING

2.1

2.2

VOLUNTARY REPORTING

2.1.1. Voluntary reporting is organised referring to the paragraph 8.2.5 of the Resolution ␣ 118 of the Cabinet of Ministers dated August 5, 2009 on ““Regulations of the activities of investigation comission on accidents and incidents in aviation””/

The SCAA encourages voluntary reporting to the same criteria across the whole spectrum of civil aviation operations in the Republic of Azerbaijan. The SCAA's organization and procedures for processing and recording reports do not, therefore, substantially differentiate between voluntary and mandatory reports.

2.1.2

2.1.3

A voluntary MOR report is that report made by a person or organization who is not required to report in accordance with the requirements of the MOR System. Persons and organizations who are required to report are detailed in paragraph 1.2.2 above.

The MOR System mandates certain requirements on the SCAA in respect of the handling and processing of voluntary MOR reports. Therefore, voluntary reports will be published in a limited format which removes information and data which is likely to identify the reporter.

ITEMS TO BE REPORTED

2.2.1

2.2.2 2.2.3

2.2.4

2.2.5

Any person specified in paragraph 1.2.2 above should report any reportable occurrence of which he has positive knowledge, even though this may not be first hand, unless he has good reason to believe that appropriate details of the occurrence have already been, or will be, reported by someone else.

In deciding whether or not to report an occurrence it must be decided whether the event meets the applicable definition as specified in paragraph 1.3 above.

A reportable occurrence in relation to an aircraft means any incident which endangers or which, if not corrected, would endanger an aircraft, its occupants or any other person. A list of examples of these occurrences appears in Appendix A to this publication. This Appendix provides more detailed guidance on the types of occurrences which are required to be reported.

A report should also be submitted on any occurrence which involves, for example, a defective condition or unsatisfactory behavior or procedure which did not immediately endanger the aircraft but which, if allowed to continue uncorrected, or if repeated in different, but likely, circumstances, would create a hazard.

It is important that reporters keep firmly in mind the concept of 'endangering' or 'potentially endangering', as used in the above definition, when deciding whether or not to submit a report. The primary objective of occurrence reporting is to monitor, disseminate and record for analysis, critical or potentially critical safety occurrences.

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Note:In order to achieve the above objectives for occurrence reporting, the criteria for a reportable occurrence need to be set above, in terms of the effect on safety, the normal day to day defects or minor incidents. Reporters should ensure that the content of their reports meets with the criteria and guidance laid out in Appendix A. Reporters should place particular emphasis on day-to-day operational anomalies, technical defects and routine reliability issues are dealt with via the normal organizational systems and procedures.

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CHAPTER 3 PROTECTION OF REPORTERS AND REPORTS 3.1CONFIDENTIALITY AND DISSEMINATION OF REPORTS

The SCAA will ensure that relevant safety information deriving from the analysis of reports, which have been de-identified, are made available to all parties so that they can be used for improving safety. Accordingly, the SCAA will not disclose the name of the person submitting the report or of a person to whom it relates unless required to do so by law or unless, in either case, the person concerned authorizes disclosure.

3.2ASSURANCE REGARDING PROSECUTION

The sole objective of occurrence reporting is the prevention of accidents and incidents and not to attribute blame or liability. No proceedings shall be instituted in respect of unpremeditated or inadvertent infringements of the law which come to the attention of the relevant authorities only because they have been reported under the MOR System, except in cases of gross negligence.

3.3POSSIBLE ACTION BY EMPLOYERS

The SCAA will work with employers to ensure that employees who report incidents of which they may have knowledge are not subjected to any prejudice by their employer.

In any event, where a reported occurrence indicated an unpremeditated or inadvertent lapse by an employee, the SCAA expects an employer to act responsibly and to share its view that free and full reporting is the primary aim, and that every effort should be made to avoid action that may inhibit reporting. Therefore, except to the extent that action is needed in order to ensure safety, the SCAA expects employers to refrain from disciplinary or punitive action which might inhibit their staff from duly reporting incidents of which they may have knowledge.

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CHAPTER 4 REPORTING PROCEDURES

4.1

4.2

MANDATORY REPORTING

4.1.1

4.1.2

4.1.3

Those occurrences which must always be reported (e.g. fires, uncontained engine failures, critically low fuel states, close proximity between aircraft, etc.) can easily be listed but it is impossible to define precisely every significant hazard which requires reporting. What is judged to be reportable on one class of aircraft may not be so on another and the absence or presence of a single factor, human or technical, can transform a minor occurrence into a significant hazard or an accident. Judgment by the reporter of the degree of hazard or potential hazard involved is therefore essential in many cases. (See Appendix A, Items to be Reported.)

Practical and effective working of the MOR System requires a constructive approach and resolve on the part of all reporters and others involved to make the MOR System a successful and worthwhile safety reporting program.

In the case of organizations providing a service or facility for aircraft operating over or in the Republic of Azerbaijan (e.g. Air Traffic Services, airfields etc.) any occurrence meeting the required criteria should be reported regardless of the nationality of the aircraft involved

SUBMISSION OF REPORTS

4.2.1

The primary responsibility for reporting is with individuals. However, the interests of flight safety are best served by full participation, in the investigation and follow- up, by the organization involved. Therefore, wherever possible, the SCAA encourages the use of company reporting systems, with a responsible person(s) within the organization being nominated to receive all reports and to establish which reports from individuals within the organization meet the desired criteria for an Occurrence Report to the SCAA. Correlation of operational and technical aspects and the provision of any relevant supplementary information, e.g. the reporter's assessment and immediate action to control the problem, is an important part of such activity. With such systems the reporting level within the organization can be, and often is, set at a lower level than the SCAA requirement in order to provide a wider monitoring of the organization's activities. However, when the employee making such a report is a person having a duty to report to the SCAA, the company must tell him if his report has been passed on to the SCAA or not. If not, and the employee is convinced that it should, he must have the right to insist that the report be passed to the SCAA or to report it directly to the SCAA himself. Procedures to ensure that this right of the individual reporter is maintained must be incorporated into the organization's reporting procedures and be clearly stated in the relevant instructions to staff.

4.2.2 In the case of occurrences arising from, or relating to, defects in the aircraft, its equipment or any item of ground equipment, it is important that the appropriate manufacturer(s) be advised of the occurrence as soon as possible. The SCAA therefore expects that any

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organization which raises an Occurrence Report (or which has been made aware of a report raised by an individual employee) will pass a copy of the report to the appropriate aircraft or equipment manufacturer(s) as soon as possible, unless it is known that the originator has already done so. In the case of incidents affecting ground installations or services, e.g. aerodrome and/or air traffic control, those responsible for those services should also be informed. The original report should list all addressees to whom it has been sent. ( Resolution of the Cabinet of Ministers ␣ 219 dated September 19, 2008 on ““Regulations on reporting of accident and incident in aviation””)

4.2.3

4.2.4

4.2.6

4.2.7

Individuals may submit an Occurrence Report directly to SCAA should they so wish, but in the interest of flight safety they are strongly advised also to notify their employers, preferably by a copy of the report, unless confidentiality is considered essential.

Reports must be dispatched within 72 hours of the event, unless exceptional circumstances prevent this. Nevertheless, when the circumstances of an occurrence are judged to be particularly hazardous, the SCAA expects to be advised of the essential details by the fastest possible means (e.g. email/telephone/fax/telex). This should be followed up within 72 hours by a full written report to the SCAA with appropriate copies. The SCAA is dependent upon the judgment of those responsible for submitting reports to establish which occurrences are in this category. Conversely, for occurrences involving a lesser degree of hazard, reporters must exercise their judgment in deciding whether, in order that all those concerned may be alerted in the minimum time, to submit immediately a report on the limited information available or if there is the likelihood of any additional and useful information becoming available within the statutory 72 hours, to delay the dispatch of the report.

(a)Incident Reports are submitted to the Operator/Employer unless the commander or crew members determine a danger to safety operation. In such cases, the Incident Report should be submitted to the SCAA. (See ARA-OPS 1.420(b)(2)).

(b)Serious incidents, Accidents, and Air traffic incidents are automatically reported to the AA in the State of the Operator. (See ARA-OPS 1.420(c) and (d)(1)).

A maintenance, overhaul, or repair organization of aircraft, components or equipment is not expected to report to the SCAA, as a matter of routine, those occurrences involving products which have been reported to it by an operator/individual, if the operator/individual has already reported the occurrence to the SCAA.

Where a repair organization, overhauler, etc. is in doubt as to the applicability of the reporting requirements, e.g. it discovers a defect in a piece of equipment which cannot be associated with a particular aircraft, or even a type of aircraft, it should, nevertheless, make a report in order to ensure that it has complied with the law. The SCAA would, in any case, request that the organization, or individual, to report voluntarily such defects on equipment fitted to aircraft types not subject to mandatory reporting.

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4.3CONFIDENTIAL REPORTS

If any reporter considers that it is essential that his/her identity not be revealed, the report itself should be clearly annotated 'CONFIDENTIAL' and submitted directly to Head of FSD or his deputy and the envelope should be marked 'Personal'. The request will be respected and the reporter will be contacted personally, either by the Head of FSD or his deputy. The SCAA cannot, of course, guarantee confidentiality when an occurrence is reported separately by another party or in cases of gross negligence. Reporters submitting a Confidential Report must accept that effective investigation may be inhibited. Nevertheless, the SCAA would rather have a Confidential Report than no report at all.

Note: Confidential reports have to be put in a special secured box in the main building of SCAA. FSD supervises the box and is responsible for the confidentiality of the uploaded documentation.

4.4OPERATORS APPROVED FOR EXTENDED RANGE TWIN OPERATIONS (ETOPS)

ETOPS approved operators should make special remarks in the reporting form if the event is occured on the ETOPS approved aircraft.

4.5

INVESTIGATION AND PROVISION OF SUPPLEMENTARY INFORMATION

4.5.1

4.5.2

To facilitate effective lines of communication when any part or equipment involved in an occurrence is being dispatched to another area or organization for investigation or repair, the item(s) should be clearly identified as the subject of an Occurrence Report to the SCAA, by appropriate annotation of the 'tag' and all accompanying paperwork.

The MOR System does not require the provision of supplementary information on reportable occurrences, except when specifically requested by the SCAA. However, the efficiency of the SCAA's follow-up work and the standard of the information service it can provide will be greatly improved if reporting organizations keep the SCAA informed of major developments in their investigations of occurrences. The SCAA seeks the cooperation of all reporting organizations in this respect.

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4.6

SCAA OCCURRENCE REPORT FORMS 4.6.1. CONFIDENTIAL REPORT FORM

This report is confidential and in accordance with the JAA requirements. Access to the identity of the report is limited to the Chief of Operational Safety and his Assistant The report will be loaded into a de-identified database, evaluated, and acted upon by the Chief of Operational Safety. Once downloaded into the secure database, the original will then be destroyed. Only if you have included your name and contact number, you may be contacted by the Chief of Operational Safety or his Assistant to verify any unclear matter. This scheme is complementary to, and not instead of the all other open reporting schemes. If you are crew please include any relevant weather information

S␣Z␣N ÖZ AD␣N␣ZI GÖST␣RM␣Y␣N␣Z VAC␣B DEY␣L Bu m␣lumat konfidensial saylr v␣ s␣n␣dl␣rin t␣l␣bl␣rin␣ cavab verir

Bu m␣lumatdan yalnz Uçu␣larn t␣hlük␣sizliyi ␣öb␣sinin r␣isi v␣ onun müavininin x␣b␣ri olacaq. M␣lumat konfidensial m␣lumatlar bazasna daxil edil␣c␣k qiym␣tl␣ndiril␣c␣k v␣ aktla␣drlacaq.

M␣lumatlar bazasina daxil edildikd␣n sonra orijinal m␣hv edil␣c␣k . Yalnz sizin öz telefonunuzu v␣ ya adresinizi göst␣rdiyiniz hallarda v␣ lazm olduqda Sizinl␣ ␣laq␣ saxlayaraq aydn olmayan m␣qamlar aydnla␣drlacaq. Bu m␣lumat formas ba␣qa m␣lumat verm␣ sisteml␣rini ␣v␣z etmir, yalnz onlara ␣lav␣dir. ␣g␣r Siz heyy␣t üzvüsünüzs␣ m␣lumatnza hadis␣y␣ aid olan hava ␣␣raitini d␣ ␣lav␣ edin.

1. 2.

3.

4. 5.

6. 7.

1. 2.

3.

4. 5.

6. 7. _______________________________________________________________________

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Reporter

Event

Significant weather

Aircrew

Captain First officer Observer/

PF/PNF Left /Right seat Cabin crew Ground crew Manager Supervisor Engineering and Maintenance Security Tug Driver Cargo worker Ramp Worker Cleaning staff Check in Staff Dispatch Crew Control Training Staff Other (please explain)

Route: From To

Management Training Flight CRM Racial/Sexual Discrimination Team skills Operating Competence Violation of SOPs Passengers

Technical Failure Failure to respond to event Security Incorrect procedures Fatigue Dangerous Practices Unsafe Equipment Personal Safety Criminal Action Other (please explain)

VMC IMC Day

Night Twilight Dry Hot Rain Cold

Ice Turbulence Windshear Low Visibility Contaminated R/W Storms Others

Please write your report here and continue overleaf as necessary. Please only report facts as this is the only way we can accurately assess your report: __________________________________________________________________________

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Narrative Hadis␣nin m␣zmunu :

May we publish your de-identified report in house for the benefit of your colleagues? Yes/No

When completed, please send to : Azerbaijan State Civil Aviation Authority, Flight Safety Division (FSD) , Fax: + 994125984947; +99412 5984209

Tel: + 994125984947; +99412 5984209

NAME Position

Contact number May we leave a message on your voice mail?Yes/No

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4.6.2. Flight crew air safety report

AIR SAFETY REPORT

1. EVENTAIRPROXATC PROCEDURALTCAS RAWAKE TURBBIRD STRIKESECURITY ASR(BOX31/32)(BOX 31/32)(BOX 31/32)(BOX33)(BOX 34)

TICK ALL THAT APPLY INCLUDING RELEVANT BOXES ON REVERSE OF FORM

2. CAPT I/D doc NO.

CO-PILOTI/D doc NO.

OTHER CREW

3. DATE OF OCCURRENCE Ddmmyyyy

4. TIMELOCAL/UTC DAY/NIGHT

5. FLIGHT NO/CALLSIGN

6. SECTOR _____-_____-__ ___

FROMTO DIVERTE

7. Transponder

8. A/C TYPE

9. REGISTRATION

10. PASSENGERS /CREW

11. FUEL JETTISONED

KG

12. ETOPS YES/NO

13. ALTITUDE/Flt level

14. SPEED/MACH NR

15. A/C WEIGHT

16. TECH LOG REF _______ - _______ - _______

17. FLIGHT PHASE TOWING / PARKED / PUSHBACK / TAXI-OUT / TAKE-OFF / INITIAL

CLIMB / CLIMB / CRUISE / DESCENT / HOLDING / APPROACH / LANDING / TAXI-IN

18.AIRPORT AND STAND

19. GOEG. POSITION / CO-ORDS FIR/Way Point

20. MET IMC

VMC___________KM

21.WX ACTUAL WINDVIS

CLOUDTEMPQNH / km / °C _____

22. SIGNIFICANT WX MODERATE / SEVERE Turbulence/ RAIN / SNOW

/ ICING / FOG / HAIL / STANDING WATER / WINDSHEAR

23. RUNWAY

24. RUNWAY STATE DRYWET ICE SNOW SLUSH RVR_ _ _ _

25. CONFIGURATION A.PILOT / A.THRUST / GEAR / FLAP / SLAT / SPOILERS

______ __ ____

26. SUMMARY (CONCISE DESCRIPTION OF THE EVENTS INCLUDING OTHER A/C DETAILS IF APPLICABLE e.g. A/C TYPE, MARKINGS, COLOUR, LIGHTING etc

MOR If you consider this event to be a Mandatory Occurrence please tick the box and it will be forwarded to the CAA

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

DELAY IF ANY

28. ACTIONS AND RESULTS (ACTIONS TAKEN, THEIR RESULT AND ANY SUBSEQUENT EVENTS)

29. OTHER INFORMATION AND SUGGESTIONS FOR PREVENTATIVE ACTION

30. STATION ENGINEER’’S / STATION MANAGER’’S REPORT

31. AIRPROX* / ATC PROCEDURAL* and/or TCAS RA* (* Delete as applicable)

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.

_ _ _ _FT

MINIMUM VERTICAL SEPARATION MINIMUM HORIZONTAL SEPARATION TCAS ALERT TYPE OF RA_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ WAS RA FOLLOWED YES/NO(VERTIC.DEV._ _ _ _ FT) WAS TCAS ALERTNECESSARY / USEFUL / NUISANCE

_ _ _ _ M /NM* RA / TA / NONE

View from astern (vertical plane: ft)

View from above (horizontal plane: metres*or NM* )

SEVERITY OF RISK TO A/C AVOIDING ACTION TAKEN REPORTED TO ATC ATC INSTRUCTIONS ISSUED_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NIL / LOW / MED / HIGH YES / NO

_ _ _ _ _ _ UNIT

FREQUENCY IN USE HEADING CLEARED ALTITUDE / FL*

_ _ _ _ _ _ _ _ _ _ _ _ _ DEG _ _ _ _ _ _

20

HEADING _ _ _ _ DEGTURNINGLEFT / RIGHT / NO

POSITION ON GLIDESLOPEHIGH / LOW / ON POSITION ON EXTENDED CENTRLINELEFT / RIGHT / ON

CHANGE IN ATTITUDE YAW _ _ DEG

PITCH _ _ ROLL _ _

CHANGE IN ALTITUDE WAS THERE BUFFET WHAT MADE YOU SUSPECT WAKE TURBULENCE? DESCRIBE ANY VERTICAL ACCELERATION GIVE DETAILS OF PRECEDING A/C (TYPE/CALLSIGN etc)

WERE YOU AWARE OF OTHER A/C BEFORE THE INCIDENT YES/NO

_ _ _ _ _ FT YES / NOSTICK SHAKE?YES / NO

33. WAKE TURBULENCE

TYPE OF BIRDS NUMBER SEEN1 2-10 11-100 MORE NUMBER STRUCK1 2-10 11-100 MORE

TIME DAWN DAY DUSK NIGHT DESCRIBE IMPACT POINTS AND DAMAGE OVERLEAF

34. BIRDSTRIKE

SIGNATURE

Rank

FILING INSTRUCTIONS FLIGHT CREWImmediately after landing hand to:

BAKU

At ““”” CONTROLLER

At All Other Stations

DUTY OPERATIONS DUTY MANAGER on receipt forward immediately to:

REPORTING OFFICIAL Azerbaijan State Civil Aviation Authority, Flight Safety Division (FSD) ,

Fax: + 994125984947; +99412 5984209

Tel: + 994125984947; +99412 5984209

ORIGINAL TO CAACHIEF of SAFETY DEPT

21

4.6.3.1 ATS ENGINEERING OCCURRENCE REPORT

NOTES:(i) See Instructions and Explanatory Notes (ii)When completed, please send to : Azerbaijan State Civil Aviation Authority, Flight Safety Division (FSD) , Fax: + 994125984947; +99412 5984209 Tel: + 994125984947; +99412 5984209

(iii)Complete and/or circle boxes 1-25 as appropriate.

Original to FSD

Make additional photocopies as required

1Categories of Occurrence

ACCIDENT 2Occurrence Location

INCIDENT 3 Date

PROCEDURAL 5Duration on

FAILURE 6ATS Facility

RTF/Radar/Nav-aid Other:

HAZARD 7Service Affected Control/Advisory/Procedural/ Radar/GMC Approach/Area/ Aerodrome/Information/Air Navigation

4Time (UTC)

8Equipment Type/Manufacturer

9 Frequency

10. Callsign

11Equipment Location

12Facility Configuration In/Out-of-service, Main-

Mode/Standby/Test Channel A(1)/B(2)/Other: External Information Source:

13Equipment Status Planned/Unplanned Outage, Serviceable/Degredation/Unserviceable, Routine/Corrective Maintenance, Modification/Replacement

14 Previous

Defects/ Occurrences?

Yes/No/ Not Known

15 RTF Frequencies/ Radar Source

16NARRATIVE - use a diagram if necessary (attach copies of all relevant information)

17 Recordings impounded

No/Yes - Details

18 Can the information be disseminated in the interests of flight safety?

YES/NO

19 Other fault report action

20 Name

21 Organisation/Position continue on additional forms if necessary

22. Start time and duration of shift

23 Address&Telephone number (if the reporter wishes to be contacted privately

24. Signature

25. Date

22

ADVICE ONTHE COMPLETION OFTHE CAA ATS ENGINEERING MOR FORM

USE AND EXPLANATION OFTERMS IN BOX 1

Circle one or more category of Occurrence. ACCIDENT: INCIDENT: A reportable occurrence PROCEDURAL:A reportable occurrence attributed to procedural aspects including operation and maintenance of any facility on the ground.

FAILURE: A reportable occurrence attributed to any defect in or malfunctioning of any facility on the ground. HAZARD: A potential accident, incident or failure. EXPLANATORY NOTES GENERAL:Complete all boxes. If NOT APPLICABLE use N/A, or if NOT KNOWN use N/K. Jargon and uncommon abbreviations are to be avoided.

BOX 1: Location of Occurrence. BOX 5: The period over which the Occurrence condition existed. Instantaneous, indefinite or unknown classifications must be identified. BOX 6:The facility type must be circled or stated. BOX 7:More than one element could be circled. DETAILS OF THE EQUIPMENT ATTRIBUTING TO THE OCCURRENCE BOX 9: Frequency (Radio) appropriate to equipment and occurrence, if applicable. BOX 10: Callsign - Navaid identification, SSR code or RTF callsign. BOX 11: Location - identify station or other physical location of equipment. BOX 12: More than one element could be identified. Additional channels, diversity, etc must be stated where applicable. External information source completed with equipment and/or the station/ location. BOX 13: More than one element could be circled. The categories apply to the subject equipment at the time of the Occurrence. BOX 15: Identification of appropriate RTF frequencies/radar source is necessary to secure recordings which may be vital to subsequent investigations. BOX 17: If records impounded, state source, effective date and retaining station. BOX 19: Other fault reporting action, including contact with agencies, must be stated. It is important to ensure that any involved agency is informed of the reporting action. Normal, immediate fault action takes precedence over MOR reporting action. CONFIDENTIAL REPORTS

A report may be submitted confidentially. Please clearly annotate the top of the form 'CONFIDENTIAL'. The second copy need not be forwarded to local management. BOXES 20 to 25 should be completed. The CAA will respect the confidentiality and the Head of FSD will contact you personally.

23

4.6.3.2 ATS OCCURRENCE REPORTING FORM

ATS OCCURRENCE REPORTING FORM for ATS personnel to report an occurrence caused by an aircraft or vehicle, by your own or another Unit, an alleged

violation of ATS provisions or clearances, equipment/ATC Procedures shortcomings, etc.

1. Date/Time of occurence in (UTC)

YY MM DD hh mm

2. Day or Night Day ␣Night

3. Geograpichal location of occurence

4. Aircraft involved:

Operator

Call sign and/ or registration

Type

AdepAdes

FL,attitude orSSRMode

RelevantFlt. route segmentrules

IFR VFR Spec.

IFR VFR Spec.

heighCode

C

actualdeared

6. Class of ATS airspace ABCD EFG

YES

YES

NO

NO

5. RTF frequency/communication and surveillance equipment used:

8. Estimated vertical distance (ft/metres): Estimated horizontal distance (NM/km/minutes):

10. Traffic information givenYesNo

7. Type of Air Traffic Service:

9. Automated Warning Systems: Ground-based␣Airborne

11. Have you reviewed relevant RTF and/or surveillance recordings?YesNo

12. Was Weather considered relevant? ( if Yes, include details in Box 13)YesNo

13. Description of occurrence with diagram,if necessary; Causes and factors believed relevant to the occurrence ; Suggested changes and improvements, if appropriate: _________________________________________________________________

_________________________________________________________________ _________________________________________________________________ _________________________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Use additional forms as necessary

17. Name of your ATS Unit and Sector:

14. Assesment of workload (very)heavymedium

18. On duty as:

light

15. Time since16. Start time of shift: last break:In UTC␣local time:

FOR OFFICE USE ONLY:

19. Your Name, Signature and local Date:

When completed, please send to : Azerbaijan State Civil Aviation Authority, Flight Safety Division (FSD) ,

Fax: + 994125984947; +99412 5984209Tel: + 994125984947; +99412 5984209

24

4.7

4.8

REPORTING OF GROUND COMMUNICATIONS OR NAVIGATION EQUIPMENT FAULTS BY AIRCRAFT COMMANDERS

4.7.1 In urgent cases an aircraft commander may request the air traffic controller by the Radar Training Facility (RTF) to complete form on his behalf.

4.7.2All such faults which meet the criteria for a reportable occurrence must also be reported by the aircraft commander using the standard Occurrence Report, and submitted through the normal Occurrence Reporting channels. This report should indicate if action has also been taken.

RETENTION OF DATA FROM A FLIGHT DATA RECORDER (FDR)

4.8.1

4.8.2

4.8.3

The SCAA expects to use flight recorder data only when this is necessary for the proper investigation of the more significant occurrences. It is not intended to use such data to check on information contained in a written report but to supplement and extend the written information. Examples of the types of occurrence for which flight data records would be most useful are: significant excursion from the intended flight parameters; significant loss of control or control difficulties; unexpected loss of performance; a genuine GPWS warning. However, the more comprehensive recorders fitted to some aircraft are capable of providing valuable data on a wider range of occurrences and the SCAA would expect to make judicious use of such information in relation to appropriate occurrences

For this purpose, the SCAA requests that operators retain the data from an FDR which is relevant to a reportable occurrence for a period of 60 days from the date of the occurrence being reported to the SCAA, or a longer period if the SCAA so requests.

The SCAA depends upon the judgment of those responsible for submitting reports to establish which occurrences require the retention of FDR data. It is equally incumbent upon the SCAA to advise the reporting organization, as quickly as possible, when it requires such data.

25

CHAPTER 5 PROCESSING REPORTS AND PUBLICATION OF INFORMATION

5.1

5.1.1

SCAA SAFETY DEPARTMENT (INVESTIGATION AND DATA)

FSD of SCAA (a)

is responsible for the handling and publishing of the reports summary.

evaluation to identify those occurrences considered to require SCAA involvement in follow-up and to direct these to the appropriate Division(s) within the SCAA for action. Such reports are classified as 'Open'. All reports not requiring SCAA follow-up are recorded as 'Closed' by the FSD and entered on the database as such;

coordinating, monitoring and progressing to satisfactory closure the SCAA follow-up on Open occurrences, entering appropriate details on the database;

dissemination of occurrence information to those who need to know through a range of occurrence publications;

recording of all occurrences on a computer database. Regardless of type or classification of occurrence, names or addresses of individual persons are never recorded on the database;

continuously monitoring all incoming data for significant hazards or potential hazards using previously stored data, when appropriate and alerting SCAA specialist Divisions and others as necessary;

regular monitoring of stored data to identify hazards or potential hazards;

carrying out searches and analyses of stored data in response to requests from within the SCAA or industry and drawing attention, by appropriate means, to any lessons learned; and

ensuring that effective coordinated communication is maintained between all appropriate areas of SCAA on all matters of significance.

5.1.2

Occurrences Closed on Receipt. A considerable number of occurrences reported to the SCAA, while meeting the criteria for a reportable occurrence, have been adequately dealt with by the reporting organization. Thus, there is no justification for further investigation by the SCAA, although details of the occurrence and action taken do provide valuable information for dissemination and storage purposes. Reports judged to be in this category are Closed on Receipt by the SCAA, the principal justification for closure being that it is evident from the report that existing requirements, procedures, documentation, etc., coupled with the reporter's action, have adequately controlled the identified hazard. When necessary, the SCAA will coordinate with the reporter and/or seek advice from appropriate SCAA staff in making this decision.

(b)

(c) (d)

(e)

(f) (g)

(h)

Note: The SCAA’’s ability to close an occurrence on receipt and thus avoid the need for further SCAA investigation is very much dependent upon the quality of

26

the information provided in the report and, specifically, information on the action taken by the reporting organization to control the situation.

5.1.3

Note:

Confidential Reports (see also section 4.3). Such reports will be directed to and reviewed personally by Chief of FSD who will initiate a de-identified record. (a)The Chief of FSD or his deputy will contact the reporter, by telephone if

possible, to acknowledge receipt, discuss implications or obtain further information as appropriate. A course of action will be mutually agreed.

(b)After discussions with the reporter have been completed the original report will be destroyed (shredded).

(c)The report will be processed as an occurrence but annotated CONFIDENTIAL.

(d)A database entry will be made based on the de-identified report and will only be accessible by restricted users.

Names of individual persons are never recorded on the SCAA database.

Reports outside the MOR System Reports on events that are outside the MOR System should be investigated by the

companies. Only reports related directly to the flight safety are evaluated and investigated by the SCAA.

5.2DATA RECORDS AND PROVISION OF INFORMATION

5.1.4

5.2.1

5.2.2

5.2.3

The SCAA computer record for each occurrence comprises three main groups of data:

(a) (b) (c)

a range of identification and progress data; a narrative; and a number of key phrases, selected from an extensive lexicon.

Based on the available evidence in the report, key phrases are selected which identify the individual elements of the occurrence and also which state and suggest other factors which have, or might have, influenced the occurrence. The key phrases, coupled with the identification data, form the basis on which searches for any individual elements or combination of elements can be made. A comprehensive key phrase lexicon has been prepared based on the ATA 100 Specification. The ATA 100 numbering concept, i.e. chapter, sub-chapter and item, has been extended, as necessary, to cover operational and human factors aspects. Key phrasing of individual occurrences is confidential to SCAA.

The SCAA will make available the information received, or a summary thereof, to a number of categories of persons outside the industry. It shall not be required to make available such information if it is satisfied that to do so will not further the safety of civil aviation. Where provided, it is the normal practice to de- identify such information. The provision of any information arising from requests

27

5.2.4

Requests for data should be directed to the SCAA in writing (including email, telex and fax). However, telephone requests will be accepted when the urgency so demands. Inquirers should state precisely which data are required, both in terms of parameters to be searched and the information required in the printout. If any doubt exists on these points it is recommended that the requirements be discussed with the SCAA.

made by such persons is normally subject to charge.

28

APPENDIX A ITEMS TO BE REPORTED

This Appendix lists the types of occurrence which are likely to fall within the definition of a reportable occurrence in which case they must therefore be reported. Whilst the Appendix lists the majority of occurrences which shall normally be reported it cannot be completely comprehensive and any other occurrences judged, by those involved, to meet the criteria shall be reported.

PART A

LIST OF AIRCRAFT OPERATIONS, MAINTENANCE, REPAIR AND MANUFACTURE——RELATED OCCURRENCES TO BE REPORTED

Note 1: Although this Part lists the majority of reportable occurrences, it is not completely comprehensive. Any other occurrences, which are judged by those involved to meet the criteria, should also be reported.

Note 2: This Part does not include accidents.

Note 3: Occurrences to be reported are those where the safety of operation was or could have been endangered or which could have led to an unsafe condition. If in the view of the reporter an occurrence did not endanger the safety of the operation but if repeated in different but likely circumstances would create a hazard, then a report should be made. What is judged to be reportable on one class of product, part or appliance may not be reportable on another and the absence or presence of a single factor, human or technical, can transform an occurrence into an accident or serious incident.

Note 4: Specific operational approvals, e.g. reduced vertical separation minimum (RVSM), extended range twin operations (ETOPS), area navigation (RNAV), or a design or maintenance program, may have specific reporting requirements for failures or malfunctions associated with that approval or program.

SECTION 1 AIRCRAFT FLIGHT OPERATIONS

1.1

Operation of the aircraft

(a)

Avoidance maneuvers:

••risk of collision with another aircraft, terrain or other object or an unsafe situation when avoidance action would have been appropriate;

••an avoidance maneuver required to avoid a collision with another aircraft, terrain or other object;

29

••an avoidance maneuver to avoid other unsafe situations.

(b)Take-off or landing incidents, including precautionary or forced landings. Incidents such as under-shooting, overrunning or running off the side of runways. Take-offs, rejected take-offs, landings or attempted landings on a closed, occupied or incorrect runway. Runway incursions.

(c)Inability to achieve predicted performance during take-off or initial climb.

(d)Critically low fuel quantity or inability to transfer fuel or use total quantity of usable fuel.

(e)Loss of control (including partial or temporary) regardless of cause.

(f)Occurrences close to or above V1 resulting from or producing a hazardous or potentially hazardous situation (e.g. rejected take-off, tail strike, engine-power loss etc.).

(g)Go around producing a hazardous or potentially hazardous situation.

(h)Unintentional significant deviation from airspeed, intended track or altitude (more than 300 ft) regardless of cause.

(i)Descent below decision height/altitude or minimum descent height/altitude without the required visual reference.

(j)Loss of position awareness relative to actual position or to other aircraft.

(k)Breakdown in communication between flight crew and other parties (cabin crew, air traffic control (ATC), engineering).

(l)Heavy landing - a landing deemed to require a "heavy landing check".

(m)Exceedance of fuel imbalance limits.

(n)Incorrect setting of an secondary surveillance radar (SSR) code or of an altimeter subscale.

(o)Incorrect programming of, or erroneous entries into, equipment used for navigation or performance calculations, or use of incorrect data.

(p)Incorrect receipt or interpretation of radio-telephony messages.

(q)Fuel system malfunctions or defects, which had an effect on fuel supply and/or distribution.

(r)Aircraft unintentionally departing from a paved surface.

(s)Collision between an aircraft and any other aircraft, vehicle or other ground object.

(t)Inadvertent and/or incorrect operation of any controls.

(u)Inability to achieve the intended aircraft configuration for any flight phase (e.g. landing gear and gear doors, flaps, stabilizers, slats etc.).

(v)A hazard or potential hazard which arises as a consequence of any deliberate simulation of failure conditions for training, system checks or training purposes.

(w)Abnormal vibration.

(x)Operation of any primary warning system associated with maneuvering the aircraft e.g. configuration warning, stall warning (stick shaker), over-speed

30

warning etc. unless:

(i)the crew conclusively established that the indication was false and provided that the false warning did not result in difficulty or hazard arising from the crew response to the warning; or

(ii)operated for training or test purposes.

(y)Ground proximity warning system (GPWS)/terrain awareness and warning system (TAWS) "warning" when:

(i)the aircraft comes into closer proximity to the ground than had been planned or anticipated; or

(ii)the warning is experienced in instrument meteorological conditions or at night and is established as having been triggered by a high rate of descent (mode 1); or

(iii)the warning results from failure to select landing gear or landing flaps by the appropriate point on the approach (mode 4); or

(iv)any difficulty or hazard arises or might have arisen as a result of crew response to the "warning" e.g. possible reduced separation from other traffic. This could include warning of any mode or type i.e. genuine, nuisance or false.

(z)GPWS/TAWS "alert" when any difficulty or hazard arises or might have arisen as a result of crew response to the "alert".

(aa)Air collision advisory system (ACAS) resolution advisories (RA). (bb)Jet or prop blast incidents resulting in significant damage or serious injury. (cc)Landing at the wrong airfield.

1.2Emergencies

(a)Fire, explosion, smoke or toxic or noxious fumes, even though fires were extinguished.

(b)The use of any non-standard procedure by the flight or cabin crew to deal with an emergency when:

(i) (ii) (iii) (iv) (v)

the procedure exists but is not used; the procedure does not exist;

the procedure exists but is incomplete or inappropriate; the procedure is incorrect; the incorrect procedure is used.

(c)Inadequacy of any procedures designed to be used in an emergency, including when being used for maintenance, training or test purposes.

(d)An event leading to an emergency evacuation. 31

1.3

1.4

(e)Depressurization.

(f)The use of any emergency equipment or prescribed emergency procedures in order to deal with a situation.

(g)An event leading to the declaration of an emergency ("Mayday" or "PAN").

(h)Failure of any emergency system or equipment, including all exit doors and lighting, to perform satisfactorily, including when being used for maintenance, training or test purposes.

(i)Events requiring any use of emergency oxygen by any crew member.

Crew incapacitation

(a)Incapacitation of any member of the flight crew, including that which occurs prior to departure if it is considered that it could have resulted in incapacitation after take-off.

(b)Incapacitation of any member of the cabin crew which renders them unable to perform essential emergency duties.

Injury

Occurrences which have or could have led to significant injury to passengers or crew but which are not considered reportable as an accident.

1.5Meteorology

(a)A lightning strike which resulted in damage to the aircraft or loss or malfunction of any essential service.

(b)A hail strike which resulted in damage to the aircraft or loss or malfunction of any essential service.

(c)Severe turbulence encounter, an encounter resulting in injury to occupants or deemed to require a "turbulence check" of the aircraft.

(d)A windshear encounter.

(e)Icing encounter resulting in handling difficulties, damage to the aircraft or loss or malfunction of any essential service.

1.6Security

(a)Unlawful interference with the aircraft including a bomb threat or hijack. (b)Difficulty in controlling intoxicated, violent or unruly passengers. (c)Discovery of a stowaway.

1.7Other occurrences

(a)Repetitive instances of a specific type of occurrence which in isolation would not be considered "reportable" but which due to the frequency with which they arise,

32

form a potential hazard.

(b)A bird strike which resulted in damage to the aircraft or loss or malfunction of any essential service.

(c)Wake-turbulence encounters.

(d)Any other occurrence of any type considered to have endangered or which might have endangered the aircraft or its occupants on board the aircraft or persons on the ground.

SECTION 2 AIRCRAFT ——TECHNICAL

2.1Structural

Not all structural failures need to be reported. Engineering judgment is required to decide whether a failure is serious enough to be reported. The following examples can be taken into consideration:

2.2

(a)damage to a principal structural element (PSE) that has not been designated as damage-tolerant (life-limited element). PSEs are those which contribute significantly to carrying flight, ground, and pressurization loads, and the failure of which could result in a catastrophic failure of the aircraft;

(b)defect or damage exceeding admissible damages to a PSE that has been designated as damage-tolerant;

(c)damage to or defect exceeding allowed tolerances of a structural element, the failure of which could reduce the structural stiffness to such an extent that the required flutter, divergence or control reversal margins are no longer achieved;

(d)damage to or defect of a structural element, which could result in the liberation of items of mass that may injure occupants of the aircraft;

(e)damage to or defect of a structural element, which could jeopardize proper operation of systems. See paragraph 2.2 below;

(f)loss of any part of the aircraft structure in flight.

Systems

The following general criteria applicable to all systems are proposed:

(a)loss, significant malfunction or defect of any system, subsystem or set of equipment when standard operating procedures, drills etc. could not be satisfactorily accomplished;

(b)inability of the crew to control the system, for example:

(i)uncommanded actions,

(ii)incorrect and/or incomplete response, including limitation of movement or stiffness,

33

(iii)runaway, (iv)mechanical disconnection or failure;

(c)failure or malfunction of the exclusive function(s) of the system (one system could integrate several functions);

(d)interference within or between systems;

(e)failure or malfunction of the protection device or emergency system associated with the system;

(f)loss of redundancy of the system;

(g)any occurrence resulting from unforeseen behavior of a system.

(h)for aircraft types with single main systems, subsystems or sets of equipment:

(i)loss, significant malfunction or defect in any main system, subsystem or set of equipment.

(j)for aircraft types with multiple independent main systems, subsystems or sets of equipment:

(i)the loss, significant malfunction or defect of more than one main system, subsystem or set of equipment.

(k)operation of any primary warning system associated with aircraft systems or equipment unless the crew conclusively established that the indication was false, provided that the false warning did not result in difficulty or hazard arising from the crew response to the warning;

(l)leakage of hydraulic fluids, fuel, oil or other fluids which resulted in a fire hazard or possible hazardous contamination of aircraft structure, systems or equipment, or risk to occupants;

(m)malfunction or defect of any indication system when this results in the possibility of misleading indications to the crew;

(n)any failure, malfunction or defect if it occurs at a critical phase of the flight and is relevant to the system operation;

(o)significant shortfall of the actual performances compared to the approved performance which resulted in a hazardous situation (taking into account the accuracy of the performance-calculation method) including braking action, fuel consumption etc.;

(p)asymmetry of flight controls; e.g. flaps, slats, spoilers etc.

Note: Section 5 of this Part gives a list of examples of reportable occurrences resulting from the application of these general criteria to specific systems.

2.3Propulsion (including engines, propellers and rotor systems) and auxiliary power units (APU).

(a)Flameout, shutdown or malfunction of any engine.

34

(b)Overspeed or inability to control the speed of any high-speed rotating component (for example: APU, air starter, air cycle machine, air turbine motor, propeller or rotor).

(c)Failure or malfunction of any part of an engine or powerplant resulting in any one or more of the following:

(i)

(ii)

(iii)

non-containment of components/debris; uncontrolled internal or external fire, or hot gas breakout; thrust in a direction different from that demanded by the pilot; thrust-reversing system failing to operate or operating

(iv) inadvertently;

(v)inability to control power, thrust or revolutions per minute; (vi)failure of the engine mount structure; (vii)partial or complete loss of a major part of the powerplant;

(viii)dense visible fumes or concentrations of toxic products sufficient to incapacitate crew or passengers;

(ix)inability, by use of normal procedures, to shutdown an engine; (x)inability to restart a serviceable engine.

(d)An uncommanded thrust/power loss, change or oscillation which is classified as a loss of thrust or power control (LOTC):

(i)for a single-engine aircraft; or

(ii)where it is considered excessive for the application; or

(iii)where this could affect more than one engine in a multi-engine aircraft, particularly in the case of a twin-engine aircraft; or

(iv)for a multi-engine aircraft where the same, or similar, engine type is used in an application where the event would be considered hazardous or critical.

(e)Any defect in a life-controlled part causing its withdrawal before completion of its full life.

(f)Defects of common origin which could cause an in-flight shut-down rate so high that there is the possibility of more than one engine being shut down on the same flight.

(g)An engine limiter or control device failing to operate when required or operating inadvertently.

(h)Exceedance of engine parameters. (i)Foreign objects damage (FOD).

2.3.1Propellers and transmission (a) Failure or malfunction of any part of a propeller or powerplant resulting in

35

2.4

Human factors

2.3.2

2.3.3

any one or more of the following: (i)an overspeed of the propeller; (ii)the development of excessive drag;

(iii)a thrust in the opposite direction to that commanded by the pilot;

(iv)a release of the propeller or any major portion of the propeller;

(v)a failure that results in excessive imbalance;

(vi)the unintended movement of the propeller blades below the established minimum in-flight low-pitch position;

(vii)an inability to feather the propeller; (viii)an inability to change propeller pitch;

(ix)an uncommanded change in pitch; (x)an uncontrollable torque or speed fluctuation; (xi)the release of low-energy parts.

Rotors and transmission

(a)

(b) APUs (a)

(b) (c) (d)

Damage or defect of main rotor gearbox/attachment which could lead to in-flight separation of the rotor assembly and/or malfunctions of the rotor control.

Damage to tail rotor, transmission and equivalent systems.

Shut down or failure when the APU is required to be available by operational requirements, e.g. ETOPS, minimum equipment list (MEL).

Inability to shut down the APU. Overspeed. Inability to start the APU when needed for operational reasons.

Any incident where any feature or inadequacy of the aircraft design could have led to an error of use that could contribute to a hazardous or catastrophic effect.

2.5Other occurrences

(a) Anyincidentwhereanyfeatureorinadequacyoftheaircraftdesigncouldhaveledto an error of use that could contribute to a hazardous or catastrophic effect.

(b) An occurrence not normally considered as reportable (e.g., furnishing and cabin equipment, water systems), where the circumstances resulted in endangering the aircraft or its occupants.

(c) Afire,explosion,smokeortoxicornoxiousfumes.

(d) Any other event which could endanger the aircraft, or affect the safety of the occupants of the aircraft, or people or property in the vicinity of the aircraft or on the ground.

36

(e) Failureordefectofpassengeraddresssystemresultinginlossof,orinaudible, passenger address system.

(f)Loss of pilot seat control during flight.

SECTION 3 AIRCRAFT MAINTENANCE AND REPAIR

(a)Incorrect assembly of parts or components of the aircraft found during an inspection or test procedure not intended for that specific purpose.

(b)Hot bleed air leak resulting in structural damage.

(c)Any defect in a life-controlled part causing retirement before completion of its full life.

(d)Any damage or deterioration (e.g. fractures, cracks, corrosion, delamination, disbonding etc.) resulting from any cause (e.g. as flutter, loss of stiffness or structural failure) to:

(i)

(ii)

(iii)

a primary structure or a principal structure element (PSE) (as defined in the manufacturers' Repair Manual) where such damage or deterioration exceeds allowable limits specified in the Repair Manual and requires a repair or complete or partial replacement;

a secondary structure which consequently has or may have endangered the aircraft;

the engine, propeller or rotorcraft rotor system.

(e)Any failure, malfunction or defect of any system or equipment, or damage or deterioration thereof found as a result of compliance with an airworthiness directive or other mandatory instruction issued by a regulatory authority, when:

(i)it is detected for the first time by the reporting organization implementing compliance;

(ii)on any subsequent compliance, it exceeds the permissible limits quoted in the instruction and/or published repair/rectification procedures are not available.

(f)Failure of any emergency system or equipment, including all exit doors and lighting, to perform satisfactorily, including when being used for maintenance or test purposes.

(g)Non-compliance or significant errors in compliance with required maintenance procedures.

(h)Products, parts, appliances and materials of unknown or suspect origin.

(i)Misleading, incorrect or insufficient maintenance data or procedures that could lead to maintenance errors.

(j)Any failure, malfunction or defect of ground equipment used for testing or checking of aircraft systems and equipment when the required routine inspection and test procedures did not clearly identify the problem, where this results in a hazardous situation.

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SECTION 4 GROUND SERVICES AND FACILITIES

4.1Air navigation services (ANS)

See Part 2, list of reportable ANS-related occurrences.

4.2

4.3

4.4

Aerodrome and aerodrome facilities

(a) (b)

(c)

Significant spillage during fuelling operations.

Loading of incorrect fuel quantities likely to have a significant effect on aircraft endurance, performance, balance or structural strength.

Failure or significant deterioration of aerodrome aircraft operating surfaces.

Handling of passengers, baggage and cargo

(a) (b) (c)

(d) (e)

Significantcontaminationofaircraftstructure,systemsandequipmentarisingfrom the carriage of baggage or cargo.

Incorrect loading of passengers, baggage or cargo, likely to have a significant effect on aircraft mass and/or balance.

Incorrectstowageofbaggageorcargo(includinghandbaggage)likelyinanywayto endanger the aircraft, its equipment or occupants or to impede emergency evacuation.

Inadequate stowage of cargo containers or other substantial items of cargo.

Carriage or attempted carriage of dangerous goods in contravention of applicable regulations, including incorrect labeling and packaging of dangerous goods.

Aircraft ground handling and servicing

(a)Failure, malfunction or defect of ground equipment used for the testing or checking of aircraft systems and equipment when the required routine inspection and test procedures did not clearly identify the problem, where this results in a hazardous situation.

(b)Non-compliance or significant errors in compliance with required servicing procedures.

(c)Loading of contaminated or incorrect type of fuel or other essential fluids (including oxygen and potable water).

(d)Unsatisfactory ground de-icing/anti-icing.

SECTION 5

EXAMPLES

The following subparagraphs give examples of reportable occurrences resulting from the application of the general criteria to specific systems listed in paragraph 2.2 of Part 1.

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5.1

Air conditioning/ventilation

(a)complete loss of avionics cooling; (b) depressurization.

Autoflight system

(a) failureoftheautoflightsystemtoachievetheintendedoperationwhileengaged;

(b) significant reported crew difficulty to control the aircraft linked to autoflight system functioning;

(c)failure of any autoflight system disconnect device; (d) uncommanded autoflight mode change.

Communications

(a) failureordefectofpassengeraddresssystemresultinginlossoforinaudible passenger address;

(b) total loss of communication in flight.

Electrical system

(a) lossofoneelectricaldistributionsystem(AC/DC); (b) total loss or loss of more than one electrical generation system; (c) failureofthebackup(emergency)electricalgenerationsystem.

Cockpit/Cabin/Cargo

(a)pilot seat control loss during flight;

(b) failure of any emergency system or equipment, including emergency evacuation signaling system, all exit doors, emergency lighting, etc.;

(c) lossofretentioncapabilityofthecargoloadingsystem.

Fire protection system

(a) firewarnings,exceptthoseimmediatelyconfirmedasfalse;

(b)undetected failure or defect of fire/smoke detection/protection system, which could lead to loss or reduced fire detection/protection;

(c)absence of warning in case of actual fire or smoke.

Flight controls

5.2

5.3

5.4

5.5

5.6

5.7

(a) (b)

(c) (d)

asymmetry of flaps, slats, spoilers, etc.;

limitation of movement, stiffness or poor or delayed response in the operation of primary flight control systems or their associated tab and lock systems;

flight control surface runaway; flight control surface vibration felt by the crew;

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5.8

5.9

5.10

5.11

5.12

(e)mechanical flight control disconnection or failure;

(f)significant interference with normal control of the aircraft or degradation of flying qualities.

Fuel system

(a) fuelquantityindicatingsystemmalfunctionresultingintotallossorwrongindication of fuel quantity on board;

(b) leakage of fuel which resulted in major loss, fire hazard, significant contamination;

(c)malfunction or defects of the fuel jettisoning system which resulted in inadvertent loss of significant quantity, fire hazard, hazardous contamination of aircraft equipment or inability to jettison fuel;

(d) fuel system malfunctions or defects which had a significant effect on fuel supply and/or distribution;

(e) inabilitytotransferorusetotalquantityofusablefuel.

Hydraulics

(a)loss of one hydraulic system (ETOPS only); (b) failure of the isolation system; (c) lossofmorethanonehydrauliccircuit; (d) failure of the back-up hydraulic system;

(e) inadvertentramairturbineextension.

Ice detection/protection system

(a)undetected loss or reduced performance of the anti-ice/de-ice system;

(b) loss of more than one of the probe-heating systems;

(c) inabilitytoobtainsymmetricalwingde-icing;

(d) abnormal ice accumulation leading to significant effects on performance or handling qualities;

(e) crewvisionsignificantlyaffected.

Indicating/warning/recording systems

(a) malfunctionordefectofanyindicatingsystemwhenthepossibilityofsignificant misleading indications to the crew could result in an inappropriate crew action on an essential system;

(b) loss of a red warning function on a system;

(c) forglasscockpits:lossormalfunctionofmorethanonedisplayunitorcomputer involved in the display/warning function.

Landing gear system/brakes/tires

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5.13

5.14

5.15

(a)brake fire;

(b) significant loss of braking action;

(c) asymmetricalbrakingactionleadingtosignificantpathdeviation;

(d) failure of the landing gear free fall extension system (including during scheduled tests);

(e) unwantedlandinggearorgeardoorsextension/retraction; (f)multiple tire burst.

Navigation systems (including precision approach systems) and air data systems

(a) totallossormultiplenavigationequipmentfailures (b) total or multiple air data system equipment failures (c) significantmisleadingindications (d) significant navigation errors attributed to incorrect data or a database coding error (e)unexpected deviations in lateral or vertical path not caused by pilot input

(f)problems with ground navigational facilities leading to significant navigation errors not associated with transitions from inertial navigation mode to radio navigation mode.

Oxygen for pressurized aircraft

(a) lossofoxygensupplyinthecockpit

(b) loss of oxygen supply to a significant number of passengers (more than 10 %), including when found during maintenance or training or testing.

Bleed air system

(a) (b) (c)

hot bleed air leak resulting in fire warning or structural damage loss of all bleed air systems failure of bleed air leak detection system.

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PART B

LIST OF AIR NAVIGATION SERVICES——RELATED OCCURRENCES TO BE REPORTED

Note 1: Although this Part lists the majority of reportable occurrences, it cannot be completely comprehensive. Any other occurrences, which are judged by those involved to meet the criteria, should also be reported.

Note 2: This Part does not include accidents and serious incidents.

Note 3: This Part includes air navigation service (ANS) occurrences which pose an actual or potential threat to flight safety, or can compromise the provision of safe ANS services.

Note 4: The contents of this Part shall not preclude the reporting of any occurrence, situation or condition which, if repeated in different but likely circumstances or allowed to continue uncorrected, could create a hazard to aircraft safety.

SECTION 1 RELATED OCCURENCES TO BE REPORTED

1.1Near collision incidents (encompassing specific situations where one aircraft and another aircraft/the ground/a vehicle/person or object are perceived to be too close to each other):

(a)separation minima infringement; (b)inadequate separation; (c)near-controlled flight into terrain (near-CFIT); (d)runway incursion where avoiding action was necessary.

1.2Potential for collision or near collision (encompassing specific situations having the potential to be an accident or a near collision, if another aircraft is in the vicinity):

(a)runway incursion where no avoiding action is necessary; (b)runway excursion; (c)aircraftdeviationfromA TCclearance; (d)aircraft deviation from applicable "ATM" (air traffic management) regulation:

(i) (ii) (iii)

aircraft deviation from applicable published ATM procedures; unauthorized penetration of airspace;

deviation from aircraft ATM-related equipment carriage and operations, as mandated by applicable regulation(s).

1.3ATM-specific occurrences (encompassing those situations where the ability to provide safe ATM services is affected, including situations where, by chance, the safe operation

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of aircraft has not been jeopardized). This shall include the following occurrences: (a)inabilitytoprovideA TMservices:

(i)inability to provide air traffic services; (ii)inability to provide airspace management services; (iii)inability to provide air traffic flow management services;

(b) failure of Communication function; (c) failureofSurveillancefunction; (d) failure of Data Processing and Distribution function; (e) failureofNavigationfunction; (f)ATM system security.

1.4Air Traffic Control (ATC) Navigation and Communications——significant malfunction or deterioration of service.

1.5An aircraft was or could have been endangered by impairment of any member of ground staff (e.g. ATC, aircraft dispatchers, Maintenance, etc.).

1.6ATC overload.

1.7Failure or unplanned shutdown of a major operational ATC computer system, requiring reversion to manual back-up and resulting in disruption to the normal flow of air traffic.

SECTION 2

EXAMPLES OF REPORTABLE ATM OCCURENCES

The following subparagraphs give examples of reportable ATM occurrences resulting from the application of the general criteria listed in paragraph 1.3 of Part 2 above.

(a)Provision of significantly incorrect, inadequate or misleading information from any ground sources, e.g. ATC, "ATIS" (automatic terminal information service), meteorological services, navigation databases, maps, charts, manuals, etc.

(b)Provision of less than prescribed terrain clearance.

(c)Provision of incorrect pressure reference data (i.e. altimeter setting).

(d)Incorrect transmission, receipt or interpretation of significant messages when this results in a hazardous situation.

(e)Separation minima infringement. (f)Unauthorized penetration of airspace. (g)Unlawful radio communication transmission. (h)Failure of ANS ground or satellite facilities. (i)MajorA TC/A TMfailureorsignificantdeteriorationofaerodromeinfrastructure.

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(j)Aerodrome movement areas obstructed by aircraft, vehicles, animals or foreign objects, resulting in a hazardous or potentially hazardous situation.

(k)Errors or inadequacies in marking of obstructions or hazards on aerodrome movement areas resulting in a hazardous situation.

Published in Legislation

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