Voluntary Safety Report Form

Tribhuvan Internation Airport Civil Aviation Office
Flight Operation Department
ATS Safety Office

Voluntary Safety Report

ATS safety office assures total confidentiality of this reporter should you require anonymity, while making this report. TIA appreciates your contribution to Safety!

Name:	Position:
Contact Number:	Email:
Request to hide identity: * Yes No	Date: *

Please check all items that are applicable to this report form Email: atssafety@caanepal.gov.np
TYPE OF REPORT	FLIGHT OPERATION RUNWAY INCURSION OTHERS
FLIGHT OF SEGMENT	FROM	TO	FLIGHT NO.	DATE *	LOCATION *
AIRCRAFT TYPE			Time GMT LT	AIRLINE OPERATOR
PHASE OF OPERATION	Parking Starting Taxiing Out Line Up Take Off Climb Cruise Descent Holding Approach Traffic Circuit Landing Go Around Taxi In Towing Maintenance Others (Specify)
TIME CLASSIFICATION	Dawn Daylight Dusk Night
METEOROLOGICAL COND.	IMC VMC SVFR SECTOR VISIBILITY
WEATHER CONDITION	Storm Icing Low visibility RAIN FOG CB Cross wind Down wind Up draft Low ceiling Gusting wind Wind shear Down draft None
EXISTING CONDITION (HAZARD TO BE REPORTED):
RECOMMENDED CORRECTIVE ACTION:
ATS SAFETY OFFICE ONLY
RECEIVED DATE: *		NUMBER:	ASSIGNED TO:
CORRECTIVE ACTION TAKEN ( TO BE COMPLETED BY AYS SAFETY OFFICE):

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