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Confidential Incident Report

This confidential incident reporting module is for the use of ASN Members. This confidential incident report once submitted comes directly to the Aerosafe incident reporting team and any detail which identifies the reporter is removed. The aim of a confidential incident report is to allow any staff or crew member to submit an incident report on a sensitive topic, situation or event in a protected and confidential manner. Once received by the Aerosafe team, the confidential report will be investigated and the CEO of the company notified that a confidential report has been received. The Aerosafe investigator will act in the interest of the reporter and bring the issues or the event itself to the attention of the CEO and seek resolution. Once resolution is reached and a course of action to address the issue has been determined or actioned, Aerosafe will get in touch with the reporter and provide feedback on this outcome. For further information on confidential reporting, please contact Aerosafe directly at asn@aerosafe.com.au.

* Indicates a mandatory field.

Composed:

Date:

Time:

Incident Number:
(To be inserted by investigator)

Incident Classification

Incident Details:

Reporting Person:

Person Involved:

Date Reported:*

Occur Date & Time:

Brief Description / Title:

Type of report:

Incident Particulars

Reportables

External Bodies:

Flight details

This Report Concerns:

Mission type:

Flight Mission No:

Phase of Flight:

Operational or Safety Issues:*

Resulted in Injury?:

Yes

Property Damage?:

Yes

If Yes, briefly Describe:

Environmental Conditions

Inflight Conditions:

Operation Time:

Wind Velocity:

Turbulence:

Temperature:

Visibility:

Cloud type/amount and Base:

Precipitation:

Other Adverse Weather:

False indication Involved?:

Yes

If Yes, Was Aircraft Maintenance a Factor?

Yes

If Yes, Did a Component Fail?

Yes

If Yes, Was Equipment Design a Factor?

Yes

Initial Risk Assessment by Person Submitting the Report

How do you rate the risk of this incident?: *
Click here for guidance on selecting category

Incident Investigation

Details

Incident Details as per Person Submitting the Report:*

Immediate/Temporary Controls:

Witness:

Remainder of report complied by Investigator.

Statements

Sequence of Events:

Witness Statements:

Investigation Report

Immediate Contributing Factors:

Underlying Contributing Factors:

Recommendations:

Human performance issues or deficiencies associated with this incident:

Investigator Risk Assessment

Division:

Department:

Ops Base:

Affiliation:

External Reportable?

Yes

How do you rate the risk of this incident?:

Risk Level:

Associated Hazard

Associated Hazard:

Rating & Description:

Associated Actions

Open Actions: (Attach Separately) :

Due Date & Description:

Closed Actions:

Close Date & Description:

Investigator Sign Off

Investigator:

Name:

Date:

Final Sign Off

Internal Authorisor:

Name:

Date:

Position:

Safety Reporting
Confidential Incident Report
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