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APPENDIX - A (Attachment 5)
Tribhuvan International Airport Civil Aviation Office
Air Traffic Incident Report Form(To be filled by Pilot or ATC on behalf of Pilot)

Instructions for completion of the Air Traffic Incident Report Form
Item
A	Aircraft identification of the aircraft filing the report.
B	An AIRPROX report should be filed immediately by radio.
C1	Date / time UTC and position in bearing and distance from a navigation aid or in LAT / LONG.
C2	Information regarding aircraft filing the report, tick as necessary.
C2 c)	E.g. FL 350 / 1013 HPA or 2500 FT / QNH 1 007 HPA or 1200 FT / QFE 998 HPA.
C3	Information regarding the other aircraft involved.
C4	Passing distance - state units used.
C6	Attach additional papers as required. The diagrams may be used to show aircraft’s positions.
D1 f)	State name of ATS unit and date / time in UTC.
D1 g)	Date and time in UTC.
E2	Include details of ATS unit such as service provided, radiotelephony frequency, SSR Codes assigned and altimeter setting. Use diagram to show the aircraft’s position and attach additional papers as required.

Designed and developed by : PCS

AIR TRAFFIC INCIDENT REPORT FOR For use when submitting and receiving reports on air traffic incidents. in an intial report by radio, shaded items should be included.
A - AIRCRAFT IDENTIFICATION	B - TYPE OF INCINDENT AIRPROX PROCEDURE FACILITY
C - THE INCIDENT
1. General a) Date/ Time of Incident UTC b) Position
2. Own aircraft a) Heading and Route b) True airspeed measured in () kt ()km/h c) Level and altimeter setting d) Aircraft climbing or descending Level flight Climbing Descending e) Aircraft bank angle wings level slight bank moderate bank steep bank Inverted Unknown f) Aircraft Direction of bank left right Unknown g) Restrictions to visibility (select as many as requird) Sunglare windscreen light Dirty windscreen Other cockpit structure none h) use of aircraft lighting (select as many as requird) Navigation lights strobe lights cabin lights Red anti-collision lights landing/taxi lights logo(tail fin) lights other none i) Traffic avoidance advice issued by ATS Yes, based On rader Yes, based On visual sighting yes, based on Other information No j) Traffic Information issued Yes, based On rader Yes, based On visual sighting yes, based on Other information No k) Airborne collision avoidance system - ACAS Not carried Type Traffic advisory issued Resolution advisory issued Traffic advisory or resolution advisory not issued L) Radar Identification No Radar Available Radar Identification No Radar Identification M) Other aircraft sighted Yes No Wrong aircraft sighted N) Avoiding action taken Yes No O) Type of Flight Plan IFR VFR None
3. Other Aircraft a) Type and call sign/registration (if known) b) if a) above not known, describe below High Wing Mid Wing Low Wing Rotorcraft 1 engine 2 engines 3 engines 4 engines More then 4 engines Marking, Colour or other available details c) Aircraft climbing or descending Level Flight Climbing Descending Unknown d) Aircraft bank angle Wings level Slight Bank Moderate Bank Steep Bank Inverted Unknown e) Aircraft Direction of bank Left Right Unknown f) Lights Displayed Navigation Lights Strobe Lights Cabin Lights Red Anti-collision Lights Landing/Taxi Lights Logo (tail fin) Lights Other None Unknown g) Traffic avoidance advice issued by ATS Yes, based on Radar Yes, based on Visual sighting Yes, based on Other Information No Unknown h) Traffic Information issued Yes, based on Radar Yes, based on Visual sighting Yes, based on Other Information No Unknown i) Avoiding action taken Yes No Unknown
4. Distance a) Closest horizontal distance b) Closest vertical distance
5. flight weather condition a) IMC VMC b) Above below* clouds fog haze between Layers* c) Distance vertically from cloudm/ft* below m/ft* above d) clouds rain snow sleet fog haze * e) Flying into out of* sun f) Flight visibilitym.km*
6. Any other information considered important by the pilot-in-command
D--MISCELLANEOUS 1. Information regarding reporting aircraft a) Aircraft Registration b) Aircraft Type c) Operator d) Aerodrome of departure Aerodrome of First Landing e) Destination f) Reported by radio or other means to (name of ATS unit) at time UTC g) Date/ time/ place of completion of from
2. Function, address and signature of person submitting report a) Function b) Address c) Signature d) Telephone number
3. Function and signature of person receiving report a) Function c) Signature
E- SUPPLEMENTARY INFORMATION BY ATS UNIT CONCERNED 1. Receipt of report a) Report received via AFTN/ radio/ telephone/ other (specify)* b) Report received by(name of ATS unit)
2. Details of ATS action Clearance, incident seen (radar/visually, warning given, result of local enquiry, etc.) DIAGRAMS OF AIRPROX Mark passage of other aircraft relative to you, in plan on the left and in elevation on the right, assuming you are the center of each diagram. Include first sighting and passing distance.

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