APPENDIX - A (Attachment 3)
Tribhuvan International Airport Civil Aviation Office
Air Traffic Safety Engineering Incident Report Form
(To be filled by ATSEP)
1. CATEGORIES OF OCCURRENCE
ACCID   INCID   PROCEDURAL   FAILURE   HAZARD
2. Occurrence Location

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3. Date (dd/mm/yyyy)

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5. Duration 6. ATS Facility
RTF   Radar
NAVAID
Other  
7. Service Affected
4. Time (UTC)

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8. Equipment Type/Manufacturer 9. Frequency 10. Call-sign 11 Equipment Location
12. Facility Configuration
In Service or   Out of service
Main Mode or   Standby/Test
CH A (1) or   CH B (2)
Other  
External Information Source:
13. Equipment Status 14. Previous Defects/ Occurrences
Yes   No Not Known
15. RTF Frequencies/ Radar Source
16. NARRATIVE - use a diagram if necessary (attach copies of all relevant information)
17. Recordings impounded
Yes   No
Details
18. Can the information be disseminated in the interests of flight safety?
Yes   No
20. Name

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23. Address & Telephone number (if reporter wishes to be contacted privately)
21. Organization/Position 24. Signature
19. Other fault report action
ATC Reporting   Local Reporting
Other:
22. Start time and duration of shift 25 Date (dd/mm/yyyy)

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