APPENDIX - A (Attachment 1)
Tribhuvan International Airport Civil Aviation Office
ATS Incident Report Form
(To be filled by ATS personnel)
CATEGORIES OF OCCURRENCE
1. ACCID   AIRPORX   INCID   VIOLATION   INFRINGEMENT   FACILITY
2. Occurrence Position

*

 3. FL ALT/HT 4. Date (dd/mm/yyyy)

*

 5. Time - UTC (HH:MM)

*

 6.
Day   Night
7.OPERATOR
 8.CALLSIGN/REGN
 9.TYPE
 10.FROM
 11.TO
 12.SSR CODE
 13.MODE C DISPLAYED
Yes   No 		14.IFR/VFR/SVFR
15. RTF Frequencies
 16. Radar Equipment
17. Equipment un-serviceability
 18. QNH
19. Runway in use
  20. Class & Type of Airspace
21. ATS PROVIDED
22. SID/STAR/ROUTE
23. Was prescribed Separation lost?
24. Min. Separation
Horizontal nm Vertical . ft 		25. Alert Activation
Collision   CA   TCAS   STCA   		26. Traffic info given by ATC?
Yes   No 		27. Avoiding action given by ATC?
28. BRIEF TITLE (Summary)
29. NARRATIVE -use a diagram if necessary (Include NOTAM if necessary.)
30. Name of
Main Controller:
Coordinator:
Ground Controller:
Supervisor:
Unit Inc.
SIC:
 31. ATS Unit
 32. Time since last break
 33. Start time of shift
 34. Radar recordings held
35. Address:

*


Telephone: 		36. Signature
 37. Date (dd/mm/yyyy)

*
Reported to: DG   GM   ANSSSD   FSSD   ASSD   FOD   TDO   other
Copyright © Tribhuvan International Airport 2019, All Right Reserved.
Designed and developed by : PCS