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

VOLUNTARY SAFETY REPORT

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

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Position:
Contact Number:
Email:

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Request to hide identity:

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 Yes No
Date:

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Please check all items that are applicable to this report form email: atssafety@caanepal.gov.np
TYPE OF REPORT
FLIGHT OF SEGMENT FROM TO FLIGHT NO. DATE

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 LOCATION
AIRCRAFT TYPE Time: GMT LT AIRLINE OPERATOR:
PHASE OF OPERATION Parking Starting Taxing 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 SECTER 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:

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 NUMBER: ASSIGNED TO:
CORRECTIVE ACTION TAKEN (TO BE COMPLETED BY ATS SAFETY OFFICE):
USE ANY ADDITIONAL PAPER IF NEEDED
Note: After filling up, please send it to ATS Safety Office or email to: atssafety@caanepal.gov.np
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