VOLUNTARY SAFETY REPORTING
Aircraft :
Airport :
Hazard Log Id :
CIAL/1042
 Reporting Date : 18-05-2013
Date of Occurrence:
*
Time of Occurrence: [HHMM]
Location of hazard:
Keeping in mind the topics shown below, discuss those which you feel are relevant and anything else you think is important. Include what you believe
really caused the problem, and what can be done to prevent a recurrence, or correct the situation
Description:
*
chain of events human performance considerations
- How the problem arose
- Contributing factors 		- How it was discovered
- Corrective actions 		- Perceptions, judgements, decisions
- Factors affecting the quality of human performance 		- Actions or inactions
Suggestions for Corrective Actions:
     
In your opinion what is the  likelihood of a similar occurrence happening again? Help
Frequent
Occasional
Remote
Improbable
Extremely Improbable
1
2
3
4
5
     
What do you consider could be the worse possible consequence if this occurrence did happen again? Help
Catastrophic
Hazards
Major
Minor
Negligible
A
B
C
D
E
Informant E-mail Address:
(Note:Use Comma(,) to serperate email Id(s))
* Indicates Mandatory   
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