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AIRLINE AIRPORTGROUND INCIDENT/ACCIDENT/DAMAGE REPORTTitle:One line statement of the main features of the incident/accident

Part 1. DAMAGE BY ( )

Other AircraftRamp EquipmentVehicleForeign ObjectJet BlastUnknown (Previously Unreported)

DateTime of OccurrencePhase of Operation

Area (Stand, etc.) Aircraft Reg. Aircraft TypeFlight Nr.Scheduled Ground TimeFlight Delay hrs. min.Flight Cancelled YES/NO (delete as appropriate)

Other (specify)

Part 2. DETAILS OF DAMAGE Part 3. NUMBER OF CASUALTIES

Fatalities Non Fatal

EmployeesPassengersOthers

Part 4. VEHICLE/RAMP EQUIPMENT DETAILS AND CONDITION REPORT

Serviceable Faulty( ) ( )

TyresBrakesSteeringLightsWipersProtectionWarning DevicesStabilisersTow HitchField of vision

from driving position

Remarks

Serial Fleet Nr.TypeOwner

Area (Stand, etc.) Age of Vehicle/Ramp Eq.Last Overhaul

Part 5. DETAILS OF PERSONNEL INVOLVED1 2 3

Name Name NameJob Title Job Title Job TitleCompany Company CompanyStaff Nr. Staff Nr. Staff Nr.Licence Licence LicencePart 6. CONDITIONS

Weather Use of official met. report

rainsnowsleet

hailfog

Surface

drywet

snowslush

icecontamination

Lighting

GoodPoor Day

NightTwilight

Visibility m kmWind/gust / If ktsTemperature c

Part 7. CONTRIBUTORY FACTORSIdentify by code from the checklist factors which in your opinion contributed to the incident/accident by major factor

Other factors (specify)Which of these contributory factors are normal practice?

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Part 8. SKETCH

Part 9. NARRATIVE Give a description of what happened. Include details of relevant contributory factors identified.

Part 10. INITIAL FINDINGS Part 11. INITIAL ACTION TAKEN

Part 12. CLOSING ACTION

Part 13. PREPARED BY

Signature

Name(Block Capitals)

StatusPAGE 2 OF 2

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SPECIMEN OF A SUMMARY FORMStatistical Summary of Damages to Aircraft by Ground Support Equipment

AIRLINE: REFERE NCE PERIOD :

FROM TO

ESTABLISHED BY:

TOTAL NUMBER OF FLIGHT DEPARTURES INREFERENCE PERIOD:

WIDE BODY A/C CON V. A/C TOTAL

Category / Type of Equipment Involved

Total Number of Damages Recorded

Damage Rate per 1000 Flight Departures

WIDE BODY A/C CONV. A/C TOTAL

WIDE BODY A/C CONV A/C TOTAL

1. PASSENGER HANDLING EQUIPMENT Air jetti es (pas senger bridges)

Passenger stairs/stepsMobile lounges (elevating)

Invalid handling vehicle

Passenger coaches/buses

Others

Sub total2. AIRCRAFT LOADING EQUIPMENTRamp tractors

Baggage/cargo carts/dollies

Container/pallet loaders

Forklifts

Belt conveyors

Catering/cleaning trucks (elev.)

Others

Sub total3. AIRCRAFT SERVICING EQUIPMENTToilet /water vehiclesFuelling trucks/services

Aircr aft tow trac tors /tow bars

Air start /ground power units

Engineering access equipment

High lift equipment/De-icers

Others

Sub total

4. MISCELLANEOUSMotor vehiclesOthers

Sub total

5. FOREIGN OBJECT DAMAGESubtotal6. JET BLAST DAMAGESubtotal

7. PREVIOUSLY UNREPORTED DAMAGESubtotalTOTAL

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