CAP 382 - The Mandatory Occurence Reporting Scheme · CAP 382 The Mandatory Occurrence Reporting...

CAP 382

The Mandatory Occurrence Reporting Scheme

Information and Guidance

www.caa.co.uk

Safety Regulation Group

Important Note

The CAA has made many of the documents that it publishes available electronically (in addition totraditional printed format). Where practical, the opportunity has been taken to incorporate a clearerrevised appearance to the documents. Any significant changes to the content of this document will beshown in the Explanatory Note. If no such changes are indicated the material contained in thisdocument, although different in appearance to the previously printed version, is unchanged. Furtherinformation about these changes and the latest version of documents can be found at www.caa.co.uk.

CAP 382

The Mandatory Occurrence Reporting Scheme

Information and Guidance

Safety Regulation Group

March 2003

CAP 382 The Mandatory Occurrence Reporting Scheme

© Civil Aviation Authority 2003

ISBN 0 86039 905 2

6th Edition, March 2003

Enquiries regarding the content of this publication should be addressed to:Safety Investigation and Data Department, Safety Regulation Group, Civil Aviation Authority, AviationHouse, Gatwick Airport South, West Sussex, RH6 0YR.

The latest version of this document is available in electronic format at www.caa.co.uk, where you mayalso register for e-mail notification of amendments.

Printed copies and amendment services are available from: Documedia Solutions Ltd., 37 WindsorStreet, Cheltenham, Glos., GL52 2DG.


Chapter Page Date Chapter Page Date

Page iii

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vi March 2003

vii March 2003

viii March 2003

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6 March 2003

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Appendix A 1 March 2003














Appendix B 1 March 2003









Appendix C 1 March 2003

Appendix C 2 March 2003

March 2003

List of Effective Pages


Contents

List of Effective Pages iii

Foreword vi

Statement by the Chairman of the CAA vii

Protection of the Interests of the Licence Holder viii

The Objectives of the Scheme 1

Division of Responsibilities 1

Relationship with the Air Accidents Investigation Branch (AAIB), Department for Transport 2

The Legislation 3

Applicability 3

Reporting Procedure 5

Reporting of Airprox, Wake Vortex and Birdstrike Occurrences 8

Reporting by Air Traffic Controllers 9

Reporting by Air Traffic Engineers 9

Reporting of Ground Communications or Navigation EquipmentFaults by Aircraft Commanders 9

Retention of Data from a Flight Data Recorder (FDR) 9

Processing of Occurrence Reports and Publication of Occurrence Information 10

Appendix A Occurrence Report Forms

Occurrence Report Form – CA1673 1

ATC Occurrence Report Form – CA1261 7

Engineering Occurrence Report Form – CA1262 11

Appendix B Occurrences Required to be Reported

Introduction 1

Aircraft Flight Operations 1

Aircraft and Equipment – Failures, Malfunctions and Defects 4

Ground Services, Facilities or Equipment 7

Page ivMarch 2003


Appendix C Occurrence Reporting System

Occurrence Publications 1

From the Safety Investigation and Data Department 1

From the United Kingdom Airprox Board (UKAB) Aircraft Proximity Hazards (Airprox) – Report 2

From the Safety Promotion Section – General Aviation Department 2

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Foreword

The purpose of this publication is to describe the CAA Mandatory OccurrenceReporting (MOR) Scheme and to provide guidance to those who, by the associatedlegislation, are involved in its operation.

If the Scheme is to make a real contribution to flight safety in UK civil aviation, it ismost important that all concerned are fully aware of its aims and requirements.

The CAA will welcome any comment and suggestion for the improvement of both theScheme and this publication. Such comments should be addressed to Head of theSafety Investigation and Data Department (SIDD) at the address below.

Channels of Reporting

Completed Occurrence Report Forms are to be sent to the Safety Investigation andData Department, (SIDD), CAA Safety Regulation Group, Aviation House, GatwickAirport South, West Sussex RH6 0YR. Alternatively, they may be sent to other CAAoffices in accordance with arrangements made with the CAA.

In some cases, particularly overseas, the use of email, fax, telex or AFTN may benecessary to minimise delays in the transmission of occurrence information.

When an Occurrence Report Form is not available, the relevant information may bepassed in letter form. Should additional information be required, the CAA may send astandard Occurrence Report Form to the person initiating the report for completion.

For those occurrences which it is considered include particularly dangerous orpotentially dangerous circumstances requiring the immediate passing of informationto the CAA, the following action should be taken:

a) Reports relating to aircraft technical defects:

b) Reports relating to all other types of occurrence:

In all such cases written confirmation of the available details of the occurrence shouldbe passed on as quickly as possible, preferably by email, fax or telex, to SIDD.

Email:Fax:Telex:AFTN:

[email protected] 573972 – ‘for SIDD’878753 – ‘for SIDD’EGGRYAYD

During normal working hours: SIDD Gatwick (email: [email protected]: 01293 573972, tel: 01293 573220), orAircraft Maintenance Standards RegionalOffice responsible for the reportingorganisation.

Outside normal working hours: A surveyor from the Aircraft MaintenanceStandards Regional Office responsible for thereporting organisation, orCAA emergency telephone system 01293563344

During normal working hours: SIDD Gatwick as above

Outside normal working hours:CAA emergency telephone system as above

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Page vii


Statement by the Chairman of the CAA

Confidentiality of Reports

It is fundamental to the purpose of the Scheme that the substance of reports shouldbe disseminated where necessary in the interest of flight safety. Without prejudice tothe proper discharge of its responsibilities in this regard, the Authority will notdisclose the name of the person submitting the report or of a person to whom itrelates unless required to do so by law or unless, in either case, the person concernedauthorises disclosure.

Should any flight safety follow-up action arising from a report be necessary, the CAAwill take all reasonable steps to avoid disclosing the identity of the reporter or of thoseindividuals involved in the reportable occurrence.

Assurance Regarding Prosecution

The CAA gives an assurance that its primary concern is to secure free and uninhibitedreporting and that it will not be its policy to institute proceedings in respect ofunpremeditated or inadvertent breaches of the law which come to its attention onlybecause they have been reported under the Scheme, except in cases involvingdereliction of duty amounting to gross negligence.

Action in Respect of Licences

The CAA has a duty to vary, revoke or suspend a licence as appropriate if it ceases tobe satisfied that the holder of the licence is competent, medically fit and a fit personto exercise the privileges of the licence. If an occurrence report suggests that thelicence holder does not satisfy these requirements, it will take appropriate licensingaction. For example, if the report indicates that the licence holder requires furthertraining, it may suspend his licence until he has undergone such training. If a reportshould indicate that the licence holder may not be a fit person to exercise theprivileges of his licence, the fact that he has reported the occurrence will be taken intoaccount in determining his fitness and will weigh heavily in his favour. Although theCAA recognises that, in practice, licensing action may be regarded as having apunitive effect, there can be no question of action being taken by the CAA on a licenceas a punitive measure. The purpose of licence action is solely to ensure safety andnot to penalise the licence holder. In all such cases, when considering what action totake, the CAA will take into account all relevant information about the circumstancesof the occurrence and about the licence holder which is available to it.

Possible Action by Employers

Where a reported occurrence indicated an unpremeditated or inadvertent lapse by anemployee, the CAA would expect the employer to act responsibly and to share itsview that free and full reporting is the primary aim, and that every effort should bemade to avoid action that may inhibit reporting. The CAA will, accordingly, make itknown to employers that, except to the extent that action is needed in order to ensuresafety, and except in such flagrant circumstances as are described under the heading‘Prosecution’ above, it expects them to refrain from disciplinary or punitive actionwhich might inhibit their staff from duly reporting incidents of which they may haveknowledge.

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Protection of the Interests of the Licence Holder

It is recognised that where a licence holder is a member of an association or tradeunion he is at liberty to inform that association or union of any prosecution or actionby the CAA in respect of his licence, and seek their assistance.

At any hearing conducted by the CAA, in respect of a licence held by a member of anassociation or trade union, a representative of that body may accompany the licenceholder and address the CAA on his behalf.

Sir Roy McNultyChairman of the CAAMarch 2003

Page viiiMarch 2003


1 The Objectives of the Scheme

1.1 The objectives of the CAA Mandatory Occurrence Reporting (MOR) Scheme are asfollows:

a) To ensure that the CAA is advised of hazardous or potentially hazardous incidentsand defects (hereafter referred to as occurrences).

b) To ensure that knowledge of these occurrences is disseminated so that otherpersons and organisations may learn from them.

c) To enable an assessment to be made by those concerned (whether inside oroutside the CAA) of the safety implications of each occurrence, both in itself andin relation to previous similar occurrences, so that they may take or initiate anynecessary action.

1.2 The overall objective of the CAA in operating occurrence reporting is to use thereported information to improve the level of flight safety and not to attribute blame.

2 Division of Responsibilities

2.1 The existence of the Occurrence Reporting Scheme to achieve the above objectivesis not intended to replace or reduce the duties and responsibilities of all organisationsand personnel within the air transport industry. The primary responsibility for safetyrests with the management of the organisations involved (Manufacturers, Operatorsand Maintenance Organisations). The CAA’s responsibility is to provide the regulatoryframework within which the industry must work and thereafter to monitorperformance to be satisfied that required standards are set and maintained. TheOccurrence Reporting Scheme is an established part of the CAA’s monitoringfunction and is complementary to the normal day to day procedures and systems (e.g.AOC, Company approvals, etc.); it is not intended to duplicate or supersede these.

It is thus no less incumbent upon any organisation:

a) to record occurrences and

b) in conjunction with the appropriate organisation (e.g. Aircraft/EquipmentManufacturer, Operating Agency, Maintenance/Repair Organisation) and whennecessary the CAA, to investigate occurrences in order to establish the causesufficiently to devise, promulgate and implement any necessary remedial andpreventative action.

2.2 In relation to all reported occurrences, including those raised by its own personnel,the CAA will

a) evaluate each occurrence report received;

b) decide which occurrences require investigation by the CAA in order to dischargethe CAA’s functions and responsibilities;

c) make such checks as it considers necessary to ensure that operators,manufacturers, maintenance, repair and overhaul organisations, air traffic controlservices and aerodrome operators are taking any necessary remedial andpreventative action in relation to reported occurrences;

d) take such steps as are open to it to persuade foreign aviation authorities andorganisations to take any necessary remedial and preventative action in relation toreported occurrences;

Page 1March 2003


e) assess and analyse the information reported to it in order to detect safetyproblems which may not be apparent to individual reporters;

f) make available the information derived from occurrence reports in accordance withthe relevant CAA Regulations (see paragraph 4.3);

g) make available the results of studies of the data provided to those who will usethem for the benefit of air safety;

h) where appropriate, issue specific advice or instructions to particular sections of theindustry;

i) where appropriate, take action in relation to legislation, requirements or guidance,e.g. revisions of the Air Navigation Order (ANO), Joint Aviation Requirements(JAR), amendments to Flight Manuals and Operations Manuals, introduction ofmandatory modifications and inspections, amendments to maintenanceschedules, terms of approval, and licences, issue of Aeronautical InformationCirculars, Airworthiness Notices, etc.

3 Relationship with the Air Accidents Investigation Branch (AAIB),

Department for Transport

3.1 In the UK the requirements and procedures for the reporting and investigation ofaccidents and serious incidents are the subject of separate legislation – Civil Aviation(Investigation of Accidents and Incidents) Regulations. The investigation of accidentsis the responsibility of the AAIB and not the CAA. To achieve the maximum analyticaland statistical benefit from an occurrence record system it is necessary that accidentsbe included. The term ‘occurrence’ as used in the UK Occurrence Reporting Systemtherefore includes accidents, serious incidents and other incidents. Close liaison ismaintained between the CAA and the AAIB and details of all occurrences reported tothe AAIB are immediately passed to the CAA for inclusion in the records.

3.2 Because of the close relationship between aircraft accidents, serious incidents andother occurrences, and between the regulations pertaining to their investigation, thefollowing explanation is included as guidance.

3.3 The Civil Aviation (Investigation of Air Accidents and Incidents) Regulations 1996provides the following definitions:

3.3.1 Accident: An occurrence associated with the operation of an aircraft which takesplace between the time any person boards the aircraft with the intention of flight untilsuch time as all such persons have disembarked, in which:

a) a person suffers a fatal or serious injury as a result of

• being in or upon the aircraft,

• direct contact with any part of the aircraft, including parts which have becomedetached from the aircraft, or

• direct exposure to jet blast,

• except when the injuries are from natural causes, self-inflicted or inflicted byother persons, or when the injuries are to stowaways hiding outside the areasnormally available to the passengers and crew, or

b) the aircraft sustains damage or structural failure which

• adversely affects the structural strength, performance or flight characteristicsof the aircraft, and

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• would normally require major repair or replacement of the affected component,

except for engine failure or damage, when the damage is limited to the engine, itscowlings or accessories; or for damage limited to propellers, wing tips, antennas,tyres, brakes, fairings, small dents or puncture holes in the aircraft skin; or

c) the aircraft is missing or is completely inaccessible.

3.3.2 Serious Incident: means an incident involving circumstances indicating that anaccident nearly occurred;

3.3.3 Incident: Means an occurrence, other than an accident, associated with the operationof an aircraft which affects, or would affect, the safety of operation.

3.4 Because the Civil Aviation (Investigation of Accidents and Incidents) Regulationsrequire that only those Accidents (as defined above) and Serious Incidents are to bereported to the Department for Transport (DfT), it is sometimes assumed that onlythese ‘Reportable Accidents’ may be subject to investigation by the AAIB. The sameRegulations, however, empower the Chief Inspector of Air Accidents to determinewhether or not an investigation is to be carried out on any occurrence, i.e. whether ornot it qualified for reporting to the Department for Transport. It should be appreciated,therefore, that although reference is made in this document to the need for theinvestigation by either or both industry and the CAA of occurrences reported underthe CAA Occurrence Reporting Scheme, the Chief Inspector of Air Accidents, underthe terms of the Accident Investigation Regulations, is also empowered to investigatesuch occurrences should he so decide.

4 The Legislation

4.1 Legislation on the CAA MOR Scheme is contained in the ANO, as amended, and theAir Navigation (General) Regulations, as amended.

4.2 It should be noted that reference must always be made to the ANO if there is anydoubt as to the responsibility for the reporting of an occurrence and to both the Articleand the associated Air Navigation (General) Regulations, to verify the types ofoccurrence to be reported and the information to be supplied.

4.3 The legislation concerning the release of information supplied under the CAA MORScheme is contained in the CAA Regulations, as amended.

5 Applicability

5.1 Category of Aircraft Involved

The ANO specifies the aircraft covered by the MOR Scheme as:

• Any public transport aircraft registered in the United Kingdom.

• Any public transport aircraft not registered in the United Kingdom but operated bythe holder of an Air Operator’s Certificate (AOC) granted by the CAA (i.e., a dryleased aircraft).

• Any turbine powered aircraft registered in the United Kingdom.

In the case of organisations providing a service or facility for aircraft operating over orin the UK (e.g. Air Traffic Services, airfields, etc.) any occurrence meeting the requiredcriteria should be reported regardless of the nationality of the aircraft involved.

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5.2 Categories of Persons Required to Report

The ANO also specifies the categories of persons (or organisations) who are requiredto report occurrences. These include:

• Operators and commanders of public transport aircraft and turbine poweredaircraft.

• Those concerned with the manufacture, repair, maintenance and overhaul of suchaircraft, or any part or item of equipment intended for use on such an aircraft.

• Those who sign Certificates of Maintenance Review or Release to Service for suchaircraft, or any part or item of equipment.

• Aerodrome licensees/managers.

• Civil air traffic controllers operating in circumstances requiring an air trafficcontroller’s licence are also included, as are

• Personnel who perform a function connected with the installation, modification,maintenance, repair, overhaul, flight checking or inspection of equipment on theground used or intended to be used for the purpose of, or in connection with, theprovision of an air traffic control service or navigational aid to an aircraft.

It should be understood that while the legislation defines those who have to report,anyone may, in fact, report should they consider it necessary.

5.3 Voluntary Reporting

The CAA encourages voluntary reporting to the same criteria across the wholespectrum of UK civil aviation operations. The CAA’s organisation and procedures forprocessing, recording and disclosing reports do not, therefore, differentiate betweenvoluntary and mandatory reports.

5.4 Items to be Reported

5.4.1 Any person specified in the legislation should report any reportable occurrence ofwhich he has positive knowledge, even though this may not be first hand, unless hehas good reason to believe that appropriate details of the occurrence have alreadybeen, or will be, reported by someone else.

5.4.2 In deciding whether or not to report an occurrence, two factors must be borne inmind. The first is whether the event meets the definition as specified in the ANO.

A reportable occurrence in relation to an aircraft means:

a) Any incident relating to such an aircraft or any defect in or malfunctioning of suchan aircraft or any part or equipment of such an aircraft, being an incident,malfunctioning or defect endangering, or which if not corrected would endanger,the aircraft, its occupants, or any other person; and

b) Any defect in or malfunctioning of any facility on the ground used or intended tobe used for purposes of or in connection with the operation of such an aircraft,being a defect or malfunctioning endangering, or which if not corrected wouldendanger, such an aircraft or its occupants.

5.4.3 The second factor to be considered is whether or not the event comes within theterms of the reportable occurrences prescribed in the Air Navigation (General)Regulations, as amended.

5.4.4 A report should also be submitted on any occurrence which involves, for example, adefective condition or unsatisfactory behaviour or procedure which did not

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immediately endanger the aircraft but which, if allowed to continue uncorrected, or ifrepeated in different, but likely, circumstances, would create a hazard.

5.4.5 It is of great importance to the success of the Scheme that the reporters keep firmlyin mind the concept of ‘endangering’ or ‘potentially endangering’, as used in theabove definition, when deciding whether or not to submit a report. The primaryobjective of occurrence reporting is to monitor, disseminate and record for analysis,critical or potentially critical safety occurrences. It is not intended to collect andmonitor the normal flow of day-to-day defects/incidents etc. The latter is an importantpart of the overall flight safety task but procedures and systems already exist to carryout this function. In the main these comprise industry responsibilities monitoredoverall by the CAA. When appropriate, such systems also provide the necessaryrecords for statistical purposes. In order to achieve the above objectives foroccurrence reporting, the criteria for a reportable occurrence need to be set above, interms of the effect on safety, the normal day to day defects or minor incidents. Overenthusiastic reporting of such items which fall below these criteria will involveunnecessary duplication and work to both the reporters and the CAA and will alsotend, by sheer volume of data generated, to obscure the more significant safetyitems. Reporters should ensure that the content of their reports meets with thecriteria and guidance laid out in Appendix B. Particular emphasis should be paid toensuring that day to day operational anomalies, technical defects and routine reliabilityissues are dealt with via the normal organisational systems and procedures.

5.4.6 Appendix B develops the above philosophy for the setting of the criteria and providesmore detailed guidance on the types of occurrences which are required to bereported.

6 Reporting Procedure

6.1 Submission of Reports

6.1.1 The ANO places the primary responsibility for reporting with individuals. However, theinterests of flight safety are best served by full participation, in the investigation andfollow-up, by the organisation involved. Therefore, wherever possible, the CAAencourages the use of company reporting systems, with a responsible person(s)within the organisation being nominated to receive all reports and to establish whichreports from individuals within the organisation meet the desired criteria for anoccurrence report to the CAA. Correlation of operational and technical aspects and theprovision of any relevant supplementary information, e.g. the reporter’s assessmentand immediate action to control the problem, is an important part of such activity.With such systems the reporting level within the organisation can be, and often is, setat a lower level than the CAA requirement in order to provide a wider monitoring ofthe organisation’s activities. However, when the employee making such a report is aperson having a duty to report to the CAA in accordance with the ANO, the companymust tell him if his report has been passed on to the CAA or not. If not, and theemployee is convinced that it should, he must have the right to insist that the reportbe passed to the CAA or to report it directly to the CAA himself. Procedures to ensurethat this right of the individual reporter is maintained must be incorporated into theorganisation’s reporting procedures and be clearly stated in the relevant instructionsto staff.

6.1.2 In the case of occurrences arising from, or relating to, defects in the aircraft, itsequipment or any item of ground equipment, it is important that the appropriatemanufacturer(s) be advised of the occurrence as soon as possible. The CAA thereforeexpects that any organisation which raises an occurrence report (or which has been

Page 5March 2003


made aware of a report raised by an individual employee) will pass a copy of the reportto the appropriate aircraft or equipment manufacturer(s) as soon as possible, unlessit is known that the originator has already done so. In the case of incidents affectingground installations or services, e.g. aerodrome and/or air traffic control, thoseresponsible for those services should also be informed. The original report should listall addressees to whom it has been sent.

6.1.3 Individuals may submit an occurrence report directly to CAA should they so wish, butin the interest of flight safety they are strongly advised also to notify their employers,preferably by a copy of the report, unless confidentiality is considered essential.When appropriate (paragraph 6.1.2 above), the employer, in turn, should then advisethe aircraft or equipment manufacturer(s).

6.1.4 Reports must be despatched within 96 hours of the event, unless exceptionalcircumstances prevent this. Nevertheless, when the circumstances of an occurrenceare judged to be particularly hazardous, the CAA expects to be advised of theessential details by the fastest possible means (e.g. email/telephone/fax/telex). Thisshould be followed up within 96 hours by a full written report to the CAA withappropriate copies as per paragraph 6.1.2 and 6.1.3 above. The CAA is dependentupon the judgement of those responsible for submitting reports to establish whichoccurrences are in this category. (See page vi for appropriate channels of reporting.)Conversely, for occurrences involving a lesser degree of hazard, reporters mustexercise their judgement in deciding whether, in order that all those concerned maybe alerted in the minimum time, to submit immediately a report on the limitedinformation available or if there is the likelihood of any additional and usefulinformation becoming available within the statutory 96 hours, to delay the despatchof the report.

6.1.5 Should the initial report be incomplete in respect of any item of information requiredby the Air Navigation (General) Regulations, a further report containing thisinformation must be made within 96 hours of the information becoming available.Prompt advice to the CAA on the results of investigations and the actions taken tocontrol the situation will minimise or may render unnecessary direct CAA involvementin the investigative activity. The CAA seeks the co-operation of all reportingorganisations in this respect. In the case of technical failures or difficulties, theavailability of photographs and/or preservation of damaged parts will greatly facilitatethe subsequent investigation.

6.1.6 A manufacturer or maintenance, overhaul or repair organisation of aircraft,components or equipment is not expected to report to the CAA, as a matter ofroutine, those occurrences involving products which have been reported to it by anoperator/individual, if the operator/individual has already reported the occurrence tothe CAA. The primary duty for reporting in such cases will rest with the operator/individual. Manufacturers etc., should report any such occurrence which they think isreportable, as per the guidance, if they know that the operator concerned has notdone so.

6.1.7 Where a repair organisation, overhauler, etc. is in doubt as to the applicability of thereporting requirements, e.g. it discovers a defect in a piece of equipment whichcannot be associated with a particular aircraft, or even a type of aircraft, it should,nevertheless, make a report in order to ensure that it has complied with the law. TheCAA would, in any case, wish the organisation, or individual, to report voluntarily suchdefects on equipment fitted to aircraft types not subject to mandatory reporting.

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6.1.8 Confidential Reports

If any reporter considers that it is essential that his/her identity not be revealed, thereport itself should be clearly annotated ‘CONFIDENTIAL’ and submitted direct toSIDD Gatwick, addressed to ‘Head of SIDD’ and the envelope should be marked‘Personal’. The request will be respected and the reporter will be contactedpersonally, either by the Head of SIDD or his deputy. CAA cannot, of course,guarantee confidentiality when an occurrence is reported separately by another partyor where the caveat on prosecution in the Chairman’s statement in this CAP applies,i.e. ‘dereliction of duty amounting to gross negligence’. Reporters submitting aConfidential Report must accept that effective investigation may be inhibited.Nevertheless, the CAA would rather have a Confidential Report than no report at all.

6.1.9 Operators approved for Extended Range Twin Operations (ETOPS)

Operators holding approval for this type of operation should, when submitting anoccurrence report on the aircraft type(s) subject to this approval, always complete theappropriate ‘box’ provided. Those operators not using CAA Occurrence Report FormCA1673 must prominently annotate all such reports ‘ETOPS’.

NOTE: The related legislation and requirements associated with ETOPS arecontained in CAP 513.

6.2 Investigation and Provision of Supplementary Information

6.2.1 To facilitate effective lines of communication when any part or equipment involved inan occurrence is being despatched to another area or organisation for investigation orrepair, the item(s) should be clearly identified as the subject of an occurrence reportto the CAA, by appropriate annotation of the ‘tag’ and all accompanying paperwork.

6.2.2 The ANO, as amended, does not require the provision of supplementary informationon reportable occurrences, except when specifically requested by the CAA. However,the efficiency of the CAA’s follow-up work and the standard of the information serviceit can provide will be greatly improved if reporting organisations keep the CAAinformed of major developments in their investigations of occurrences. The CAAseeks the co-operation of all reporting organisations in this respect.

6.3 The CAA Occurrence Report Forms (CA1673, CA1261 and CA1262)

6.3.1 To facilitate consistent reporting and subsequent storage and analysis of data, threestandard report forms, designed in consultation with industry, are available and ideallyshould be used. Organisations may wish to use a report form designed to meet theirown requirements. In such cases the ‘in house’ document(s) should, as far aspossible, follow the general format of the CAA model. Certainly any ‘in house’document(s), use of which will require CAA approval, should seek at least the sameinformation as is required to be reported on the appropriate CAA form(s). The threeCAA forms are:

a) Form CA1673 (see Appendix A) is to be used for all types of occurrence except:

i) air traffic occurrences reported by Air Traffic Controllers, and

ii) air traffic services ground equipment occurrences reported by Air TrafficEngineers. (AIRPROX occurrences, wake vortex incidents and birdstrikes arealso separately reported – see Sections 7 and 8 below).

b) Form CA1261 (see Appendix A) for use solely by Air Traffic Controllers and FlightInformation Service Officers when reporting ATS occurrences.

c) Form CA1262 (see Appendix A) for use solely by Air Traffic Engineers for alloccurrences associated with Air Traffic Service Ground Equipment.

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Page 8

Pads of forms may be obtained (free of charge) from:

Alpha Office LimitedThe Birches Industrial EstateImberhorne LaneEast GrinsteadWest Sussex, RH19 1XLTel: 01342 313866Fax: 01342 311866Email: [email protected]

6.4 Completion of the Forms

Sample occurrence report forms and advice on their completion are contained inAppendix A.

7 Reporting of Airprox, Wake Vortex and Birdstrike Occurrences

Because of both the specialist and detailed nature of the information required onbirdstrike, AIRPROX and wake vortex occurrences, an alternative to the standardOccurrence Report form is necessary. All such reports, including those requiredunder the terms of the ANO, should be submitted on the specialised Report Formdesigned for the purpose and transmitted in accordance with the instructions on theform.

Namely:

Form CA1094 should be used by pilots for Airprox occurrences, Form CA1282 forBirdstrikes and Form CA1695 for Wake Vortex Incidents.

With the exception of wake vortex incidents, completion of such a form will normallyconstitute compliance with the Occurrence Reporting Regulations. The CAA willthen, by internal arrangement, ensure that reports of those occurrences which qualifyas MORs are incorporated into the Occurrence Reporting System, thereby avoidingthe need for duplication of reporting.

AIRPROX (reported by pilots,in UK airspace)

United Kingdom Airprox Board Hillingdon House Uxbridge Middlesex UB10 0RU

Tel: 01895 815122Fax: 01895 815124Telex: 934725AFTN: EGGFYTYA

Birdstrikes Safety Investigation and Data Department Civil Aviation AuthorityAviation HouseGatwick Airport SouthWest Sussex RH6 0YR

Wake Vortex Incidents Wake Vortex Analysis TeamNational Air Traffic Services LimitedT4G9 One Kemble StreetLondon, WC2B 4ADEmail: [email protected]: 020 7832 6225

March 2003


8 Reporting by Air Traffic Controllers

Reports (including AIRPROX) should be submitted in accordance with the procedurescontained in the CAA Manual of Air Traffic Services Part 1 using Report Form CA1261.Initial reports for AIRPROX incidents should be submitted using the AFTN Signal FormCA1094A.

9 Reporting by Air Traffic Engineers

9.1 Reports should be submitted in accordance with this publication following theinstructions on the reverse of the CA1262 reporting form.

9.2 MOR reporting action must not interfere in any way with existing local reportingschemes (i.e. ground fault reports), which may take precedence where immediateEngineering action is appropriate.

10 Reporting of Ground Communications or Navigation Equipment Faults

by Aircraft Commanders

10.1 The routine procedure for aircraft commanders to notify ground faults is by means ofa Form CA647 as advised in the UK Aeronautical Information Publication GEN 3.4.2and the instructions on the form. This action will normally ensure immediate attentionby the telecommunications staff. In urgent cases an aircraft commander may requestthe air traffic controller by RTF to complete a Form CA647 on his behalf.

10.2 All such faults which meet the criteria for a reportable occurrence must also bereported by the aircraft commander using the standard Occurrence Report orapproved company form, and submitted through the normal Occurrence Reportingchannels. This report should indicate if Form CA647 action has also been taken.

11 Retention of Data from a Flight Data Recorder (FDR)

11.1 The CAA expects to use flight recorder data only when this is necessary for the properinvestigation of the more significant occurrences. It is not intended to use such datato check on information contained in a written report but to supplement and extendthe written information. Examples of the types of occurrence for which flight datarecords would be most useful are: significant excursion from the intended flightparameters; significant loss of control or control difficulties; unexpected loss ofperformance; a genuine GPWS warning. However, the more comprehensiverecorders fitted to some aircraft are capable of providing valuable data on a widerrange of occurrences and the CAA would expect to make judicious use of suchinformation in relation to appropriate occurrences.

11.2 For this purpose, the ANO requires that operators retain the data from an FDR whichis relevant to a reportable occurrence for a period of 14 days from the date of theoccurrence being reported to the CAA, or a longer period if the CAA so directs.

11.3 The CAA depends upon the judgement of those responsible for submitting reports toestablish which occurrences require the retention of FDR data. It is equally incumbentupon the CAA to advise the reporting organisation, as quickly as possible, when itrequires such data.

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12 Processing of Occurrence Reports and Publication of Occurrence

Information

12.1 The CAA Safety Investigation and Data Department (SIDD)

12.1.1 The Safety Investigation and Data Department is established within the SafetyRegulation Group of the CAA and its technical staff have engineering, operational andair traffic expertise. The Department has advanced data processing facilities for thestorage, on a database, of occurrence data, AAIB safety recommendations etc. but isnot responsible for regulating organisations or individuals.

12.1.2 The Department provides the CAA’s management and co-ordination centre for theOccurrence Reporting System and thus forms the central point for receipt, evaluation,processing dissemination, storage, and initial analysis of occurrence report data. Itsmain responsibilities may be summarised as: The evaluation and analysis of safetyinformation from occurrence reports (including accidents) by:

a) evaluation to identify those occurrences considered to require CAA involvement infollow-up and to direct these to the appropriate specialist Department(s) within theCAA for action. Such reports are classified as ‘Open’. All reports not requiring CAAfollow-up are recorded as ‘Closed’ by the SIDD and entered on the database assuch.

b) co-ordinating, monitoring and progressing to satisfactory closure the CAA follow-up on Open occurrences, entering appropriate details on the database;

c) dissemination of occurrence information to those who need to know through arange of occurrence publications;

d) recording of all occurrences on a computer database. Regardless of type orclassification of occurrence, names or addresses of individual persons are neverrecorded on the database;

e) continuously monitoring all incoming data for significant hazards or potentialhazards using previously stored data, when appropriate and alerting CAA specialistDepartments and others as necessary;

f) regular monitoring of stored data to identify hazards or potential hazards;

g) carrying out searches and analyses of stored data in response to requests fromwithin the CAA or industry and drawing attention, by appropriate means, to anylessons learnt;

h) Ensuring that effective co-ordinated communication is maintained between AAIBand CAA in respect of accident and serious incident investigation and follow up,and that all appropriate areas of CAA are fully briefed on all matters of significance.

(Preparation of statistical reports and longer term analysis is the responsibility of theStrategic Safety and Analysis Unit.)

12.1.3 Occurrences Closed on Receipt

A considerable number of occurrences reported to the CAA, while meeting thecriteria for a reportable occurrence, have been adequately dealt with by the reportingorganisation. Thus, there is no justification for further investigation by the CAA,although details of the occurrence and action taken do provide valuable informationfor dissemination and storage purposes. Reports judged to be in this category areClosed on Receipt by the SIDD, the principal justification for closure being that it isevident from the report that existing requirements, procedures, documentation, etc.,coupled with the reporter’s action, have adequately controlled the identified hazard.

Page 10March 2003


When necessary the SIDD will liaise with the reporter and/or seek advice fromappropriate CAA staff in making this decision.

The ability of the SIDD to close an occurrence on receipt and thus avoid the need forfurther CAA investigation is very much dependent upon the quality of the informationprovided in the report and, specifically, information on the action taken by thereporting organisation to control the situation.

12.1.4 Confidential Reports (see also 6.1.8)

a) Such reports will be directed to and reviewed personally by The Head of SIDD orhis deputy who will initiate a dis-identified record.

b) The Head of SIDD or his deputy will contact the reporter, by telephone if possible,to acknowledge receipt/discuss implications/obtain further information asappropriate. A course of action will be mutually agreed.

c) After discussions with the reporter have been completed the original report will bedestroyed (shredded).

d) The report will be processed as an occurrence but annotated CONFIDENTIAL.

e) A database entry will be made based on the dis-identified report and will only beaccessible by restricted users. (Names of individual persons are never recorded onthe SIDD database.)

12.1.5 Reports outside the remit of the MOR Scheme

When reporting to the CAA is through a company system, any reports which do notmeet the desired criteria for a reportable occurrence should normally be filtered outby the company. However, when reports are received by SIDD which are judged tofall within this category, basic details are entered into the database. Details are alsoplaced on a separate listing which is circulated to the originators to advise them of thedecision and to provide the opportunity to question it. When a report in this categoryis considered to provide supplementary supporting data for a reportable occurrence,it will be treated as the latter. The Classification by the CAA of a report as ‘non-reportable’ does not mean that it is considered insignificant or unimportant, butindicates that the routine monitoring and control procedures are considered adequateto cater for any required follow-up, investigation and initiation of action for theparticular occurrence. It is important that this point be made known to, andappreciated by, all individuals with responsibility for initiating occurrence reports.

12.2 Data Records and Provision of Information

12.2.1 The SIDD computer record for each occurrence comprises three main groups of data:

a) a range of identification and progress data,

b) a narrative,

c) a number of key phrases, selected from an extensive lexicon.

Based on the available evidence in the report, key phrases are selected which identifythe individual elements of the occurrence and also which state and suggest otherfactors which have, or might have, influenced the occurrence. The key phrases,coupled with the identification data, form the basis on which searches for anyindividual elements or combination of elements can be made. A comprehensive keyphrase lexicon has been prepared based on the ATA 100 Specification. The ATA 100numbering concept, i.e. chapter, sub-chapter and item, has been extended, asnecessary, to cover operational and human factors aspects. Key phrasing of individualoccurrences is confidential to CAA.

Page 11March 2003


12.2.2 The Occurrence Publications listed in Appendix C and data from the SIDD recordsrequired for the purposes of furthering flight safety will be made available on request.For those directly participating in the Scheme (e.g. the UK operating andmanufacturing industry) the supply of data will normally be at no charge; however, inexceptional cases which require extensive computer time and hence expense, theCAA must reserve the right to make a charge. Any data made available for purposesother than flight safety, e.g. commercial, will also normally be subject to charge.

12.2.3 The CAA Regulations require that the CAA make available the information received,or a summary thereof, to a number of categories of persons outside the industry. Italso provides that it shall not be required to make available such information if it issatisfied that to do so will not further the safety of civil aviation. Where provided, it isthe normal practice to dis-identify such information. The provision of any informationarising from requests made by such persons is normally subject to charge.

12.2.4 Requests for data should be directed to the SIDD, preferably in writing, but email,telex, fax and telephone requests will be accepted when the urgency so demands.The computer system is extremely flexible as indicated in paragraph 11.2.1. It is,therefore, particularly important that inquirers state precisely which data are required,both in terms of parameters to be searched and the information required in theprintout. If any doubt exists on these points it is recommended that the requirementsbe discussed with the SIDD.

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Appendix A Occurrence Report Forms

Occurrence Report Form – CA1673

CA 1673 (Nov 2002)

When completed, please send to : Safety Investigation and Data Department (SIDD), Civil Aviation Authority,Safety Regulation Group, Aviation House, Gatwick Airport South,

West Sussex,RH6 0YR.

OCCURRENCE REPORT

CAA Occurrence NumberUK Civil Aviation Authority

If report is CONFIDENTIAL - mark clearly at the top and provide contact address/Tel no. Your wish will be respected.

AIRCRAFT TYPE & SERIES REGISTRATION OPERATOR DATE LOCATION/POSITION/RW TIME

UTC

DAY

NIGHT

TWILIGHT

FLIGHT NR ROUTE FROM ROUTE TO FL/ALT/HT (FT) IAS (KTS) ETOPS

YES NO

NATURE OF FLIGHT PAX FREIGHT POSITIONING FERRY TEST TRAINING BUSINESS AGRICULTURAL SURVEY PLEASURE CLUB/GROUP PRIVATE PARACHUTING TOWING

FLIGHT PHASE PARKED TAXYING TAKE OFF INITIAL CLIMB CLIMB CRUISE DESCENT HOLDING APPROACH LANDING CIRCUIT AEROBATICS HOVER

Any procedures, manuals, pubs (eg AIC, AD, SB etc) directly relevant to occurrence and (when appropriate) compliance state of aircraft, equipment or documentation.

COMPONENT/PART MANUFACIURER PART NR SERIAL NR MANUAL REF COMPONENT OH/REPAIR ORGANISATION

ETOPS APPROVED

YES NO

A/C CONSTRUCTORS NR ENGINE TYPE/SERIES GROUND PHASE

MAINTENANCE

GROUND HANDLING

UNATTENDED

AIRCRAFT BELOW 5700KG ONLY - MAINTENANCE ORGANISATION

TEL NO.

GROUND STAFF REPORT

WIND CLOUD PRECIPITATION OTHER METEOROLOGICAL CONDITIONS RUNWAY STATE

DIRN SPEED (kts) TYPE HT (ft) 8th RAIN SNOW SLEET HAIL VISIBILITY ICING TURBULENCEo

OAT (C) DRY WET ICE SNOW SLUSH

LIGHT LIGHTKM/M LIGHTMOD MOD MODHEAVY SEVERE SEVERE CATEGORY I II III

ENVIRONMENTAL DETAILS

BRIEF TITLE

DESCRIPTION OF OCCURRENCE

Continue on back as necessary

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Appendix A Page 1March 2003


CA 1673 (Nov 2002)

DESCRIPTION OF OCCURRENCE CONTINUED

If report is voluntary (ie, not

subject to mandatory

requirements) can the

information be published in the

interests of safety?

YES

NO

Address and tel no. (if reporter wishes to be contacted privately)NOTE 1: If additional information, as below, is available please provide.

NOTE 2: If the occurrence is related to a design or manufacturing

deficiency, the manufacturer should also be advised promptly.

NOTE 3: Where applicable, a report of this incident should be forwarded

directly to other agencies involved, e.g. Aerodrome Authority, ATC

agency.

ORGANISATION NAME POSITION SIGNATURE DATE

UTILISATION - AIRCRAFT UTILISATION - ENGINE/COMPONENT MANUFACTURER

ADVISED

FDR DATA

RETAINED

ORGANISATION

NAME

TEL/FAX

POSITION

YES

YES

NO

NO

TOTALTOTAL SINCE OH/REPAIRSINCE OH/REPAIR SINCE INSPECTIONSINCE INSPECTION

HOURS

CYCLES

LANDINGS

HOURS

CYCLES

LANDINGS

REPORTERS REF REPORT REPORTERS INVESTIGATION

NEW SUPPL NIL CLOSED OPEN

SIGNATURE DATE

REPORTING ORGANISATION - REPORT

ORGANISATION COMMENTS - ASSESSMENT/ACTIONTAKEN/SUGGESTIONSTO PREVENT

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Advice on the Completion of the CAA Occurrence Report Form – CA1673

1 General

1.1 Reporters must provide the information required by the Air Navigation (General)Regulations as amended. This means that, wherever possible, they should completeall sections of the Form where the information requested is relevant to a specificoccurrence. (Relevance is the important aspect and where any of the informationrequested is clearly not relevant it may be omitted, e.g. weather details whenweather is not a factor.)

1.2 The individual ‘box’ headings for all items of data are mostly self-explanatory, and theForm comprises a combination of blank boxes for entry of data and boxes listing anumber of alternatives: the reporter should annotate the appropriate item.

1.3 The Form is arranged such that entries above Description of Occurrence apply to anin-flight occurrence: these parts of the Form are headed FLIGHT CREW REPORT.Below the Description of Occurrence, are boxes for the GROUND STAFF REPORTand, on the back of the Form, the REPORTING ORGANISATION REPORT.

1.4 Where reports of either in-flight or ground occurrences are channelled to the CAA viaan organisation, any relevant information which is not readily available to the personpreparing the initial report should, wherever possible, be added by the personsubmitting the report on behalf of the organisation. Alternatively, where this is notpossible within the required timescale, the outstanding information should besubmitted as a supplementary report.

1.5 Evaluation and processing of reports is greatly facilitated if the reports are typewrittenbut it is appreciated that this may not always be possible in this case the report shouldbe completed in black ink.

1.6 ETOPS Operations. Operators holding approval for this type of operation should,when submitting any occurrence report on the aircraft type(s) subject to this approval,always complete the appropriate ‘box’ provided. Those operators not using CA1673,should prominently annotate all reports ‘ETOPS’.

NOTE: The related legislation and requirements associated with ETOPS arecontained in CAP 513.

2 The following are brief notes against each block:

2.1 Aircraft Type, Series and Operator. To be completed for all occurrences involvingan aircraft. Provides basic identification data.

2.2 Flight and Weather Details. Relates to in-flight occurrences only. Provides flightdata in support of the narrative.

The flight phases listed on the report are defined as follows:

Parked On ramp with flight crew on board.

Taxying (a) From commencement of moving (including pushback) to start oftake-off run.

(b) From completion of landing run to terminal gate or point ofstopping engines, whichever occurs later.



2.3 The nature of flight descriptions listed on the report are defined as follows:

Take-off Start of take-off run to lift-off.

Init Climb Lift-off to a height of 1500 ft or aircraft ‘clean-up’ whichever occurslast.

Climb End of initial climb to top of climb.

Cruise Top of climb to top of descent including en-route climb or descent.

Descent Top of descent to a height of 1500 ft.

Holding Flying to a set procedure at a point which intentionally delays theaircraft, usually according to a set procedure at a ‘fix’.

Approach A height of 1500 ft to threshold.

Landing Threshold to end of landing run.

Circuit Flying to a set pattern in the vicinity of an airfield with intention oflanding.

Aerobatics Deliberate aerobatic manoeuvres, including spinning.

Hover Airborne and stationary.

Pax Flight under Class 1, 2–5 and 7 Air Transport Licence or anexemption.

Freight Flight under Class 1 or 6 Air Transport Licence or an exemption.

Positioning Positioning without revenue load to/from point of departure/arrival ofrevenue flight.

Ferry Ferry for technical reasons without revenue load, e.g. 3-engine ferryto maintenance base.

Test Check of serviceability, issue or renewal of C of A, experimental ordevelopment flying.

Training Training course or examination for any standard of licence or ratingtype training, continuation training.

Business Carriage of company staff in aircraft owned or hired by a company.

Agricultural Aerial application, crop spraying, top dressing, etc.

Survey Aerial photographic or mapping survey.

Pleasure Commercial pleasure flying. e.g. sightseeing.

Club/Group Flying other than training by members in a club or group aircraft.

Private Other than club/group flying or training.

Parachuting Carriage of parachutists for the purpose of parachuting.

Towing Towing of gliders, banners, etc.



3 Description of Occurrence – relates to all occurrences

3.1 This should be a clear and concise description of the occurrence, preferably startingwith a brief title indicating the type of occurrence. The description should containdetails of what happened or what was found; what immediate action was taken tocontain the situation; any additional information, comments or recommendationswhich it is considered might assist subsequent assessment of the report and/orinvestigation.

3.2 Wherever possible the description should be supported by the results of subsequentinvestigation and details of any action taken by the reporter’s organisation to avoid arecurrence.

4 Ground Staff/Reporting Organisation

Relates to both in-flight and ground occurrences. Provides maintenance/engineeringdata in support of the description of occurrence.

4.1 In the case of reports submitted from a component manufacturer or overhaul/repairagency, the information in this block will provide the primary identification data for theoccurrence. Nevertheless, if any of the information contained in paragraph 2 isavailable and is relevant it should also be provided.

4.2 The ground phases listed on the Form are defined as follows:

4.2.1 Aircraft or component times should be quoted in the units most relevant to theoccurrence or to the component function, e.g. flying hours/cycles/landings, or acombination of each. Provision is made for total times and times since overhaul, repairor inspection.

4.2.2 Information should be provided which allows for the identification of the existence ofany such information or procedures (e.g. Mandatory Inspections, AirworthinessDirectives, crew drills, etc.) issued for the purposes of controlling or avoiding such orsimilar occurrences. When such information or procedures exist, the provision of theappropriate reference numbers and the compliance status of the aircraft, equipment,facility or organisation is important both in terms of assessing the occurrence anddisseminating the details to others.

4.2.3 Manufacturer should be advised as the provision of this information is an importantaspect of any occurrence report relating to a specific aircraft type or any item ofaircraft equipment. Wherever possible such information should be provided as thiscan significantly reduce any requirements for follow-up activity. The date sent and the

Ambulance Patient transport, emergency medical service, accident response.

Police Aircraft operating on a Police Aircraft Operating Certificate.

Maintenance Aircraft on maintenance, overhaul or repair or at themanufacturers facility.

Ground Handling Movements of aircraft on the ground other than as defined in‘Taxying’.

Unattended Standing, with no personnel on board.



content of this information should be entered, together with any requests for strip/repair data.

4.2.4 It is important that reporters consider whether other agencies, such as AerodromeAuthorities, ATS providers etc., should also be notified when occurrences arereported in which they have a direct interest.

5 Non-Technical Details - Relevant to all occurrences

5.1 Provision is made on the form for important non-technical information, identificationof the reporter and/or reporting organisation; whether the report is mandatory orvoluntary and whether the report may be disseminated in the interests of air safety.

5.2 The provision of the reporter’s address and telephone number is optional and isintended for an individual who may wish to be contacted by this means rather than athis place of employment.

6 Acknowledgement of Reports

6.1 Acknowledgement of reports (other than CONFIDENTIAL – see below) is normallygiven via the SIDD’s monthly ‘Occurrence Listings’. If, exceptionally, individualacknowledgement is required, please contact the SIDD direct.

6.2 Confidential Reports

An occurrence may be reported confidentially. Please clearly annotate the top of theform ‘CONFIDENTIAL’ and mark the envelope ‘Personal for Head of SIDD’. The SIDDwill respect the confidentiality and contact you personally (see paragraph 6.1.8).



ATC Occurrence Report Form – CA1261

1 ACCIDENT AIRPROX INCIDENT ABNL (CA939 Action YES/NO) INFRINGEMENT

CATEGORIES OF OCCURRENCE

NB Signal action is required for Accident and AIRPROX as per MATS Part 1 Section 6

2 Occurrence Position 3 FL/Alt/Ht 4 Date 5 Time - UTC 6 Day/Night

OPERATOR CALLSIGN/REGN TYPE FROM TO SSRCODE

MODE CDISPLAYED

IFR/VFR/SVFR

7

15

23

8

16

24

9

17

25

10

18

26

11

19

27

12

20

28

13

21

29

14

22

30

YES/ NO

YES/ NO

YES/ NO

31 RTF Frequencies 32 Radar Equipment 33 Equipment Unserviceabilities 35 Runway in use34 QNH

36 CLASS & TYPE OF AIRSPACE 37 TYPE OF ATC SERVICE 38 SID/STAR/ROUTEA C E GB D F

CTR/CTA/TMA/AWY/UAR/ADR/ATZ/UIR/FIR/Purple/Other

Control/Advisory - Procedural/Radar/ADC/

GMC/Approach/Area/RAS/RIS/FIS/ALR

39 Was prescribedseparation lost?

YESNO

YESNO

40 Min Sepn Horiz/Vert 41 Collision/Conflict Alert/

TCAS/STCA/SMF

42 Traffic info given by ATC?

YESNO

43 Avoiding action given by ATC?

45 NARRATIVE - use a diagram if necessary (Aerodromes submit weather report including local and regional QNH)

44 BRIEF TITLESummary

46 Name 47 On duty as 48 ATS Unit 49 Time since last break

50 Start time of shift (UTC)

51 RadarrecordingsheldYES/NO

52 RTF recordings heldYES/NO

continue on a separate sheet if necessary

53 List other agencies advised

CA 1262 action?

55 Address/Telephone

CA 1261 (Nov 2002)

NOTES:(i) See Instructions and Explanatory Notes.

(ii) When completed, please send to : Safety Investigation and Data Department (SIDD), Civil Aviation Authority, Safety Regulation Group, Aviation House, Gatwick Airport South, WestSussex, RH6 0YR.

(iii) Circle or fill-in boxes 1-55 as required.

PLEASE USE BLACK INK

ATC OCCURRENCE REPORT

CAA Occurrence Number

54 Sign/Date

UK Civil Aviation Authority

Original to SIDDMake additional photocopies as required

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USE AND EXPLANATION OF TERMS IN BOX 1ACCIDENT: A UK reportable accident.AIRPROX: A situation in which, in the opinion of a pilot or a controller, the distance between aircraft as well as

their relative positions and speed have been such that the safety of the aircraft involved was or may have been compromised.

INCIDENT: Any Occurrence not appropriate to the other categories.ABANL: An Alleged Breach of Air Navigation Legislation, as a Supplementary Report whenever CA939 action

is taken.

INFRINGEMENT: An alleged unauthorised infringement of regulated airspace.

EXPLANATORY NOTES (Please also refer to MATS Part 1, Section 6)

GENERAL: Complete ALL boxes. If NOT APPLICABLE use N/A, or if NOT KNOWN use N/K. Avoid use of technical jargon, hieroglyphics and abbreviations.

BOX1: Should the Occurrence involve more than one category (eg an ABANL could arise from an INFRINGEMENT), circle both categories.

BOXES 7 to 14 }BOXES 15 to 20 } These boxes cater for up to three involved aircraft. Use the narrative for additional aircraft.BOXES 23 to 30 }

BOX 36: More than one element could be circled (eg CLASS A and AWY).

BOX 37: More than one element must be circled (eg CONTROL, RADAR and AREA).

BOX 39: Must be completed if prescribed separation was required to be achieved in accordance with MATS Part 1 or 2.

BOX40: Should contain your estimate, where possible, of the minimum separation achieved and must be completed for an AIRPROX. This will be coded for computer input purposes and amended if necessary after investigation.

BOX44: This box should contain a simple, one-line statement summarising the Occurrence, ie 'Co-ordination problems', 'Level bust', 'Overload' etc.

BOX 51/52: Relevant RTF and Radar recordings can be vitally important to subsequent investigations. Retention action should be considered for all reports and is to be in accordance with MATS Part 1 and any local procedures.

BOX53: It is important to ensure that any involved agency (eg Pilot, Operator, ATSU) is informed of the reporting action. This box should also indicate those organisations required by MATS Part 1 to be informed (eg AAIB for an aircraft accident).

REPORTING TIME

Reports must be despatched within 96 hours of the event unless exceptional circumstances prevent this.

ACKNOWLEDGEMENT OF REPORTS

Acknowledgement of reports (other than CONFIDENTIAL see below) is normally given via the SIDD's monthly list of 'ATC Reported Occurrences'. If, exceptionally, individual acknowledgement is required please contact the SIDD direct.

UNIT MANAGEMENT ACTION

Reporters are requested to send a copy to the Unit Management. This is for local assessment and any immediate follow-up action. Additional input and/or covering comment from Unit Management is highly desirable for both SIDD evaluation and any follow-up investigation.

CONFIDENTIAL REPORTS

A report may be submitted confidentially. Please clearly annotate the top of the form 'CONFIDENTIAL'. The second copy need not be forwarded to local management. BOXES 46 to 55 should be completed. The CAA will respect the confidentiality and the Head of SIDD will contact you personally.

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Advice on the Completion of the CAA ATC Occurrence Report Form –

CA1261

Use and Explanation of Terms in Box 1

Accident A UK Reportable Accident.

Aircraft Proximity

(Airprox)

An AIRPROX is a situation in which, in the opinion of a pilot or acontroller, the distance between aircraft as well as their relativepositions and speeds were such that the safety of the aircraftinvolved was, or may have been, compromised.

Incident Any Occurrence not appropriate to the other categories.

ABANL An Alleged Breach of Air Navigation Legislation, as aSupplementary Report whenever CA939 action is taken.

Infringement An alleged infringement of regulated airspace.

Explanatory Notes (Please also refer to CAP493: Manual of Air Traffic Services(MATS) Part 1, Section 6).

General Complete ALL boxes as appropriate. IF NOT APPLICABLE, useN/A or if NOT KNOWN, use N/K. Avoid use of technical jargon,hieroglyphics and abbreviations.

Box 1 Should the Occurrence involve more than one category (e.g. anABANL could arise from an INFRINGEMENT), circle bothcategories.

Boxes 7 to 30 These boxes cater for up to three involved aircraft. Use thenarrative for additional aircraft.

Box 36 More than one element could be circled (e.g. CLASS A andAWY).

Box 37 More than one element must be circled (e.g. CONTROL,RADAR and AREA).

Box 39 Must be completed if prescribed separation was required to beachieved in accordance with MATS Part 1 or 2.

Box 40 Should contain the reporter’s estimate, where possible, of theminimum separation achieved and must be completed for anAIRPROX. This will be coded for computer input purposes andamended, if necessary, after investigation.

Box 44 This box should contain a simple, one line statement,summarising the occurrence, i.e. ‘co-ordination problems’, ‘levelbust’, ‘overload’ etc.

Box 51/52 Relevant RTF and Radar recordings can be vitally important tosubsequent investigations. Retention action should beconsidered for all reports and is to be in accordance with MATSPart 1 and any local procedures.

Box 53 It is important to ensure that any involved agency (e.g. Pilot,Operator, ATSU) is informed of the reporting action. This boxshould also indicate those organisations required by MATS Part1 to be informed (e.g. AAIB for an aircraft accident).



Acknowledgement of Reports

Acknowledgement of reports (other than CONFIDENTIAL – see below) is normallygiven via SIDD’s monthly ‘Occurrence Listings’. If, exceptionally, individualacknowledgement is required please contact the SIDD direct.

Unit Management Action

Additional input and/or covering comment following Unit Management’s localassessment and any immediate action taken is highly desirable for both SIDDevaluation and any follow-up investigation.

Confidential Reports

An occurrence may be reported confidentially. Please clearly annotate the top of theform ‘CONFIDENTIAL’ and mark the envelope ‘Personal for Head of SIDD’. A copyneed not be forwarded to local management. The SIDD will respect the confidentialityand contact you personally (see paragraph 6.1.8).



Engineering Occurrence Report Form – CA1262

8 Equipment Type/Manufacturer 9 Frequency 10 Callsign

ACCIDENT INCIDENT PROCEDURAL FAILURE HAZARD

1 Categories of Occurrence

2 Occurrence Location 7 Service Affected

Control/Advisory/Procedural/Radar/GMC Approach/Area/Aerodrome/Information/Air Navigation

12 Facility Configuration

In/Out-of-service, Main-Mode/Standby/Test

Channel A(1)/B(2)/Other:

External Information Source:

13 Equipment Status

Planned/Unplanned Outage,Serviceable/Degredation/Unserviceable,Routine/Corrective Maintenance,Modification/Replacement

14 Previous

Defects/Occurrences?

Yes/No/Not Known

15 RTF Frequencies/

Radar Source

6 ATS Facility

RTF/Radar/Nav-aidOther:

16 NARRATIVE - use a diagram if necessary (attach copies of all relevant information)

CA 1262 (Nov 2002)

NOTES:(i) See Instructions and Explanatory Notes.(ii) When completed, please send to : Safety Investigation and Data Department (SIDD), Civil

Aviation Authority, Safety Regulation Group, Aviation House, Gatwick Airport South, WestSussex, RH6 0YR.

(iii) Complete and/or circle boxes 1-25 as appropriate.PLEASE USE BLACK INK

ATS ENGINEERING OCCURRENCE REPORT

3 Date

4 Time (UTC)

5 Duration

11 Equipment Location

22 Start time and duration of shift

23 Address & Telephone number (if the reporter wishes to be contacted privately)

24 Signature

25 Date

21 Organisation/Position

20 Name17 Recordings impounded

No/Yes - Details

19 Other fault report action

ATC CA 1261/Local Reporting/Other:

18 Can the information be disseminated in the interests of flight safety?

YES/NO

continue on additional forms if necessary

CAA Occurrence NumberUK Civil Aviation Authority

Original to SIDDMake additional photocopies as required

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ADVICE ON THE COMPLETION OF THE CAA ATS ENGINEERING MOR FORM CA1262

USE AND EXPLANATION OF TERMS IN BOX 1

Circle one or more category of Occurrence.

ACCIDENT: A UK reportable accident.INCIDENT: A reportable occurrence (see 'General').PROCEDURAL: A reportable occurrence attributed to procedural aspects including operation and

maintenance of any facility on the ground.FAILURE: A reportable occurrence attributed to any defect in or malfunctioning of any facility on the

ground.HAZARD: A potential accident, incident or failure.General: A reportable occurrence is defined in the Air Navigation Order or CAP 382.

EXPLANATORY NOTES (Please also refer to MATS Part 1, Section 6)

GENERAL: Complete all boxes. If NOT APPLICABLE use N/A, or if NOT KNOWN use N/K. Jargon and uncommon abbreviations are to be avoided.

BOX 1: Location of Occurrence.BOX 5: The period over which the Occurrence condition existed. Instantaneous, indefinite or

unknown classifications must be identified.BOX 6: The facility type must be circled or stated.BOX 7: More than one element could be circled.

DETAILS OF THE EQUIPMENT ATTRIBUTING TO THE OCCURRENCEBOX 9: Frequency (Radio) appropriate to equipment and occurrence, if applicable.BOX 10: Callsign - Navaid identification, SSR code or RTF callsign.BOX 11: Location - identify station or other physical location of equipment.BOX 12: More than one element could be identified. Additional channels, diversity, etc must be

stated where applicable. External information source completed with equipment and/or the station/ location.

BOX 13: More than one element could be circled. The categories apply to the subject equipment at the time of the Occurrence.

BOX 15: Identification of appropriate RTF frequencies/radar source is necessary to secure recordings which may be vital to subsequent investigations.

BOX 17: If records impounded, state source, effective date and retaining station.BOX 19: Other fault reporting action, including contact with agencies, must be stated. It is important

to ensure that any involved agency is informed of the reporting action. Normal, immediate fault action takes precedence over MOR reporting action.

ACKNOWLEDGEMENT OF REPORTSAcknowledgement of reports (other than CONFIDENTIAL - see below) is normally given via the SIDD's monthly list of 'ATC Reported Occurrences'. If, exceptionally, individual acknowledgement is required please contact the SIDD direct.

UNIT MANAGEMENT ACTIONReporters are requested to send a copy to Unit Management. This is for local assessment and any immediate follow-up action. Additional input and/or covering comment from Unit Management is highly desirable for both SIDD evaluation and any follow-up investigation.

CONFIDENTIAL REPORTSA report may be submitted confidentially. Please clearly annotate the top of the form 'CONFIDENTIAL'. Thesecond copy need not be forwarded to local management. BOXES 20 to 25 should be completed. The CAA will respect the confidentiality and the Head of SIDD will contact you personally.



Advice on the Completion of the CAA ATS Engineering Occurrence

Report Form – CA1262

Use and Explanation of Terms in Box 1

Circle one or more category of Occurrence.

Explanatory Notes

Accident A UK Reportable Accident.

Incident A reportable occurrence.

Procedural A reportable occurrence attributed to procedural aspects including operationand maintenance of any facility on the ground.

Failure A reportable occurrence attributed to any defect in or malfunctioning of anyfacility on the ground.

Hazard A potential accident, incident or failure.

General Complete ALL boxes. If not applicable, use N/A or if not known, useN/K. Jargon and uncommon abbreviations are to be avoided.

Box 2 Location where occurrence happened.

Box 5 The period over which the occurrence condition existed. Instantaneous,indefinite or unknown classifications must be identified.

Box 6 More than one element could be circled, other types of facility can becompleted if necessary.

Box 7 More than one element could be circled.

Box 9 Frequency (Radio) appropriate to equipment and occurrence, ifapplicable.

Box 10 Callsign – Navaid Identification, SSR code or RTF callsign.

Box 11 Location – identify station or other site of equipment.

Box 12 More than one element could be identified. Additional channels,diversity, etc. must be stated where applicable. Data source completedwith equipment and/or the station/location.

Box 13 More than one element may be circled. The categories apply to thesubject equipment at the time of the Occurrence.

Box 15 Identification of appropriate RTF frequencies/Radar Source is necessaryto facilitate procurement of recordings which may be vital to subsequentinvestigations.



Acknowledgement of Reports

Acknowledgement of reports (other than CONFIDENTIAL – see below) is normallygiven via the SIDD’s monthly ATC Occurrence List. If, exceptionally, individualacknowledgement is required please contact the SIDD direct.

Unit Management Action

Additional input and/or covering comment following Unit Management’s localassessment and any immediate action taken is highly desirable for both SIDD and anyfollow-up investigation.

Confidential Reports

An occurrence may be reported confidentially. Please clearly annotate the top of theform ‘CONFIDENTIAL’ and mark the envelope ‘Personal for Head of SIDD’. A copyneed not be forwarded to local management. The SIDD will respect the confidentialityand contact you personally (see paragraph 6.1.8).

Box 17 If records are impounded, state source, effective date and retainingstation.

Box 19 Other fault reporting action, including contact with agencies, must bestated. It is important to ensure that any involved agency is informed ofthe reporting action. Normal immediate fault action takes precedenceover MOR reporting action.



Appendix B Occurrences Required to be Reported

1 Introduction

1.1 The objectives of occurrence reporting and the formal definition of a reportableoccurrence are contained in the legislation and further amplified in paragraphs 1 and5 of this CAP. Reporters should ensure that the content of their reports meets thecriteria and guidance laid out below. Particular emphasis should be paid to ensuringthat day to day operational anomalies, technical defects and routine reliability issuesare dealt with via the normal organisational systems and procedures.

1.2 The Occurrence Reporting Scheme is an essential part of the CAA’s monitoringfunction; it is complementary to the normal day to day procedures and ‘control’systems (e.g. AOC, Company Approvals, etc.) and is not intended to duplicate orsupersede them. The Occurrence Reporting Scheme aims to identify thoseoccurrences where the routine control procedures have failed. To achieve thisobjective the criteria for a reportable occurrence need to be set above (in terms of theeffects on safety) the normal day to day defects and minor incidents.

1.3 Those occurrences which must always be reported (e.g. fires, uncontained enginefailures, critically low fuel states, close proximity between aircraft, etc.) can easily belisted but it is impossible to define precisely every significant hazard which requiresreporting. What is judged to be reportable on one class of aircraft may not be so onanother and the absence or presence of a single factor, human or technical, cantransform a minor occurrence into a significant hazard or an accident. Judgement bythe reporter of the degree of hazard or potential hazard involved is therefore essentialin many cases.

1.4 Within the above constraints, this Appendix lists the types of occurrence which, in theview of the CAA, are likely to fall within the definition of a reportable occurrence inwhich case they must therefore be reported. Whilst the Appendix lists the majority ofoccurrences which shall normally be reported it cannot be completely comprehensiveand any other occurrences judged, by those involved, to meet the criteria shall bereported.

1.5 Practical and effective working of the Occurrence Reporting Scheme requires aconstructive approach and resolve on the part of all reporters and others involved tomake the Scheme a successful and worthwhile safety reporting programme.

1.6 In the case of organisations providing a service or facility for aircraft operating over orin the UK (e.g. Air Traffic Services, airfields etc.) any occurrence meeting the requiredcriteria should be reported regardless of the nationality of the aircraft involved

2 Aircraft Flight Operations

The following should be reported by Flight Crew:

2.1 Control of the Aircraft

• Rejected take-off resulting from or producing a hazardous or potentially hazardoussituation (e.g. at speeds close to, or above, V1).

• Go around producing a hazardous or potentially hazardous situation.

• Unintentional significant deviation from intended track or altitude (more than300 ft), caused by a procedural, systems or equipment defect or human factor.

Appendix B Page 1March 2003


• Descent below decision height/altitude or minimum descent height/altitude ininstrument landing conditions.

• Heavy landing, a landing deemed to require a ‘heavy landing check’.

• Unintentional contact with the ground, including touching down before the runwaythreshold.

• Over-running the ends or sides of the defined runway or landing strip.

• Significant inadvertent reduction in airspeed.

• Significant loss of control from any cause.

• Approach to, landing on, lining up on or taking off from a wrong runway or airfield.

• Occurrence of a ‘stick push’ operation, other than for training or test purposes.

• Operation of any primary warning system associated with manoeuvring of theaircraft e.g. configuration warning, stall warning (stick shake), over speed warningetc. unless:

a) the crew conclusively established that the indication was false, at the time itoccurred, or

b) the indication is confirmed as false immediately after landing.

provided that, in either case, the false warning did not result in difficulty or hazardarising from the crew response to the warning.

• Reversion to manual control of powered primary controls, other than for training ortest purposes.

• Loss or malfunctioning of any rotorcraft AUTO stabiliser mode.

• Inadvertent incorrect operation of any controls which resulted in, or could haveresulted in, a significant hazard.

• A hazard or potential hazard which arises as a consequence of any deliberatesimulation of failure conditions for training, system checks or test purposes.

• In flight fuel quantity critically low or exhausted.

• Significant fuel imbalance.

• Incorrect setting of an SSR code.

• Incorrect setting of an altimeter sub-scale.

• Significant incorrect programming of navigation equipment.

• Flight at a level, or on a route, different from that allocated.

• Incorrect receipt or interpretation of RTF messages which resulted in, or couldhave resulted in, a significant hazard.

• EGPWS ‘warning’ when:

a) the aircraft comes into closer proximity to the ground than had been planned oranticipated; or

b) the warning is experienced in IMC or at night and is established as having beentriggered by a high rate of; or

c) the warning results from failure to select landing gear or land flap by theappropriate point on the approach; or



d) any difficulty or hazard arises or might have arisen as a result of crew responseto the ‘warning’ e.g. possible reduced separation from other traffic. This couldinclude warning of any Mode or Type i.e. genuine, nuisance or false.

• GPWS ‘alert’ when:

a) any difficulty or hazard arises, or might have arisen, as a result of crew responseto the ‘alert’.

• ACAS Resolution Advisory except for an “unnecessary alert”, e.g. when triggeredby a high rate of climb/descent but standard separation not compromised.

• Repetitive arisings at an excessive frequency of a specific type of occurrencewhich in isolation would not be considered ‘Reportable’, e.g. a high frequency of:

a) minor loading errors at a particular airfield,

b) GPWS nuisance warnings at a particular airfield.

NOTE: In such cases it is expected that the reporter will submit a single occurrencereport together with the supporting evidence of high frequency and/or ratewhen it is considered that such a situation has been reached. Further reportsshould be submitted if the situation remains unchanged.

2.2 Emergencies

• The use in flight or on the ground of any emergency equipment or prescribedemergency procedures in order to deal with a situation.

• The use of any non-standard procedure adopted by the flight crew to deal with anemergency.

• The declaration of an emergency, (‘Mayday’ or ‘PAN’).

• An emergency, forced or precautionary landing.

• Failure of any emergency equipment or procedures to perform satisfactorilyincluding when being used for training or test purposes.

2.3 Crew Incapacitation

• Incapacitation of any member of the flight deck operating crew, including thatwhich occurs prior to departure if it is considered that it could have resulted inincapacitation after take-off.

• Incapacitation of any member of the cabin crew which renders him/her unable toperform essential emergency duties.

2.4 Injury

• Any significant injury to any person which directly results from the operation of theaircraft or its equipment but which is not considered to constitute a ReportableAccident.

2.5 Other Incidents

• A lightning strike which resulted in significant damage to the aircraft or the loss ormalfunction of any essential service.

• A hail strike which resulted in significant damage to the aircraft or the loss ormalfunction of any essential service.

• A bomb threatNOTE: Security occurrences may require to be reported

under Department for Transport Rules.• A hijack



• Wake vortex encounter – an encounter resulting in significant handling difficulties(NB: The CAA will pass suitably dis-identified copies of reports relating to wakevortex incidents to the National Air Traffic Services Wake Vortex Analysis Team).

• A bird strike which resulted in significant damage to the aircraft or the loss ormalfunction of any essential service.

• Turbulence encounter – an encounter resulting in injury to occupants or deemedto require a ‘turbulence check’ of the aircraft.

3 Aircraft and Equipment – Failures, Malfunctions and Defects

3.1 The following should be reported by Flight Crew or Maintenance Staff:

3.1.1 Structure

• Any damage or deterioration (i.e. fractures, cracks, corrosion, delamination,disbonding etc.) resulting from any cause to:

a) primary structure or a principal structural element (as defined in themanufacturer’s Repair Manual) where such damage or deterioration exceedsallowable limits specified in the Repair Manual and requires a repair or completeor partial replacement of the element;

b) secondary structure which consequently has, or may, have endangered theaircraft.

• Any damage or deterioration (as above) found as a result of compliance with anAirworthiness Directive or other mandatory instruction issued by a RegulatoryAuthority, when:

a) it is detected for the first time by each operator or organisation implementingcompliance;

b) on any subsequent compliance where it exceeds the permissible limits quotedin the instruction and/or published repair/rectification procedures are notavailable. For example, a report is required if the condition found necessitates arequest to the Design Authority or Regulatory Authority for an extension oflimits and/or special repair/rectification schemes or procedures;

c) separation from the aircraft in flight of any part of the aircraft;

3.1.2 Engines – All aircraft types

• Flameout, shutdown or significant malfunction of any engine when:

a) it occurs at a critical phase or time (e.g. V1, or during approach/landing);

b) exceptional circumstances exist or unforeseen consequences arise (e.g.uncontained failure, fire, aircraft handling problems etc.);

c) standard operating procedures, drills etc. could not be satisfactorilyaccomplished;

d) inability, by use of normal procedures, to shutdown an engine or to controlpower, thrust or rpm;

e) significant engine overspeed;

3.1.2.1 Aircraft types with one or two engines

Flameout, shutdown or significant malfunction of any engine.



3.1.2.2 Aircraft types with three or more engines

Flameout, shutdown or significant malfunction of more than one engine.

3.1.3 Systems and Equipment. For any occurrence involving a system or componentwhich is monitored/protected by a warning and/or protection system (for example –fire detection/extinguishing) the occurrence report should always state whether suchsystem(s) functioned properly.

3.1.3.1 All aircraft types

• Fire or explosion.

• Smoke or noxious fumes in the aircraft which resulted in the use of emergencyequipment or procedures.

• Uncontained failure or significant overspeed of any high speed rotating component(for example: Auxiliary power unit, air starter, air cycle machine, air turbine motor).

• Significant deviation of the aircraft from its intended flight path, attitude, airspeedor altitude resulting from system or equipment failure, malfunction or defects.

• Significant contamination of aircraft systems and equipment arising from thecarriage of baggage or cargo.

• Failure, malfunction or defect of any system or equipment found as a result ofcompliance with an Airworthiness Directive or other mandatory instruction issuedby a Regulatory Authority when:

a) it is detected for the first time by each operator or organisation implementingcompliance.

b) on any subsequent compliance where the permissible limits or tolerancesquoted in the instruction are exceeded and/or published rectification proceduresare not available. For example, a report is required if the condition foundnecessitates a request to the Design Authority or Regulatory Authority for anextension of limits or tolerances and/or special rectification or procedures.

• Failures or defects to any part subject to a finite life or any rotorcraft ‘critical items’(as defined in Manufacturer’s Manuals).

• Loss, significant malfunction or defect of any system, sub-system or set ofequipment (for example: ATA 21 Air, 22 Autoflight, 23 Communications, 24Electrical Power, 26 Fire Protection, 27 Flight Control, 28 Fuel, 29 Hyd Power, 30Ice Protection, 32 Landing Gear, 34 Navigation, 36 Pneumatics, 63 & 65 Rotordrives, 67 Rotor flight control) when:

a) it occurs at a critical phase or time, relevant to the operation of that system; or

b) relevant back-up systems, sub-systems or equipment did not performsatisfactorily; or

c) exceptional circumstances existed or unforeseen consequences arose; or

d) standard operating procedures, drills etc. could not be satisfactorilyaccomplished.

• Leakage of hydraulic fluids, oil or other fluids which resulted in a fire hazard orpossible hazardous contamination of aircraft equipment or structure.

• Asymmetry of flaps, slats, spoilers etc.

• Limitation of movement, stiffness or poor or delayed response in the operation ofprimary flight control systems or their associated tab and lock systems.



• Significant interference with normal control of the aircraft or degradation of flyingqualities.

• Inability to achieve the intended aircraft configuration for any flight phase (forexample: landing gear and its doors, flaps, stabiliser, slats etc.).

• Significant loss of braking action.

• Leakage of fuel which resulted in major loss, fire hazard or significantcontamination.

• Malfunction or defects of the fuel jettisoning system which resulted in inadvertentloss of significant quantity, fire hazard, hazardous contamination of aircraftequipment or inability to jettison fuel.

• Fuel system malfunctions or defects which had a significant effect on fuel supplyand/or distribution.

• Operation of any primary warning system associated with aircraft systems orequipment unless:

a) the crew conclusively established that the indication was false at the time itoccurred; or

b) the indication was confirmed as false immediately after landing. Provided thatin either case the false warning did not result in difficulty or hazard arising fromthe crew response to the warning.

• Malfunction or defect of any indication system when the possibility of significantmisleading indications to the crew resulted.

• Failure of any emergency system or equipment, including all exit doors andlighting, to perform satisfactorily, including when being used for training or testpurposes.

• Significant failures or defects of a propeller or rotor.

• Significant overspeed or inability, by normal procedures, to control speed or pitchof a propeller or rotor.

• Inability, by normal procedures, to feather or unfeather a propeller.

3.1.3.2 Aircraft types with single main systems, sub-systems or sets of equipment (for

example, as ‘All Aircraft’ above)

• Loss, significant malfunction or defect in any main system, sub-system or set ofequipment.

3.1.3.3 Aircraft types with multiple independent main systems, sub-systems or sets of

equipment (for example, as per ‘All Aircraft’ above)

• Loss, significant malfunction or defect of more than one main system, sub-systemor set of equipment.

3.1.4 General

• A malfunction, failure or defect to any system or component not normallyconsidered as reportable (for example, furnishing and cabin equipment, watersystems, items included in the Minimum Equipment List) where thecircumstances of the occurrence or its association with other occurrences resultedin endangering of the aircraft or its occupants.



• Possible endangering of the aircraft resulting from a high repetitive frequency of atype of occurrence which in isolation would not be reportable – unless thefrequency is already being monitored under an approved maintenance programme.

NOTE: In such cases a single occurrence report together with supportingevidence of high frequency or rate is required.

• Incorrect assembly of parts or components of the aircraft where the condition wasnot found as a result of the inspection and test procedures required for thatspecific purpose.

• Any other malfunction, failure or defect which is considered to have endangeredor might have endangered the operation of the aircraft.

4 Ground Services, Facilities or Equipment

4.1 The following should be reported as indicated:

4.1.1 Air Traffic Control Services - by Flight Crew/ATCOs/Ground Ops Support Staff.

• Provision of significantly incorrect, inadequate or misleading information from anyground sources, e.g. ATC, ATIS, Meteorological Services, maps, charts, manuals,etc.

• Provision of less than prescribed terrain clearance.

• Provision of incorrect altimeter setting.

• Misidentification of aircraft by an ATCO or radar operator.

• Incorrect transmission, receipt or interpretation of significant messages.

• Airprox and any occurrence in which separation between aircraft is less than thatprescribed for the situation.

• Non-compliance with prescribed let-down or departure procedures or any ATC/ATM instruction.

• Declaration of an emergency (‘Mayday’ or ‘Pan’) by an aircraft.

• Unauthorised infringement of any form of regulated airspace.

• Unauthorised or illegal RTF transmissions.

• ATC Overload reports

• Declaration of an ACAS Resolution Advisory by an aircraft

4.1.2 Navigation and Communications Equipment etc. – failures, malfunctions or

defects - by Flight Crew/ATCO/ATS Maintenance Staff.

• Total failure of navigation system or subsystem being used by an aircraft.

• Total failure of communications system.

• Total failure of radar system or subsystem.

• Failure or unplanned shutdown of a major operational ATC computer systemrequiring reversion to manual back up and resulting in disruption to the normal flowof air traffic

• Significant malfunction or deterioration of Service.

• Significant deficiency in maintenance.



• Repetitive events of a specific type of occurrence which in isolation may not beconsidered reportable (e.g. excessive monitor alarms).

• Provision of erroneous information in the absence of any alarms.

4.1.3 Airfields and Airfield Facilities - by Flight Crew/Airfield Staff/ATCOs.

• Failure or significant malfunction of airfield lighting.

• Major failure or significant deterioration of surfaces of runways or aircraftmanoeuvring areas.

• Runways or aircraft manoeuvring areas obstructed by aircraft, vehicles or foreignobjects, resulting in a hazardous or potentially hazardous situation.

• Runway incursions

• Errors or inadequacies in marking of obstructions or hazards on runway or aircraftmanoeuvring areas.

• Collision between a moving aircraft and any other aircraft, vehicle or other groundobject.

• Aircraft departing from a paved surface which results in, or could have resulted in,a significant hazard.

• Jet or prop blast incidents resulting in significant damage or serious injury.

• Significant spillage of fuel on airfield ramps.

4.1.4 Passengers/Baggage/Cargo - by Flight Crew/Ground Support Staff.

• Difficulty in controlling intoxicated, violent or armed passengers.

• Incorrect loading of passengers, baggage or cargo, likely to have a significant effecton aircraft weight and balance.

• Incorrect stowage of baggage or cargo likely in any way to hazard the aircraft, itsequipment or occupants or to impede emergency evacuation (includes handbaggage).

• Inadequate storing of cargo containers or substantial items of cargo.

• Significant contamination of aircraft structure, systems or equipment arising fromthe carriage of baggage or cargo.

• Presence of a stowaway(s).

4.1.5 Aircraft Ground Handling/Servicing - by Flight Crew/ATS Maintenance Staff/Ground Support Staff.

• Loading of incorrect fuel quantities likely to have a significant effect on aircraftendurance, performance, balance or structural strength.

• Loading of contaminated or incorrect type of fuel or other essential aircraft fluids(includes oxygen and potable water).

• Significant spillage of fuel.

• Failure, malfunction or defect of ground equipment used for test/check of aircraftsystems and equipment when the required routine inspection and test proceduresdid not clearly identify the problem before safe operation of the aircraft could havebeen affected.

• Non compliance or significant errors in compliance with required maintenance/servicing procedures.



4.1.6 Ground Staff Incapacitation - by Flight Crew/Ground Staff

• When an aircraft was, or could have been, endangered by the impairment of anymember of ground staff (e.g. Aircraft Maintenance Staff, Air Traffic Controllers, AirTraffic Services Maintenance Staff, Airfield Support Staff etc.)

4.1.7 Any other occurrence of any type considered to have endangered, or which mighthave endangered, the aircraft or its occupants



Appendix C Occurrence Reporting System

1 Occurrence Publications

1.1 All occurrence publications are provided free to those organisations participatingdirectly in the reporting scheme i.e. the UK civil aviation industry and supportingorganisations. For an annual subscription publications are available to any otherorganisation worldwide which has a legitimate interest in flight safety. Manyorganisations subscribe to this service. The following publications containinginformation on occurrences are currently available from the Civil Aviation AuthoritySafety Regulation Group.

NOTE: Where information on occurrences or items of general safety information arerelevant to more than one type of operation, the information may appear inmore than one publication.

2 From the Safety Investigation and Data Department

2.1 The Digest – issued monthly

2.1.1 This contains a selection of recently reported occurrences which are considered tohave a particular safety message to convey.

2.2 Occurrence List – issued monthly

2.2.1 This is a computer listing of all new occurrences which have been recorded during theperiod. Each occurrence contains the essential details (e.g. aircraft type or service/facility involved, flight phase, etc.) together with a brief narrative describing theoccurrence. The top right hand entry for each occurrence is the ‘Reporter’ so that thelist may also provide a rapid acknowledgement of the occurrences received by CAA.

2.2.2 The Occurrence List is produced in 4 versions: Fixed Wing (aircraft more than40,750 kg), Fixed Wing (less than 40,750 k.g.), Rotary Wing and ATC. Someoccurrences (e.g. those relating to balloons, gliders and ground equipment/services)appear in all versions. An additional listing contains details of those reports consideredto be outside the MOR criteria.

2.2.3 Also included in the appropriate Occurrence List are those occurrences which were‘Open’ for CAA investigation and which have been ‘Closed’ during the period.Previously entered occurrences for which significant new information has becomeavailable during the period may also appear in any one (or all) of the Lists.

2.3 Follow-up Action on Occurrence Report (FACTOR) – issued as required

2.3.1 These reports contain details of the CAA response to Safety Recommendationscontained in an Accident Report or Bulletin issued by the Air Accidents InvestigationBranch. Circulation is with The Digest.

2.4 Progress Report – CAA Responses to Air Accidents Investigation Branch (AAIB)

Safety Recommendations

2.4.1 These Reports are published annually in response to the Secretary of State forTransport’s request to the CAA for reports on the status and progress on itsresponses to the Recommendations made to the CAA by the Air AccidentsInvestigation Branch.

Appendix C Page 1March 2003


3 From the United Kingdom Airprox Board (UKAB) Aircraft Proximity

Hazards (Airprox) – Report

3.1 The AIRPROX Report Book is produced twice yearly by the UKAB, an independentbody. This book collates the AIRPROX occurrence reports. The UKAB assesses thedegree of risk, determines causal factors and may make Recommendations to theCAA. The Report also records the CAA’s Responses to any such Recommendations.

4 From the Safety Promotion Section – General Aviation Department

4.1 General Aviation Safety Information Leaflet (GASIL)

This leaflet contains summaries of the more significant occurrences affecting generalaviation aircraft and operations. Factual information, CAA comment and, whenappropriate, advice on remedial or preventative measures are included. In addition itcontains other items of general safety information relevant to GA operations. Acomputer listing of all GA occurrences recorded during the 2 months prior topublication is enclosed.

Appendix C Page 2March 2003

CAP 382 - The Mandatory Occurence Reporting Scheme · CAP 382 The Mandatory Occurrence Reporting...

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