Civil Aviation Administration of Vietnam

Ministry of TransportCIVIL AVIATION ADMINISTRATION OF VIETNAM

OCCURRENCE REPORT FORMIf report is CONFIDENTIAL - mark clearly at the top and provide contact address /Tel no. your wish be respected.

When completed, please send to: Flight Safety Standard Department - CAAV

119 Nguyen Son-Long Bien Dist. Hanoi - Vietnam

Email: fssd@caa.gov.vn

Fax: 04-8.271.993 / 8.732.291

Tel: 04-8.271.992

AIRCRAFT TYPE & SERIES

REGISTRATION

OPERATOR

DATE

LOCATION/POSITION/RW

TIMEUTCDAYNIGHT

TWINIGHT

FLIGHT NRROUTE FROMROUTE TOFL/ALT/HT (FT)IAS (KTS)ETOPS

YESNO

NATURE OF FLIGHT

PAXFREIGHTPOSITIONINGFERRYTESTTRAININGBUSSINESSAGRICULTURESURVEYPLEASURECLUB/GROUPPRIVATEPARACHUTINGTOWING

FLIGHT PHASE

PARKEDTAXYINGTAKE OFFINITIAL CLIMBCLIMBCRUISEDESCENTHOLDINGAPPROACHLANDINGCIRCUITAEROBATICSHOVER

EVIRONMENTAL DETAILS

WINDCLOUDPRECIPITATIONOTHER METEOROLOGICAL CONDITIONSRUNWAY STATE

DIRNSPEED (kts)TYPEHT(ft)8thRAINSNOWSLEETHAILVISIBILITYICINGTURBULENCEOAT(0 C)DRYWETICESNOWSLUSH

LIGHTMODHEAVYKM/MICEMODSEVEREICEMODSEVERECATEGORYIIIIII

BRIEF TITLE

DESCRCIPTION OF OCCURRENCEContinue on next page as necessary

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

GROUND STAFF REPORT

A/C CONSTRUCTORS NR

ENGINE TYPE / SERIES

ETOPS APPROVEDGROUND PHASEAIRCRAFT BELOW 5700 KG ONLY - MAINTENANCE ORGANISATION

TEL No

YESNOMAINTENANCE

GROUND HANDLING

UNATTENDED

COMPONENT / PART

MANUFACTUREPART NRSERIES NRMANUAL REFCOMPONENT OH/REPAIR ORGANISATION

DECRCIPTION OF OCCURENCE CONTINUED

ORGANISATION AND APPROVAL REF.

NAMEPOSITIONSIGNATUREDATE

If report is voluntary (ie, not subject to mandatory requirements) can the information be published in the interest of safety?YESAdress and tel No. (if reporter wishes 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 manufacture 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.

NO

REPORTING ORGANISATION - REPORT

ORGANISATION COMMENTS - ASSESSMENT / ACTION TAKEN / SUGGESTIONS TO PREVENT

UTILISATION - AIRCRAFTUTILISATION - ENGINE / COMPONENTMANUFACTURE

ADVISE

TOTALSINCE OH/REPAIRSINCE INSPECTIONTOTALSINCE OH/REPAIRSINCE INSPECTIONYESNO

HOUR

CYCLES

LANDINGSHOUR

CYCLES

LANDINGSFDR DATA

RETAINED

ORGANISATION

TEL / FAXREPORTER REFREPORTREPORTER INVESTIGATIONYESNO

NEWSUPPLNILCLOSEDOPEN

NAME

POSITIONSIGNATUREDATE

CAAV Form 14B

Occurrence Ref . Number: