Aerodrome Event Report

Aerodrome Notification Form

This form is to be used to report any Aerodrome Event.

Note: If an injury was sustained or there was a Health & Safety Risk due to the incident described in this report an Incident Notification Form must also be completed

Note: This form is only to be used for the incident types detailed in Section E of this form. Form. For all other incident categories complete the Incident Notification Form.

Section A - Location Details

Report Type

Location *

DarwinAlice SpringsTennant Creek

Work Area *

Location *

Match information provided above to the available filters when entering into RMSS. If no suitable filter is available contact HSE Department - Ext 969

Section B - Incident Occurrence Details

Date and Time of Incident *

Incident Type

Incident Severity *

LowMediumHighExtreme

Is this a “NOTIFIABLE INCIDENT” *

YesNo

Section C - Reported By

First Name *

Last Name *

Employer *

Phone Number *

Email Address *

Date Reported *

Section D - Incident Details

(Provide details as to the cause of the incident & why it occurred)

Actual Location *

Describe the Incident *

Contributing Factors *

What Actions Were Taken Immediately *

Additional Notes

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Section E - Incident Type

Please specify

Suggested remedial actions to prevent reoccurrence

Log Entry Reference #

Contact #

Signed *

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Operations Manager Tasks

Event entered into HSE Report *

YesNo

AVCRM SMS report entered *

YesNo

Further Investigation Required

YesNo/ CLOSED

Report ID

Investigation Assigned to

Name *

Email *

Follow up actions required *

Operation Manager Name *

Date *

Signed *

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Received by Health and Safety Manager

Name *

Contact *

Signed *

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Date *

*You will also receive a copy of this completed form for your records after submitting it.

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