GROUND SAFETY REPORT

safety@kamair.com

A A A N N N D D M M Y Y
Tracking Number Form KAM/SD-003

1.Reference Information

Date: Flight №: A/C Reg.: Place: Time:

2. Detection Phase
 Check-in of passengers   Towing   Non-scheduled maintenance 
 Security check of passengers   Ramp driving   Airworthiness review 
 Bridge Operations   Taxi run-up   Pre-flight inspection 
 Boarding of passengers   Equipment position/staging   Scheduled maintenance 
 Ground handling   Load/Offload   Other, specify: 
3. Occurrence Description

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Attach additional sheets of paper if necessary

Name: Position:

ID №: Mob. № E-mail: Signature:

4. Contributing Acts (Human Factors) (should be filled by responsible manager)

 Lack of Communication   Lack of Teamwork   Lack of Assertiveness 
 Complacency   Fatigue   Stress 
 Lack of knowledge   Lack of Resource   Lack of suspension 
 Distraction   Pressure   Inadequate Instructions 
5. Contributing Factors (should be filled by responsible manager)
 Inadequate standard/procedure   Lack of suspension   Safety practices not enforce 
 Insufficient manpower   Inadequate instructions   Other, specify: 
 Lack of relevant training for task   A/C settling/movement 
6. Unsafe Conditions (should be filled by responsible manager)
 Defective equipment   Significant Damage/Deterioration   Incorrect Parts Supplied 
 Inadequate lighting   A/C Docs out of Compliance   Incorrect Parts/Fluids Used 
 Work surface condition   Spillage Causing Hazard to A/C   Incorrect Assembly/Installation 
 Weather/visibility   Parts Missing in Flight   U/S on Fit 
 Congested work area   Result of AD or Alert SB   DMI Raised 
 Significant System Failure   Transit Damage   Other, specify: 
Component(s) Description Part No. Serial No. TAG No. ATA Chapter

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 GROUND SAFETY REPORT
safety@kamair.com

7. Cause of Occurrence (should be filled by responsible manager)

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8. Action to Prevent Re-occurrence (should be filled by responsible manager)

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9. Responsible Manager Name: Position:

Date: Signature:

10. Risk Assessment Risk before Corrective Action Risk after Corrective Action

11. Action Accepted Yes  No  12. Further Action Required Yes  No 

13. Director of Safety Comments

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14. Modified / New Corrective / Preventive Action(s) description (should be filled by responsible manager)

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15. Residual Risk Is the Risk ALARP? Yes  No  16. Status of the Report Open  Closed 

17. Director of Safety Date: Signature:

SAFETY RISK ASSESSMENT MATRIX

SEVERITY
A B C D E
Catastrophic Hazardous Major Minor Negligible
5A 5B 5C 5D 5E
5 Frequent
Unacceptable Unacceptable Unacceptable view Review
PROBABILITY

4A 4B 4C 4D 4E
4 Occasional
Unacceptable Unacceptable Review Review Review
3A 3B 3C 3D 3E
3 Remote
Unacceptable Review Review Review Acceptable
2A 2B 2C 2D 2E
2 Improbable
Review Review Review Acceptable Acceptable
1A 1B 1C 1D 1E
1 Extremely Improbable
Review Acceptable Acceptable Acceptable Acceptable

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