ETHIOPIAN AVIATION ACADEMY

PILOT TRAINING SCHOOL

INCIDENT REPORTING FORM

Event Date: ___________________________ Description of all possible

Report date: __________________________ consequences:__________________________________________________
Title: ___________________________ ____________________________________________________________
Location: ___________________________ ______________________________________________________________
______________________________________________________________
GENERAL INFORMATION ______________________________________________________________
Aircraft Type: __________________________ __________________________________________________________
Aircraft Registration:
ET-AXD____________________________ Action taken to mitigate or avoid the risk ( by the safety
Flight Phase: ____________________________ office/officer):__________________________________________________
Flight From: __________________________ ______________________________________________________________
Flight To: __________________________ ___________________________________________________________
Report Type: ________________________________ ______________________________________________________________
Name: _______________________ ____________________________________________________________

Is the incident occurred while you are on the Job? ▢ Yes ▢ No Initial Risk Score: ________________________________________
Is the incident related to your work? ▢ Yes ▢ No Risk Category: __________________________________________
Is there any equipment Damage ▢ Yes ▢ No Risk Acceptability: ______________________________________
Risk Priority: ______________________________________
Description of the Residual Risk Level: _____________________________________
Inciden: .______________________________________________________ Risk Rating After Corrective Action: ________________________
______________________________________________________________ Implementation Status: ___________________________________
______________________________________________________________
______________________________________________________
Possible Cause of incident:
____________________________________________________
______________________________________________________________
______________________________________________________________
___________________________________________________________

HAZARD ANALYSIS RISK ASSESSMENT (OFFICE USE ONLY)