Southeastern Aviation Safety Management System

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Southeastern Aviation Sciences Institute 2/8/11 Safety Management System Intentionally Blank 32
Southeastern Aviation Sciences Institute 2/8/11 Safety Management System APPENDIX 1 Hazard and Incident Reporting Form (revised 3/2/11) The information supplied in this form will only be used to promote safety. You may choose not to provide your name. If you do provide your name, your name and position will be removed before dissemination. An email reply will follow. Under no circumstances will your identity be disclosed to any university personnel, any other organization, agency, or person without your express permission. When you have completed Part A of the form, submit it to the SASI Safety Manager— paper copy or email. Forms are found on Blackboard (http://blackboard.se.edu/) under Safety Reporting. Name: ____________________________Email:_____________________________ Position: ______________________ [Only Safety Manager has access to name/position] Report Number:____________________ Date Received: ________________ PART A: Please fully describe the Hazard or Incident. . Date of occurrence: ___________________ Time: _________________ Location: ______________________________________________________________ Description:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Suggest Solution: ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ In your opinion, what is the probability of a similar occurrence happening again? Frequent Occasional Seldom Remote Improbable 30 days 6 months 1 year 5 years > 5 years P5 P4 P3 P2 P1 What do you consider could be the worst possible consequence (severity) if this occurrence did happen again? Catastrophic Critical Concerning Minor Negligible S5 S4 S3 S2 S1 33
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