AIP SWITZERLAND AIR TRAFFIC INCIDENT REPORT FORM - 1

SKYGUIDE, CH-8602 WANGEN BEI DÜBENDORF

AIR TRAFFIC INCIDENT REPORT FORM(for pilot)

Please forward written form to:

1 Airprox Procedure Facility TCAS / ACAS

2 Radio callsign of reporting aircraft: _______________________________________

Date and time of incident: Pilot: Aircraft registration:

_______________________UTC ________________________________ ________________________________

Time in min./sec. elapsed between first sighting and closest proximity: Avoiding action: If yes, based on TCAS:

________________________________ yes no yes no

Type of aircraft: Aerodrome of departure: Aerodrome of destination:

________________________________ ________________________________ ________________________________

In communication with: FIR and/or country: Frequency:

________________________________ ________________________________ ________________________________

Radar identified: Traffic information received: Transponder / SSR-code:

yes no yes no ________________________________

3 Position HDG or route: TAS

__________________________ ___________________________ ___________ kts

4 FL, altitude or height 1) At time of incident: Level flight Climb Descend

________________ m / ft / FL 2) At first sighting: Level flight Climb Descend Altimeter setting:

____________________ m / ft / FL ________________ hPa

5 Flight weather conditions 1) In general: IMC VMC

2) In particular: On top Below clouds In clouds Between layers In and out of clouds Sky clear

3) Distance from clouds Vertical: Horizontal: Sky coverage:

________________ m / ft _________________ m / ft / NM

4) Flight visibility: Into sun Out of sun In haze Remarks:

__________________ km / NM

Swiss Accident Investigation Board (SAIB)Aéropôle 1

1530 Payerne/SwitzerlandFax: +41 (0) 58 484 33 01

E-Mail: info-av@sust.admin.ch

Federal Office of Civil Aviation (FOCA)Safety Risk Management (SRM)

3003 Bern/SwitzerlandFax: +41 (0) 58 463 59 83

E-Mail: occurrence@bazl.admin.ch

and

SKYGUIDE, CH-8602 WANGEN BEI DÜBENDORF

AIR TRAFFIC INCIDENT REPORT FORM - 2 AIP SWITZERLAND

6 Description of other aircraft 1) Registration / RTF call sign: 2) Type of aircraft:

______________________________ ____________________________

3) Markings, colours and or lights: Camouflage: 4) Shape:

yes no

5) Low wing High wing Shoulder wing 6) Number and position of engines: 7) Estimated heading:

Turning left Turning right

8) Level flight Climb Descend 9) Other relevant information: SSR-code:

_________________________

7 Description of incident

8 Pilot's judgement: Risk of incident was: high low none

9 Information from ATC Unit 1) Traffic information issued: 2) Information issued:

yes no Direction Distance Heading

sertem fo sderdnuHsertem fo sderdnuH

10

9

8

7

6

5

4

3

2

1

0

1

2

3

4

5

6

7

8

9

10

14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 1410

9

8

7

6

5

4

3

2

1

0

1

2

3

4

5

6

7

8

9

10

14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14300

270

240

210

180

150

120

90

60

30

0

30

30

90

120

150

180

210

240

270

300

Hun

dred

s of

feet

MET

RES

Hun

dred

s of

feet

PLANVIEW PROFILEVIEW

Signature of reporting person: Date:

Please forward written form to:

20 NOV 2008

Swiss Accident Investigation Board (SAIB)Aéropôle 11530 Payerne/Switzerland Fax: +41 (0) 58 484 33 01E-Mail: info-av@sust.admin.ch

Federal Office of Civil Aviation (FOCA)Safety Risk Management (SRM) 3003 Bern/SwitzerlandFax: +41 (0) 58 463 59 83E-Mail: occurrence@bazl.admin.ch

and

In case of airprox/sighting: including relative flight path, vertical and horizontal distance to other aircraft at first sighting and at time of incident, executed and/or observed avoiding actions. If avoiding action was based on TCAS, state kind ofadvisory.