Safety or Irregularity Report
Date of Occurrence
*
-
Month
-
Day
Year
Date
Local Time
*
Hour Minutes
Type of Occurrence
*
Training Quality Concern
Safety Concern
Event, Incident, & Accident Report
Irregularity Report - VFA Requested
Other
Location of Occurrence
*
Flight Operations (Engine Start to Shutdown)
VFA Facilities
Non-VFA Facilities
Other
Phase of Operation
*
Please Select
Pre-flight briefing
Pre-flight
Fueling
Start-up
Taxi
Takeoff
Climb
En route / Cruise
Descent
Approach
Landing
Park / Shutdown
Postflight briefing
Planned Flight Completed?
*
Yes
Started, but prematurely terminated
Cancelled (no flight)
Not Applicable
Unknown
Flight Type
*
IFR
VFR
Not Applicable
Unknown
Weather and Environment (select all that apply)
*
VMC
IMC
Sunrise
Day
Sunset
Night
Icing
Turbulence
High wind
Low clouds
Low visibility
Precipitation
Poor runway conditions
Not Applicable
Other
Narrative: Weather Conditions and Explanation
*
Aircraft Issues (select all that apply)
*
Mechanical (non-engine)
Flight Controls
Avionics
Engine
Not Applicable
Other
Aircraft Registration Number
*
Type N/A if Not Applicable
Aircraft Make & Model
*
Type N/A if Not Applicable
Departure Point
*
Type N/A if Not Applicable, Type unknown if unknown
Destination Point
*
Type N/A if Not Applicable, Type unknown if unknown
Diversion Point (If none, leave blank)
Altitude
*
Type N/A if Not Applicable
Number of Crew and Passenger(s)
*
Type N/A if Not Applicable
People on Board? Click all that apply
*
Flight Instructor
Student
Renter
Passenger(s)
Unknown
People Involved? Click all that apply (even indirectly)
*
Flight Instructor
Student
Renter
Other
Unknown
Flight Instructor's Name
*
First Name
Last Name
Student's Name
*
First Name
Last Name
Renter's Name
*
First Name
Last Name
Other People or Passenger(s)
*
List the full name of all other people involved. Separate by comma or other means.
Did you witness or experience this occurrence personally?
*
Yes
No
Was part of the event communicated on ATC frequency?
*
Yes
No
Not Applicable
What ATC Facility Name (Frequency if Available)?
*
Type N/A if not applicable
Narrative: ATC Communication
*
Type N/A if not applicable
Narrative: Explanation of Occurrence, Event, or Concern
*
Please provided a detailed explanation of the event or concern
Is this a hazard which requires an immediate mitigation action?
*
Yes
No
Not Applicable
Was an Emergency Declared?
*
Yes
No
Was ARFF Assistance Required OR Provided?
*
Yes
No
Did you file a NASA (ASAP) form yet?
*
Yes
No
Corrective Action Suggestions
*
Describe policy or procedure changes that would mitigate the likelihood of this occurrence. Type N/A if not applicable
Will this occurrence continue to happen if not addressed?
*
Yes
No
Would you like your report to remain anonymous?
*
Yes
No
Name
*
First Name
Last Name
Signature
*
Email
*
example@example.com
Internal Review Details
Internal Start Date
*
-
Month
-
Day
Year
Date
Comments
Number of Comments
Please Select
1
2
3
4
5
#1 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#2 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#3 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#4 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#5 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Action Items
Actions Needed
Remedial Training
Consultation
None
Other
List / Description of Action Items to Complete
Remedial / Consultation Training
Remedial / Consultation Comments Needed
Please Select
1
2
3
4
5
#1 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#2 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#3 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
#4 Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of Comments
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Comment(s)
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Occurrence Closure Approval
Name of Approver
First Name
Last Name
Approver Notes
Take Photo
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Who Should Be Notified?
Flight Department
Safety Team
Management
VTC
VFA Board
Date of Completion / Close
-
Month
-
Day
Year
Date
Occurrence Status
*
Please Select
In Progress
Completed / Closed
Submit
Should be Empty: