SGA SMS Self-Reporting

Form SGA/SMS/001
SMS SELF-REPORTING

(Incident, Error, Near Miss, Aircraft Safety and Non-conformance)
If you have encountered or been involved in any operation or non-operation ground incident hazard, unsafe act, error, near miss, aircraft safety or non-conformance, please give a brief description of it below. Your inputs will help towards preventing a recurrence. Please complete Section 1 to 9 of this form. This is part of our non-punitive confidential reporting policy as defined in SGA Safety Management System manual. Your feedback is important to us, as it will help us to identify the root cause and take the necessary actions towards preventing an incident. Together we can develop a safe, efficient, and informed working environment.

This form will be sent to Safety Manager, Safety Management System (SMS) Department.
1. General
Is this reporting and UAS operation (flying) event or involve an UAS unit?
Please fill the below if its UAS Operation
UAS Owner

First NameLast Name
UAS Make/Model/Serial Number
Please fill the below for all reporting
Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Location*
2. Type of Event / Situation
For UAS operation

Airspace Incursion / ExcursionCollision (Aircraft, Person, Object)Deviation (Altitude, Procedure)Equipment IssueFly AwayInjuryLost Mid AirSightingImproper serviceUncontrolled DescentOther
For Others

ManagementMaintenanceEquipmentFacilityProceduresEnvironmentOverworkOther
3. How are You Involved?

Not InvolvedWitness/ObserverInstructorStudentOther
4. Weather Condition

ClearRainSmoke/HazeThunder StormWindyOther
5. Description of event
6. Contributing Factors
7. Any additional information (pictures etc)
8. Personnel Involved (OPTIONAL)
Name

First NameLast Name
Staff No
Designation
9. Reporting Person (MANDATORY)
Name

First NameLast Name
Contact No
Please enter a valid phone number.
Date

MonthDayYear
Date
Email
example@example.com
If employee (Please provide your details below)
Staff No
Designation
Department
Section 1- 9 will be returned to you when all relevant information has been confirmed.
NO RECORD OF YOUR NAME WILL BE KEPT
Should be Empty:

SMS SELF-REPORTING