LASER ILLUMINATION REPORT FORM
This form is IN ADDITION to reporting the illumination to ATC and your company reporting requirements
Captain's name
*
First Name
Last Name
First Officer's name
First Name
Last Name
What type of operation were you conducting?
*
Fixed wing
Helicopter
Company/Organisation that you fly for
Flight number (if applicable)
Date of incident
*
-
Month
-
Day
Year
Date
Time of incident in UTC
*
Hour Minutes
Position when incident occurred (referenced to Navaid or other prominent feature, such as a runway, or co-ordinates)
*
Phase of flight
*
Take off
Climb
Cruise
Descent
Approach
Landing
Taxi
Other
If other, please supply information of operation/phase of flight
Altitude
*
Visibility
*
Atmospheric conditions
*
Colour of laser
*
Did the colour change during exposure? If so, describe ...
Did you attempt an evasive manoeuvre or any other avoidance techniques? If so, did the beam follow you through the manoeuvre after use of the avoidance technique?
Did you extinguish exterior lights (navigation lights) as an avoidance technique?
*
Yes
No
Did extinguishing exterior lights result in a cessation of the illumination?
Yes
No
Can you estimate how far from the aircraft the source of the laser was?
What was the position of the laser in relation to the aircraft?
Was the source moving?
*
Yes
No
Was the laser coming direct from its source, or did it appear to be reflected?
*
Yes
No
Unknown
Were there multiple sources of light?
*
Yes
No
How long was the exposure?
*
Did the light seem to track your flight path or was there incidental contact?
*
Yes
No
Unknown
What tasks were you/your crew performing when the exposure occurred?
*
Did the exposure prevent or hamper your performance of those tasks, or was it more of an annoyance? Please specify what impact it had on the performance of your duties:
*
What were the visual after-effects that you experienced? For example: after-image, blind-spots, flash-blindness, glare, etc. Include how long the effect lasted.
*
Did you report the incident to ATC?
*
Yes
No
Were you warned about possible exposure?
*
Yes
No
Any other pertinent information?
Submit
Should be Empty: