Details notifier
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n Pilot n ATS-personnel
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Details aircraft
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An aircraft proximity (airprox) is an occurrence in which, in the opinion of a pilot or air traffic personnel, the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved may have been compromised.
Initial report:
An initial report of an airprox initiated by the party concerned should be made immediately by radio, prefixing the message with the word
"Airprox".
Confirmation report:
Initial reports must be confirmed within 72 hours by completing the full "airprox report" or an equivalent incident report form as used by the ATS-unit or the company. Reporting should be done by or on behalf of a pilot or the ATS-personnel concerned.
Purpose of investigation:
To promote the safety of air traffic by recommending where necessary to the appropriate authorities or aircraft operators any action which needs to be taken to avoid similar occurrences. No disciplenary action shall be taken in the event of pilot or controller error because the fundamental objective of the investigation is prevention of an airprox, not to apportion blame or liability, except in case of gross negligence.
The Dutch CAA (occurrence reporting bureau) determines the
‘occurrence class’ of the incident. In case of a serious incident; the report shall be forwarded to the Dutch Investigation board. It is the responsibility of the Dutch Investigation Board to decide if further investigation is necessary.
The trend for the reports which are classified as ‘incident’ will be closely monitored by the Dutch CAA. If necessary; corrective actions shall be taken by the authorities.
Send the form to abl@ilent.nl or send to Inspectie Leefomgeving en Transport / Luchtvaart P.O. Box 16191, 2500 BD Den Haag
Additional information about this form can be obtained via telephone +31 88 489 00 00 or E-mail abl@ilent.nl
Visiting address: Kingsfordweg 1, 1043 GN Amsterdam, the Netherlands
Additional information 088 489 00 00 | www.ilent.nl
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1.1 Name (incl. initials and prefix) 1.2 Function notifier
1.3 Residence address
1.4 Postcode and place of residence 1.5 Country
1.6 Phonenumber(s) 1.7 E-mailaddress
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2.1 Aircraft registration 2.2 Aircraft type
2.3 Name of pilot in command 2.4 Operator
Report
Aircraft proximity
ILT.052.08 | 1 of 4
Details flight
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n IFR n VFR n None
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n A n B n C n D n E n F n G
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n Ft n FL|
Altimeter setting hPa n Level flight n Climbing n Descending n Turning left n Turning right|
Rate of climb Ft/min|
Rate of descend Ft/minFlight weather conditions at time of airprox
n IMC n VMC
n Cloud n Haze n Fog Feet n Above n Below
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n feet n metersn In cloud n In fog n Between cloudlayers
n In snow n In rain n In sleet n In haze n Into the sun n Out of sun
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n KM n NMDetails airprox
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n Yes n No
n AFIS n TWR n APP n ACC n FIC
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Details other aircraft
n Civil n Military
n High wing n Low wing n Other:
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3.1 Radio callsign
3.2 Callsign of groundstation 3.3 Frequency at time of airprox 3.4 Aerodrome of departure 3.5 Aerodrome of first intended
landing and destination, if different
3.6 Type of flight plan 3.7 Position at time of airprox 3.8 Airspace classification 3.9 Heading or route 3.10 True airspeed 3.11 Altitude or FL 3.12 Attitude
3.13 Rate of climb or descend
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4.1 Meteorological conditions 4.2 Vertical distance from
4.3 Horizontal distance from cloud 4.4 The aircraft was
4.5 The aircraft was flying 4.6 Flight visibility
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5.1 Date and time of airprox (in UTC) 5.2 Initially reported by radio 5.3 Reported to
5.4 Name of the station 5.5 Date and time of the report
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6.1 Other aircraft was 6.2 Other aircraft had 6.3 Aircraft registration 6.4 Type of aircraft 6.5 Radio callsign 6.6 Lighting
6.7 Number of engines
Report
Aircraft proximityHuman Environment and Transport Inspectorate Ministry of Infrastructure and Water Management
ILT.052.08 | 2 of 4
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n N n NE n E n SE n S n SW n W n NW n Climbing n Level flight n Descending
View from above View from astern Example
Estimated horizontal separation: Estimated vertical separation:
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n Meters n NM n Meters n FeetACAS
n Yes n No n Yes n No
n Traffic advisory n Resolution advisory n Both
n Yes n No
n Yes (state advice) n No (please explain)
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n Yes n No
Transponder
n Yes n No n Yes n No
n Off n Standby n On n ALT / C
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Form proceeding
n Yes n No 6.8 Aircraft colour
6.9 Other characteristic details or markings
6.10 Movement horizontal 6.11 Movement vertical
6.12 Mark the passage of the other aircraft relative to you in plan on the left and in elevation on the right, assuming you are in the centre of each diagram. Indicate horizontal and vertical distance.
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7.1 Did you carry ACAS?
7.2 If yes, was ACAS active?
7.3 What did ACAS give?
7.4 Did you take avoiding action?
7.5 Was avoiding action based on ACAS advisory?
7.6 Was ACAS advisory in conflict with ATC instruction?
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8.1 Did you carry a transponder?
8.2 Was it mode S capable?
8.3 What was the operational status 8.4 Transponder code selected
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9.1 Do you want this form to be sent to the inspector (via the occurrence bureau)?
Report
Aircraft proximityHuman Environment and Transport Inspectorate Ministry of Infrastructure and Water Management
ILT.052.08 | 3 of 4
Comments or suggestions
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10.1 Give comments or suggestions, including your opinion on the probable cause of the airprox.
Please add the following items:
- avoiding action by own and/or other aircraft
- kind of avoiding action - estimated shortest distance to the other aircraft vertically and/
or horizontally.
Report
Aircraft proximityHuman Environment and Transport Inspectorate Ministry of Infrastructure and Water Management
ILT.052.08 | 4 of 4
