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13
Departure aerodrome
and time
–
16
Destination aerodrome and total estimated elapsed time, alternate aerodrome(s)
–
18
Other information (using more than one line if necessary)
A3-44 Air Traffic Management (PANS-ATM)
1/11/01
2.5.3.2 Example
The following is an example of a supplementary flight plan message sent by the departure aerodrome of a flight to an ATS unit
which had requested supplementary information recorded on the flight plan form (but not transmitted in filed flight plan messages
or current flight plan messages).
(SPL-SAW502A
–EDDW0920
–EKCH0400 EKVB
–REG/GBZTA RMK/CHARTER
–E/0640 P/9 R/V J/L A/BLUE C/DENKE)
2.5.3.2.1 Meaning
Supplementary flight plan message — aircraft identification SAW502A no SSR — departed Bremen 0920 UTC — destination
Kastrup, total estimated elapsed time 4 hours — alternate Viborg — aircraft registration GBZTA — charter flight — endurance
6 hours and 40 minutes after departure — 9 persons on board — portable radio working on International Distress Frequency
121.5 MHz is carried — life jackets fitted with lights are carried — the aircraft colour is blue — the pilot’s name is Denke.
–
19
Supplementary information (using more than one line if necessary)
)
PANS-ATM A4-1 1/11/01
APPENDIX 4. AIR TRAFFIC INCIDENT REPORT
1. ICAO model air traffic incident report form
2. Instructions for the completion of the air traffic
incident report form
A4-2 Air Traffic Management (PANS-ATM)
1/11/01
1. ICAO model air traffic incident report form
AIR TRAFFIC INCIDENT REPORT FORM
For use when submitting and receiving reports on air traffic incidents. In an initial report by radio, shaded items should be included.
A — AIRCRAFT IDENTIFICATION B — TYPE OF INCIDENT
AIRPROX / PROCEDURE / FACILITY*
C — THE INCIDENT
1. General
a) Date / time of incident ___________________________________________________________________________________________ UTC
b) Position ___________________________________________________________________________________________________________
2. Own aircraft
a) Heading and route __________________________________________________________________________________________________
b) True airspeed ____________________________________ measured in ( ) kt _____ ( ) km/h _____
c) Level and altimeter setting
d) Aircraft climbing or descending
( ) Level flight ( ) Climbing ( ) Descending
e) Aircraft bank angle
( ) Wings level ( ) Slight bank ( ) Moderate bank
( ) Steep bank ( ) Inverted ( ) Unknown
f) Aircraft direction of bank
( ) Left ( ) Right ( ) Unknown
g) Restrictions to visibility (select as many as required)
( ) Sunglare ( ) Windscreen pillar ( ) Dirty windscreen
( ) Other cockpit structure ( ) None
h) Use of aircraft lighting (select as many as required)
( ) Navigation lights ( ) Strobe lights ( ) Cabin lights
( ) Red anti-collision lights ( ) Landing / taxi lights ( ) Logo (tail fin) lights
( ) Other ( ) None
i) Traffic avoidance advice issued by ATS
( ) Yes, based on radar ( ) Yes, based on visual sighting ( ) Yes, based on other information
( ) No
j) Traffic information issued
( ) Yes, based on radar ( ) Yes, based on visual sighting ( ) Yes, based on other information
( ) No
k) Airborne collision avoidance system — ACAS
( ) Not carried ( ) Type ( ) Traffic advisory issued
( ) Resolution advisory issued ( ) Traffic advisory or resolution advisory not issued
l) Radar identification
( ) No radar available ( ) Radar identification ( ) No radar identification
m) Other aircraft sighted
( ) Yes ( ) No ( ) Wrong aircraft sighted
* Delete as appropriate
Appendix 4 A4-3
1/11/01
n) Avoiding action taken
( ) Yes ( ) No
o) Type of flight plan IFR / VFR / none*
3. Other aircraft
a) Type and call sign / registration (if known) _______________________________________________________________________________
b) If a) above not known, describe below
( ) High wing ( ) Mid wing ( ) Low wing
( ) Rotorcraft
( ) 1 engine ( ) 2 engines ( ) 3 engines
( ) 4 engines ( ) More than 4 engines
Marking, colour or other available details
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
　
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