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121.5 MHz is carried — life jackets fitted with lights are carried — the aircraft colour is blue — the pilot’s name is Denke.
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

PANS-RAC (Doc 4444)  A4-1
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 

* Delete as appropriate

*
 Delete as appropriate

*
 Delete as appropriate

4. Distance a) Closest horizontal distance ___________________________________________________________________________________________ b) Closest vertical distance _____________________________________________________________________________________________ 5. Flight weather conditions a) IMC / VMC* b) Above / below* clouds / fog / haze or between layers* c) Distance vertically from cloud  __________ m / ft* below    __________  m / ft* above d) In cloud / rain / snow / sleet / fog / haze* e) Flying into / out of* sun f) Flight visibility _______ m / km* 6. Any other information considered important by the pilot-in-command ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ D — MISCELLANEOUS 1. Information regarding reporting aircraft a) Aircraft registration _________________________________________________________________________________________________ b) Aircraft type _______________________________________________________________________________________________________ c) Operator _________________________________________________________________________________________________________ d) Aerodrome of departure _____________________________________________________________________________________________ e) Aerodrome of first landing _______________________ destination ___________________________________________________________ f) Reported by radio or other means to (name of ATS unit) at time _________________________________________________________ UTC g) Date / time / place of completion of form ________________________________________________________________________________ 2. Function, address and signature of person submitting report a) Function __________________________________________________________________________________________________________ b) Address __________________________________________________________________________________________________________ c) Signature _________________________________________________________________________________________________________ d) Telephone number __________________________________________________________________________________________________ 3. Function and signature of person receiving report a) Function __________________________ b)    Signature ________________________________________________________________ 
　
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