Issuu on Google+

Boeing SH - Aviation Safety Report System

MAINTENANCE INCIDENT REPORT FORM Do not report Occupation and Health/Evirament incident on this form. Occupation and Health/Evirament incident are not included in the ASRS program and should not be submitted to EHS. All identities contained in this report will be removed to assure complete reporter anonymity. IDENTIFICATION STRIP: Please fill in all blanks to ensure return of strip. NO RECORD WILL BE KEPT OF YOUR IDENTITY. This section will be returned to you.

Witness of this occurrence. Name

chensheng

Manager xianghuasun

Department

QS

Date/Time

Nov

TYPE OF EVENT/SITUATION NAME Address DATE OF OCCURRENCE (MM/DD/YYYY) Email Address LOCAL TIME (24 HR. CLOCK) [HH:MM]

Team

Department

Phone:

please fill in appropriate spaces and check all items which apply to this event or situation.

Experience Describe your

A

NDT

qualifications

P

Repairman

Inspection Authority

Other:

Avionics What is your technician /

Lead Technician

Technician

Avionics

Inspector

Repairman

Other:

maintenance experience in years?

Factors Location Was training a factor?

No

Yes

I was instructing

What other factors may

Lighting

Work cards

Briefing

have contributed?

Weather

Manuals

Other:

Email to:safetyreport@boeingshanghai.com

I was receiving training


Boeing SH - Maintenance Report Form

Check items which were

Inspection

Yes

No

Installation

Yes

No

Testing

Yes

No

Scheduled maintenance

Yes

No

Repair

Yes

No

MEL

Yes

No

Logbook entry

Yes

No

Other:

Fault isolation

Yes

No

involved in the event

Component / System / Sub-system involved:

jhnkjn,

Was maintenance deferred? Yes

When was problem detected?

No

Routine inspection

While aircraft was prepare to rlease

Line Maint.

Pre-flight

Taxi

Other:

Consequences / Outcome Flight delay

Improper service

Flight cancellation

Property damage

Air turn back

Injuries Aircraft / engine damage

Rework

Other: Aircraft / Airworthiness Status

Mission

Reporter Organization

Aircraft released for service

Passenger

Training

Department

Aircraft records completed

Personal

Ferry

Other Other:

Aircraft required documents aboard Not released for service

Cargo / Freight Other:

Unknown Type of Aircraft (Make / Model) and Engine Type Type of Aircraft

Series

ATA Code

Aircraft zone

Engine model

Other

Describe event/situation

Email to:safetyreport@boeingshanghai.com


ASRS - Maintenance Report Form Keeping in mind the topics shown below, discuss those which you feel are relevant and anything else you think is important. Include what you believe really caused the problem, and what can be done to prevent a recurrence, or correct the situation.

chain of events - How the problem arose - Contributing factors (Nov.2010)

human performance considerations

- How it was discovered - Corrective actions

- Perceptions, judgements, decisions - Factors affecting the quality of human performance

MAINTENANCE FORM

- Actions or inactions

v0

From the Boeing SH Aviation Safety Reporting System: Boeing SH has established an Aviation Safety Reporting System (ASRS) to identify issues in the aviation system which need to be addressed. The program of which this system is a part is described in detail in Boeing SH SMS part of MMM. Your assistance in informing us about such issues is essential to the success of the program. Please fill out this form as completely as possible. The information you provide on the identity strip will be used only if Boeing SH determines that it is necessary to contact you for further information. THIS IDENTITY STRIP WILL BE RETURNED DIRECTLY TO YOU. The return of the identity strip assures your anonymity.

Thank you for your contribution to aviation safety. Email to:safetyreport@boeingshanghai.com


ASRS -BSH Maintenance Report Form3_distributed