Cabin Safety Report

Date 0f incident: Date submitted:

Aircraft Registration Aircraft Type Staff Number / 3 Crew Name

Letter Code

Flight Number From To Time

Incident Location on Aircraft Did you use any safety/emergency equipment Phase of Flight
If Yes please describe On Ramp
Front Galley Boarding
Rear Galley Push back
Passenger Aisles Taxi out
Boarding Areas Take-off
Toilets In-flight
Hold Landing
Other Taxi In
Disembarking

Please write in clear print describing the incident

Guidance when to submit a report is detailed overleaf

The Commander must be informed of any incident that has an effect on the immediate safety of the
aircraft, passengers or crew

After completion, scan your report and send to airline.safety@thomson.co.uk

Or post to
Risk, Safety & Quality Department - Thomson Airways - Wigmore House - Wigmore Lane
Luton LU2 9TN

Thank you for submitting this Cabin Safety Report

CSR Issue August 2009

 THOMSON AIRWAYS – OCCURRENCE REPORTING PROCEDURE
Cabin Safety Report

The Thomson Airways Safety Management System (SMS) is built upon a positive and just safety culture. This
means that every individual within the airline is responsible for ensuring that safety is given priority and that
occurrences, errors and hazards are honestly and openly reported without fear of retribution. A full description
of the SMS is included within the SMS Manual available on Livelink or the Flight Deck laptop.

The purpose of the family of Safety Reports is to record those occurrences, errors and hazards that have or
could have affected the safe operation of our aircraft. The information gathered will be used to enhance safety
by helping to identify safety trends within the airline. Crews are encouraged to submit reports on all
occurrences that affect safety. The submission of a Cabin Safety Report would not exclude the submission of
further reports such as an Air Safety Report or a Ground Occurrence Report.

It is important that the facts of the event are reported on the CSR. Any other relevant information which may
assist with the investigation should also be included. Reports must be filed as soon as possible after an incident,
but no later than 72 hours of the event occurring to the Safety & Security Department in Luton.

Crews are encouraged to contact their base management should they wish to discuss an occurrence prior to
submission if they have a doubt over its relevance.

As a general principle for all events, if in doubt, submit a CSR.

All received reports will be acknowledged by the Risk, Safety & Quality Department.
The Commander should be informed when any incident occurs that warrants the completion of a CSR and must
be informed of any incident that has an immediate impact on safe operation.

Examples of Reportable Cabin Safety Occurrences:

Act of aggression, hijack, terrorist device or bomb threat.
Any serious disruptive passenger event. (Use DPR Report Form).
Any rapid disembarkation or evacuation event with or without slide activation.
Escape slide deployment (intentional or unintentional).
Employee injury on or near the aircraft (complete Accident/Incident report).
Passenger injury on or near the aircraft
All cabin crew incapacitation events - if unable to perform essential emergency procedures.
Smoke, fire or fumes detected in the cabin / galley / lavatory.
Any other occurrence concluded without injury or damage but which could have resulted in an accident or
incident under different circumstances.
Any event where safety standards are significantly reduced.
Any cabin event involving Dangerous Goods.
When communications fail, are impaired or lost both internally and with external agencies incl. CRM issues.
– excluding technical failures.
Cabin defect which directly affects flight safety.
Any other cabin or passenger related occurrence which may affect safety.
Any event which may provide useful information for the enhancement of cabin safety.
When deficiencies are identified in any operating procedures.
When safety equipment or procedures are inadequate.
This list is not exhaustive. The general principle is always if in doubt submit a CSR.

CSR Issue August 2009

PASSENGER DISTURBANCE REPORT - PART 1

PART 1 MUST BE COMPLETED IN ALL CASES OF PASSENGER DISTURBANCES

Date ……………………………………… Flt No …………………………………………… Route ……………………………………………………

The incident occurred: Outbound Inbound
Number of disruptive male passenger(s) Number of disruptive female passenger(s)
Behaviour Which Causes Distress Serious Incident
Rowdiness 1 Damage or theft of aeroplane 4
equipment/systems
Abusive language 2 Damage or theft or personal effects 4
Throwing objects 2 Threatening or threats - Bomb 8
Hitting seat backs 2 made with intent to cause - Gun 8
Refuse To Obey Lawful Commands alarm or distress of - Weapon 8
Seat belt 2 - Assault 4
Remain seated 2 Attempt to enter the FCC 10
Stowage of luggage 2 Behaviour likely/intended to endanger 10
the safety of the aeroplane & persons
onboard
Drinking own alcohol 3 Loss
Observed/admitted smoking in lavatory 2 - Aeroplane equipment 6
Observed/admitted smoking in cabin 2 - Personal effects 6

Assault Victim/Injured
Assault prod 1 Crew 8
Assault pushing/grabbing 2 Passenger not travelling with 4
Assault hit or kick 3 Passenger travelling with 3
Assault with weapon 4
Sexual language or harassment 2
Sexual assault – non intimate 3
Sexual assault - intimate 5

Perceived Passenger State Crew Actions Effective

Sober Verbal warning given Y/N Y/N
Under influence Commander’s Notice of Violation Y/N Y/N
warning letter issued
- Alcohol Restraints used by crew Y/N Y/N
- Drugs Aeroplane diverted Y/N Y/N
Phobia Emergency declared Y/N Y/N
Panic attack(s)

If ACC or Refusal of return travel required Part 2 must be completed for each individual

Reference should be made on the flight report to advise PDR completed under codes 08 & 14

Once completed SCCM must fax this form with the Flight Report to Customer Operations
Executives +44 (0)870 2438315 (Tel 01582 640043)
SCCM Faxed Report Y/N Base Admin Faxed Report Y/N

Passenger Disturbance Report

Version 1
October 14
PASSENGER DISTURBANCE REPORT - PART 2

ONLY TO BE COMPLETED IF FURTHER ACTION REQUIRED –

Complete one Part 2 per passenger (Please give details of incident)
Total Score

Recommendation of the Crew (to be completed)

Additional Conditions of Carriage (4-7 points)

Refusal/Warning Letter sent to Passenger (8 or more points)

SCCM Name: ………………………………………………………………… Date: ………………………………………………………………….

Commander’s Name: …………………….................................... Signature………..…………………………………………………..

PASSENGER’S DETAILS

Name of passenger …………………………………………………….. Booking Ref ……………………………………………………….

Sex: Male/Female Date of Birth ………………………….. (Approx age if not known)………………………………

Passport Number ……………………………………………………….. Place of issue if not UK ………………………………….

Height (approx) ……………… Build ……………………………… Hair Colour ……………………………………………………….

Tour Operator ……………………………………………………………..

Ethnic Origin:

White Black Asian Oriental Middle Eastern Mixed Race Other

Any distinguishing marks:

…………………………………………………………………………………………………………………………………………………………………………....

…………………………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………………………….

Seat Allocated ……………………………………………………….. Seat Occupying ……………………………………………………

Police Called Y/N

Name & Contact Details of Police ………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………

Date ………………………………………………………….. Flight Number …………………………………………………………………………

Passenger Disturbance Report

Version 1
October 14
INDIVIDUAL WITNESS ACCOUNT OF INCIDENT
If witness is a Crew member, include Crew member’s Name & Crew No as an entry on the log.

Date ………………………………................ Flight Number ………………………………………… Seat No …………………………

Name: …………………………….………………………………………. Contact Tel No: ……………….………………………………………..

Address: ……………………………….………………………………………….………………………………………………………………………………

…………………………………………………………………………………. Email ……………………………………………….................................

Return Date: …………………………………………………………. Return Flight No: ………………………………………………………

We understand that you saw/heard what happened. We would be grateful if you could take a few moments to
Time note what you saw/heard.
Please only include things you actually witnessed or heard on the form below. Thank you for your co-operation.

Passenger Disturbance Report

Version 1
October 14
INDIVIDUAL WITNESS ACCOUNT OF INCIDENT
If witness is a Crew member, include Crew member’s Name & Crew No as an entry on the log.

Date ………………………………................ Flight Number ………………………………………… Seat No …………………………

Name: …………………………….………………………………………. Contact Tel No: ……………….………………………………………..

Address: ……………………………….………………………………………….………………………………………………………………………………

…………………………………………………………………………………. Email ……………………………………………….................................

Return Date: …………………………………………………………. Return Flight No: ………………………………………………………

We understand that you saw/heard what happened. We would be grateful if you could take a few moments to
Time note what you saw/heard.
Please only include things you actually witnessed or heard on the form below. Thank you for your co-operation.

Passenger Disturbance Report

Version 1
October 14
NOTICE OF VIOLATION

This notice is given on behalf of the Commander of this aeroplane.

You have already been given a verbal warning by our Cabin Crew.

You are now being given this formal written warning because your
behaviour continues to be unacceptable.

YOU MUST STOP THIS BEHAVIOUR IMMEDIATELY

The Commander considers your behaviour a risk to the flight safety of

the aeroplane and its occupants.

If you refuse to comply with this request to stop this behaviour, you
may incur one or more of the following consequences:

Refusal of onward carriage and/or refusal of carriage on your

return flight.

Physical restraint

Criminal prosecution resulting in the imposition of a fine or

imprisonment as well as a criminal record.

Civil proceedings against you for the recovery of any costs incurred
by the Airline or your Tour Company (for example as a result of
aircraft diversion) or the claims from other passengers or crew.

Passenger Disturbance Report

Version 1
October 14
 FLIGHT DETAIL FORM

Date: Flt No: Route: A/C Reg:

3 Letter Code Position* Name Standby Duty No of Crew

Duty Started Start Time Hold Bags Tag No
CDR
F/O

ICM

By signing my name above I declare that I have read and fully understood my Ops/Safety Notice(s)

SECURITY SEARCH – Confirmed completed in accordance with Thomson Airways SEP Manual * *

Place of Last Departure Sector 1 Sector 2

CABIN Sector 1 Sector 2

Cabin Security Search – Time Commenced
Cabin Security Search Complete * *
(Operating ICM to Sign)
Flight Ex USA - Toilet Seals Intact
(Operating ICM to Sign)

Sector 1 Sector 2
Commander’s Signature
Time Security Search Completed
* Position operated
In the appropriate sector box, the ICM must record the time that the security search commenced and sign to indicate that the search is complete.
In the appropriate sector box, the Commander must sign and record the time that the security search was completed.

Distribution
Commander to retain one copy for the flight envelope. Prior to each departure, one copy must be given to the handling agent. This copy must reflect the
exact crew composition.

One Flight Detail Form must be completed prior to every flight or sector that involves for any reason a change in the crew composition.

TF1092 Issue 9
 LOADSHEET INFO

FLIGHT NO M.T.O.W.

DATE M.L.W.

A/C REG RAMP FUEL

CAPT TAXI FUEL

CREW TRIP FUEL

CATERING CODE TRIP TIME

TA0000 issue 01
 LOADSHEET

1 FLIGHT INFORMATION
Flight Number ► Date ► / / From ► To ►
FCM CCM
AC Registration ► Crew ► TOB ► Catering ►

2 ▼ PAYLOAD INFORMATION FROM GROUND HANDLING ▼

PASSENGERS BAGGAGE / CARGO (all weights in kg)

Destination Male Female Adults Child. Infants Hold 1 Hold 2 Hold 3 Hold 4 Hold 5 (*)
1.►

2.►

Totals ►

OA ▼ OB ▼ OC (*) ▼ Total in holds ►

Distribution►
Prepared by ►

3 ▼ FCM COMPLETES THIS SECTION ▼ 4 ▼ COMMANDER COMPLETES THIS SECTION ▼

Weight CG (%MAC) Last minute changes ▼ Commander name and signature▼
Zero fuel ►
Landing ►
Takeoff ►
Stab trim* ►
*if applicable
 MEDLINK PATCH CHECKLIST
CONTACT INFO: 001(602)8241132 (In Flight Medical Events) / 001(602)2826651 (Fitness to Fly)
ACARS: PHXMACR
FOR FLIGHT CREW USE

Incident Date: Aeroplane Type: Flt No:

Time (GMT): Aeroplane Reg: Sector:

Name of person: Age:
Seat No: M F
Profession of medical personnel on board (if applicable):

Past medical history:

Medication being taken:

List of allergies:
Conscious Y N Unconscious Y N
FOR CABIN CREW USE
NATURE OF INCIDENT
Features of illness/injury
Nausea Vomiting Confused Cough
Pale Faint Breathless Blue
Flushed Sweating Feverish Cold
Dizzy Weakness Convulsion Anxious
Diarrhoea Aggressive Intoxicated Rash/spot

Other
CABIN CREW ACTIONS
Oxygen given Y / N
AED used Y / N
CPR given Y / N
Medication given (specify):

PLEASE CONTINUE TO NEXT PAGE

Page 1 of 2 V8 Oct 2014

Other treatment (specify):

Assistance of on-board medical Health professional requested? Y / N

Assisting medical professional's name & contact details:

Advice given by MEDLINK/other professional advice:

END

Page 2 of 2 V8 Oct 2014

 Passenger Accident Report Form
Guidance Note
This form can be completed electronically using built in drop-down menus or as a hard copy using the Crib Sheet
(see reverse) to ascertain the content of the drop downs and using the most appropriate descriptor.
SCOPE
Accidents resulting in injury to Thomson Airways Passengers (PAX) from the point of check-in to boarding
aircraft, whilst onboard the aircraft or the point of disembarking the aircraft to baggage reclaim.
RESPONSIBILITY
It is the Ground Handling Agents responsibility to report accidents to PAX (except when PAX is onboard aircraft).
It is Cabin Managers responsibility to report accidents to PAX whilst onboard aircraft only.
Complete the report on behalf of the Injured PAX and send within 48 hours of the accident to
OccupationalRisk@thomson.co.uk or
Thomson Airways, Occupational Risk, Risk Safety and Quality, Wigmore House, Luton, LU2 9TN
NOTES FOR COMPLETING THE FORM ELECTRONICALLY:
Only the shaded sections of this form can be amended and these consist of free text fields or drop down menus.
Click on the shaded cell you wish to complete or use the tab key to move from one cell to the next.
About the Injured Passenger – the person who had the accident
Name Age Contact No.
Sex Airport Flight No. TOM Route sector /
About You – the person making the report
Name Company Contact No.
About Witnesses
Name Contact No. Name Contact No.

About the Accident – where, when and how it happened

Location at airport Date Time Flight phase
Location on aircraft What was PAX doing at time
Hazard event Select an appropriate descriptor based on the initiating event
Exposure to Manual handling
Striking against Fall from height
Road traffic Struck by
Slip, trip, fall Other
Provide details of the events leading up to and the accident itself giving as much information as possible

Defective equipment – If the accident involved defective equipment, specify:

Type of equipment:
Nature of defect Part / Serial / ID No.
About the injury – if multiple injuries have been sustained list in order of severity, starting with most serious
Injury Part of body
Injury Part of body
Treatment received Side of Body
Did PAX.. Specify*
Further details (e.g. First aid/Doctor/Paramedic details, medication/treatments received), travel curtailed etc

Thomson Airways – Occupational Risk Use Only

Date Received Severity Likelihood Risk level
Risk action level AQD investigation
Forwarded to Insurance Forwarded to Airport Services
Comments:

Document Passenger Accident Report Form Issue 1

Department Risk Safety and Quality Page 1 of 2
Authority Occupational Risk Manager Date January 2011
Passenger Accident Report Form Crib Sheet
Crib Sheet – to be used if completing the report as a hard copy to select an appropriate descriptors
Airport Location at airport Location on aircraft Flight Phase What PAX doing at time
ABZ Check In Aircraft steps On ramp Check in
BFS Security Boarding areas Boarding Security checks
BHX Public Concourse Cabin Pre-departure Handling baggage
BOH Passport Control Door location Push back Moving around
BRS Departure Lounge Front galley Taxi out Being served food / drink
CWL Restaurant Jump seat Take off Eating / drinking
DSA Shop Passenger aisle Climb Shopping
DUB Toilet Passenger seat Cruise Emergency
EDI Terminal Rear galley Descent Passenger in vehicle
EMA Stairs Toilet Holding Boarding aircraft
EXT Escalator Other* Approach Disembarking aircraft
GLA Lift Not applicable Landing Reclaiming baggage
LBA Boarding gate Taxi-in Stowing baggage
LGW Airbridge Disembarking Sitting down
LTN Baggage reclaim Other* Using toilet
MAN Coach Not applicable Being disruptive / violent
NCL Footpath / walkway Other*
STN Ramp / stand
Overseas* Aircraft steps
Other*
Exposure to Manual handling Striking against Fall from height Road traffic Other
Hot food / drink / water / Bags – own Aircraft equipment Aircraft doors Collision Body movement
steam Bags – other PAX Bulkhead Aircraft seat Shunt Trapped
Hot surface / fire Equipment* Carts Aircraft steps Other* Unsafe practice
Contact with cold Person Equipment* Escalator Other*
Turbulence Trolley Fixed object* Lost footing
Hard landing Other* Galley Platform
Hazardous substance cupboards/doors Stairs
(specify) Galley work surface Waste chute
Fumes/Smoke Seat Other*
Contaminated food/drink Video monitor
Electricity Other*
Sharp object
Insect bites
Other*
Struck by Slip trip & fall Injury Part of body Treatment received Did PAX …
Aircraft doors Caught footing Bite / Sting Head None Become unconscious
Assault – other Contaminated Bruise Face First aid (self Need resuscitation
Assault – PAX surface Burn – chemical Eye(s) administered) Go to hospital
Cart Debris Burn – heat Nose First aid (administered) None of the above
Doors De-icing fluid Crush Mouth Paramedics All of the above
Equipment* Footwear Cut Ear(s) Doctor
Falling object* Icy surfaces Diarrhoea & vomiting Neck Nurse
Flying object* Lost footing Dislocation Shoulder Hospital
Galley Obstructions Foreign body Arm First aid & doctor
cupboards/doors Potholes Fracture Elbow First aid & hospital
Moving object* Rushing Generalised pain Wrist Doctor & hospital
Passenger Slippery Headache Hand Paramedics & hospital
Other person surface Inflammation/swelling Finger(s) First aid, paramedics &
Trolley Turbulence Internal Thumb hospital
Vehicle Uneven surface Irritation Back First aid, doctor &
Other* Unexpected Laceration Chest hospital
movement Light Stomach Other*
Wet surface headed/dizzy/faint Buttocks
Other* Loss of sight Hip
Nausea Groin
Penetration/puncture Leg
Scald (Hot Knee
water/steam) Ankle
Shock Foot
Sprain/strain Toe
Other* Whole body
Other*
* specify exact details
Document Passenger Accident Report Form Issue 1
Department Risk Safety and Quality Page 2 of 2
Authority Occupational Risk Manager Date January 2011
Personal Accident and Incident Report Form
Guidance Note
This form can be completed electronically using the built in drop-down menus or as a hard copy using the
Personal Accident and Incident Report Drop-Down Crib Sheet to ascertain the content of the drop downs.
RESPONSIBILITY
It is the injured persons’ (IP) responsibility to ensure that this report is completed and submitted to their Line
Manager and Occupational Risk in a timely manner, except in circumstances where the IP is incapacitated to such
an extent that they are unable to make the report, in which case, the report should be made by someone acting
on the IP behalf who is aware of the circumstances of the accident.
NOTES FOR COMPLETING THE FORM ELECTRONICALLY:
- Only the shaded sections of this form can be amended.
- These shaded sections consist of free text fields or drop down menus
- Click on the shaded cell you wish to complete or use the tab key to move from one cell to the next.
NOTES FOR COMPLETING A HARD COPY
If there is no access to a computer, then use the Personal Accident Report Drop Down Crib Sheet to ascertain
the content of the drop down fields, and complete by using the most appropriate descriptor.
GENERAL NOTES FOR COMPLETING AND REPORTING
- Complete all sections of this report that apply. If there is insufficient data, you may be contacted.
- Reports should be submitted as soon as possible and in any respect within 48 hours of the accident. If
the accident occurred outside the UK, the report should be made within 48 hours of returning to the UK.
- When you are absent from work as a result of your injury, RIDDOR reports may be made to the Health
and Safety Executive. You need to update Occupational Risk with your absence dates.
- Reports should be submitted as outlined below.
- A copy of the report should be given to your Line Manager and a copy retained for your records.
About you – the person who had the accident
Full Name ID No Base
Employment Sex Length of service
Job Type Age Other (specify)
About the accident – where you were, when and how it happened
General Location Date Time
Location on ground Task being performed
Location on aircraft Flight phase
Flight No. A/C Registration Route sectors / /
Aircraft Type No. of crew Other (specify here)
Hazard event Select an appropriate descriptor based on the initiating event
Exposure to Slip, trip, fall
Fall from height Striking against
Manual handling Struck by
Road traffic accident Other
Provide details of the events leading up to and the accident itself giving as much information as possible

Working conditions (cross all that apply)

Wet/slippery floors Inadequate / restricted space Poor lighting Low headroom
Defective work equipment – If the accident involved defective or U/S work equipment, specify:
Type of equipment:
Nature of defect Part / Serial / ID No.
I confirm the equipment has been reported via the appropriate channel so that it can be removed from use
Method used to report defect:

Document Personal Accident and Incident Report Form Issue 3

Department Risk Safety and Quality Page 1 of 2
Authority Occupational Risk Manager Date December 2010
Personal Accident and Incident Report Form
About the injury – if multiple injuries have been sustained list in order of severity, starting with most serious
Injury type Part of body
Injury type Part of body
Injury type Part of body
Injury type Part of body
Treatment received Side of Body
Name of first aider First aider ID No
Did you.. Other (specify here)
Dates absent from work (if applicable) To:
Further details (e.g. date visited doctor/hospital, medication given, treatments received, diagnosis given)

Witnesses – Witnesses may be contacted as part of the investigation.

Names ID No. Names ID No.

Other Information - Further details which do not fall into any of the above can be provided here

Photos taken Submit any photos of injuries, location, equipment

Statements taken and witnesses statements
Who was the accident reported to Line Manager
Date this report submitted Line Manager position
E-MAIL A COPY OF THIS REPORT IMMEDIATELY TO
OccupationalRisk@thomson.co.uk
OR SEND A HARD COPY TO
OCCUPATIONAL RISK, RISK SAFETY & QUALITY, WIGMORE HOUSE, LUTON
AND
PROVIDE YOUR LINE MANAGER WITH A COPY OF THE REPORT
Line Manager Confirmation – I confirm that I have reviewed the accident report, and where necessary
implemented actions to eliminate or reduce the likelihood / consequence of re-occurrence.
Name Signed Date
Comments:

I confirm that I have followed up on the welfare of the injured person.

Please send completed form to: Occupational Risk, Risk Safety & Quality Department, Wigmore House, Luton.
Occupational Risk Use Only
Date Received Type of accident
Severity Likelihood Risk level
Risk action level Date RIDDOR reported
AQD investigation required RIDDOR reference No.
Comment:

Document Personal Accident and Incident Report Form Issue 3

Department Risk Safety and Quality Page 2 of 2
Authority Occupational Risk Manager Date December 2010
 PRELIMINARY DEATH CERTIFICATE
FO/008

1 Passenger Information

Date of death (dd/mm/yyyy) / / Time of death hrs minutes

Name of passenger died Mr/Mrs (*) Place of birth
Date of birth (dd/mm/yyyy) / / Profession
Marital status Single / Married / Divorced / Other: (*)
Name partner
Father Mother
Name of parents
Profession of parents
Residence of parents
(*) Cross-out inapplicable item.

2 Flight Information

Flight No. A/C Reg. A/C Type Date / /

Captain F/O CA 1 CA 2
Route from to

3 Witness Information

This entry has been made by

Commander of above mentioned aircraft in presence of the following witnesses

st nd
1 Witness 2 Witness
Name of witness
Profession of witness
Residence of witness

In witness where of this certificate having been read aloud by me and signed by above
mentioned witnesses and myself on (dd/mm/yyyy) / /

st nd
Signature of commander Signature of 1 witness Signature of 2 witness

Remarks (if applicable):

Routing: Postholder Flight Operations

Iss.2 Rev.2 – 01-06-2014 Flight Operations Engineering Page 1 of 2

 FLIGHT ORDER AND WRR DATA SHEET
FO/019

Date / / Place Date UTC (hh:mm)

A/C Reg. (dd/mm/yy) Cockpit Cabin
Log # On Blocks / / : :
On Duty / / : :
Duty Type FDP.: : :
Flight Max. FDP according Table # ___ : :
Positioning Captain’s Discretion: YES / NO
Training
Office Planning
Other Normal Crew Heavy Crew Seat A
Normal Crew Ext. Heavy Crew Seat A Ext.
Heavy Crew Seat B Cockpit Bunk / Cabin Seat B
Heavy Crew Seat B Ext. Cockpit Normal / Cabin Seat B

Capt Name Purser Name

F/O Name Cabin Name

MX Name

T/O LDG Date

FLT # FM STD TO STA
(was made by) (was made by) (dd/mm/yy)
: : / /
: : / /
: : / /
: : / /
: : / /

Remarks: Commander Sign.:

3-Ltr. Code:
For Office use only
Entered: By: Routing:
Checked: By: Crew Control
*Form of payment: € = Cash A = Account

Iss.1 Rev.6 – 01-06-2014 Flight Operations Engineering Page 1 of 2

 GENERAL DECLARATION
FO/022

1 Flight Information

Owner or Operator: ArkeFly (TUI Airlines Nederland B.V.)

Marks of Nationality and Registration:
Flight Nr. Date (dd-mm-yyyy)
Departure from (place) Arrival at (place)

2 Flight Routing

Place (1) Total Nr. Of Crew (2) Nr. of passengers on this stage (3)

Departure place:

Embarking

Through on same flight

Arrival place:

Disembarking

Through on same flight

(1) “Place” Colum always to list origin, every en-route stop and destination. (2) To be completed only when required by the
State. (3) Not to be completed when passengers are presented and to be completed only required by the State.
3 Declaration of health
Persons on board with illnesses other than airsickness or the effect of accidents (including For official use only
persons with symptoms or signs of illnesses as rash, fever, chills diarrhea) as well as those
cases of illness disembarked during the flight:
Any other conditions on board which may lead to the spread of disease:
Details of each disinsecting or sanitary treatment (place, date, time, method) during the flight. If
no disinsecting has been carried out during the flight give details of most recent disinsecting:
Signed if required:

Crew member concerned

4 Signature
I declare that all statements and particulars contained in this General Declaration, and in any supplementary forms required to
be presented with this General Declaration are complete, exact and true to the best of my knowledge and that all trough
passengers will continue/have continued the flight.
Signature:

Authorized Agent or Pilot in Command

Iss.2 Rev.0 – 01-06-2014 Flight Operations Engineering Page 1 of 1

 LOADSHEET

1 FLIGHT INFORMATION
Flight Number ► Date ► / / From ► To ►
FCM CCM
AC Registration ► Crew ► TOB ► Catering ►

2 ▼ PAYLOAD INFORMATION FROM GROUND HANDLING ▼

PASSENGERS BAGGAGE / CARGO (all weights in kg)

Destination Male Female Adults Child. Infants Hold 1 Hold 2 Hold 3 Hold 4 Hold 5 (*)
1.►

2.►

Totals ►

OA ▼ OB ▼ OC (*) ▼ Total in holds ►

Distribution►
Prepared by ►

3 ▼ FCM COMPLETES THIS SECTION ▼ 4 ▼ COMMANDER COMPLETES THIS SECTION ▼

Weight CG (%MAC) Last minute changes ▼ Commander name and signature▼
Zero fuel ►
Landing ►
Takeoff ►
Stab trim* ►
*if applicable
 SAFETY REPORT
FS/001

Anonymous (no name, flight number or registration required)

Confidential (name will only be known within QSSE department)

1 General Information

Reporter:
Event date: Time:
Flight No.:* Registration:*
Route:* Place of Event:
Feedback to:
Type:** Flight Cabin Security Technical Environment

Ground Medical Office ETOPS Other

* If applicable
** Select one or more applicable items

2 Event Information
Event Title:

Please describe, as completely as possible, the event that took place:

(Although English is preferred, you may also write your report in Dutch):

CONTINUE ON NEXT PAGE

Iss.1 Rev.0 – 23-01-2014 QSSE Department Page 1 of 2

 SAFETY REPORT
FS/001

2 Event Information (continued)

Which factors caused the event?

My suggestion to improve / avoid this:

When should I report? Confidential or anonymous reporting

Whenever you think something is unsafe or non-compliant or
whenever you have found yourself in an unsafe situation. The directors and managers of ArkeFly take safety very
seriously and encourage you to mention anything that is unsafe,
Why should I report? so we can improve our organization. However, if you still feel
There is only one way for us to find out that something needs to uncomfortable with reporting a safety or non-compliant issue
become safer in our day-to-day work: when other people tell us there is the possibility of confidential reporting and anonymous
that something needs to be done. reporting. With confidential reporting, the name on the report is
You can share what you have learned, so we can prevent only known to the QSSE department. To anyone outside the
incidents from happening again. QSSE department your name will be taken off the report.
You can also report anonymously (you do not have to fill in your
Where do I submit this form? name). Of course, if you report anonymously we cannot contact
You can submit your hardcopy form at the reception desk at the you to give you feedback, ask your opinion on how to improve
office or in the crew room. The form can also be submitted the situation or contact you to provide additional information.
online, send it to report@arkefly.nl.

What happens to my report?

Every report is taken seriously and will be processed by the
QSSE department. If necessary, the QSSE department will
make sure that actions will be taken to prevent the situation from
reoccurring.

Iss.1 Rev.0 – 23-01-2014 QSSE Department Page 2 of 2

 FATIGUE REPORT
FS/002

1 General Information

Reporter: Flt Nr: From: Diverted to:

Date: Registration: To: Nr of flight crew:
Feedback to: Confidential: Via: Nr of cabin crew:

2 Fatigue Information
Fatigue description (what happened / cause / action and results / suggestions):

Activities in the past 24 hours (list all activities at home / work / outstation):

Provide all times related to the Fatigue event

First moment of fatigue symptoms: (UTC)
Actual start of duty: (UTC)
Actual end of duty: (UTC)
Duration of scheduled duty: (hh:mm)
Duration of pre-duty commute: (hh:mm)
In the preceding 24 hours: (hh:mm)
In the preceding 48 hours: (hh:mm)
How many hours awake since your last sleep prior to duty: (hh:mm)
Controlled rest: (hh:mm)
Bunk: (hh:mm)
Seat class A: (hh:mm)
Seat class B: (hh:mm)
To what extent has the home situation and / or have the home activities contributed in the development of
the reported fatigue?
No influence Large influence
To what extent has the work situation and / or have work activities contributed in the development of the
reported fatigue?
No influence Large influence

3 Contributing Factors

Tick all factors that you feel contributed to the fatigue / your general concern:
Sleep disruption at home Rostered rest time
Personal issues Roster disruption
Short rest at home Early to late transition
Health issues Late to early transition
Long-term fatigue Long duty day
Commute Hotel rest
Early start time Delay(s)
Late finish time Positioning
Other:

Iss.1 Rev.2 – 21-03-2014 Flight Safety Department Page 1 of 2

 FATIGUE REPORT
FS/002

4 Countermeasures

Tick all taken countermeasures:

Advised colleague of fatigue risk Caffeine
Coordinated workload Food and drink
Increased communication In-flight rest / cockpit napping
Other:

5 Alertness Description

How alert did you feel immediately prior to feeling fatigued? (tick one)
Extremely alert Some signs of sleepiness
Very alert Sleepy but no effort to keep alert
Alert Sleepy, some effort to keep alert
Rather alert Very sleepy, great effort to keep alert, fighting sleep
Neither alert nor sleepy

6 List of Definitions

Bunk Afsluitbare rustruimte waar horizontaal gerust kan worden.

Commute Reis tussen huis en werk (woon-werkverkeer).
Contributing factors Factoren die bijgedragen hebben aan de buitengewone vermoeidheid.
Rustperiode tijdens de flight duty, zoals beschreven in OM-A1, waarbij
Controlled rest
geen taken worden verricht en eventueel geslapen kan worden.
Duration of pre-duty commute Reistijd voordat de duty begon.
Early to late transition Vroege duty volgend op een late duty.
Fatigue is de algemene term die wordt gebruikt om fysieke en / of
Fatigue mentale vermoeidheid buiten de normale vermoeidheid te beschrijven
(buitengewone vermoeidheid).
De verschijnselen van fatigue. Enkele voorbeelden zijn:
- verminderde alertheid
- moeite dingen te onthouden
- afname in communicatie
- verminderd situationeel bewustzijn
Fatigue symptoms
- maken van onbedoelde fouten en / of vergissingen
- zware oogleden
- staren
- knikkebollen
- onbedoelde momenten van korte slaap (micro sleeps)
Late to early transition Een late duty volgend op een vroege duty.
Het vervoer van een niet-dienstdoend bemanningslid tussen twee
Positioning bestemmingen, in opdracht van de operator, exclusief commute en
lokaal vervoer.
Roster disruption Verandering van het gepubliceerde rooster.
Rostered rest time Rusttijd volgens het rooster.
Seat class A Ruststoel klasse A conform definitie OM-A1.
Seat class B Ruststoel klasse B conform definitie OM-A1.

Iss.1 Rev.2 – 21-03-2014 Flight Safety Department Page 2 of 2

 AIRPROX Report Form
FS/003

Iss.2 Rev.2 – 02-06-2008 Flight Safety Department Page 1 of2

 AIRPROX Report Form
FS/003

Iss.2 Rev.2 – 02-06-2008 Flight Safety Department Page 2 of2

 Dangerous Goods Occurence Report
FS/004

Iss.1 Rev.0 – 17-09-2008 Flight Safety Department Page 1 of2

 SECURITY SEARCH FORM
SC/001

SECURITY SEARCH OF THE AEROPLANE IN COMPLIANCE WITH EU REGULATIONS 185 / 2010

1 Previous Flight

Origin of previous flight:

2 Departing Flight

Flight Number:
Destination:

3 Security Search Cabin and Cockpit (refer to Security Search Checklist onboard of aeroplane)

Security Search performed: Yes No

Date and time of Security Search: / / : hrs
Name and Signature of Commander:

4 External Search Maintenance (refer to Pre-flight Security Search Card)

Security Search performed: Yes No

Received Security Search Card: Yes No

IF THERE ARE ANY REMARKS (FROM ALL PERSONS INVOLVED),

THEY SHALL ALL BE STATED IN THE FLIGHT CREW REPORT

THIS FORM SHALL BE KEPT ON FILE AT THE DEPARTURE STATION

(WITH THE GROUND HANDLING AGENT) FOR THE DURATION OF THE FLIGHT
OR FOR 24 HOURS, WHICHEVER IS LONGER

Iss.3 Rev 2 – 02-05-2013 Security Department Page 1 of 2

 General Declaration Rev1.0 15SEP14
1 Flight Information

Owner or Operator: TUI Airlines Belgium trading as Jetairfly

Marks of Nationality and Registration:

Flight Nr. Date (dd-mm-yyyy)

Departure from (place Arrival at (Place

2 Flight Routing

Place (1) Total Nr. Of Crew (2) Nr. Of passengers on this stage (3)

Departure Place:

Embarking

Through on same flight

Arrival Place:

Disembarking

Through on same flight

(1) “Place” column always to list origin, every en-route stop and destination. (2) To be completed only
when required by the State. (3) Not to be completed when passengers are presented and to be
completed only required by the State.
3 Declaration of Health
Persons on board with illnesses other than airsickness or the effect of accidents For official use only
(including persons with symptoms or signs of illnesses as rash, fever, chills,
diarrhea) as well as those cases of illness disembarked during the flight:

Any other conditions on board which may lead to the spread of disease:

Details of each disinsecting or sanitary treatment (place, date, timle, method) during
the flight. If no disinsecting has been carried out during the flight give details of most
recent disincsecting:

Signed if required:

Crew member concerned

4 Signature
I declare that all statement and particulars contained in this General Declaration, and in any supplementary
forms required to be presented with this General Declaration are complete, exact and true to the best of my
knowledge and that all through passengers will continue/have continued the flight.
Signature:

Authorized agent or Pilot in Command

 Birth on Board Certificate Rev1.0 15SEP14
Aircraft Registration:
Departure Airport:
Destination Airport:
Date of Birth (UTC): (dd/mmm/yyyy)
Time of Birth (UTC): (HH:mm)
Given Names of the
Newborn:

Place of Birth:
Coordinates or
City and Country

Sex of the Newborn: Male / Female

Father Mother
Name of Parents:
Profession of Parents:
Birthday and place of
Parents:
Nationality of Parents:

Residence of Parents:

This entry has been made by Captain______________________________

Commander of above mentioned aircraft in presence of the following witnesses:
1st Witness 2nd Witness
Names of Witnesses:
Profession of Witnesses:

Residence of Witnesses:

In witness where of this certificate having been read aloud by me and signed by above
mentioned witnesses and myself on ________/________/____________(dd/mm/yyyy)
Signature of Commander Signature of 1st Witness: Signature of 2nd Witness

Remarks (if applicable): Send to

Director of Flight Operations
 Disappearance Certificate Rev1.0 15SEP14
Aircraft Registration:
Departure Airport:
Destination Airport:
Date of Disappearance
(dd/mmm/yyyy)
(UTC):
Time of Disappearance
(HH:mm)
(UTC):
Given Names of the
Disappeared:
Last Names of the
Disappeared:

Place of Disappearance:
Coordinates or
City and Country

Sex of the Disappeared: Male / Female

Airport where the
disappeared boarded:
Airport where the
disappeared was expected
to disembark:

Circumstances of
disappearance:

This entry has been made by Captain______________________________

Commander of above mentioned aircraft in presence of the following witnesses:
1st Witness 2nd Witness
Names of Witnesses:
Profession of Witnesses:

Residence of Witnesses:

In witness where of this certificate having been read aloud by me and signed by above
mentioned witnesses and myself on ________/________/____________(dd/mm/yyyy)
Signature of Commander Signature of 1st Witness: Signature of 2nd Witness

Remarks (if applicable): Send to

Director of Flight Operations
 Preliminary Death Certificate Rev1.0 15SEP14
1 Passenger Information
Date of Death / / Time of Death: Hrs minutes
(dd/mm/yyyy)
Name of passenger Mr/Mrs
Place of birth:
died
Date of Birth / / Profession:
(dd/mm/yyyy)
Marital Status: Single / Married / Divorced / Other:

Name Partner:

Father Mother

Name of Parents:
Profession of
Parents:

Residence of
Parents:

2 Flight Information

Flight No. A/C Reg. A/C Type Date / /

Captain F/O CCM 1 CCM 2

Route From To

3 Witness Information

This entry has been made by:

Commander of above mentioned aircraft in presence of the following witnesses:

st nd
1 Witness 2 Witness

Name of Witness:

Profession of Witness:

Residence of Witness:

In witness where of this certificate having been read aloud by me and signed by above mentioned witnesses and

myself on (dd/mm/yyyy) ________/________/________________

st nd
Signature of Commander Signature of 1 Witness Signature of 2 Witness

Remarks (if applicable):

Routing: Postholder Flight Operations

 Toilet Service Sheet Rev1.0 15SEP14
TO THE CAPTAIN AIRCRAFT REG:
FLIGHT No: Date:

Each lavatory holding tank has been drained, flushed with a minimum of 10 gallons of
water and left to dry.

Each centre toilet has received a two sachet chemical charge.

Company Representative
Service Person Name Service Person Signature
Signature
 Notification Form (Warning Letter) Rev1.0 15SEP14
Geachte passagier op stoel nummer ……………

De cabine bemanning heeft mij geïnformeerd dat Uw gedrag in strijd is met de wettelijke
veiligheidsbepalingen.

Ik verzoek U onmiddellijk te stoppen met dit gedrag en alle aanwijzingen van de bemanning op te
volgen.
Mocht U ervoor kiezen geen gevolg te geven aan dit verzoek, dan ben ik genoodzaakt actie te nemen
om de veiligheid van deze vlucht te waarborgen.
De consequentie hiervan kan zijn dat U vervolgd wordt volgens Belgisch civiel- en/of strafrecht.

Ik vertrouw erop dat het niet zover zal komen, en dat deze vlucht zonder verdere problemen kan
worden voortgezet.

Hoogachtend,
Namens de Gezagvoerder: (in opdracht)

Handtekening:
Cher passager assis au numéro de siège suivant .........

J’ai été informé par un des mes membres d’équipages que votre comportement va à l’encontre des
règles aériennes.

Je vous demande d’arrêter immédiatement ce comportement et de suivre les instructions qui vous
sont données par le membre d’équipage.
Si vous décidez de garder ce comportement inacceptable, je serais dans l’obligation d’intervenir afin
de garantir la sécurité de ce vol.
A ce moment, vous pourrez être passible de poursuites civiles et/ou pénales en vertu du droit Belge.

J’espère que ce genre d’action ne devra être requis et que nous pourrons continuer le vol sans autre
problème.

Bien à vous,

Au nom du Commandant et à son ordre :

Signature :
Dear passenger seated at seat number ...............

I have been informed by my cabin crew members that your behavior is in violation of the law.

I request you to stop this behavior immediately and follow all instructions given to you by the cabin
crew.
If you choose to continue with this unacceptable behavior, I will be forced to take action in order to
secure the safety of this flight. As a result of this you may be prosecuted under the Belgian criminal
and/or civil law.

I trust that no such action will be required, and that we can continue the flight without further
problems.

Sincerely yours,

In name of the Commander:

Signature:
 Security Search Form Rev1.0 15SEP14
1 Previous Flight

Origin of Previous Flight:

2 Departing Flight

Date:

Flight Number:

Departure:

Destination:

3 Security Search

Security Search Required: Yes X No

Yes, at time:
Security Search Performed:
No

4 Signature
Commander Signature:
 LOADSHEET

1 FLIGHT INFORMATION
Flight Number ► Date ► / / From ► To ►
FCM CCM
AC Registration ► Crew ► TOB ► Catering ►

2 ▼ PAYLOAD INFORMATION FROM GROUND HANDLING ▼

PASSENGERS BAGGAGE / CARGO (all weights in kg)

Destination Male Female Adults Child. Infants Hold 1 Hold 2 Hold 3 Hold 4 Hold 5 (*)
1.►

2.►

Totals ►

OA ▼ OB ▼ OC (*) ▼ Total in holds ►

Distribution►
Prepared by ►

3 ▼ FCM COMPLETES THIS SECTION ▼ 4 ▼ COMMANDER COMPLETES THIS SECTION ▼

Weight CG (%MAC) Last minute changes ▼ Commander name and signature▼
Zero fuel ►
Landing ►
Takeoff ►
Stab trim* ►
*if applicable