Form No. NAC/QA/05 Rev.

01
INTERNAL OCCURRENCE REPORT
Quality Assurance & Flight Safety Department
TIA, Kathmndu
E-mail: qafs@nac.com.np & qadd@nac.com.np NAC Occurrence Number: ONAC/
Issue Number:
Please complete this form in accordance with * To be filled by Quality Assurance
CAMMOE 2.18 and send it to above address.

1. Reference Information:
Name of Reporting Person Position Telephone No. Fax

E-mail Address Signature / Authorization No. Reported Date

Confidential ? Reported Type

Yes Initial
No Follow-up

2. Occurrence Summary:
Occurrence Title:
Place: Time(local): Date: ATA Chapter Aircraft Type Registration No. Detection Phase

Type of Occurrence: Detection Phase:

Maintenance Repair Maintenance Take-off
Unapproved Parts Fatigue Workshop In Flight
Human Factor Operational Standing Landing
Corrosion Unknown Taxi Unknown
Other (Specify): Other (Specify):

3. Details:
DESCRIPTION OF OCCURRENCE:

Occurrence Attachments: Documents Images Audio / Video

REMEDIAL ACTION TAKEN:

If you consider this event to be a "Mandatory Occurrence" requiring immediate attention, tick the box

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4. Aircraft Information (if relevant)
Aircraft Manufacturer and Type/Model Aircraft Serial No. Aircraft Registration

Aircraft Usage Details:

Aircraft Total Time (hrs) Aircraft Total Cycles
Since New
Since Overhaul
Since Inspection or Defect Found

5. Engine Information (if relevant)

Engine Model TC Holder Engine Serial No. Engine Position on Aircraft

Engine Event:
Uncontained Failure LOTC/LOPC
Fire Other
Shutdown Unknown
Engine Usage Details:
Engine Total Time (hrs) Engine Total Cycles
Since New
Since Overhaul
Since Inspection or Defect Found

6. Propeller Information (if relevant)

Propeller Model TC Holder Propeller Serial No. Propeller Position on Aircraft

Propeller Usage Details:

Propeller Total Time (hrs) Propeller Total Cycles
Since New
Since Overhaul
Since Inspection or Defect Found

7. Component Information (if relevant)

Component Manufacturer Part No. Serial No. ATA No. IPC Name

Component Usage Details:

Component Total Time (hrs) Compt. Total Cycles
Since New
Since Overhaul
Since Inspection or Defect Found

8. Manager of Concerned Department Comments

Signature/
Date

Note: Please verify that the above Occurrence is / are under CAMMOE 2.18

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 FOR QA USE ONLY

Initial Risk Assessment:

Database only

Monitored

More information needed

Short investigation

Full investigation

Corrective Action Taken / Conclusion / Additional Information

Date Received Date Closed Feedback QA Code/Stamp/Sign

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