GCAA E/EM/89

EASA 145.0054

EASA 21J.103

FAA EENY256XEngineering Safety Report(EK EPM 07-24) SENTINEL REFERENCE

GCAA ROSI REFERENCE

For internal use only

TO BE COMPLETED IN FULL BY ORIGINATOR (PRINT IN BLOCK CAPITALS)Originator:

Staff Number: Shift:

Operational Phase:

Do you consider this a reportable occurrence to the GCAA (See note above) ?

Date of Occurrence: (DD/MM/YY)

Time of Occurrence:

Work Location/Station: FORMTEXT

Sub Location: (Stand, gate, hangar etc)

Aircraft Type: Registration:

Tech. Log Ref :

Operator:

Flt. No:

ETOPS:

Component / System Name:

Part Number:

Serial Number:

Tag/Demand Number:

Defective Part(s) Quarantined: (Attach incident label QA/F/0159)ATA: ATA Sub Code:

SUMMARY / TITLE (Please describe in brief the effect of the event i.e. Bird strike, in-flight shut down, hydraulic loss etc.)

EVENT DESCRIPTION (A detailed description of the event and its immediate cause add pictures or diagrams if necessary)

MAINTENANCE ACTION (Describe in detail the maintenance action carried out to rectify the reported event. Attach copies of technical/cabin/IFE log pages, work cards or any additional documentation as necessary).IMPORTANT NOTE: As required by EPM 09-45, all structural defects must also be reported via the Structural Defect Report (SDR) form QA/F/0399.

SUBMITTED BY:

SIGNATURE:

TITLE:

DATE: TIME:

Please complete all sections of the form where the information is relevant. If information is not known or not available, N/A must be annotated. If necessary, attach photographs and/or diagrams to assist in detailing the event.

DISPOSAL INSTRUCTIONS:Originator: Immediately after completing the report, please do the following:

1. For reports raised in Dubai, please e-mail to DL ESR, or fax it to Flight Safety: 04 286 4086 or 04 286 4087.2. For reports raised at an overseas station, e-mail to ESR@emirates.com or it can be faxed to;

MCC; + 971 (4) 286 4072 and Flight Safety; +971 (4) 286 4086 or + 971 (4) 286 4087.3. Reports faxed to MCC must be forwarded to Quality Assurance by hand or by fax: 04 299 7859.All original reports must be returned to Quality Assurance as soon as possible after the event, send to: Emirates Engineering - Quality Assurance, P.O. Box 686, Dubai, United Arab Emirates.

EK QUALITY ASSURANCE:

If the report is classified as a ROSI report following GCAA CAAP 22 guidance, as soon as practicable, but not exceeding 72 hours from when the occurrence took place, the report must reported to the GCAA via the ROSI on-line reporting system.

QAE reporting Occurrence:

Date and Time:

ROSI File number:

......................

This internal Emirates form is used to report safety related occurrences or issues. Please ensure that you annotate YES or NO, if the report raised is considered a reportable occurrence to the GCAA. Please refer to EK EPM 07-24, GCAA CAAP 22 and Information Bulletin #01/2010 for guidance, accessible via the Quality Assurance web site. Quality Assurance is responsible for reporting occurrences to the GCAA via their ROSI (Reporting of Safety Incident). This form is to be used when reporting any EK aircraft, engine, maintenance or workshop related concern(s), at any station. Third party operator reportable occurrences must also be reported using this report form, unless specified by the operator.

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