COMPANY __________________________________ FLIGHT NUMBER__________________
Date and time (UTC) ?__________________________________________________________________________
Position of event (lat/long and/or FRD)? ___________________________________________________________________________
Altitude? _____________________________________________________________________________________________________
What was the visibility?
What were the atmospheric conditions? (Circle those which apply) – Clear, overcast, rainy, foggy, hazy, sunny.
What was the color(s) of the light?
Did the color(s) change during the exposure?
Did you attempt an evasive maneuver?
If so, did the beam follow you as you tried to move away?
Can you estimate how far away the light source was from your location?
What was the position of the light relative to the aircraft? ______________________________________________________________
Was the source moving?
Was the light coming directly from its source or did it appear to be reflected off other surfaces?
Were there multiple sources of light?
How long was the exposure?
Did the light seem to track your path or was there incidental contact?
What tasks were you performing when the exposure occurred?
Did the light prevent or hamper you from doing those tasks, or was the light more of an annoyance?
What were the visual effects you experienced (after-image, blind spot, flash-blindness, glare*)?
Did you report the incident by radio to ATC?
Any other pertinant information: ___________________________________________________________________________________
_____________________________________________________________________________________________________
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This questionnaire may be filled out by the competent authority during interviews with aircrews exposed to unauthorized laser illumination. This information will be used to aid in subsequent investigation by ATC, law enforcement and other governmental agencies to safeguard the safety and efficiency of civil aviation operations in the NAS
*Examples of common visual effects:
After-image. An image that remains in the visual field after an exposure to a bright light.
Blind spot. A temporary or permanent loss of vision of part of the visual field.
Flash-blindness. The inability to see (either temporarily or permanently) caused by bright light entering the eye and persisting after the illumination has ceased.
Glare. A temporary disruption in vision caused by the presence of a bright light (such as an oncoming car's headlights) within an individual's field of vision. Glare lasts only as long as the bright light is actually present within the individual's field of vision.
Paperwork Reduction Act Statement: This form is being used to collect information regarding the unauthorized laser illumination of aircraft. We estimate that it will take 15 minutes to provide this information. The collection is voluntary. Note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number associated with the collection is 2120-0698. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington DC, 20591, Attn: Information Collections Clearance Officer, AES-200.
| File Type | application/msword |
| File Title | Appendix B |
| Author | AF LAN |
| Last Modified By | Taylor CTR Dahl |
| File Modified | 2011-08-26 |
| File Created | 2011-08-26 |