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X
X
In-Flight
Take-Off
X Landing X Open
Taxi Closed
X Parking
Date Occurred: Qty/Acft Effected MTBF FRACAS
4 1 50,000 PCR
Report Date: X PSSA/FTA
Qty/LRU Effected MTBF X FFMEA
4 4 15-75 X PPFMEA
X Vendor FMEA
RMS Engineer
LRU's Effected:
Item # Damaged Removed Item# Damaged
LRU#1 X X
LRU#2 X
SRU#1 X X
SRU#2 X X
Safety Initial Description:
Engineering Initial Description:
LRU Operational/Functional Description:
SRU Operational/Functional Description:
CAT III (Major)
Report #
2016-005
Safety Incident
Systems Manager
P/N
Removed
LRU
LRU
The SRU is part of a power supply for the LRU. The power supply provides X vdc, y vdc, and q vdc.
Ref doc no
Part failure either damages the immediate area and assocaited voltage, and/or explodes and leaks effecting Loss of LRU or specific damaged parts/areas and assocaited functions.
Part Number
123-22
123-45
2265-101
2265-102
LRU P/N
XYZ 12345
Safety Officer Ref doc noUnit 1
Part NumberS/N S/NLRU
ABC
LRU/SRU uses electrolytic capacitors. Capacitors explode, leak and either cumulatively or depending upon power surge explode and/or leak
Loss of communications PN 123-22. Loss of 2 of 3 VHF channels PN 123-45.
CAT I (Catastrophic)
CAT II (Hazardous)
Flight Test
Ref doc no
ABC
Powere Supply LHS
Power Supply RHS
File: Safety Incident Report (sample).xlsx
Tab: Safety Cover Sheet

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Safety incident report (sample)

  • 1. X X In-Flight Take-Off X Landing X Open Taxi Closed X Parking Date Occurred: Qty/Acft Effected MTBF FRACAS 4 1 50,000 PCR Report Date: X PSSA/FTA Qty/LRU Effected MTBF X FFMEA 4 4 15-75 X PPFMEA X Vendor FMEA RMS Engineer LRU's Effected: Item # Damaged Removed Item# Damaged LRU#1 X X LRU#2 X SRU#1 X X SRU#2 X X Safety Initial Description: Engineering Initial Description: LRU Operational/Functional Description: SRU Operational/Functional Description: CAT III (Major) Report # 2016-005 Safety Incident Systems Manager P/N Removed LRU LRU The SRU is part of a power supply for the LRU. The power supply provides X vdc, y vdc, and q vdc. Ref doc no Part failure either damages the immediate area and assocaited voltage, and/or explodes and leaks effecting Loss of LRU or specific damaged parts/areas and assocaited functions. Part Number 123-22 123-45 2265-101 2265-102 LRU P/N XYZ 12345 Safety Officer Ref doc noUnit 1 Part NumberS/N S/NLRU ABC LRU/SRU uses electrolytic capacitors. Capacitors explode, leak and either cumulatively or depending upon power surge explode and/or leak Loss of communications PN 123-22. Loss of 2 of 3 VHF channels PN 123-45. CAT I (Catastrophic) CAT II (Hazardous) Flight Test Ref doc no ABC Powere Supply LHS Power Supply RHS File: Safety Incident Report (sample).xlsx Tab: Safety Cover Sheet