SAFETY & COMPLIANCE MONITORING HANDBOOK
FDAR FLIGHT CREW COUNSELING FORM Doc No: F-C/SCM-45
Side A — Crew Section
The purpose of this Form is to collect data to enhance flight safety.
The information in this Form shall be confidential, protected, and subject to company FDM Program Non-Punitive Environment
Policy laid down in IMSM
This side A shall be filled by Flight Crew and managed by SCM officer, for further information refer to IMSM
If required, please contact us via email: jzr.fdm@jazeeraairways.com
1. Flight Information
Safety Report Received:
*
Yes
No
Departure Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Occurrence:
*
FLT No:
*
FLT Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sector ICAO code:
*
A/C Type & Registration:
*
Start with 9K-
Occurrence Type Event Classification:
*
Phase of Flight:
*
Taxi Out
Take-Off
Initial Climb
Climb
Cruise
Descent
Approach
Final Approach
Landing
Taxi In
Commander 1
*
Commander 1 Role
*
Please Select
PF
PM
Commander 2
*
Commander 2 Role
*
Please Select
PF
PM
FDAR Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PM
PF
2. Summary Of The FDM Event/ Exceedance
Summary
*
To be filled by Crew Only
3 Crew Statement:
Statement
*
Contributing Factors
*
Fatigue
Physical
Psychological
Personal issue
Environmental
Operational
CRM
Others
Contributing Others Reason
*
Specify the reason
*
Crew Name
*
Initials
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Side B — SCM Evaluation
4 SCM EVALUATION:
Evaluation
*
Event ID:
*
Event Contributing Factors
*
Human Factor
Environmental Factor
Technical Factor
Organizational Factor
5 SAFETY MITIGATION ACTION:
Action
*
Initial Risk Assessment
Risk Severity (A–E):
*
Please Select
A
B
C
D
E
Risk Probability (1–5):
*
Please Select
1
2
3
4
5
Risk Index
*
Risk Tolerability:
*
Intolerable
Tolerable
Acceptable
6. EFFECTIVENESS:
Follow up date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow up action
*
Rating:
*
Poor
Fair
Satisfactory
Good
Excellent
7. JUST CULTURE PROCESS
*
Rows
No Action (Crew managed the incident sufficiently)
No Blame Error (Consultation provided, Threat Error Management (TER) completed)
Repeated Incident with similar RCA
Negligent Error
Reckless Violation
Intentional Violation
Comment:
*
7. REMARKS
Remarks
*
Consulted by
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Initials
*
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