Appendix 5. Checklist for Reported Headset Tone Incidents
This form will be completed by the operations supervisor (OS)/controller-in-charge (CIC) and must be retained by the employee's OS for a period of 1 year.
Checklist Requirement for Headset Tone Incidents |
OS/CIC Initials |
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Ensure that Technical Operations is notified to evaluate the affected operational position and associated NAS equipment for normal operations as soon as possible. |
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Secure the affected headset for testing by facility Air Traffic Management. |
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Secure the recording of the headset tone incident. |
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Record the incident on FAA Form 7230-4, Daily Record of Facility Operation, using the “E” entry. |
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When headset testing is complete, annotate the facility log using an “E” entry with the statement, “Tests complete. (Record test results).” Report any abnormal test results (headset or other communications equipment), as appropriate, on FAA Form 7230-4, Daily Record of Facility Operation. |
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Update the Safety Management Information System (SMIS) to reflect the headset tone incident. |
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Determine if the employee intends to file a DOL Form CA-1, Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation. The facility supervisor will assist the employee in filing DOL Form CA-1, if requested. |
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If any employee wishes to be medically evaluated due to a headset tone incident, complete DOL Form CA-16, Authorization for Medical Treatment, in accordance with the Federal Employee Compensation Act (FECA). |