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

Ensure that Technical Operations is notified to evaluate the affected operational position and associated NAS equipment for normal operations as soon as possible.

Secure the affected headset for testing by facility Air Traffic Management.

Note: The affected employee and their union representative will be given the opportunity to observe the headset testing.

Secure the recording of the headset tone incident.

Note: FAA Tech Ops may use the recording to conduct a root-cause analysis.

Record the incident on FAA Form 7230-4, Daily Record of Facility Operation, using the “E” entry.

Note: Carry the item on the facility log until headset testing has been completed.

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.

Note: The ATM must ensure headsets which fail the headset testing are secured and, within 30 days, contact the Oklahoma Communications Engineering Team, AJW-173, at (405) 954-0066 for instructions to return the headset to the manufacturer.

Update the Safety Management Information System (SMIS) to reflect the headset tone incident.

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.

Note: FAA employees file CA-1 claims forms via ECOMP.

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).

Note: FAA employees file CA-16 claims forms via ECOMP.