ARC 277B ASRS General Form

B
DO NOT REPORT AIRCRAFT ACCIDENTS AND CRIMINAL ACTIVITIES ON THIS FORM.
ACCIDENTS AND CRIMINAL ACTIVITIES ARE NOT INCLUDED IN THE ASRS PROGRAM AND SHOULD NOT BE SUBMITTED TO NASA.
ALL IDENTITIES CONTAINED IN THIS REPORT WILL BE REMOVED TO ASSURE COMPLETE REPORTER ANONYMITY.
(SPACE BELOW RESERVED FOR ASRS DATE/TIME STAMP)

IDENTIFICATION STRIP: Please fill in all blanks to ensure return of ID strip to you.
NO RECORD WILL BE KEPT OF YOUR IDENTITY. This section will be returned to you.
TELEPHONE NUMBERS where we may reach you for further details of this occurrence:

PRIMARY

Area______ No._______________ Hours____________

H

M

W

ALTERNATE Area______ No._______________ Hours____________

H

M

W
TYPE OF EVENT/SITUATION

NAME ____________________________________________________

________________________________________

ADDRESS/PO BOX _________________________________________

________________________________________

__________________________________________________________

DATE OF OCCURRENCE ___________________

CITY __________________________ STATE _____ ZIP ____________

LOCAL TIME (24 hr. clock) _________________

(MM/DD/YYYY)
(HH:MM)

PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.

REPORTER
 Single Pilot

 Captain


Total Time

hrs

Last 90 Days

hrs

Time in Type

hrs

 Instructor



 relief pilot
 check airman

 Trainee
 Dispatcher:

yrs

 Other:
 VMC

 Class E

 Class B

 Class G

 IMC

 Class C

 Special Use

 Mixed

 Flight Instructor

 FPL  Developmental

 Sport/Rec

 Multiengine

radar

yrs

 Private

 Instrument

non-radar

yrs

 Commercial

 Flight Engineer

supervisory

yrs

 ATP

 Other:

military

yrs

 Class D

 TFR

 Marginal

LIGHT / VISIBILITY

 fog

 snow

 hail

 thunderstorm

 haze/smoke

 turbulence

 icing

 windshear

 rain

 other:

 dawn
 daylight

(e.g. B737, Not "N#", Flt#", etc.):

ATC / ADVISORY SVC.

 night
 dusk

Ceiling

feet

Visibility

miles

Operating
FAR Part:

Other
Aircraft:

 Ramp

 Center

 Ground

 FSS

 Tower

 UNICOM

 TRACON

 CTAF

ATC Facility
Name:
AIRCRAFT 2

RVR

feet

AIRCRAFT 1
Your Aircraft Type (Make/Model)

ATC EXPERIENCE

 Student

CONDITIONS / WEATHER ELEMENTS

AIRSPACE
 Class A

CERTIFICATES & RATINGS

FLYING TIME (in hours)

Operating
FAR Part:

Operator

 air carrier
 air taxi
 corporate

 fractional
 FBO
 government

 military
 personal
 other:

 air carrier
 air taxi
 corporate

 fractional
 FBO
 government

 military
 personal
 other:

Mission

 passenger
 personal

 cargo/freight
 training

 ferry
 other:

 passenger
 personal

 cargo/freight
 training

 ferry
 other:

Flight Plan

 VFR
 IFR

 SVFR
 DVFR

 none

 VFR
 IFR

 SVFR
 DVFR

 none

Flight Phase

 taxi
 parked
 takeoff
 initial climb

 climb
 cruise
 descent
 initial approach


 missed / GAR
 landing
 other:

 taxi
 parked
 takeoff
 initial climb

 climb
 cruise
 descent
 initial approach


 missed /GAR
 landing
 other:

Route
in Use

 airway (ID):
 direct
 SID (ID):

 STAR (ID):
 oceanic
 vectors

 visual approach
 none
 other:

 airway (ID):
 direct
 SID (ID):

 STAR (ID):
 oceanic
 vectors

 visual approach
 none
 other:

If more than two aircraft were involved, please describe the additional aircraft in the "Describe Event/Situation" section.

LOCATION
Altitude:

(single value)

CONFLICTS
Estimated miss distance in feet:

 MSL  AGL

horiz

Was evasive action taken?

Distance:

and/or Radial (bearing):

 Airport

 ATC Fac

Was TCAS a factor?

 Intersection

 NAVAID

Did terrain warning system activate?

NASA ARC 277B

from:

vert

GENERAL

 Yes

 No

 TA

 RA

 No

Reset

 Yes

 No

OMB No. 2700-XXXX Exp. mm/dd/yyyy

NATIONAL AERONAUTICS AND SPACE ADMINISTRATION

AVIATION SAFETY REPORTING SYSTEM

NASA has established an Aviation Safety Reporting System (ASRS)
to identify issues in the aviation system which need to be addressed.
The program of which this system is a part is described in detail in FAA
Advisory Circular 00-46E. Your assistance in informing us about such
issues is essential to the success of the program. Please fill out this form
as completely as possible, enclose in an sealed envelope, affix proper
postage, and and send it directly to us.

Section 91.25 of the Federal Aviation Regulations (14 CFR 91.25) prohibits
reports filed with NASA from being used for FAA enforcement purposes. This
report will not be made available to the FAA for civil penalty or certificate
actions for violations of the Federal Air Regulations. Your identity strip,
stamped by NASA, is proof that you have submitted a report to the Aviation
Safety Reporting System. We can only return the strip to you, however,
if you have provided a mailing address. Equally important, we can often
obtain additional useful information if our safety analysts can talk with
you directly by telephone. For this reason, we have requested telephone
numbers where we may reach you.

The information you provide on the identity strip will be used only if NASA
determines that it is necessary to contact you for further information. THIS
IDENTITY STRIP WILL BE RETURNED DIRECTLY TO YOU. The return
of the identity strip assures your anonymity.
NOTE:

Thank you for your contribution to aviation safety.

AIRCRAFT ACCIDENTS SHOULD NOT BE REPORTED ON THIS FORM. SUCH EVENTS SHOULD BE FILED WITH THE NATIONAL
TRANSPORTATION SAFETY BOARD AS REQUIRED BY NTSB Regulation 830.5 (49CFR830.5).

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The
OMB control number for this information collection is 2700-XXXX and it expires on mm/dd/yyyy. We estimate that it will take about 30 minutes to read the
instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: P.O. Box 189 Moffett Field, CA 94035-0189.
Send only comments relating to our time estimate to this address.

If you want to mail this form, please fold pages, enclose in a sealed, stamped envelope, and mail to:

NASA AVIATION SAFETY REPORTING SYSTEM
POST OFFICE BOX 189
MOFFETT FIELD, CA 94035-0189
DESCRIBE EVENT/SITUATION
Keeping in mind the topics shown below, discuss those which you feel are relevant and anything else you think is important. Include what you believe really caused the
problem, and what can be done to prevent a recurrence, or correct the situation. (USE ADDITIONAL PAPER IF NEEDED)

CHAIN OF EVENTS
- How the problem arose
- How it was discovered
- Contributing factors
- Corrective actions

NASA ARC 277B

Page 2 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance

DESCRIBE EVENT/SITUATION (continued)

CHAIN OF EVENTS
- How the problem arose
- How it was discovered
- Contributing factors
- Corrective actions

NASA ARC 277B

Page 3 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance