ARC 277# Rotary Wing

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 ensure complete reporter anonymity.
IDENTIFICATION STRIP: Please fill in all blanks to ensure return of strip. NO RECORD WILL BE KEPT OF YOUR IDENTITY. This section will be returned to you.

Telephone numbers where we can reach you for further details of this occurrence:
Type

Area Code

Number

Space Below Reserved for ASRS Date and Time Stamp

Best Call Hours

Primary
Backup
Name and address where we can return this identification strip:

Type of Event/Situation

Name
Address 1
Date of Occurrence

Address 2
City

State

Zip

(MM/DD/YYYY)

Local Time (24 hr clock)

(HH:MM)

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

Flying Time (in hours)

Certificates & Ratings (check all that apply)

ATC / Advisory Service

 Captain/PIC
 Copilot

 Single Pilot

 Student

 Flight Instructor

 Ground

 FSS

 Instructor

 Multiengine

 Tower

 UNICOM

 Pilot Flying
 Pilot Not Flying

 Trainee

Total Time

 Sport/Recreational
 Private

 Instrument

 TRACON

 CTAF

 Rotorcraft

 Center

 Dispatch

 Check Airman
 Relief Pilot

 Ground Crew

Last 90 Days

 Commercial
 ATP

 Powered Lift

 Remote

 Other

 Air/Mission Crew
 Other

Time in Type

Airspace
 Class B

 Class G

 Class C

 TFR

 Class D

 Offshore

Light/NVG

Conditions / Weather Elements
 VMC








 IMC

 Class E

 Mixed

 Special Use (MOA, Restricted, etc.)

 Marginal

Brownout
Fog
Hail
Haze/Smoke
Icing
Rain








Snow
Thunderstorm
Turbulence
Whiteout
Windshear
Other

(Not N# or Flight)

Aircraft
Operator
Aircraft
Activity

















Ceiling

 Daylight
 Dusk

(feet)

Visibility

 Night – Unaided

(miles)

RVR

 Night – NVG Aided

(feet)

Aircraft 2

Make/Model (e.g., Airbus H135, etc.)

Air Carrier
Air Taxi
Corporate
Agriculture
Air Ambulance
Air Tour
Corporate

Ceiling/Visibility

 Dawn

Aircraft 1
Your Aircraft Type

ATC Facility Name

Operating FAR Part

Fractional
FBO
Government
Firefighting
Law Enforcement
News/Photo/Film
Offshore









Military
Personal
Other
Personal
Training
Utility
Other

Other Aircraft Type
 Remotely Piloted








Air Carrier
Air Taxi
Corporate
Agriculture
Air Ambulance
Air Tour
Corporate

Make/Model (if known)









Operating FAR Part

Fractional
FBO
Government
Firefighting
Law Enforcement
News/Photo/Film
Offshore









Military
Personal
Other
Personal
Training
Utility
Other

Flight
Plan

 VFR
 IFR

 SVFR
 DVFR

 Internal
 None

 VFR
 IFR

 SVFR
 DVFR

 Internal
 None

Flight
Phase

 Parked
 Ground Taxi
 Hover

 Takeoff/Climb
 Cruise
 Descent/Landing

 Approach
 Missed
 Other

 Parked
 Ground Taxi
 Hover

 Takeoff/Climb
 Cruise
 Descent/Landing

 Approach
 Missed
 Other

Route
in Use

 Direct
 Helo Route Chart

 Visual Approach
 Instrument Procedure

 None
 Other

 Direct
 Helo Route Chart

 Visual Approach
 Instrument Procedure

 None
 Other

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

Conflicts

Location
Altitude:

(single value)

Distance:

and/or Radial (bearing):

 Airport

 NAVAID

NASA ARC 277# .........................

 MSL

■ AGL


Estimated miss distance in feet:
from:

 Waypoint

(Horizontal)

Was Evasive Action Taken?
 Yes
Was TCAS a Factor?
 Yes
Did terrain warning system activate?  Yes

Rotary-Wing Form

(Vertical)
 No
 No
 No

■ NA

■ NA

■ NA


.OMB.2700-xxxx.Exp..mm/dd/yyyy

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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,
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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
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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

Page 2 of 3

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

NASA ARC 277#

DESCRIBE EVENT/SITUATION, continued...

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

NASA ARC 277#

Page 3 of 3

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

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