Arc 277u Uas

U
For immediate action of UNSAFE or UNAUTHORIZED drone operations contact local authorities.

DO NOT REPORT UAS 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.
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.

(SPACE BELOW RESERVED FOR ASRS DATE/TIME STAMP)

TELEPHONE NUMBERS where we may reach you for further details of this occurrence:

Area _______ No. _____________________

Hours ________________

OTHER Area _______ No. _____________________

Hours ________________

HOME

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
How were you involved
in the UAS operation?

 Single Person Crew

If part of a Multi-Person
crew tell us:

Crew Size: ________ (total including reporter)
Role at time of event:
(select all that apply)

 Multi-Person Crew

 Not Involved (e.g. eyewitness)

o Person Manipulating Controls
o Remote Pilot in Command (RPIC)

o Visual Observer
o Other Crew Member: _____________________

Reporter Location

 Outdoor / Field Station

Time manipulating
controls of UAS

Total Time to Date in all UAS Make / Models: ________ hrs (e.g. 14.25)
Time Last 90 Days in all UAS Make / Models: ________ hrs (e.g. 9.50)
Time to Date in UAS Make / Model involved in event: ________ hrs (e.g. 0.75)

(Estimated Time, round to
nearest quarter hour)

 Indoor / Ground Control Station

Manned aircraft flight
experience (if applicable)
FAA Certificates /
Ratings held

 Repair Facility

Total Time: ________ hrs
o Remote Pilot / Part 107
o Private - Manned
o Commercial - Manned

o ATP - Manned
o Flight Instructor - Manned
o Instrument - Manned

o Multiengine - Manned
o N/A (non-certificated recreational flyer)
o Other: _____________________

WEATHER ELEMENTS
o Clear
o Fog
o Hail

o Haze/Smoke
o Icing
o Rain

 Other: _________________

o Snow
o Thunderstorm
o Turbulence

LIGHT / VISIBILITY

o Wind
o Windshear
o Other: __________________

o Dawn

o Night

Cloud Ceiling __________ feet

o Daylight

o Dusk

Visibility ______________ miles

AIRSPACE AUTHORIZATION PROVIDER

AIRSPACE
o Class A

o Class D

o Special Use (e.g. MOA, Restricted, Prohibited)

o Class B

o Class E

o Temporary Flight Restriction (TFR)

o Class C

o Class G

 Authorized Third Party (e.g. USS / UTM App, LAANC provider)
 FAA Authorization (e.g. FAA Drone Zone, Fixed Flying Site LOA)
 N/A (e.g. class G airspace)
 Other: _________________________________

UAS INVOLVED IN EVENT
UAS Make / Model / Series:
(or write "Homebuilt")

__________________________________________ (do not include registration or serial number)

(at takeoff with payload)

 Micro UAS (< 0.55 lbs)
 Small UAS (at or above .55 lbs & < 55 lbs)

Configuration

 Multi-Rotor

How many UASs were you
controlling? (at time of event)

____________________

Weight Category

 Fixed Wing

 Medium UAS (at or above 55 lbs < 1320 lbs)
 Large UAS (at or above 1320 lbs)

 Helicopter

 Hybrid (e.g. VTOL)

 137 (Agricultural Operations)
 Public Aircraft Operations
 Limited Recreational Operations, 349 / 44809
 Other: _________________________________

Rule Flying Under

 91 (Private / non-commercial)
 107 (UAS)
 133 (Helicopters w/ external loads)
 135 (Chartered / non-scheduled flights)

Airworthiness Approval
Certification (if applicable)

 Standard AC

Waivers / Exemptions /
Authorizations

Were you operating under any Waivers / Exemptions / Authorizations?
FAR Section Number / Other: _________________________

NASA ARC 277U (February 2021)

 Special AC

 Other: ____________________

 Special Authorization / Section 44807

UAS

 Yes

 No
OMB No. 2700-0172 Exp 7/31/2022

UAS INVOLVED IN EVENT (continued)
Operator

 Air Carrier
 Air Taxi

 Commercial Operator
 Government (local, state, federal, tribal)

 Military
 Recreational / Hobbyist

Mission

 Agriculture
 Banner Tow
 Cargo / Freight / Delivery
 Communications
 Observation / Surveillance

 Passenger
 Photo Shoot / Video
 Public Safety / Pursuit
 Recreational / Hobbyist
 Search & Rescue

Flight Operated As

 VLOS (Visual Line of Sight)

 BVLOS (Beyond VLOS)

UAS Control Mode
(at time of event)

 Autonomous / Fully Automated
 Waypoint Flying

Flight Phase (at time of event)

___________________________

 Other: _______________

 Surveying / Mapping
 Test Flight / Demonstration
 Training
 Utility / Infrastructure (Inspection)
 Other: _____________________
With Visual Observer?

 Yes

 No

 Manual Control
 Transitioning Between Modes

Was the UAS flying in, near or over: (select all that apply)

o Aerial Show / Event (e.g. fireworks, airshow)
o Aircraft / UAS
o Airport / Aerodrome / Heliport
o Critical Infrastructure
o Crowds (e.g. sporting event, concert, festival)

o Emergency Services (e.g. police, fire)
o Indoors / Confined Spaces
o Moving Vehicles (e.g. highways, busy streets, bridges)
o Natural Disaster
o No Drone Zone

o Open Space / Field
o People / Populated Areas (e.g. residential)
o Private Property
o Recreational Club / Fixed Flying Site
o Other: __________________________

UAS / AIRCRAFT 2 INVOLVED IN EVENT
Make / Model: (or describe)

__________________________________________

 UAS

UAS Weight Category

 Micro UAS

 Small UAS

 Medium UAS

 Large UAS

UAS Configuration

 Multi-Rotor

 Fixed Wing

 Helicopter

 Hybrid (e.g. VTOL)

Operator

 Air Carrier
 Air Taxi
 Commercial Operator (UAS)

Flight Phase (at time of event)

___________________________

 Manned Aircraft

 Corporate
 Government (local, state, federal, tribal)
 Military

 Other: ____________________
 Personal
 Recreational / Hobbyist (UAS)
 Other: ____________________

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

UAS LOCATION

NEAR MISS CONFLICTS

Altitude: ___________ feet

 AGL (above ground level)

 MSL (mean sea level)

Closest Airport:
___________________

State:
__________

Distance: (nautical miles)
__________________

Closest VOR / NAVAID:
___________________

State:
__________

Distance: (nautical miles)
__________________

Estimated miss distance from UAS / Aircraft:
Vertical: ___________ feet
Horizontal: ___________ feet
How was the UAS / Aircraft conflict avoided?
Operator commanded evasive action
 Yes
Collision avoidance system maneuver
 Yes

 No
 No

CONTRIBUTING FACTORS
What factors may
have contributed:
(select all that apply)

o Airspace Authorization / Flight Planning App
o Command and Control (e.g. lost link, frequency interference)
o Environment (e.g. terrain, obstructions, lighting, fire)
o FAA Regulation Misinterpretation / Unaware
o Ground Control Station / Remote Control Transmitter

o Human Factors (e.g. fatigue, confusion, situational awareness)
o Software and Automation (e.g. geofencing, return to home)
o UA Equipment (e.g. components, sensors, payload)
o Weather Conditions (e.g. wind gust, lightning)
o Other: __________________________

(e.g. hardware failure, interface / display)

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 277U (February 2021)

Page 2 of 3

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

Reset Form

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 00-46F. 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 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 (49CFR830).

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 2700-0172 and it expires on 7/31/2022. 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.

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 (continued)

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

NASA ARC 277U (February 2021)

Page 3 of 3

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