Fillable NASA - General ASRS General Report Form

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NASA - General ASRS General Report Form

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fog
o snow
o dawn o night
o Ramp
o Center
hail
thunderstorm
o daylight o
o
o
dusk
o Ground
o FSS
o Class B
o Class G
o IMC
o haze/smoke
o
Ceiling
feet
o Tower
as evasive action taken?
o Ye
s o No
Was TCAS a factor?
o TA o RA
ATC Fac
o
o
No
o Intersection o NAVAID
Did terrain warning system activate?
o Yes o No
NASA ARC 277B (May 2009)
GENERAL
OMB No. 2700-0172 Exp 7/31/2022
other:
Mission
o passenger o cargo/freight o ferry o passenger o cargo/freight o ferry
o personal o training o other: o personal o training o other:
Flight Plan
o VFR o SVFR o none o VFR o SVFR o none
o IFR o DVFR o IFR o DVFR
Flight Phase
o taxi o climb o nal approach o taxi o climb o nal approach
o parked o cruise o missed/GAR o parked o cruise o missed/GAR
o takeo o descent o landing o takeo o descent o landing
o initial climb o initial approach o other: o initial climb o initial approach o other:
Route
o
airway (ID):
o
STAR (ID):
o visual approach o
airway (ID):
o
STAR (ID):
o visual approach
in Use
o direct o
oceanic
o none o direct o
oceanic
o none
o
SID (ID):
o vectors o other: o
SID (ID):
o vectors o other:
If more than two aircraft were involved, please describe the additional aircraft in the "Describe Event/Situation" section.
turbulence
o UNICOM
o Class C
o Special Use
o Mixed
o icing
o windshear
o TRACON
o CTAF
Visibility
miles
o Class D
o TFR
o Marginal
o rain
o other:
ATC Facility
RVR
feet
Name:
Hours _________________
o Instrument
non-radar
yrs
o pilot not ying
Dispatcher:
yrs
Commercial
o Private
o Trainee
Last 90 Days
yrs
hrs
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:
HOME Area _______
PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.
REPORTER FLYING TIME (in hours)
CERTIFICATES & RATINGS
ATC EXPERIENCE
o Captain
Student
FPL
o pilot ying
o Single Pilot
o o Flight Instructor
o o Developmental
Total Time
hrs
o First Ocer
o Instructor
o Sport/Rec o Multiengine
radar
No. ______________________ Hours _________________
No. ______________________
NAME ____________________________________________________
TYPE OF EVENT/SITUATION
________________________________________
________________________________________
(HH:MM)
DATE OF OCCURRENCE ___________________
o o Flight Engineer
supervisory
o relief pilot
Time in Type
hrs
o check airman
o Other:
o ATP o Other:
ADDRESS/PO BOX _________________________________________
__________________________________________________________
CITY __________________________ STATE _____ ZIP ____________
WORK Area _______
yrs
military
yrs
(MM/DD/YYYY)
LOCAL TIME (24 hr. clock) _________________
o
AIRSPACE
CONDITIONS / WEATHER ELEMENTS LIGHT / VISIBILITY ATC / ADVISORY SVC.
o Class A
o Class E
o VMC
o
AIRCRAFT 1 AIRCRAFT 2
Your Aircraft Type (Make/Model)
Operating Other Operating
(e.g. B737, Not "N#", Flt#", etc.):
FAR Part: Aircraft: FAR Part:
Operator
o air carrier o fractional o military o air carrier o fractional o military
o air taxi o FBO o personal o air taxi o FBO o personal
o
corporate
o government o other: o
corporate
o government o
LOCATION CONFLICTS
Altitude:
(single value) o MSL o AGL
Estimated miss distance in feet: horiz vert
W
Distance:
and/or Radial (bearing): from:
o Airport
Reset
NATIONAL AERONAUTICS AND SPACE ADMINISTRATION AVIATION SAFETY REPORTING SYSTEM
NASA has established an Aviation Safety Reporting System (ASRS) Section 91.25 of the Federal Aviation Regulations (14 CFR 91.25) prohibits
to identify issues in the aviation system which need to be addressed. reports filed with NASA from being used for FAA enforcement purposes. This
The program of which this system is a part is described in detail in FAA report will not be made available to the FAA for civil penalty or certificate
Advisory Circular 00-46E. Your assistance in informing us about such actions for violations of the Federal Air Regulations. Your identity strip,
issues is essential to the success of the program. Please fill out this form stamped by NASA, is proof that you have submitted a report to the Aviation
as completely as possible, enclose in an sealed envelope, affix proper Safety Reporting System. We can only return the strip to you, however,
postage, and and send it directly to us. if you have provided a mailing address. Equally important, we can often
obtain additional useful information if our safety analysts can talk with
The information you provide on the identity strip will be used only if NASA
you directly by telephone. For this reason, we have requested telephone
determines that it is necessary to contact you for further information. THIS
numbers where we may reach you.
IDENTITY STRIP WILL BE RETURNED DIRECTLY TO YOU. The return
of the identity strip assures your anonymity. Thank you for your contribution to aviation safety.
NOTE:
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 2700-0172 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. 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)
NASA ARC 277B (May 2009)
CHAIN OF EVENTS
- How the problem arose - How it was discovered
- Contributing factors - Corrective actions
HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions - Actions or inactions
- Factors affecting the quality of human performance
Page 2 of 3
DESCRIBE EVENT/SITUATION (continued)
NASA ARC 277B (May 2009)
CHAIN OF EVENTS
- How the problem arose - How it was discovered
- Contributing factors - Corrective actions
HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions - Actions or inactions
- Factors affecting the quality of human performance
Page 3 of 3
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NASA - General ASRS General Report Form

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Completed 25 May 2020

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