Form Nasa Arc 277a - Atc Form 1994
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2DO 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 strip.
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 _______
No. _________ - ___________
Hours ______
WORK
Area _______
No. _________ - ___________
Hours ______
NAME ____________________________________________________
TYPE OF EVENT/SITUATION ________________
ADDRESS/PO BOX _________________________________________
________________________________________
__________________________________________________________
DATE OF OCCURRENCE ___________________
CITY __________________________ STATE _____ ZIP ____________
LOCAL TIME (24 hr. clock) _________________
PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.
REPORTER
In what type of facility do you work?
Tower
Approach
Center
FSS
Facility ID ___________________
Describe your ATC qualifications.
FPL
Developmental
Time certified on position/sector: ____________ yrs/mos
What is your ATC experience in years?
radar______ limited radar _______ non-radar _______ military _______ supervisor _______
What was your control position or activity
radar
local
arrival
clrnc delivery
pre-flight
supervisor
during the occurrence? (Check all that
hand-off
ground
departure
coordinator
in-flight
monitor
apply for combined position)
radar assoc
assistant
data
manual
flight watch
other________
Was instruction a factor?
I was instructing
I was receiving training
yes
no
Do you have pilot experience?
no
yes, ______ hours
instrument rated
AIRSPACE
WEATHER
LIGHT/VISIBILITY
Class A (PCA)
Special Use Airspace
VMC
ice
daylight
night
Class B (TCA)
airway/route _______________
IMC
snow
dawn
dusk
Class C (ARSA)
unknown/other _____________
mixed
turbulence
ceiling___________ feet
Class D (Control Zone/ATA)
_________________________
marginal
thunderstorm
visibility_________miles
Class E (General Controlled)
_________________________
rain
windshear
RVR ___________ feet
Class G (Uncontrolled)
_________________________
fog
___________
AIRCRAFT 1
AIRCRAFT 2
Type of Aircraft
(Make/Model) ________________________________
(Make/Model) ________________________________
Operator
air carrier
military
corporate
air carrier
military
corporate
commuter
private
other __________
commuter
private
other __________
Mission
passenger
training
business
passenger
training
business
cargo
pleasure
unk/other_______
cargo
pleasure
unk/other_______
Flight plan
VFR
SVFR
none
VFR
SVFR
none
IFR
DVFR
unknown
IFR
DVFR
unknown
Flight phases at
taxi
cruise
landing
taxi
cruise
landing
time of occurrence
takeoff
descent
missed apch/GAR
takeoff
descent
missed apch/GAR
climb
approach
other __________
climb
approach
other __________
Control status
visual apch
on vector
on SID/STAR
visual apch
on vector
on SID/STAR
controlled
none
unknown
controlled
none
unknown
no radio
radar advisories
no radio
radar advisories
If more than two aircraft were involved, please describe the additional aircraft in the “Describe Event/Situation” section.
LOCATION
CONFLICTS
Altitude
_______________________________
MSL
AGL
Estimated miss distance in feet:
horiz
______ vert ______
Distance and radial from airport, NAVAID, or other fix _______
Was evasive action taken?
Yes
No
______________________________________________________
Was TCAS a factor?
Yes
No
Nearest City/State ______________________________________
Did Conflict Alert Activate?
Yes
No
ATC
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NASA ARC 277A (January 1994)
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