Form Nasa Arc 277a - Atc Form 1994 (Page 2 of 2) in pdf

NATIONAL AERONAUTICS AND SPACE ADMINISTRATION

AVIATION SAFETY REPORTING SYSTEM

NASA has established an Aviation Safety Reporting System (ASRS) to

Section 91.25 of the Federal Aviation Regulations (14 CFR 91.25)

identify issues in the aviation system which need to be addressed. The

prohibits reports filed with NASA from being used for FAA enforcement

program of which this system is a part is described in detail in FAA

purposes. This report will not be made available to the FAA for civil

Advisory Circular 00-46D and FAA Handbook 7210.3. Your assistance

penalty or certificate actions for violations of the Federal Air Regulations.

in informing us about such issues is essential to the success of the

Your identity strip, stamped by NASA, is proof that you have submitted

program. Please fill out this form as completely as possible, enclose in

a report to the Aviation Safety Reporting System. We can only return the

an sealed envelope, affix proper postage, and and send it directly to us.

strip to you, however, if you have provided a mailing address. Equally

important, we can often obtain additional useful information if our safety

The information you provide on the identity strip will be used only if NASA

analysts can talk with you directly by telephone. For this reason, we have

determines that it is necessary to contact you for further information.

requested telephone numbers where we may reach you.

THIS 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 NA-

TIONAL TRANSPORTATION SAFETY BOARD AS REQUIRED BY NTSB Regulation 830.5 (49CFR830.5).

Please fold both pages (and additional pages if required), enclose in a sealed, stamped envelope, and mail to:

NASA AVIATION SAFETY REPORTING SYSTEM

POST OFFICE BOX 189

MOFFETT FIELD, CALIFORNIA 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)

Page 2 of 2

CHAIN OF EVENTS

HUMAN PERFORMANCE CONSIDERATIONS

- How the problem arose

- How it was discovered

- Perceptions, judgments, decisions

- Actions or inactions

- Contributing factors

- Corrective actions

- Factors affecting the quality of human performance

Form Nasa Arc 277a - Atc Form 1994 Page 2

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