Form Nasa Arc 277b - General Form

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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 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 __________________
TYPE OF EVENT/SITUATION
NAME ____________________________________________________
________________________________________
ADDRESS/PO BOX _________________________________________
________________________________________
__________________________________________________________
DATE OF OCCURRENCE ___________________
(MM/DD/YYYY)
CITY __________________________ STATE _____ ZIP ____________
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
ATC EXPERIENCE
O Student
O FPL O Developmental
O Captain
O Single Pilot
o Flight Instructor
Total Time
hrs
O First Officer
O Sport/Rec
o Multiengine
O Instructor
radar
yrs
o pilot flying
O Trainee
Last 90 Days
O Private
o Instrument
hrs
non-radar
yrs
o pilot not flying
O Dispatcher:
yrs
O Commercial
o Flight Engineer
supervisory
yrs
o relief pilot
Time in Type
hrs
o check airman
O Other:
O ATP
o Other:
military
yrs
AIRSPACE
CONDITIONS / WEATHER ELEMENTS
LIGHT / VISIBILITY
ATC / ADVISORY SVC.
O dawn
O night
O VMC
O Ramp
O Center
o Class A
o Class E
o fog
o snow
O daylight
O dusk
O Ground
O FSS
o hail
o thunderstorm
O IMC
o Class B
o Class G
O Tower
O UNICOM
o haze/smoke
o turbulence
Ceiling
feet
O Mixed
o Class C
o Special Use
O TRACON
O CTAF
o icing
o windshear
Visibility
miles
ATC Facility
O Marginal
o rain
o other:
o Class D
o TFR
RVR
feet
Name:
AIRCRAFT 1
AIRCRAFT 2
Your Aircraft Type (Make/Model)
Operating
Other
Operating
:
FAR Part:
Aircraft:
FAR Part:
(e.g. B737) NOT “N #”, Flt #, etc.
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 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 final approach
o taxi
o climb
o final approach
o parked
o cruise
o missed/GAR
o parked
o cruise
o missed/ GAR
o takeoff
o descent
o landing
o takeoff
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.
LOCATION
CONFLICTS
Estimated miss distance in feet:
horiz
vert
Altitude:
O MSL O AGL
(single value)
Was evasive action taken?
O Yes
O No
Distance:
Radial (bearing):
from:
and/or
Was TCAS a factor?
O TA
O RA
O No
O Airport
O ATC Fac
Did terrain warning system activate?
O Yes
O No
O Intersection
O NAVAID
Reset
GENERAL FORM
Page 1 of 3
NASA ARC 277B (January 1994)

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