ATC FORM
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.
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. 		NASA logo
TELEPHONE NUMBERS where we may reach you for further details of this occurrence.

HOME 
HOURS 
  
OTHER 
HOURS 
NAME 
ADDRESS/PO BOX  
ADDRESS LINE 2  
CITY  
STATE  ZIP 
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?



Describe your ATC qualifications.
yrs  
What is your ATC experience in years?
Radar:  yrs Military:  yrs
Non-radar:  yrs Supervisor:  yrs
What was your control position or
activity during the occurrence?
(Check all that apply)












Was instruction a factor?
Do you have pilot experience?
hours
AIRSPACE CONDITIONS / WEATHER ELEMENTS Light / Visibility
aircraft 1
iF MORE THAN one AIRCRAFT Was INVOLVED, PLEASE ADD AN ADDITIONAL AIRCRAFT.
Location   Conflicts  
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.

chain of events     human performance considerations
- How the problem arose
- Contributing factors 		- How it was discovered
- Corrective actions 		    - Perceptions, judgements, decisions
- Factors affecting the quality of human performance 		- Actions or inactions
NASA ARC 277A (May 2009) OMB No. 2700-0172
 

From the NASA 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.

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.

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.

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. ยง 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. 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.

Thank you for your contribution to aviation safety.