ASRS - UAS Report Form

UAS FORM

For immediate action of UNSAFE or UNAUTHORIZED drone operations contact local authorities.

Do not report UAS 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.

TELEPHONE NUMBERS where we may reach you for further details of this occurrence.

HOME

HOURS

TYPE OF EVENT / SITUATION (select all that apply)

(Use Command/Ctrl to multi-select)
Other:

DATE OF OCCURRENCE (MM/DD/YYYY)

LOCAL TIME (24 HR. CLOCK) [HH:MM]

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

How were you involved in the UAS operation?

Single Person Crew Multi-Person Crew Not Involved (e.g. eyewitness)

If part of a Multi-Person crew tell us:

Crew Size: (total including reporter)

Role at time of event: (select all that apply)
Person Manipulating Controls (ground control station / remote control transmitter)
Remote Pilot in Command (RPIC)
Visual Observer
Other Crew Member:

Reporter Location

Outdoor / Field Station
Indoor / Ground Control Station

Repair Facility
Other:

Time manipulating controls of UAS
(Estimated Time, round to nearest quarter hour)

Total Time to Date in all UAS Make / Models:

hrs (e.g. 14.25)

Time Last 90 Days in all UAS Make / Models:

hrs (e.g. 9.50)

Time to Date in UAS Make / Model involved in event:

hrs (e.g. 0.75)

Manned aircraft flight experience
(if applicable)

Total Time: hrs

FAA Certificates / Ratings held

Remote Pilot / Part 107
Private - Manned
Commercial - Manned
ATP - Manned

Flight Instructor - Manned
Instrument - Manned
Multiengine - Manned
N/A (non-certificated recreational flyer)

Other:

WEATHER ELEMENTS

Light / Visibility

AIRSPACE

Airspace Authorization Provider

UAS INVOLVED IN EVENT

IF MORE THAN ONE AIRCRAFT OR UAS WAS INVOLVED, PLEASE ADD ADDITIONAL AIRCRAFT / UAS.

UAS Location

NEAR MISS Conflicts

Altitude: feet

AGL (above ground level)
MSL (mean sea level)

Closest Airport:

State:

Distance: (nautical miles)

Closest VOR/NAVAID:

State:

Distance: (nautical miles)

Estimated miss distance from UAS / Aircraft:

Horizontal: feet Vertical: feet

How was the UAS / Aircraft conflict avoided?

Operator commanded evasive action

Yes No

Collision avoidance system maneuver activated

Yes No

Contributing FACTORS

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 277U (February 2021)

UAS FORM
v1.5.1

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 (49CFR830).

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. 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.