Form Nasa Arc 277d - Maintenance (Mechanic) Reporting 1996
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3DO 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.
EXPERIENCE
repairman
inspection authority
other _______________
Describe your qualifications
A & P
A
P
FCC
What is your technician/main- lead technician _________
technician _________
repairman _________
avionics ____________
other _______________________________________________________________________________________
tenance experience in years?
FACTORS
Location
_____________________________________________________________________________________________
yes
no
Was training a factor?
I was instructing
I was receiving training
lighting
work cards
briefing
What other factors may
weather
manuals
other_______
have contributed?
inspection
yes
no
installation
yes
no
Check items which were
testing
yes
no
scheduled maintenance
yes
no
involved in the event
repair
yes
no
yes
no
MEL
logbook entry
yes
no
* Other
_____________
fault Isolation
yes
no
(* Describe in the Describe Event/Situation sector)
Component/System/Sub-system involved: __________________________________________________________________________________
yes
no
routine inspection
while aircraft was in
Was maintenance deferred?
When was problem detected?
in-flight
service at gate
taxi
pre-flight
other_______
CONSEQUENCES/OUTCOME
flight delay
gate return
aircraft damage
improper service
flight cancellation
in-flight shut down
rework
air turn back
other_______
AIRCRAFT/AIRWORTHINESS STATUS
MISSION
OPERATOR
(Check all that apply)
aircraft released for service
passenger
air carrier
government
aircraft records completed
cargo
commuter
military
aircraft required documents aboard
business
corporate
part 121
not released for service
training
air-taxi
part 135
unknown
pleasure
charter
repair Station
other_______
self employed
FBO
flight school
other_______
TYPE OF AIRCRAFT (MAKE/MODEL) AND ENGINE TYPE
type of aircraft _____________
series
_____________
ATA Code _____________
aircraft zone
engine model _____________
other
_____________
_____________
MAINTENANCE FORM
NASA ARC #277D
Rev Date: 08/1/96
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