Form Nasa Arc 277d - Maintenance Form

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D
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.
EXPERIENCE
o
o
o
o
o
o
o
Describe your qualifications
A
P
NDT
repairman
inspection authority
avionics
other ______________
What is your technician/main- lead technician _________
technician _________
repairman _________
avionics __________
tenance experience in years?
inspector _________
other ______________________________________
FACTORS
Location
____________________________________________________________________________________
o
o
o
o
Was training a factor?
Yes
No
I was instructing
I was receiving training
Reset
o
o
o
What other factors may
lighting
work cards
briefing
o
o
o
have contributed?
weather
manuals
other______________________________________________
o
o
o
o
Check items which were
inspection
Yes
No
installation
Yes
No
o
o
o
o
involved in the event
testing
Yes
No
scheduled maintenance
Yes
No
Reset
o
o
o
o
repair
Yes
No
MEL
Yes
No
o
o
logbook entry
Yes
No
* other
_____________
o
o
fault isolation
Yes
No
(*Describe in the Describe Event/Situation sector)
Component/System/Sub-system involved: ____________________________________________________________________________________
o
o
o
o
Was maintenance deferred?
Yes
No
When was problem detected?
routine inspection
while aircraft was in
o
in-flight
service at gate
o
o
taxi
pre-flight
Reset
o
other_____________
CONSEQUENCES/OUTCOME
o
o
o
o
flight delay
gate return
improper service
in-flight shut down
o
o
o
o
flight cancellation
air turn back
rework
aircraft/engine damage
o
other_______
AIRCRAFT/AIRWORTHINESS STATUS
MISSION
REPORTER ORGANIZATION
(Check all that apply)
o
o
o
o
aircraft released for service
passenger
air carrier
FBO
o
o
o
o
aircraft records completed
personal
air taxi
government
o
o
o
o
aircraft required documents aboard
cargo/freight
contracted service
military
o
o
o
o
not released for service
training
corporate
personal
o
o
o
o
other________
unknown
ferry
fractional
o
other________
TYPE OF AIRCRAFT (MAKE/MODEL) AND ENGINE TYPE
type of aircraft _____________
series
_____________
ATA Code _____________
aircraft zone
_____________
engine model _____________
other
_____________
MAINTENANCE FORM
Page 1 of 3
NASA ARC 277D (May 2009)

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