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NATIONAL AERONAUTICS AND SPACE ADMINISTRATION

AVIATION SAFETY REPORTING SYSTEM

NASA has established an Aviation Safety Reporting System (ASRS)

Section 91.25 of the Federal Aviation Regulations (14 CFR 91.25) prohibits

to identify issues in the aviation system which need to be addressed.

reports ﬁled with NASA from being used for FAA enforcement purposes.

The program of which this system is a part is described in detail in FAA

This report will not be made available to the FAA for civil penalty or cer-

Advisory Circular 00-46D. Your assistance in informing us about such is-

tiﬁcate actions for violations of the Federal Air Regulations. Your identity

sues is essential to the success of the program. Please ﬁll out this form

strip, stamped by NASA, is proof that you have submitted a report to the

as completely as possible, enclose in a sealed envelope, afﬁx proper

Aviation Safety Reporting System. We can only return the strip to you,

postage, and send it directly to us.

however, if you have provided a mailing address. Equally important, we

can often obtain additional useful information if our safety analysts can

The information you provide on the identity strip will be used only if NASA

talk with you directly by telephone. For this reason, we have requested

determines that it is necessary to contact you for further information. THIS

telephone numbers where we may reach you.

IDENTITY STRIP WILL BE RETURNED DIRECTLY TO YOU. The return of

the identity strip assures your anonymity.

Thank you for your contribution to aviation safety.

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).

If you want to mail this form, please fold both pages (and additional pages if required), enclose in a sealed,

stamped envelope, and mail to:

NASA AVIATION SAFETY REPORTING SYSTEM

POST OFFICE BOX 189

MOFFETT FIELD, CALIFORNIA 94035-0189

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. ( USE ADDITIONAL PAPER IF NEEDED)

Page 2 of 3

CHAIN OF EVENTS

HUMAN PERFORMANCE CONSIDERATIONS

- How the problem arose

- How it was discovered

- Perceptions, judgments, decisions

- Actions or inactions

- Contributing factors

- Corrective actions

- Factors affecting the quality of human performance

NASA ARC 277D (May 2009)