NASA ARC 277C ASRS Cabin Report Form

C
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 ID strip to you.
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 ___________________

CITY __________________________ STATE _____ ZIP ____________

LOCAL TIME (24 hr. clock) _________________

(MM/DD/YYYY)

(HH:MM)

PLEASE FILL IN APPROPRIATE SPACES AND CHECK ALL ITEMS WHICH APPLY TO THIS EVENT OR SITUATION.

REPORTER

EXPERIENCE

o Flight Attendant (FA)
o FA in charge

o Off-Duty FA
o Other_________________________

Total years as Flight Attendant _________________________
Total years as FA with your current airline
_________________________
Number of aircraft types currently qualified to work on
_________________________
Percent of duty time in past year on aircraft type involved _________________________
FLIGHT INFORMATION

Type of Aircraft

(Make/Model) ______________________________________________________________________________

number of seats __________

number of exits: floor level __________

Flight Segment

flight origin _______________________ destination _______________________ departure time ________

time since takeoff __________ hrs/mins nearest city/state (if known) _________________________________

Cabin Activity
(check all that
apply)

o boarding
o beverage service
o cart service
o deplaning
o meal service
o tray service
o other _______________
o safety related duties, specify ________________________________________________________________

OPERATOR

o air carrier
o air taxi
o corporate
o fractional
o other _____________

number of pax on board __________
window __________

FLIGHT PHASE
o parked
o taxi
o takeoff
o climb
o cruise

number in cabin crew __________
tailcone __________

WEATHER

o descent
o approach
o landing
o gate arrival
o other ___________

o clear
o cloudy
o rain
o fog
o turbulence
o snow
o thunderstorms o ice
o unknown

(HH:MM)

LIGHTING
CABIN

o high
o medium
o low
o off

OUTSIDE
o daylight
o night

EVENT CHARACTERISTICS

Reporter's location in aircraft at time of event _______________________________________________________________________
Reporter's activity at time of event ________________________________________________________________________________

Was a passenger directly involved
in the event?

o Yes o No Reset

Did this event result in an injury?

to passenger?

o Yes o No
o Yes o No

Was fire/smoke involved in the event? o Yes

o No

Reset

Was there an evacuation during or
as a result of this event?

o No

Reset

o Yes

Reset

NASA ARC 277C (May 2009)

CABIN CREW

OMB No. 2700-0172

NATIONAL AERONAUTICS AND SPACE ADMINISTRATION

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, enclose in an sealed envelope, affix proper
postage, and and send it directly to us.

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.

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.
NOTE:

Thank you for your contribution to aviation safety.

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. § 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.

If you want to mail this form, please fold pages, enclose in a sealed, stamped envelope, and mail to:

NASA AVIATION SAFETY REPORTING SYSTEM
POST OFFICE BOX 189
MOFFETT FIELD, CA 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)

CHAIN OF EVENTS
- How the problem arose
- How it was discovered
- Contributing factors
- Corrective actions

NASA ARC 277C (May 2009)

Page 2 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance

DESCRIBE EVENT/SITUATION (continued)

CHAIN OF EVENTS
- How the problem arose
- How it was discovered
- Contributing factors
- Corrective actions

NASA ARC 277C (May 2009)

Page 3 of 3

HUMAN PERFORMANCE CONSIDERATIONS
- Perceptions, judgments, decisions
- Actions or inactions
- Factors affecting the quality of human performance