AC 120-55C Air Carrier TCAS - Code7700

2/23/11 AC 120-55CAppendix 2APPENDIX 2. SAMPLE TCAS EVENT REPORTING INFORMATION TCASMONITORING PROGRAMPilot Event QuestionnaireThe FAA and the airline industry have established the TCAS Transition Program to assess the operational acceptability of TCAS inthe NAS. Your participation in the program is essential to the success of the program. Please complete and return this questionnaireas quickly as possible. The information contained herein will be used only by the program participants to assess the operation ofTCAS and will not be released to the public in a manner which allows the identification of you or the airline. The information WILLNOT be used to initiate or pursue enforcement action against you or the crew. Once the data is entered into the TCAS TransitionProgramming (TTP) databases the questionnaire will be maintained for no longer than 60 days, at which time it will be destroyed.Please fill out the form in full and check all that apply. NOTE: TCAS events may be reported electronically at www.tcasreport.com.DATE:TIME: ______________ UTC AIRLINE:_____________ FLIGHT #: __________________/_____/_____A/C TYPE:TAIL NUMBER: ___________ ORIGIN: _________ DESTINATION: __________________________OWN ALTITUDE:_______________________________________ OWN POSITION:__________/__________/__________FTVOR RADIAL DMEPHASE OF FLIGHT DEPARTURE (TAKEOFF TO 10,000 FT) CLIMB (10,000 FT TO TOC)CRUISE DESCENT (TOC TO 10,000 FT) APPROACH (BELOW 10,000 FT)TCAS DISPLAY RANGE SETTING: 5 NM 10 NM 20 NM 30 NM OTHER __________ NMINTRUDER AIRCRAFTID (IF KNOWN):________________ TCAS-EQUIPPED (IF KNOWN)? YES NORELATIVE ALTITUDE AT TA: _________FT CLOCK POSITION:____________ EST. RANGE AT TA:____________NMWERE MULTIPLE TAS (AURALS) ISSUED ON THE SAME AIRCRAFT? YES NO IF YES HOW MANY?__________RELATIVE ALTITUDE AT RA: _________FT CLOCK POSITION:____________ EST. RANGE AT RA:____________NMWERE MULTIPLE RAS ISSUED ON THE SAME AIRCRAFT? YES NO IF YES HOW MANY?__________ESTIMATED CLOSEST PROXIMITY RANGE ____________ NM ALTITUDE ____________ NMINITIAL RA ISSUED CLIMB, CLIMB CLIMB, CLIMB, CLIMB DESCEND, DESCENDLEVEL OFF, LEVEL OFF DESCEND, DESCEND, DESCEND CLIMB, CROSSING CLIMB DESCEND, CROSSING DESCENDADJUST VERTICAL SPEED, REDUCE CLIMB, REDUCE CLIMB REDUCE DESCENT. REDUCEADJUSTDESCENTMONITOR VERTICAL MAINTAIN VERTICAL SPEED,SPEEDMAINTAINDID THE INITIAL RA CHANGE ANY OF THE FOLLOWING?MAINTAIN VERTICAL SPEED,CROSSING MAINTAINADJUST VERTICAL SPEED,ADJUSTADJUST VERTICAL SPEED, ADJUST INCREASE CLIMB, INCREASE CLIMB INCREASE DESCENT, INCREASE DESCENTCLIMB, CLIMB, NOW DESCEND, DESCEND NOW LEVEL OFF, LEVEL OFFTYPE OF RA DISPLAY IN YOUR AIRCRAFTIVSI PITCH CUES VERTICAL SPEED TAPEFOR THE ENCOUNTER, PLEASE INDICATE THE SEQUENCE OF EVENTS (E.G., ATC ADVISORY 1, VISUAL CONTACT 2, TA 3, RA 4)ATC ADVISORY:__________ TA:__________ RA:________ VISUAL CONTACT:__________WAS THE RAFOLLOWED: YES NO NECESSARY FOR THE SITUATION: YES NOCONFLICT WITH ATC INSTRUCTIONS: YES NO RESULT IN A CLEARANCE DEVIATION: YES NOIF YES, WHAT WAS THE DEVIATION? _____________FTREMARKS: (PLEASE PROVIDE COMMENTS/CONCERNS ON THIS ENCOUNTER)______________________________________________________________________________________________________________________________________________________________________________________________________________Page 1 (and 2)