Violations of Controlled Airspace Survey Survey

1.	ESIR Reference Number

2.	Location

3.	UTC Date/Time

4.	Reporting Unit

5.	When did you become aware that an air safety incident report regarding a VCA had been submitted by ATC in relation to the operation specified in the Electronic Safety Incident Report (ESIR)?

6.	Who notified you of the incident?

Demographics

7.	Years of flying experience

8.	Total Hours of flying experience

9.	Frequency of operation at this location For example: xx / month

10.	If student, date of commencement
	mm/dd/yyyy

11.	Please give a brief description of your recollection of the occurrence (including any issues you think contributed to the incident)

Factors

	Highly Significant	Significant	Moderately Significant	Slightly Significant	Not Significant
ATC knowledge of aircraft performance
Non-standard phraseology used in communication from ATC
Complex ATC instruction
Too much information in one ATC instruction
Poor timing of ATC instruction
Unexpected ATC instruction (not able to anticipate requirements)
Inconsistent ATC instruction
Apparent high ATC workload
ATC to Pilot communication breakdown
Pilot to ATC communication breakdown
Distracted by onboard systems
Call Sign confusion
Radio frequency congestion
Radio frequency interference
High workload in cockpit
Pilot inattention
Pilot distraction
Fatigue
Language accent issue
Weather conditions (Low VIS, glare, etc)
Training (see next page for more detail)
Inaccurate VTC chart
Misreading VTC chart
Charts too complex
Charts difficult to read
Complex airspace design
Published topographical features not prominent
Misread NOTAMS
Too many NOTAMS
Confusing NOTAMS
ERSA entries unclear
More details required in ERSA
Incorrect use of navigation aids
Inaccurate or incomplete flight planning

Further Information

13.	What in your view is required to prevent this type of occurrence from happening again?

14.	If training is a significant factor, explain how? For example, what had you been told about the flight planning, reading charts, etc?