Safety Risk Assessment Worksheet Title of Risk Assessment Risk Assessment Performed By: Date: Department:

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1 Title of Risk Assessment Risk Assessment Performed By: Date: Department: Choose the appropriate type of change from the list below: Revision To Existing New Choose the appropriate system/task from the list below: System An integrated set of elements (people, hardware, procedures etc.) combined to accomplish a defined objective. Operational Process A set of interrelated or interacting activities that transform inputs to outputs Operational Procedure A sequence of steps that are used to perform a work task. Organization Any group providing aviation specific services. Operational Environment The aggregate of all external and internal conditions Identification of a Hazard Ineffective Risk Control(s) Other describe Step 1 System and Task Description a. Please describe the function and purpose of the current system, organization, operational process or procedure. Be sure to include the operating environment, the personnel, equipment, and facilities necessary for operation of the system. Consider and describe inter/intra-departmental interfaces with the system, organization, process or procedure being described (see step 5 for more info). b. Describe the new or proposed change to the system, organization, operational process or procedure, or operational environment.

2 Step 2 Hazard Identification Hazard any existing (or potential) condition that affects human performance or system performance that can lead to injury, illness or death: damage to or loss of a system, equipment or property. A hazard is a condition that might cause (is a prerequisite to) an accident or incident. a. Describe all hazards you have identified that may exist in the current state of the system, organization, operational process or procedure, or operational environment. Hazard 1: Current Controls/Mitigation: Hazard 2: Current Controls/Mitigation: Hazard 3: Current Controls/Mitigation: Potential Consequences: Hazard 4: Current Controls/Mitigation: Step 3 Risk Assessment a. Reference the Risk Assessment Matrix on the following page. Identify the most likely level of risk associated with each hazard identified above; include any current controls/mitigation in your assessment. Hazard 1: Severity: Likelihood: Risk: Hazard 2: Severity: Likelihood: Risk: Hazard 3: Severity: Likelihood: Risk: Hazard 4: Severity: Likelihood: Risk:

3 Risk Assessment: Likelihood Scale Safety Risk Assessment Worksheet Frequent 5 Likely to occur often. Probable 4 Likely to occur sometimes. Occasional 3 Unlikely to occur, but possible. Remote 2 Very unlikely to occur. Improbable 1 Almost inconceivable that the event will occur. Risk Assessment: Severity Scale Catastrophic: 5 Hazardous: 4 Results in fatalities and/or loss of the system. Results in serious injury and/or major system damage. Major: 3 Results in minor injury and/or minor system damage. Minor: 2 Nuisance, Minor incident. Negligible: 1 Little consequence. Severity Negligible 1 Risk Assessment Matrix Minor 2 Major 3 Hazardous 4 Catastrophic 5 Likelihood Frequent Probable Occasional Remote Improbable Red = Bad Not acceptable for day to day operations, operation must not begin or continue without mitigation to a lower risk level. White = Acceptable with Mitigation, risk controls, and or risk control monitoring Green = Acceptable Risk without mitigation.

4 Step 4 Risk Control/Mitigation Controls are elements of the system (including hardware, software, special procedures or steps, and supervisory practices) designed to keep processes on track to achieve their intended results. Mitigation plans should either eliminate the hazard or lessen the risk associated with the hazard. Mitigation plans should be applied in order to achieve As Low As Reasonable Practicable (ALARP) risk. Once you have assessed the risk for the identified hazard(s), it may be necessary to implement or alter mitigation activities or controls in order to bring the risk within acceptable levels. a. Are mitigation activities warranted for any of the Hazards Identified to bring the risk within acceptable levels? If the risk falls within the green area of the matrix then this is considered acceptable risk. If all of the Hazards Identified fall into the acceptable level, then you will check NO and complete step 5 and step 8. If yes to any, then proceed to step b. below. Yes No Unsure b. If yes, what are the proposed mitigation activities for the risks identified? H1: H2: H3: H4: c. Are there alternative mitigation strategies that were considered? Please identify. d. What is the timeline associated with the risk mitigation activities?

5 Step 5 Intra/Inter Departmental Interfaces When considering changes to system, organization, operational process or procedure, or operational environment, it is likely that other operating departments may be affected in some way. a. Place a check mark by the departments listed below if the proposed change(s) you make could potentially affect activities in that department (including regulatory impact). Flight Accounting Sales Maintenance IT Human Resources Security Airport Services Accounting Legal Environmental Other - Safety FBO s Other - b. Ensure that the proposed change has been appropriately coordinated with the affected departments. c. Place a check mark next to the Manuals listed below if there is a potential impact to a process or procedure already documented. GOM (General Operations Manual) SMS (Safety Management System) FAM (Flight Attendant Manual) GMM (General Mx Manual) PTP (Pilot Training Program) Op Specs (Maintenance) Op Specs (Fight Ops) Repair Station Manuals (145) LTP (Line Service Training Prog) Employee Manual Other (Specify) Other (Specify) d. Please list the specific program(s) that may be affected. e. Based on your knowledge, does this change relate to any CFR, Ops Spec, or standard(s) set by ISBAO, ARGUS, DOT, DOD, Insurance etc.? If so specify.

6 Step 6 Re-Evaluating Risk With New Controls (Substitute Risk Assessment) Substitute Risk is a risk unintentionally created as a consequence of safety risk control(s)/mitigation activities. Once you have identified proposed mitigation strategies and verified impact in other departments, it is necessary to reassess the system or task with the new control(s) in place. This will ensure that the proposed changes do not inadvertently introduce unacceptable risk elsewhere. a. Describe any new hazards that you have identified that may exist as a result of the mitigation strategies implemented in Step 4(b). Hazard 1: Hazard 2: Hazard 3: Hazard 4: b. Identify the level of risk associated with each potential hazard listed above using the Risk Matrix provided in Step 3. Hazard 1: Severity: Likelihood: Risk: Hazard 2: Severity: Likelihood: Risk: Hazard 3: Severity: Likelihood: Risk: Hazard 4: Severity: Likelihood: Risk: c. Note: If the risk value for the above identified hazards does not fall into the green area (acceptable risk) then more effective controls will need to be implemented in Step 4(b) in order to reduce the risk to the acceptable level.

7 Step 7 Follow-up/Monitoring Plan Monitoring: to track and measure the effectiveness of risk controls/mitigation actions. a. What type of monitoring plan should be involved in tracking any proposed changes and mitigation activities? Step 8 Submitting The Risk Assessment Worksheet Once completed, send this completed Risk Assessment Worksheet packet to your immediate supervisor for review and acceptance. You should receive feedback/approval within 7 business days. If you have any questions or additional information to add, you can contact the Director of Safety via telephone or ron.barnum@flycfm.com for assistance. Step 9 Department Manager/Supervisor Review and Acceptance Note: This part of the form to be filled out and completed by the associated Department Manager/Supervisor. All applicable fields in the SRA Worksheet are completed and associated files are attached. Hazard Identification, Risk Rating and Substitute Risk are completed and validated as applicable. Risk-mitigation strategies are completed and validated as applicable. Inter/Intra-Departmental Interfaces have been considered and validated. Appropriate source references are identified. SRA to validate impact and continued compliance with source references. CFR s ARGUS Operation Specifications (FO/MX) DOT ISBAO DOD Insurance Other Specify

8 Step 9 (Continued) - Review and Acceptance Is monitoring recommended? Yes No If Yes, what is the monitoring plan and who is responsible, for example (CASS, IEP, QA, Self Audit, etc.). Department Manager/Supervisor Sign-Off. Approved Not Approved Comments: Name Title Date NOTE: When this form has been completed, return this Worksheet to the Process Owner and the Director of Safety via with approval for implementation or reasons for disapproval. Director of Safety: Save a copy of the completed Worksheet under the appropriate folder on the company Safety Drive server and file in the Event Log and Documentation Manual for documentation purposes.