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95 APPENDIX I Sample Worksheets for Safety Assessments Source: ACRP Report 131: A Guidebook for Safety Risk Management for Airports. TABLE I1 SAFETY ASSESSMENT TEMPLATE
Source: FAA Office of AirportsâSafety Management System (SMS)âDesk Reference, V 1.0, Jun 2012. TABLE I2 FAA ARP SMS TEMPLATE FOR PRELIMINARY HAZARD ANALYSIS
97 Table A - Hazard and Consequence: OPERATION/ PROCESS: [Describe the process/operation/equipment/system being subject to this HIRM exercise] HAZARD [H]: [If there is more than one Hazard to the Operation/Process, use separate Worksheet to address each Hazard] UNSAFE EVENT [UE]: [If there is more than one UE to the Hazard, use separate Worksheet to address each UE-U combination] CONSEQUENCE [UC]: [If there is more than one UC to the Hazard, use separate Worksheet to address each UC] Table B - Evaluate Risk Index and Tolerability of Consequence/ UE (See Annex 1): Table B-1 Table B-2 CURRENT Risk Index & Tolerability (taking into consideration any existing PC/RM/EC) RESULTANT Risk Index & Tolerability (taking into consideration any new PC/RM/EC) Severity Likelihood Tolerability Severity Likelihood Tolerability Unsafe Event Ultimate Consequence Table C - Risk Mitigation: Hazard [H] Preventive Control [PC] Escalation Factor [EF] Escalation Control [EC] Recovery Measure [RM] Escalation Factor [EF] Escalation Control [EC] H PC1 (Existing) EF (Existing) EC1 (Existing) UN SA FE EV EN T [UE] RM1(Existing) EF (to RM1) EC (to EF) U L T IM A TE C O N SEQUENCE [U C] EC2 (New) PC2 (Existing) EF1 (New) EC (New) RM2 (New) EF (to RM2) EC (to EF) EF2 (New) EC (New) PC3 (New) EF (New) EC (New) RM3 EF (to RM3) EC (to EF) Source: Editable Appendices of the ICAO Safety Management Manual (SMM) 3rd Ed. (2013). TABLE I3 ICAO SRM WORKSHEET 1
Source: Editable Appendices of the ICAO Safety Management Manual (SMM) 3rd Ed. (2013). TABLE I4 ICAO SRM WORKSHEET 2
