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112 APPENDIX K SRA Report Template Courtesy: HartsfieldâJackson Atlanta International Airport (2015). Safety Risk Assessment (SRA) Report 1 From the desk of: 2 Duty Title: 3 Office Phone: 4 Cell Phone: Office Fax: Email address: 5 To: 6 IN TURN Date: 7 Subject: 8 Safety Risk Assessment - # Change Control and Version Tracking Version Number Changes Made Changes By Date of Change 1.1 COMPLIANCE: SMS Manual; Part III, dated 1 June, 2011, paragraph 3.0. Procedures for conducting a Safety Risk Assessment (SRA). SRA stakeholders will review the corrective actions taken in response to Safety or Hazard Reports and make recommendations when necessary to increase the safety of the Hartsfield â Jackson Atlanta International Airport (H-JAIA) and the Department of Aviation. 1.2 PURPOSE: Facilitate the interfaces between various operational divisions within the Department of Aviation (Airport Operations, Safety, Risk Management, Facilities, Airfield Maintenance, ARFF, Airport Police, Planning & Development, Property Management, Environmental, Finance, etc.) and tenants on the Airport. They will conduct an SRA when necessary or as requested by the SMS Committee or Executive Committee on safety concerns related to H-JAIA. 1.3 ATTENDEES SRA Principal Stakeholder-Office Names Attended (date) Attended (date) Attended (date) â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO â« YES/â« NO
113 1.4 Location: where the SRA was accomplished 1.5 Overview: 1.5.1 â Executive Summary(unlimited text field) 1.5.1 â Current System(unlimited text field) 1.5.2 â Proposed Change (unlimited text field) 1.5.3 â SRM Planning and Impacted Organizations (unlimited text field) 1.5.4 â Assumptions (unlimited text field) 1.6 Safety Risk Assessment: 1.6.1 Describe the System: (unlimited text field) 1.6.2 Identify the Hazard: (unlimited text field) 1.6.3 Analyze the Risk: (unlimited text field) 1.6.4 Assess the Risk: (unlimited text field) 1.6.5 Risk Mitigation The corrective actions consist of design and procedural requirements to enhance the safety of the proposed change. The following corrective actions are described for each hazard identified: Hazard 1: (text field) Hazard 2: (text field) Hazard 3: (text field) 1.6.5.1 Residual Risk The panel members reviewed the proposed actions and considered the expected residual risk with the identified hazards as follows: Hazard Severity Likelihood Risk Hazard 1 /Name (1) Catastrophic (E) Improbable Medium Hazard 2 /Name Prepopulated from Hazard Assessment section Hazard 3 /Name Hazard Severity Likelihood Risk Hazard 1 (2) Catastrophic (E) Improbable Medium Hazard 2 Hazard 3
114 Safety Risk Assessment Report Template Hartsfield-Jackson Atlanta International Airport 1.6.6 Manage the Risk (text field) 1.7 Remarks (text field) Attachments: (text field) 1.8 SRA Approval SRA Participant Role/Position Signature & Date Contact Safety Risk Assessment (SRA) Report Item Number Title Instructions Item 1 through 16 will be completed by the SRA Owner as appropriate 1 Safety Risk Assessment Report Enter the Title of the SRA 3 Duty Title Enter the Duty Title of the SRA Owner 4 Phone numbers Enter the phone numbers for each: Office Phone â Cell Phone â Office FAX 5 Email Address Enter the email address of the SRA owner 6 TO: Enter the name of each person that the SRA owner want to review this SRA Report as a minimum SMS Manager and Appropriate Assistant Director (Note: the SMS Manager may take it to one of the Committee 7 Date: Enter Date that this SRA Report is completed 8 Subject Enter the SRA assigned number for the division in the following format: Year / Enter the current year â2010â SRA Number / Enter the numerical number of the SRA that has been completed in SRA owner Division. e.g. if this is the third one accomplished with in the division enter 003 Division Codes / as stated in paragraph 4.4.1.7.1.2 of this chapter 9 Attendees Enter the required information as indicated at the top of each column, also you should have a sign in sheet for them to sign in on that will be attached to the SRA Report. Para - 1.4 Location Enter the location where this SRA has taken place e.g. SAT or SSF and physical address of the meeting Para - 1.5 Overview Enter a short overview of the SRA Para - 1.6 System Description Enter a short explanation of the System that this SRA effects Para - 1.6.6 Manage the Risk Enter the overall assigned risk level for this SRA Para - 1.6.6 Manage the Risk Enter the overall action plan that will be taken by the Aviation Department to correct this hazard Para - 1.7 Remarks: Enter any additional comments in the remarks section Para - 1.8 SRA Approval Enter the names of the SRA panel participants, who initiated the SRA, who facilitated with respective roles in SRAs, date, signature and contact information for each person
