### AVIATION RISK ASSESSMENT WORKSHEET

Assess the risks involved with the proposed operation. Use additional
sheets if necessary.

+----------+---------+---+-------+--------+--------+-------+-------+
| Chart    |         |   | # HAZ |        |        |       |       |
| 3-2:     |         |   | ARD P |        |        |       |       |
|          |         |   | ROBAB |        |        |       |       |
| Risk     |         |   | ILITY |        |        |       |       |
| As       |         |   |       |        |        |       |       |
| sessment |         |   |       |        |        |       |       |
|          |         |   |       |        |        |       |       |
| # Matrix |         |   |       |        |        |       |       |
+----------+---------+---+-------+--------+--------+-------+-------+
|          |         |   | Fre   | Likely | Occa   | S     | Unl   |
|          |         |   | quent |        | sional | eldom | ikely |
+----------+---------+---+-------+--------+--------+-------+-------+
|          |         |   | A     | B      | C      | D     | E     |
+----------+---------+---+-------+--------+--------+-------+-------+
| #        | Catas   | I | Extr  |        |        |       | M     |
| # EFFECT | trophic |   | emely |        |        |       | edium |
|          |         |   |       |        |        |       |       |
|          |         |   | Hi    |        |        |       |       |
|          |         |   | gh(4) |        |        |       |       |
+----------+---------+---+-------+--------+--------+-------+-------+
|          | C       | I |       |        | H      | M     |       |
|          | ritical | I |       |        | igh(3) | edium |       |
+----------+---------+---+-------+--------+--------+-------+-------+
|          | M       | I | High  | Med    |        | L     |       |
|          | oderate | I |       | ium(2) |        | ow(1) |       |
|          |         | I |       |        |        |       |       |
+----------+---------+---+-------+--------+--------+-------+-------+
|          | Neg     | I | M     |        |        |       |       |
|          | ligible | V | edium |        |        |       |       |
+----------+---------+---+-------+--------+--------+-------+-------+

Assignment: Date:

+------------------------------------------------+-------+------+-----+
| Describe Hazard:                               | P     | Ef   | R   |
|                                                | robab | fect | isk |
| **Pre-Mitigation hazards rate out as:**        | ility |      |     |
|                                                |       | (I   | Le  |
|                                                | (A-E) | -IV) | vel |
+================================================+=======+======+=====+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
| Mitigation Controls:                           | P     | Ef   | R   |
|                                                | robab | fect | isk |
| **Post-Mitigation hazards rate out as:**       | ility |      |     |
|                                                |       | (I   | Le  |
|                                                | (A-E) | -IV) | vel |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+
|                                                | ####  | #    |     |
|                                                |       | ###  |     |
+------------------------------------------------+-------+------+-----+
|                                                |       |      |     |
+------------------------------------------------+-------+------+-----+

Operation Approved by Title: Date: