SMS Report

REV: 0

09/01/2015

DS-100

Event Reporter

Reporter 

Name Position

Email 

Address

Phone 

Number

Event Location

Location Event 

Date

Date 

Reported

UAS Type Registration Flight 

Number

Operating 

Area

PIC

Name

Event Detail Hazard Detail

Department Phase of Flight Flight Condition Weather Reported to

Maintenance

Flight Operations

Administrative

Other

Preflight

Takeoff

Cruise

Descent

Approach

Landing

Remote Area

Mountains

Overwater

Training

FCF

Clear

Rain

Thunderstorm

Hail

Snow

Fog

Haze

Freezing

FAA

Foreign Authorities

Event Detail Hazard Type

Equipment Failure Operational Safety Issues Maintenance

Engine Failure*

Fire (Warning)*

Smoke or Fumes*

Flight Control Failure*

Electrical*

Communications

Navigation

UAS Damage*

UAS Collision* 

Equip. Damage

Flight Interruption

Aborted Takeoff

Unsched. Landing

Go Around

Navigation Error

Bomb Threat

ATC Deviation

Flight Planning

Security Event

Crew Incapacitation*

Fatigue

Unlawful Interference

Airworthiness

Documentation

Parts/ Tools

Other (Please specify)

Narrative
SMS Report

REV: 0

09/01/2015

DS-100

For additional comments or continuation of narrative, attach numbered pages and indicate number of additional pages here: _________
SMS Report

REV: 0

09/01/2015

DS-100

INSTRUCTIONS FOR USING FORM DS-100

PURPOSE

The purpose of the DS-100 is to facilitate appropriate response to safety related information and to satisfy mandatory 

reporting requirements to inform the FAA following a reportable incident, after identifying safety issues (or incidents), or 

encountering opportunities for improvement in airline operations. 

Form DS-100 must be submitted to the office of the director of safety as soon as practicable (no more than 72 hours) 

following the events depicted with an asterisk (*) Depending on the circumstances, submitters should also consider 

completing an Aviation Safety Action Program (ASAP) report. 

INSTRUCTIONS

Event Reporter

Reporter Name Enter name of the person completing the form

Position Enter the position of the person completing the form, use the titles found in COP Chapter 2

Email Address Enter the email address of the person completing the form

Phone Number Enter the phone number of the person completing the form

Event Location

Location Enter the location of the event. Enter the three letter IATA identifier.

Event Date Enter the date of the event. For a hazard, leave blank.

Date Reported Enter date of the report.

UAS Type Enter UAS type.

Registration Enter UAS registration, if not UAS related, leave blank

Flight Number When applicable, enter the date of the revision

Operating Area Enter the operating area 

PIC Name Enter the name of the Pilot in Command

Event/ Hazard Detail

Mark the appropriate check box. If an event, check the Event Driven box. If it is a perceived hazard check the Hazard 

Detail box.

If the report is event driven, complete all applicable sections, if the report is used to document a potential hazard or an 

opportunity for improvement, complete on the header named “Department”

Department Select the affected department

Phase of Flight Select the phase of flight for the event/ hazard.

Flight Condition Enter the Flight Conditions that existed for the event.

Weather Enter the prevailing weather, check all that applies.

Report to Enter to which departments/ entities the event has been reported to.

Event/ Hazard Type

Select if the SMS report is event driven or Hazard driven 

Equipment Failure If applicable, select the equipment failure(s) 

Operation Safety Issues If applicable, select the Operation Safety Issues

Maintenance If applicable, select the maintenance issues

Narrative

Enter the narrative of the event or hazard. For additional comments or continuation of narrative, attach numbered 

pages and indicate number of additional pages
Manual Change Request

REV: 0

09/01/2015

GOM-01

Control Number

Step 1 – Manual and Requester

Manual Current Revision

Requester Date of Request

Step 2 – Proposed Changes

Chapter/ Section Page

Summary of 

Changes

Step 3 – Owner Disposition

Manual Owner Date

Approved Implement as Bulletin

Approved with Mods Implement as a Revision

Rejected Implement as a Revision – Urgent

If rejected or 

approved with 

Mods, list reasons

STEP 4 – Implementation Assessment (Completed by Safety Department)

MCR APPROVED REJECTED Comments

Safety Risk Management Completed

YES NO

Additional Training Required
Manual Change Request

REV: 0

09/01/2015

GOM-01

STEP 5 –Manual Interfaces and References

N/A OK UPDATED

Manual References maintained 

Perform Adobe Search for subject matter

Affected Manual Chapter/ 

Section MCR

Affected Manual Chapter/ 

Section MCR

Affected Manual Chapter/ 

Section MCR

STEP 6 - Owner Review

Approved Signature

Approved with Mods

Rejected

If rejected or 

approved with 

Mods, list reasons

STEP 7 - Manual Reviewer

Approved Signature

Approved with Mods

Rejected

If rejected or 

approved with 

Mods, list reasons

STEP 8 – Final Action

The MCR can only be closed once: 1. Safety Risk Management in Step 4 has been completed and

2. Training in Step 4 has been completed and documented and 

3. MCR have been incorporated in approved or accepted manuals and 

all MCR listed in Step 5 have been incorporated in approved or 

accepted manuals and

4. FAA approval is obtained for Approved Manuals or

5. MCR is rejected

Manual Revision Date

Nature of Change Change 

Driver

Change 

Source

FAA Approval by Date Not 

Required

MCR closed by Date
Training Record

REV: 0

09/01/2015

GOM-02

Ground Training

Curriculum Segment Course Required

Hours

Actual

Hours Location Instructor

Name

Instructor

Signature

Basic Indoctrination BI

UAS Ground Training GRD

Emergency Training ET

Other ___________

Flight Training

Curriculum Segment Course Required

Hours

Actual

Hours UAS Instructor

Name

Instructor

Signature

Flight Training 1 FT

Flight Training 2 FT

Flight Training 3 FT

Flight Training 4 FT

Flight Training 5 FT

Flight Training 6 FT

Flight Training 7 FT

Flight Training 8 FT

Flight Training 9 FT

Proficiency Check

Curriculum Segment Course UAS Results Check Airmen

Name

Check Airmen

Signature

Proficiency Checks PC PASS

Remarks:

STUDENT CERTIFICATION STATEMENT

(I certify that I have received the above listed training)

Name Signature EMP # Remarks
Training Record

REV: 0

09/01/2015

GOM-02

INTENTIONALLY

BLANK
Flight Risk Assessment

REV: 0

09/01/2015

GOM-03

Flight Details

Location Type of 

Flight

UAS Type Registration Flight 

Number

Operating 

Area

PIC

Name

Risk Assessment

Risk Value Release Value

PILOT IN COMMAND - EXPERIENCE / DUTY

1 Captain has less than 100 hours PIC time in type 3

2 More than 30 days since PIC’s last flight assignment 2

3 Newly Qualified VO (less than 10 flights) 2

OPERATING CONDITIONS

4 High Winds forecasted 4

5 Wet conditions forecasted 1

6 Low Sun conditions at ETD 3

7 Ceiling/ Visibility at Operating Area at minimums 2

8 Performance limited - Temperature less than 0 Degrees Celsius 3

9 Performance limited - Takeoff Point above 6,000 Feet MSL 3

10 Birds/ other animals in Operating Area 5

11 Obstacles in Operating Area 4

12 Over Water operation 1

EQUIPMENT

13 UAS new to DroneWorks fleet 4

14 UAS first flight after scheduled check or major maintenance 2

MISCELLANEOUS

15 Minimum preparation time (less than 24 hours) 1

16 Other 2

Total Flight Risk Value

Review and Approvals

Completed 

by Date

Approved Date

10 or less = Monitor (Green Zone) - Release Authorized

11-20 = Action (Yellow Zone) - DO notification required

20 or move = Unacceptable (Red Zone) - Release not Authorized

APPROVED FOR

Type Level 1 Level 2
Flight Risk Assessment

REV: 0

09/01/2015

GOM-03

INSTRUCTIONS FOR USING FORM GOM-03

PURPOSE

DroneWorks utilizes a Flight Risk Assessment (FRA) tool to aid in the identification of risks associated with its specific 

flights. The DO assigns a risk values to a pre-determined set of criteria corresponding to each flight. The risk score is 

recorded on the flight release. Monitor Zone and Unacceptable Zone scores require specific additional action and/or 

authorization as described below.

INSTRUCTIONS

Flight Details

Location Enter the location of the proposed flight, e.g. “6819 Polo Farms Drive, 27358”

Type of Flight Enter the type of Flight e.g. “Real Estate Photography”

UAS Type Enter the Make/ Model UAS

Registration Enter aircraft registration

Flight Number Enter the Flight Number

Operating Area Enter the operating area, e.g. “Residential Neighborhood”

PIC Name Enter the name of the Pilot in Command

Risk Matrix

The Risk Matrix identifies various operational criteria and their associated risk values. DroneWorks management has 

determined these criteria individually exhibit acceptable operational risk. Collectively, these criteria may increase the 

flight risk to a value that may require further scrutiny or mitigation prior to authorization of the planned operation. 

Prior to release, the DO will assess the risk for the proposed operation utilizing the Risk Matrix provided on this form, 

and determine which of these criteria are applicable. The value of each applicable risk factor will be totaled to 

determine the release level associated with the proposed operation as planned. In the event that the total flight risk 

value indicates the proposed operation meets Monitor Zone and Unacceptable Zone release criteria, the flight will not 

be released until the DO and the Director of Safety have authorized its release.

In the event that the flight involves criteria that are not listed in the Risk Matrix, the identified risk (other) will 

automatically be assigned a value of 2 and added to the remaining criteria to determine the appropriate release level.

RETENTION

Upon Completion, the DO will sign and attach the FRA to the Flight Release and an electronic copy is retained by the

DO for 120 days. 
Flight Release

REV: 0

09/01/2015

GOM-04

Flight Release Details

Date of Flight Flight 

Number

FRA Score

UAS 

Make

UAS

Model Registration

Next Service 

Check Due

Current 

Hours

Next 50 hour 

Inspection 

PIC VO DO

Operating 

Area

Departure 

Waypoint

Mission Statement

Copy of Filed NOTAM

Certification

DO 

Signature Date

PIC 

Signature Date
Flight Release

REV: 0

09/01/2015

GOM-04

INSTRUCTIONS FOR USING FORM GOM-04

PURPOSE

All DroneWorks Air flights conducted under the FAA issued exemption for purpose of conducting aerial data collection 

must have specific authority from the person authorized by the operator to exercise operational control over the flight. 

1. The DO has ultimate authority and responsibility for the exercise of operational control. 

2. No DroneWorks PIC may start a flight unless the PIC and the Director of Operations has executed a flight release 

setting forth the conditions under which the flight will be conducted. 

3. The PIC may sign the flight release only when he and the DO believe that the flight can be conducted safely. 

INSTRUCTIONS

Flight Details

Date of Flight Enter the location of the proposed flight, e.g. “6819 Polo Farms Drive, 27358”

Flight Number Enter the Flight Number

FRA Score From the FRA form GOM-03, enter the total FRA score

UAS Make Enter the Make

UAS Model Enter UAS model

Registration Enter UAS registration

PIC Enter the name of the Pilot in Command

VO Enter the name of the Visual Observer

DO Enter the name of the Director of Operations

Operating Area Enter the operating area, e.g. “Residential Neighborhood”

Departure Waypoint Enter the point that the flight is originating from, enter this in LAT/ LON

Mission Statement

The DO will enter the mission statement of the proposed flight. Enter all relevant details, such as the reason for the

flight e.g. photography, data collection, FLIR, mapping etc. The mission statement should provide as much detail as 

possible and should state any hazards identified by the FRA. If needed, insert the proposed flight route and/ or profile 

and any limitations if applicable.

Copy of Filed NOTAM

Cut and paste the NOTAM that is filed with local ATC

Certification

DO Signature the Flight Release must be signed by the Director of Operations

Date Enter the date that the DO signed the Flight Release

PIC Signature the Flight Release must be signed by the PIC

Date Enter the date that the PIC signed the Flight Release

RETENTION

Upon Completion, the DO and PIC will sign and carry a copy of the Flight Release to the operating area. An electronic 

copy is retained by the DO for 120 days. 
UAS Flight Log

REV: 0

09/01/2015

GOM-05

LOGPAGE No

UAS TYPE

UAS INDENT

DATE LOCATION TYPE OF FLIGHT DURATION 

[H:MM]

NUMBER 

LANDINGS

PIC SIGNATURE

TOTAL ON THIS PAGE

AMOUNT FORWARDED

TOTAL TO DATE
UAS Flight Log

REV: 0

09/01/2015

GOM-05

LOGPAGE No

UAS TYPE

UAS INDENT

DATE LOCATION TYPE OF FLIGHT DURATION 

[H:MM]

NUMBER 

LANDINGS

PIC SIGNATURE

TOTAL ON THIS PAGE

AMOUNT FORWARDED

TOTAL TO DATE
Permission Acquisition

REV: 0

09/01/2015

GOM-06

DroneWorks Certification

I have completed the briefing of all procedures to participating personnel of the risks involved, 

emergency procedures, and safeguards to be followed during the filming production event. 

Personnel have been briefed on additional provisions that may be issued by the FSDO that has 

geographic responsibility for the operational area, including the location of boundaries or time 

limits.

Name

Signature Date

Declaration

All persons associated with the motion picture and television area production must be briefed on 

the potential risk of the proposed flight operation(s) and they must acknowledge and accept 

those risks.

DroneWorks will also obtain permission to conduct these operations from property owners and 

local officials as necessary or appropriate. Persons from whom permission may be required are 

listed below:

1. Property owners

2. Law enforcement officials

3. Fire department officials

4. Local, State and Federal government

5. Air traffic control

In signing this form, I am giving DroneWorks permission to operate their UAS at less than 500 

feet from property, or in some jurisdiction in which I am responsible for or affiliated with, for the 

purpose of film or television production.

Certification

Basis of Authority to 

Grant Permission

Location Date of Operation

Name

Title

Signature Date
Permission Acquisition

REV: 0

09/01/2015

GOM-06

INTENTIONALLY 

BLANK
Maintenance Discrepancy Log

REV: 0

09/01/2015

MX-01

Total hours brought forward Enter total Flight hours from Flight Log

DISCREPANCY CORRECTIVE ACTION

ITEM 1

DATE FLT # STA DATE

FCF REQUIRED 

PART NOMENCLATURE

REPORTED BY: FC QM POSITION

P/N OFF

S/N OFF

P/N ON

S/N ON

SIGNATURE: NAME

ITEM 2

DATE FLT # STA DATE

FCF REQUIRED 

PART NOMENCLATURE

REPORTED BY: FC QM POSITION

P/N OFF

S/N OFF

P/N ON

S/N ON

SIGNATURE: CERTIFICATE #

ITEM 3

DATE FLT # STA DATE

FCF REQUIRED 

PART NOMENCLATURE

REPORTED BY: FC QM POSITION

P/N OFF

S/N OFF

P/N ON

S/N ON

SIGNATURE: CERTIFICATE #
Maintenance Discrepancy Log

REV: 0

09/01/2015

MX-01

INTENTIONALLY

BLANK
Check Log

REV: 0

09/01/2015

MX-02

SERVICE CHECK

DATE TECHNICIAN NAME SIGNATURE NEXT DUE

Service Check – To be accomplished at an interval not to exceed 10 calendar days since the last Service 

Check. An UAS getting a Service Check signed off at the very beginning of day zero would fly that day, 

day one through day ten. UAS out of service for maintenance will be except from the Service Check. 

However, once maintenance is completed, the Service Check must be accomplished prior to further 

flight

50 HOUR CHECK

TIME CYCLES TECHNICIAN NAME SIGNATURE

NEXT DUE

TIME CYCLES

50 Hour Check - To be accomplished at intervals not exceeding 200 flights or 50 flight hours whichever 

occurs first. The 50 hour Check accomplishes the requirements of a Service Check
Check Log

REV: 0

09/01/2015

MX-02

INTENTIONALLY

BLANK