Drone Risk Assessment Form

• Conducted on

  Date

• Prepared by

  Darren Leatherbarrow

  Other

• Named of other person

• Flight Location

• Specific launch location
  Address

• Class of Drone

  < 250g

  250g - 500g

  500g - 1kg

  < 2kg

  > 2kg

• Make & Model of Drone

  DJI Mini 3

  DJI Air 3

• Drone Operator

  Darren Leatherbarrow

  Other

• Name of other person

• ID & Compatency

  Select Operator ID Flyer ID A2 CofC Artical 16 Operators Authorisation

  • Operator ID
  • Flyer ID
  • A2 CofC
  • Artical 16 Operators Authorisation

• Are you registered with an organisation and hold a valid Merbeship

  Select Yes NO (DO NOT FLY UNDER ARTICLE 16)

  • Yes
  • NO (DO NOT FLY UNDER ARTICLE 16)

• Description of Operation

  Leisure use

  Commercial use

• Is public liability insurance in place

  YES

  NO (DO NOT FLY)

Carry out RA of area and suroundings

• Complexity of Mission

  Simple

  Moderate

  Complex

• Property

  Select Residential, Commercial, Industrial Recreational Private Non Urban

  • Residential, Commercial, Industrial
  • Recreational
  • Private
  • Non Urban

• Daylight

  Daytime only

  During dusk/dawn

  Night time

• Wires/Trees/Structures

  Not present

  Nearby >30m

  Present

• Maximum Distance from the Operator that the Drone will be traveling

  Select Vertical Distance < 120m Horizontal Distance < 200m Horizontal Distance > 200m

  • Vertical Distance < 120m
  • Horizontal Distance < 200m
  • Horizontal Distance > 200m

• Proximity to Roads

  Not over open roadways

  Open road < 30m

  Over open roads

• Proximity to Radio Towers

  Not present

  Nearby > 50m

  Present

• Nearby Airport/Heliport

  Select Not present Nearby - Out side of 5km radius Nearby - within 5km radius (Authorization required DO NOT FLY)

  • Not present
  • Nearby - Out side of 5km radius
  • Nearby - within 5km radius (Authorization required DO NOT FLY)

• Ground restriction areas

  Not present

  Nearby > 50m

  Present

• Pedestrians/distraction

  Not present

  Nearby 0-30m

  Nearby 31-50m

  Nearby >51m

• Over Water

  Not over water

  Near water

  Over water

• GPS/Radio Dead Spots

  Select Unlikely Possible Likely (DO NOT FLY IN THIS LOCATION)

  • Unlikely
  • Possible
  • Likely (DO NOT FLY IN THIS LOCATION)

Overall Site Risk Rating

• Fill in highest rating from the above inspection criteria

  Select Low Medium High (DO NOT FLY UNTIL FURTHER MEASURES ARE IMPLIMENTED)

  • Low
  • Medium
  • High (DO NOT FLY UNTIL FURTHER MEASURES ARE IMPLIMENTED)

Signature

• Drone Operator

  Select Darren Leatherbarrow Other

  • Darren Leatherbarrow
  • Other

• Signature

  Sign