1. Operational Risk Management in the Navy
Managing the Human Component of an Operational System
Ken Neubauer
Futron Corporation
Ted Wirginis
Naval Safety Center

2. Navy Systems

3. 4 of Every 5 Mishaps Involve Human Error
The Biggest Challenge
4 of Every 5 Mishaps Involve Human Error
Operator Error
Supervisory Error
Supporting Personnel Error
Poor Decision Making
Poor Planning
Organizational Failures
Etc.

4. OVERVIEW Background Foundations Strategy History ORM Elements
Revitalization
Targets for success
Strategy
Initiatives
Tools

5. Watershed Event History of Navy ORM - January 1996, Nashville, TN
- Navy F-14 crashes into
local neighborhood killing:
-- Two aircrew
-- Three local residents
- Mishap investigation opens the eyes of Navy leadership….

6. 3 Levels 4 Principles 5 Steps
ORM Fundamentals In
Depth
Deliberate
Time Critical
3 Levels 4
ORM Principles
1. Accept risks when benefits outweigh costs
2. Accept no unnecessary risk
3. Anticipate and manage risk by planning
4. Make risk decisions at the right level
4 Principles
5. Supervise
4. Implement Controls
1. Identify Hazards
2. Hazard Assessment
3. Make Risk Decisions
5 Steps

7. Military Planning Identify Hazards Assess Supervise Hazards Make Risk
Implement
Controls
Receive Tasking
&
Analyze
Staff
Estimates
Commander ’ s
Guidance
Recommend
Options
Command
Decisions
Identify Hazards
Assess
Hazards
Make Risk
Supervise
Naval Operational
Planning Process

8. Formal Classroom training No change in the approach for a decade
Unit Risk Management CO
Strategic planning
Deliberate ORM
On-Line Training
ORM Instructors
Subject Matter Expert
Formal Classroom training
Unit Personnel
Mission Execution
Change Management
On-Line Training
No change in the approach for a decade

9. The Status Quo Solid Concepts but Little Change to --- Guidance
Approach
Application

10. Secretary of Defense Memo Reducing Preventable Accidents
Why Revitalize ORM?
Secretary of Defense Memo
Reducing Preventable Accidents
“ I have set some very specific mishap reduction goals for the department to achieve There is no excuse for losing lives given proper planning, attention to detail, and the active involvement of the chain of command.”

11. The Cost of Risk
$316 Million
12 Aircraft Lost
28 Lives Lost

12. The Cost of Risk 326 Lives Lost Crew of 1 Destroyer Or
1 F/A-18 Squadron

13. Secretary of Defense Memo Zero Preventable Accidents
Continuing the Charge
Secretary of Defense Memo
Zero Preventable Accidents
“We can no longer tolerate the injuries, costs and capability losses from preventable accidents. Accidents cost the Department about $3 billion per year, with indirect costs up to four times that amount.”

14. Why the reattack on ORM? ORM Revitalization
Provide a needed course correction for an initiative stagnant for a decade
Fully infuse Navy Culture with a proven process to manage risk
Proactive tactic to attack mishap reduction
Standardize widely varied views of ORM and how to support it
Bridge a vital gap in decision making skills for our Sailors

15. NSC Strategic Principles
Shaping Navy culture is key to safety and all dimensions.
ORM accepted as the primary tool for achieving mishap reduction and cultural change.
ORM integral to Navy operational planning and a routine aspect of both team execution and individual decision making.
Safety Center adapting processes to meet today’s demands --- organizing around ORM

16. OUR TARGETS A Revised Strike Plan SAILORS WAR FIGHTER LEADERSHIP
Training
SAILORS
WAR FIGHTER
Tactics
LEADERSHIP
Tools
OUR TARGETS

17. Reaching the War Fighter
The Blue Threat
Puts the concepts in to terms the War Fighter understands
Hazards = Threats
ORM = Tactics

18. Blue Threat Origins TRM
Tactical Risk Management
Partnership between Operational Experts and Safety Experts
MAWTS-1
School of Aviation Safety
Leadership Inspired
Looking for mishap reduction answers
Calling on all resources within the organization Not just the “Safety Guys”.
WTI 2-06 Operationalizing Safety for WTIs
Col J.M. Davis
“Dog”

19. Navy ORM Support Structure Leadership Driving the Revitalization
Leadership Support
Navy ORM Support Structure
Leadership Driving the Revitalization
Key leaders with buy-in influence acceptance of the process
Institutionalizing the mindset and the forcing/accountability elements is key with frequent leadership turnover

20. UNITS ORM Assessment FFC/CPF NSC Use teams already in place
Provide assessors with specific ORM training
Identify exemplars and disseminate best practices
ASSESSMENT
FFC/CPF
&
TYCOM
SFTG – COMTUEX
NSC – Safety Surveys
NSAWC – AIRWING Fallon
ATG – TSTA
TACTRAGRU – BG Staff
Others IG
INSERV
ASSESSMENT
UNITS
UNITS
Application
Mentoring
Reinforce Training
Expand understanding on the job
Expand application off duty
Feedback
NSC
Feedback/Best Practices

21. ORM Program Assessment ORM Application Assessment
ORM Assessment
ORM Program Assessment
Evaluates ORM instructional compliance
Gives an indication of the relative unit ORM program strength
ORM Application Assessment
Evaluates operational planning, briefing, execution, debriefing, and lessons learned/best practices
Only provides a snapshot of ORM use during evolutions observed

22. ORM Guidance and Support
Naval Safety Center ORM Website
Process and Model Management
Tools for Leaders
Examples for Sailors

23. ORMAS
Operational Risk Management Assessment System

24. ORMAS
Compare disparate data elements with a safety and risk bias
Provide unit commanders / decision makers with a view of present risk
Focus leaders on weak areas needed a concentration of resources to manage risk

25. ORM Model Enterprise Support Model Management Unit Application
Guidance
Training and Education
Assessment
Cycle Of
Application
And
Assessment
Model Management
ORM Elements and Standards
Best Practices Collection and Dissemination
Unit Application
Operational
Off-Duty

26. Shaping the Base Shaping a Risk Managing Culture Time
Criticality, People, Tools
Analytical
Deliberate
Time Critical
Shaping a Risk Managing Culture
Demonstrate & Mentor New Accessions
Boot Camp
USNA
ROTC
Educate the Leaders
Leadership Schools
Instructor Courses
Learning Continuum
Time
Where the Majority of Navy Personnel Operate ™

27. Time Critical Risk Management
Skills Process
1. Situational Awareness
I know my environment
I can see changes
2. Mission Analysis
I can assess the changes
I can see how they affect my job/mission
3. Assertiveness
I have confidence in myself, my team, and my leadership to bring new threats to their attention
4. Communication
I need to let my teammates or others involved know what I know
5. Leadership
My leaders accept my plan for action or know how to act to manage new risk
6. Adaptability/Flexibility
The plan is flexible and we can adapt to changes
7. Decision Making
We have enough information, time and a good plan of action, or we need help
ABCD for Decision Making
Assess the mission for potential adverse consequences
Balance the use of Resources to minimize risk
Communicate Risks and Intentions
Do (and debrief to improve future performance)

28. Time Critical Scenarios™
NIGHT UNREP
Routine Evolution
Time Constrained
Supply ship committed (perceived)
What’s Different?
Late at night start (2300)
Winds and seas different than forecast
Maintaining station difficult
Keeping fuel hoses seated very difficult
Decision Distractions
Desire to get the job done now
Fatigue
Routine Evolution
Option A
Continue with evolution
Risks – damage to equipment, people
Option B
Breakaway and reassess hazards and controls
Risks – delay, lower than normal fuel

29. Time Critical Scenarios™
RETURN FROM LEAVE
Routine Drive of 300 miles
End of Major Holiday Weekend
Muster at 0730
Getting underway in two days
What’s Changed?
Family early PM dinner runs late
Rear tire deflated (slow leak from nail puncture)
Light fog forms (not forecasted)
Decision Distractions
Never been late from leave
New Division CPO
Made this drive many times before
Option A
Continue with Drive
Risks – fatigue, flat tire, heavy traffic
Option B
Call ship and speak to OOD
Risks – Angry CPO, miss underway briefs

30. Source of Safety Input in the Birth of a Navy Aircraft
Reactive
Human
Influence on Decision Makers
Proactive
Systems
Design
Design Test
OTE
Fleet Introduction
Time
- Engineers
- Operators / Maintainers

31. Special Edition Magazine
Summary
Humans are part of all Navy systems
Managing the risk of human error improves capabilities and reduces losses
ORM for the Navy is:
A tactic to defeat Blue Threats
A leadership tool
A decision making process for our youngest people
Partnering systems designers and safety professionals makes saving lives and assets easier in the operational world
Special Edition Magazine

32. Questions ??? Ken Neubauer Ted Wirginis
Technical Director, Aerospace Safety
Futron Corporation
 (757) , x317
Ted Wirginis
Executive Assistant,
ORM Division
Naval Safety Center
 (757) , x7271