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Presentation on theme: "1 www.public.navy.mil/navsafecen. 2 This presentation is designed to be tailored. Review the slides and select the ones that are appropriate for your."— Presentation transcript:

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2 2 This presentation is designed to be tailored. Review the slides and select the ones that are appropriate for your audience and time allotted – hide the rest. Hidden Slide

3 3 Were the following mishaps preventable?

4 Temporary Insanity II

5 Night Time, Weekend Alcohol, Speed mix for Disaster Service member and cousin were killed when the Acura they were traveling in hit the semi-trailer truck. The Acura, which investigators said was going more than 80 mph, crumpled on impact.

6 April 2007, 1:00 am Excess of 100 mph Fatal Motorcycle Accident

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10 10 Have you heard this? Safety First! What’s the Most Important Take Away Today Or this one Mission First! How do we get there? Correct application of ORM/TCRM Successful Mission Accomplishment Thru Correct Application Of ORM/TCRM Allows Safety to be a by-product Allowing us to Perform our task or mission again and again Do you agree with this statement?

11 11 Overview Operational Risk Management Why ORM? Implementation Strategy Process Resources Summary

12 12 Why Risk Management?

13 13 Why Risk Management?

14 CostFatalities PMV 73 Current as of 02 Oct 2012 AVIATION $791M Total Cost: $865M DoN – FY 2012 Total Fatalities: 122

15 Cost Total Fatalities: 58 Fatalities PMV 42 Current as of 02 Oct 2012 AVIATION $448M Total Cost: $496M USN – FY 2012

16 Cost Total Fatalities: 64 Fatalities PMV 31 Current as of 02 Oct 2012 AVIATION $343M Total Cost: $369M USMC – FY 2012

17 Risk Management is the process that assists organizations and individuals in reducing or offsetting risk (by systematically identifying, assessing, and controlling risk arising from operational necessity, task loading, additive conditions and crew or human factors) and making decisions that weigh risks against mission or task benefits. The process can be used both on and off duty. Operational Risk Management

18 ORM Concepts ORM is a decision making tool Reduce loss, increase success Ability to make informed decisions Minimizes risks to acceptable levels Same process in wartime or peacetime Efficient use of resources

19 Cultural Challenges Can do “anything, anywhere, anytime, at any cost” mentality “Do more with less” mindset Reluctance to say “no” Making decisions based on “the way we’ve always done it” Letting others worry about our mission hazards Doing only what we “have to” and not what we “should do” Taking advantage of professional courtesies.

20 20 Accident (aka “Mishap”) An unplanned and unfortunate event that results in damage and/or injury.

21 21 Why do mishaps occur? Lack of:Abundance of: - Communication+ Distraction - Awareness+ Complacency - Resources+ Norms - Assertiveness+ Stress - Teamwork+ Fatigue - Knowledge+ Pressure Over 85% of all mishap are attributable to human factors failures Mishap investigations (reactive approach) reveal causal factors…

22 22 Are we learning? On the job? – Aircraft Movement:  2000: Tow tractor hit parked acft. Fatal injury.  2003: During acft towing, person fatally crushed between store & dolly  2004: Sqdn acft under tow direction of yellow shirt ran over ship's blue shirt. Permanent disability  2005: Wing walker's leg run over by acft during move – permanent disability  2006: Acft ran over airman's right leg during taxi on flight deck – permanent disability  2007: While towing acft airman caught and dragged under right wheel and suffered skin and muscle damage  2007: Wing walker injured while acft being towed. – Lack of supervision – guidance – enforcement – Complacency - Perceived “Low Risk” evolution – Loss of Situational Awareness – Lack of Time Critical RM Off-Duty?

23 23 Are we learning?

24 24 Are we learning?

25 25 Bottom-line Red Threat Action / Inaction by own forces causing losses far exceeding those caused by Red Threat Degradation in mission readiness Impact to mission accomplishment Impact to the Team, Family & Friends ORM is a tactic to help reduce the Blue Threat

26 26 Puts the concepts in to terms the War Fighter understands Hazards = Threats ORM = Tactics CRM = Skills The Blue Threat Threat Losses (FY Jan ‘91- Mar ‘11) Red Threat - 18 Aircraft Destroyed vs. Blue Threat Aircraft Destroyed Reaching the War Fighter

27 Controls Controls derived from In-Depth & Deliberate ORM exist everywhere, in all activities throughout the unit maintenance programs, redundant systems, Standard Operating Procedures, checklists, flight briefs, Rules of Engagement, flight gear, survival equipment, etc. Recognize ORM It’s Already in Place, but… It’s Already in Place, but… Integration Strategy

28 28 How do you change a mindset? ( Who is looking out for whom?)

29 29  Policy & Leadership Focus all levels of leadership on key ORM implementation issues Develop and refine policy and guidance for the Fleet  Assessment & Feedback Accountability Assist in development and integration of assessment process for the Fleet Partner with force commanders and readiness evaluators Institute vehicles for “Best Practice” dissemination  Education & Training Implement an ORM Learning Continuum from accession to retirement Partner with training and accession commands Standardize training and education across the Fleet  Resources & Tools Create and share tools to facilitate integration across the Fleet Establishing an ORM Mindset Goal: Risk Management is an integral part of Navy Culture

30 30 ORM integration strategy – 2 nd page of notes.

31 31 ORM is a systematic approach to managing risks to increase mission success with minimal losses. This involves identifying and assessing hazards for risk, controlling risks, supervising and revising as needed. ORM Process Risk to Mission, Force, and Self

32 32 About avoiding risk A safety only program Limited to complex-high risk evolutions Just another program Only for on-duty Just for your boss Just a planning tool Automatic or Static A replacement for: –Sound tactical decision making –Rehearsals and TTPs A ‘zero defect’ mindset A fail-safe process A bunch of checklists A bullet in a briefing guide An excuse to violate the law, policies, directives, or procedures Someone else’s job A well kept secret Difficult About limiting the commander’s flexibility, initiative or accountability What ORM Is Not

33 33 A methodology, applicable to any activity, to enhance decision- making skills Accomplishing the mission with acceptable risk Planning using a systematic, continuous and repeatable process Based on experience Following TTPs Watching for change Flexible and scalable Working as a team A mindset Asking "What's Different" Skill and knowledge dependent Sharing experience, lessons learned About Using available tools and resources – Resource Management Applied, standardized "common sense" "Looking before you leap" As in-depth as time permits What ORM Is

34 Organizational Factors Unsafe Supervision Unsafe Act Preconditions Preventing Mishaps A Proactive Approach Hazard – Condition w/ potential to cause personal injury, damage to property, or mission degradation Unsafe Acts Misha p Remove one causal factor or consequential error Failed or Absent Controls

35 ORM A systematic process 4 Principles Accept no unnecessary risk. Anticipate and manage risk by planning. Make risk decisions at the right level. Accept risks when benefits outweigh the costs. 3 Levels In Depth Long term process with extensive research and planning. Deliberate Pre-mission planning, time available for planning, recorded on paper. Time Critical Little time, done on the run, applied to control hazards introduced by unexpected events and changes to the plan. 1. Identify Hazards 2. Assess Hazards 3. Make Risk Decisions 4. Implement Controls 5. Supervise 5 Steps

36 In-Depth DeliberateTime Critical Limited / No Time for Planning Time Available for Planning Controls from one level become resources for the next Mission & Task Success Charts/Flips Ship / Aircraft (Systems Safety) Instructions (3710, 5102, 4790) NATOPS Equipment (PPE) Training Ops Planning SOPs Briefings CO Guidance OJT Mission Execution Checklist Change Management (Environment, Mission, Emergency Procedures, Crew Change) Equipment / Systems Degradation Strategic Tactical Risk Management Levels

37 37  “Anticipate and manage risk by planning” – risks are more easily controlled when identified early in planning 4 Principles Integrate risk management into all levels of planning Dedicate time and resources to apply risk management effectively Include hazards in orders to assist subordinates Don’t assume hazards away Implement Controls Receive Tasking & Analyze Staff Estimates Commander’s Guidance StaffRecommend Options Command Decisions Identify Hazards Assess Hazards Make Risk Decisions Supervise Naval Operational Planning Process

38 38  “Accept risk when benefits outweigh the costs” – the goal is not to eliminate risk, which is inherent in what we do, but to manage it so that we can accomplish the mission with minimal losses. Leaders must consider benefits and costs associated with a hazard’s risks to make informed decisions. 4 Principles Sustaining a bold, risk-taking organization is always a challenge in peace and war…ORM helps.

39 39  “Accept no unnecessary risks” – only accept those risks that are necessary to accomplish the mission. 4 Principles If all detectable hazards and their associated causes have not been detected, then unnecessary risks are being accepted. ORM process provides a systematic, repeatable approach to identify hazards / threats that otherwise may go undetected.

40 40  “Make risk decisions at the right level” – risk management decisions should be made by the leader directly responsible for the operation. If the hazard’s risk cannot be controlled at his level, leaders shall elevate the risk decision to their chain of command. 4 Principles Who has the legal / organizational authority to make the decisions? Who has the maturity and experience to make the decisions? Who has on-scene knowledge? Who has the resources to mitigate the risk? Who will answer in the event of a mishap?

41 41 5 Step Systematic Process 1. Identify Hazards 2. Assess Hazards 3. Make Risk Decisions 4. Implement Controls 5. Supervise

42 42 Identify Hazards Spend 30-40% of total ORM time List hazards for each step Use “What if…” tool Focus on “What’s different today?” Target root causes vice symptoms Keep asking “Why?” until answered Operational Analysis List Hazards Determine Hazard Root Causes Determine specified & implied tasks Break down into small steps Pull from lessons learned Involve Operators / Subject Matter Experts

43 Straits Transit Risk Assessment Deliberate ORM Example

44 44 Assess Hazards What’s the probability of all factors Use past data Look at total exposure Use risk assessment matrix Rank hazards by risk level Assess Severity Assess Probability Complete Risk Assessment What’s the impact on mission, people, & things Involve Operators / Subject Matter Experts

45 Risk Assessment Matrix The Risk Assessment Code (RAC) Matrix is used to determine the RAC for a hazard. You must cross probability and severity to obtain this code. Risk Assessment Matrix PROBABILITY Frequency of Occurrence Over Time A Likely B Probable C May D Unlikely I Loss of Mission Capability, Unit Readiness or Asset; Death 1123 II Significantly Degraded Mission Capability or Unit Readiness; Severe Injury or Damage III Degraded Mission Capability or Unit Readiness; Minor injury or Damage 2345 IV Little or No Impact to Mission Capability or Unit Readiness; Minimal Injury or Damage Risk Assessment Codes 1 – Critical 2 – Serious 3 – Moderate 4 – Minor 5 – Negligible SEVERITY Effect of Hazard

46 46 Severity and Probability SEVERITY Category I - The hazard may cause death, loss of facility/asset, or mission failure. Category II - The hazard may cause severe injury, illness, property damage, or serious mission degradation. Category III - The hazard may cause minor injury, illness, property damage, or minor mission degradation. Category IV - The hazard presents a minimal threat to personnel safety or health, property, or mission. PROBABILITY Sub-Category A - Likely to occur immediately or within a short period of time. Expected to occur frequently to an individual item or person or continuously to a fleet, inventory or group. Sub-Category B - Probably will occur in time. Expected to occur several times to an individual item or person or frequently to a fleet, inventory or group. Sub-Category C - May occur in time. Can reasonably be expected to occur some time to an individual item or person or several times to a fleet, inventory or group. Sub-Category D - Unlikely to occur.

47 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

48 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

49 Straits Transit Risk Assessment Identified Risk = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

50 50 Assessment Pitfalls Over optimism Misrepresentation Alarmism Indiscrimination Prejudice Inaccuracy Complacency

51 51 Make Risk Decisions What’s the impact on probability & severity What’s the risk control cost How do they work together Determine residual risk Make risk decisions at right level Ensure benefits outweigh costs Identify Control Options Determine Control Effects Make Risk Decisions Systems / Engineering: Material selection, Design Often not feasible Supervisory / Administrative: Instructions, Policies, SOPs, ROEs Flight briefs, checklists TTPs Training Effective if properly used / enforced Personal Protective Equipment: Eye & hearing protection Flight & survival Gear Least effective type of control - does not reduce the probability of a mishap occurring, it only reduces the severity when a mishap does occur. Involve Operators / Subject Matter Experts

52 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

53 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

54 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

55 Straits Transit Risk Assessment Residual Risk = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

56 56 Implement Controls Assign individuals clear risk control responsibilities Command provide personnel & resources Make it sustainable Employ a feedback mechanism Integrate into plans Consider control conflicts Make Implementation Clear Establish Accountability Provide Support Use examples, pictures, or charts Describe expectations clearly Involve Operators / Subject Matter Experts

57 57 Supervise Measure risk controls’ effectiveness Was mission successful Identify root causes of conditions that led to failures Implement new controls Save all documentation Recommend actionable solutions to prevent other failures Submit lessons learned Monitor Review Feedback Are the controls working Manage emerging changes (ABCD) Identify new hazards Involve Operators / Subject Matter Experts

58 Supervise, Monitor & use personal tool - ABCD Action 1: Monitor Action 2: Review Action 3: Feedback A ssess B alance Resources C ommunicate D o – D ebrief Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D

59 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example

60 60 In the bigger picture In planning –we conduct risk assessment and develop controls. In operations –we update risk assessment and implement controls. In sustainment –we continue to update assessments and adjust controls. After action –we provide feedback and capture lessons learned to integrate the next time.

61 –Technique to connect all three levels of ORM –Spurs the use of Time Critical ORM during execution –The missing piece in ORM understanding and proper application Change the Perception ORM Mind Set… Change the Perception of Risk Management WDT ? What’s Different Today?

62 5-Step ORM and ABCD Time Critical Process and Mnemonic Time Critical Process and Mnemonic A A – Assess (your situation, your potential for error) B B – Balance Resources (to prevent and trap errors) C C – Communicate (risks and intentions) D D – Do and Debrief (take action and monitor for change) 5-Step Deliberate and 5-Step Deliberate and In-depth Process In-depth Process 1.Identify Hazards 2.Assess Hazards 3.Make Risk Decisions 4.Implement Controls 5.Supervise (watch for changes)

63 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o – D ebrief

64 Situational Awareness  The Green – You catch errors before they occur Good Situational Awareness Tools and Procedures in place to catch possible errors  The Yellow – Higher chance of errors Situational Awareness could be decreasing Tools and Procedures not in place to catch errors  The Red – Very high chance of consequential error Tasking and/or stress may be high, tunnel vision may occur Resources not effective to catch error

65 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o – D ebrief

66 Understand your situation and required jobs Brief others, share your situational awareness Use automation to increase awareness Write things down; use a checklist or job aid Follow procedures and routines Policies, Tactics, Procedures and Processes Checklists Automation Briefings & External Resources Knowledge, Skills and Techniques Resources are Tools to get the Job done Balance your resources to catch possible errors

67 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o – D ebrief

68 Why a Common Language? オペレーショナル 冒険 弁理 Gestione dei rischi operativa Delle operazioni Rischio Amministrazione Gestión de riesgos operacional Рабочее управление при допущениеи риска Betriebsrisikomanagement 操作的风险管理 작전 위험 관리 تشغيل وإدارة المخاطر Operational Risk Management λειτουργική διαχείρηση κινδύνων การบริหารความเสี่ยงการ ดำเนินงาน CVORRTTEX SPOT STORM TRM Navy Lingo STAR SOAP R.I.T.E.

69 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o – D ebrief

70 Your Part on a Team Know your duties and also duties of members on your team Maintain Situational Awareness for you and your Teammates Communicate clearly Be observant of stress levels for you and your Teammates ABC D

71 71 Put into Action Review of ABCD and Resources On duty Off duty What can we do better tomorrow? ABC D

72 72 Reconsider this situation…

73 73 Reconsider this situation…

74 74 It’s about informed decisions.

75 75 NSC Website: a Valuable Resource Resources & Tools

76 76 Web Enabled Safety System (WESS): –Web-enabled reporting and data retrieval system –Allows submission & routing of 5102 mishap / hazard notifications & 3750 hazard reports –Provides real-time reporting –Allows retrieval of data so activities can perform their own analyses (across DOD) Travel Risk Planning System (TRiPS): –Provides ORM trip assessment and actual mishap cases relevant to planned trip –Risk values / models based on National Transportation Safety Board (NTSB) data –Trip map, times, distances and other products improve supervisor interaction –Computer based training (CBT) course content designed to help change behavior Total Risk Assessment and Control System (TRACS): –Evolution risk assessment tool –Allows user to assess, manage and report on hazards, risks & controls –Public library of completed assessments available for others to modify for their specific needs Resources & Tools

77 77 Risk management… It is a mindset

78 78 We will manage risk to operate by following a standardized and institutionalized common model of ORM application and assessment across the fleet. Integrate risk management concepts across the fleet as part of every decision made and every action taken by every Sailor and DON Civilian employee – on and off duty ORM Where we want to be…

79 79 Summary  Humans are part of all Navy systems  Managing the risk of human error improves capabilities and reduces losses  ORM: A proactive, systematic tactic to defeat Blue Threats A leadership tool to assist in making informed risk decisions Should be integrated into your command planning, briefing, execution and after action processes Relies on education, training, experience and teamwork Requires outstanding communication skills at all levels

80 80 The Challenge  Engaged Leadership  Support and actively promote integration of ORM On and Off Duty Use Deliberate Assessment Process Integrate TCRM - “What’s different today?”; “ABCD” Support ORM Assessment at all levels  Use the resources and tools available  Establish an environment where hazards can be identified by anyone at any time  Provide feedback and share  Work together to lookout for our shipmates (on and off duty) and preserve DOD resources in order to ensure mission readiness and help eliminate these…

81 81 Questions? Thanks for your attention


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