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Operational Risk Management in the Navy

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Presentation on theme: "Operational Risk Management in the Navy"— Presentation transcript:

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


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

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