Presentation on theme: "1 Operational Risk Management in the Navy Ken Neubauer Futron Corporation Ted Wirginis Naval Safety Center Managing the Human Component of an Operational."— Presentation transcript:
1 Operational Risk Management in the Navy Ken Neubauer Futron Corporation Ted Wirginis Naval Safety Center Managing the Human Component of an Operational System
2 Navy Systems
3 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 –History –ORM Elements Foundations –Revitalization –Targets for success Strategy –Initiatives –Tools
5 Watershed Event - 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…. History of Navy ORM
6 4 ORM Fundamentals 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 3 Levels 4 Principles 5 Steps In Depth Deliberate Time Critical 5. Supervise 4. Implement Controls 1. Identify Hazards 2. Hazard Assessment 3. Make Risk Decisions
7 Military Planning 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
8 Unit Risk Management CO Unit Personnel ORM Instructors Strategic planning Deliberate ORM On-Line Training Subject Matter Expert Formal Classroom training 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 --- GuidanceApproachApplication
10 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. 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 $316 Million 12 Aircraft Lost 28 Lives Lost The Cost of Risk
12 The Cost of Risk 326 Lives Lost Crew of 1 Destroyer Or 1 F/A-18 Squadron
13 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 ORM Revitalization Why the reattack on ORM? –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. organizing around ORM Safety Center adapting processes to meet todays demands --- organizing around ORM
16 A Revised Strike Plan OUR TARGETS
17 Reaching the War Fighter Puts the concepts in to terms the War Fighter understands Hazards = Threats ORM = Tactics The Blue Threat
18 Blue Threat Origins WTI 2-06 Operationalizing Safety for WTIs Col J.M. Davis Dog TRM Tactical Risk Management Partnership between Operational Experts and Safety Experts Partnership between Operational Experts and Safety Experts MAWTS-1 MAWTS-1 School of Aviation Safety School of Aviation Safety Leadership Inspired Leadership Inspired Looking for mishap reduction answers Looking for mishap reduction answers Calling on all resources within the organization... Not just the Safety Guys. Calling on all resources within the organization... Not just the Safety Guys.
19 Leadership Support Leadership Driving the Revitalization Navy ORM Support Structure Key leaders with buy-in influence acceptance of the process Key leaders with buy-in influence acceptance of the process Institutionalizing the mindset and the forcing/accountability elements is key with frequent leadership turnover Institutionalizing the mindset and the forcing/accountability elements is key with frequent leadership turnover
20 ORM Assessment FFC/CPF & TYCOM UNITS Application Mentoring Reinforce Training Expand understanding on the job Expand application off duty ASSESSMENT SFTG – COMTUEX NSC – Safety Surveys NSAWC – AIRWING Fallon ATG – TSTA TACTRAGRU – BG Staff Others IG INSERV ASSESSMENT UNITS NSC Feedback Feedback/Best Practices Use teams already in place Provide assessors with specific ORM training Identify exemplars and disseminate best practices
21 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 Process and Model Management Tools for LeadersTools for Leaders Examples for Sailors 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 Unit Application Model Management Enterprise Support ORM Elements and Standards Best Practices Collection and Dissemination Guidance Training and Education Assessment Operational Off-Duty Cycle Of Application And Assessment ORM Model
26 Shaping a Risk Managing Culture Demonstrate & Mentor New Accessions Boot Camp USNA ROTC Educate the Leaders Leadership Schools Instructor Courses Learning Continuum Analytical Deliberate Time Critical Time Criticality, People, Tools Shaping the Base Where the Majority of Navy Personnel Operate
27 Time Critical Risk Management 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 ABC D for Decision Making A A ssess the mission for potential adverse consequences B B alance the use of Resources to minimize risk C C ommunicate Risks and Intentions D Do (and d ebrief to improve future performance)
28 NIGHT UNREP Routine Evolution Time Constrained Supply ship committed (perceived) Time Critical Scenarios Whats 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 RETURN FROM LEAVE Routine Drive of 300 miles End of Major Holiday Weekend Muster at 0730 Getting underway in two days Whats 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 Time Critical Scenarios
30 Influence on Decision Makers Time DesignDesign Test OTEFleet Introduction - Engineers - Operators / Maintainers Reactive Proactive Systems Human Source of Safety Input in the Birth of a Navy Aircraft
31 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