1. Vision of risk management
Risk is inherent in all activities regardless of how routine. However, taking calculated risks is essential to the Coast Guard missions. Risk Management (RM) is a systems-oriented process to identify, assess, and control risk associated with any activity, both on- and off-duty. The vision of RM is to develop an environment in which every officer, enlisted, or civilian person is trained and motivated to personally manage risk in everything they do, including removing a line from a propeller, driving in a new town while on-liberty; and even stripping the floor.

3. There are two levels of RM: Deliberate and Real-Time.
Deliberate RM focus is on gathering information prior to the mission/activity to identify and mitigate hazards during mission analysis and planning. Performing Deliberate RM as early as possible (e.g., months, weeks, days, early on the actual day) increases hazard mitigation options. For example, performing Deliberate RM just prior to a mission and you realize that crew experience/proficiency is not ideal. Mitigating this hazard may have been more feasible early in the workday vice just prior to the mission activity.
Real-Time RM focus is on monitoring and evaluating activities during the mission/activity to identify hazards and assess whether mitigation is necessary and/or feasible. In an ideal scenario, Real-Time RM is leveraging Deliberate RM results and ensuring that mitigation decisions and behaviors are controlling hazard exposure during the mission/activity. If new hazards appear, or mitigation strategies are not successful, Real-Time RM should detect these potential hazard exposures and activate the RM process.

4. Depicts the RM continuum in relation to time sequence of events as well as typical activities associated with the RM analysis. The two levels of RM, Deliberate and Real Time, are depicted in the arrow along with potential time estimates of when these activities may occur (months, weeks, days). Other terms often used to articulate the Deliberate levels of RM are Strategic or Tactical. Real Time is always associated with the execution of the mission/activity and involves continuous and dynamic application of RM.

5. 3. Develop Controls and Make Decisions
1. Identify
Hazards
2. Assess
3. Develop Controls and Make Decisions
4. Implement
Controls
5. Supervise /
Evaluate
Identify hazards
Find, recognize, and describe the hazards that could compromise the safety and success of a mission or activity. An unidentified hazard cannot be controlled. Effort spent identifying hazards has a multiplier effect on the impact of the total RM process. This step describes how to identify hazards for any given mission/activity and conditions.
Assess hazards
Analyze each hazard to determine the level of risk to the mission or activity. Assessing hazards provides an opportunity to determine what mitigation strategies are required and even whether the mission should continue.
Develop Controls and Make decisions
Explore hazard controls to reduce risk exposure to an acceptable level. Make GO/NO GO decisions based on risk exposure and benefits of mission or activity. Decisions and controls reduce risk by lowering the likelihood of the hazard causing a mishap or the severity of the consequence if a mishap occurs.
Implement controls
Once control measures have been selected, communicate the plan and implement the controls.
Supervise and Monitor
Supervise and evaluate operational conditions and controls during the mission or activity to ensure effectiveness. If the operational conditions change or the controls are not effective, revisit Risk Management steps 1-3 and determine if other controls should be implemented. Repeat the Risk Management cycle.
2-1

6. Hazard Risk Mishap Consequence Hazard
Any real or potential condition that can (1) result in death, injury, property loss or environmental damage and (2) can be controlled in some way. The hazard associated with a slick deck could be controlled with putting up an orange cone in front of the area, ensuring members wear proper footwear, and mandating that members should only walk in the affected area. Alternatively, a non-example might be “poor visibility” because it lacks the details that suggest how it can be controlled. In order to “control” poor visibility you have to recognize why this state occurs (e.g., reduced lighting at night or fog)
Risk
Risk is the possibility of loss or injury; the exposure to hazard or danger; and a dangerous element or factor. It is the possibility that something may happen that could cause a loss or harm to people, property, or environment. Risk is often interpreted in terms of hazard, mishap and consequence.
Mishap
Any unexpected, undesirable or unplanned event that causes death, injury, occupational illness, materiel loss, or damage to the environment. , e.g., collision or running aground. Members commonly consider slips, trips, and falls as hazards. They are not. They are mishaps that result from exposure to hazards, e.g., loose flooring, clutter.
Consequence
The result of a mishap, such as injury, illness, or death to personnel; and/or damage to or loss of equipment or property.
Hazard vs consequence
Inability to correctly identify a hazard hampers ability to manage risk. Many people confuse a consequence with a hazard. Consequences are the result of an action or mishap, such as injury, illness, or death to personnel; and/or damage to or loss of equipment or property. Hazards, on the other hand, are a specific real or potential condition that can cause a mishap.

7. Poor efforts to identify and assess hazards and risk mitigations commonly cause mission failure, task degradation, and mishaps. Deliberate RM is integral for mission analysis, mission planning, and mission brief.
Provides team awareness of actions important to mission safety in the planning stage and gives methods for managing risk. Also provides supervisors with briefing techniques that will enhance mission safety.
Objective: Student Shall be capable of making long-term and contingency plans, and organizing, allocating, and monitoring team resources.
Risk Management
Detect all hazards or potential failures of any consequences to the unit
Evaluate the levels of risk
Create risk control alternative
Implement risk controls
Monitor the situation
React

8. Indentify, assess, and establish hazard controls to mitigate the risk to an acceptable level.
Develop contingency plans
Why:
Provides critical information to develop the common operational picture.
Provides team awareness of actions important to mission safety in the planning stage and gives methods for managing risk. Also provides supervisors with briefing techniques that will enhance mission safety.
Objective: Student Shall be capable of making long-term and contingency plans, and organizing, allocating, and monitoring team resources.
Risk Management
Detect all hazards or potential failures of any consequences to the unit
Evaluate the levels of risk
Create risk control alternative
Implement risk controls
Monitor the situation
React

9. First 3 steps of the RM Process
Identify Hazards
Assess Hazards
Develop Controls and Make Decisions

10. A hazard is any real or potential condition that can endanger a mission; cause personal injury, illness or death; or damage equipment or property.
Remember this definition for our exercise pertaining to case study
Ask what can go wrong and why?? Remember hazards are the conditions that allow MISHAPS to happen.

11. E C A E P Identify hazards using the PEACE MODEL.
P- Planning – Do you have the necessary information and time to conduct “What can go wrong” analysis?
E –Event Complexity -
A –Asset Selection – includes materiel/equipment, and personnel (number and qualification/experience/psychophysical state)
C – Communication (and Supervisors) – access to information and guidance
E - Environmental Conditions – weather, climate, physical barriers.
Identify hazards using the PEACE MODEL.

12. PEACE Model is used to sensitize member to critical aspects of task/evolution/mission or used in time critical scenarios.
Assists in developing a deliberate assessment of risk.
Very similar to the GAR model, except there are no scores only Low, Moderate, and High Risk determinations. Forces participants to verbally communicate.

13. Mission/Task Analysis: What can go wrong
Mission/Task Analysis: What can go wrong? Review current and planned operations and or tasks associated with mission or task.
List Hazards: Identify and list all hazards and factors that can generate hazards and affect the mission.(Hazard Inventory) What can go wrong? PEACE model
List causes: List the causes associated with each hazard and try to identify the root cause(s) to apply RM strategies against. Ask why!

14. Break into groups and identify hazards associated with safety zone enforcement at 4th of July Fireworks.
Your facility, along with one RBS-2 from local station and one OGA vessel are assigned to enforce a 1-hour security zone during fireworks.

15. The purpose of this step is to evaluate the risk potential associated with hazards. To calculate risk, each hazard is assessed based on the potential that it can result in a mishap, and the consequence of the mishap if it occurs.
So when we determine risk we must consider the probability of each hazard resulting in a mishap, and the severity/consequences of the mishap if it were to occur.
Determining how probability and severity affect risk levels in the focus of the step 2 in RM process

16. The RAM assesses hazards using a Severity by Probability matrix to compute a Risk Assessment Code (RAC). The RAC can be used to priortize hazards based on the required actions table.
RAC Value
Risk Category
Action Required 1
Extremely High
Discontinue, Stop 2
High
Correction Required 3
Medium
Attention Needed 4
Low
Possible Acceptance

17. The consequences of exposure to a hazard should the mishap occur:
Injury, occupational illness or death
Equipment damage
Mission degradation
Reduced morale
Adverse publicity
Administrative and/or disciplinary actions

18. I =. Catastrophic- Death, Loss of Asset, Mission
I = Catastrophic- Death, Loss of Asset, Mission Capability or Unit Readiness
II = Critical- Permanent Disabling Injury or Damage Significantly Degraded Mission Capability or Unit Readiness.
III = Moderate- (Non-Permanent Disabling injury or Damage, Degraded Capability or Unit Readiness.
IV = Negligible- (Minimal Injury or Damage. Little or No Impact to Mission Capability or Unit Readiness.

19. The likelihood the hazard will cause a mishap.

20. A = Almost Certain- past experience.
B = Likely – may occur frequently.
C = Possible- may occur several times.
D = Unlikely- remote possibility but not probable.
E = Rare- improbable, but has occurred in the past

21. 1 = Extremely High - Stop work Immediately
2 = High – Consider Stopping, Urgent Correction
3 = Moderate – Corrective Attention Needed
4 = Low – Possible Acceptance

22. Establish controls that either reduce or eliminate hazards by either eliminating or reducing the hazard to an acceptable level. Use the STAAR Model:
S - Spread out
T - Transfer
A - Avoid
A - Accept
R - Reduce
Step 3 you develop controls and make decisions to reduce hazard exposure and manage risk.
Using the STAAR we can identify some common strategies to control risk.
A control must decrease the probability of a MISHAP occurring or the severity of the consequence if MISHAP occurs- and could reduce exposure to a hazard.
Spread out- move assets, equipment, or tasks in order to avoid risk to entire mission. Reducing risk and exposure of these resources in a single, combined area.
Transfer- risk could be reduced by transferring all or some portion of the that mission or task to another individual, platform, or unit that is better suited or positioned.
Avoid- may be possible to avoid specific risks by doing the mission or task a different way. Days ops vs. night
Accept- very important and crucial part. Accept no unnecessary risk, accept risk when the benefits clearly outweigh the costs
Reduce- by simply reducing the number of members, equipment, or resources exposed to a risk can be a simple way in mitigating overall risk. Consider wisely though, reduction can also lead to not having back-up

23. Hazards need to be eliminated or mitigated to reduce the risk to an acceptable level.
Use the STAAR Model to identify how to mitigate potential risk.

24. Identify Control Options: Starting with highest risk hazards as assessed in Step 2, identify as many risk control options as possible for all hazards. Each hazard should have one or more controls to effectively eliminate, avoid or reduce risk to an acceptable level .

25. Determine Control Effects: Determine the effect of each control on the risk(s) associated with the hazard. With controls identified, reassess each hazard by repeating step 2 (RAM) and the effect of the control on the severity and/or probability. Produces the residual risk.
Prioritize Risk Controls: For each hazard, prioritize those controls. Best controls must be consistent with mission objectives and optimize use of available resources.

26. Select Risk Controls: For each identified hazard, select risk controls that reduce the risk to an acceptable level. If controls cannot reduce risk to an acceptable level or there are no additional controls then inform next level in chain of command that risk of mission exceeds benefits and should be modified. Risk versus Gain!
Take a look at the bottom line- Risk vs. Gain! If you are trying to develop controls or way to mitigate risk and they are happening you must take a step back on reevaluate situation. Our goal is to eliminate unnecessary risk in these first 3 steps or reduce to an acceptable level

27. Discuss results of steps 1-3 as a crew to establish common operating picture.
Integrate/refine analysis and mitigations taking into account crew contributions
Assign roles and responsibilities
Conduct final “real-time” analysis

28. Steps 4 and 5 (Implement Controls and Monitor and Supervise) are the required RM steps during mission execution.
If change is identified or controls are not effective, steps 1-3 are also used to identify and assess new hazards or explore alternate mitigation strategies.

29. Once the controls are selected, an implementation strategy must be developed and carried out. For mission related controls, accountability must be emphasized at all levels of leadership and personnel associated with the action clear understanding of risks an responsibilities.
Make Implementation clear: Provide a road map for implementation, a vision of end state . Describe successful implementation
Three parts to this:
Conduct the mission brief. Communicate plan and confirm understanding. Provide that road map. Then check to make sure everyone is onboard!

30. Establish Accountability: Accountability is a critical part of RM
Establish Accountability: Accountability is a critical part of RM. The accountable person is the one who makes the decision (approves the control measures), and hence the right person(appropriate level) must make the decision.
Provide Support: Command /Leadership must support control measure(s) in place. Provide necessary personnel and resources to implement the control measures. Feedback is important to ensure the control measure is achieving the intended purpose.
2. Assign those roles to establish accountability- you have to know who, what where, and when, and cost of associated with control measures.
3. Provide support and ensure plan is set! Make sure they have what they need and listen to feedback!
Through this step the leadership must provide the personnel and resources necessary to implement controls; then follow up to make sure they have the tools, skills, and knowledge to do it!

31. Engineering is the preferred control
Engineering Controls
Configuration changes, safety devices
Administrative
PPE, training, awareness, attitude change, rest breaks, look-outs…
Engineering is the preferred control
Evaluate Risk versus Gain.
Continually monitor mission for hazards or a change in direction.
Re-evaluate risk if there are any hazard changes or if the mission changes.
TCT Human Factors plays a major role in maintaining team effectiveness during the mission.

32. Key aspects of the step are:
RM is a continuous process. Member must monitor controls for effectiveness.
Key aspects of the step are:
Controls are effective and remain in place.
Changes in PEACE elements may require further RM or refinements.
Action is taken when necessary to correct ineffective risk controls and reinitiate the RM steps in response to the new hazard.
This is vital part of process where the team supervises and monitors the activities and conditions of the mission for change- and evaluates the effectiveness of the hazard controls from Step 4.
This is why each team member works like a sensor- supervising, monitoring, and keeping that overall situational awareness of their team and self, equipment, and conditions surrounding the.
By using RM whenever anything changes, we can consistently control risk exposure: those known before and those that develop during an operation/ activity. By identifying risks up front saves resources, enhances mission effectiveness and prevents mishap chains from forming.

33. Overoptimism Misrepresentation Alarmism Prejudice Inaccuracy
Over-optimism: excessive hopefulness or over confidence.
Misrepresentation: to share the sense of presenting information in a way that does not accord with the truth or usually involves a deliberate intention to deceive.
Alarmism: exaggerating dangers or prophesying calamities.
Prejudice: any preconceived opinion or feeling, either favorable or unfavorable.
Inaccuracy: reporting an error, mistake, or slip as fact.

34. Break class into small groups and hand out exercise for Mission analysis
Give time to analyze and do RM
Have each group report their results to class for discussion

36. This becomes the more fluid and relative part of the training in that we can start pulling those threads of memory from our students relating back to these six additional factors.
Most importantly we want to remain focused on the relationship back to our Mission Analysis steps of RM, and how they are all integral parts of the RM process.

37. (C)ommunications {effective}
(S)ituational awareness
(A)ssertiveness
(L)eadership
(A)daptibility/flexibility
(D)escision making

38. Analysis of mishaps reveals that Mission Analysis is one of the leading contributing factors to mishap events. The deficits in Mission Analysis are typically manifested in one of the 6 areas depicted in the illustration. That is to say, poor Mission Analysis typically produces knowledge deficits that can compromise each of the six elements in the illustration. A proper Mission Analysis will produce the necessary information to identify hazards and corresponding mitigation strategies, as well as, contingency plans if mission/activity deviations occur. If this information is lacking, the six elements that border Mission Analysis, and depend on this information, will be compromised. For example, if hazards are not identified, and corresponding mitigation strategies developed, how will a member be successful at maintaining situational awareness. Mission Analysis produces the necessary information for our members to maintain proper situational awareness.

39. “Plans often do not survive first contact with the environment, but a leader should have the flexibility and resiliency to succeed in dynamic situations by relying on the diverse, adaptable skills and capabilities of his or her team. Leadership is the cross-cutting necessity that gets the mission done while maintaining a service culture elevated to the highest standards” Commandants Strategic Intent
“Plans often do not survive first contact with the environment, but a leader should have the flexibility and resiliency to succeed in dynamic situations by relying on the diverse, adaptable skills and capabilities of his or her team. Leadership is the cross-cutting necessity that gets the mission done while maintaining a service culture elevated to the highest standards” Commandants Strategic Intent

40. How can we relate these to TCT/ RM?
Leading Self
Leading Others
Leading Performance and Change
Leading the Coast Guard
How can we relate these to TCT/ RM?
Effective Leadership traits
Types of Leaders
Leadership Styles
These four groups encompass the 28 Leader ship Competencies set forth by the Coast Guard
- What these traits are showing us is that leaders need to have that self confidence and drive to create the followership trait in themselves and in others.
That being a leader is not only about having that self assurance but instilling and influencing the ones that surround us through respect, communication, knowledge, mentorship, patience, etc. This creates our TEAM
And with these collective traits we lead furthermore with technical expertise, experience, innovation, and vision for accomplishing the mission and sustain that TEAM
So what we want to focus on in how these leaders can be effective, how they are defined in the Coast Guard, and the different leadership style

41. Proactive/ Passive at the right moments
Ability to diffuse situation/ conflict
Imaginative / Creative
Win / Win Attitude- Motivator
Receptive and communicative
What is an effective leader then? Solicit traits from the class
Some possible traits to expound upon: Imaginative, resourceful, innovative, tempered, rewarding, etc
These will be worked out in more detail with the objectives leaders have- next slide

42. Allow others to lead- provide guidance
Motivate the Team
Problem solver- individually and collectively
Lead!
Listen, reason, mentor
Avoid / Recover From Mishaps (Trap Errors not People)

43. All Team Members from their
Designated - Positional
Coxswain
Helmsman
CO/OIC
What are Some Others?
Functional –Situation Driven
All Team Members from their
Duty
Experience
Knowledge
Designated: Positional (CO/XPO/ Coxswain/CDO) These are assigned leaders designated to perform a task. More than likely possessing the knowledge and skills, but not always
Functional: These are the leaders whom exhibit strong qualities through personal or professional experience that may not be designated on a leadership position but still offer a large amount of effectiveness and cohesion in the tea. These individuals can step into a significant leadership role in more difficult and unpredictable situations.
**Must remember that each type serves a unique and important position in the team composition, and that each must be respected for what they are offering.**

44. Lessoned more in the Assertiveness Slide
These are all incorporated in “Leadership Styles” in that a delicate balance must be had within a team, as these three traits are inevitably going to happen at some time during an evolution.
Through Mission Analysis we can control and effectively steer these styles to be a useful attributes to the Team

45. No accidents or Injuries.
Mission is Successful
High Team Morale
Hazards are
Mitigated
Controlled
No accidents or Injuries.
This is the ultimate goal with Leadership- mission success with the highest output, in the safest manner.
When this happens each team member is willing to exercise leadership in contributing to the team effort.

46. As Leaders, we cannot expect error-free operations 100% of the time
As Leaders, we cannot expect error-free operations 100% of the time. The zero-defect mindset creates timid leaders, unwilling to make decisions (Passive). The Marine Corps’ ORM Instruction says this mindset leads to “higher casualties and failure in battle.”

47. CLASS EXERCISE
Who were the designated leaders during the San Juan case study?
Where were the failures in leadership? What levels?
Could an aggressive leadership style at any level have avoided this MISHAP?
Were there signs of passive leadership?

48. We begin this lesson with the stressing the importance of effective communication. We have to remember that without effective communication verbally, and physically, our teams can misinterpret our desires, thoughts, direction, and intent in completing a mission.
Focus will be on understanding the communication process, discussing the types of communication, identifying effective communication skills, and recognizing possible barriers.
“Words account for 7% of the information communicated. Vocal tone accounts for 55% and body language accounts for 38%”

49. Clear and effective communication is essential for good team coordination.
Communication is the process that permits us to effectively use the tools we have learned in the previous lessons. It is essential that team members communicate effectively at all times. Communication has been selected as a key lesson in Team Coordination Training and Risk Management to assist individuals and teams in reducing mishap potential through clear and effective communication.
Student shall be able to clearly and accurately send and acknowledge information, instructions, and commands; and provide useful feedback.

50. The Message Message that Is Heard
FEEDBACK
SENDER
INTENDED
LISTENER
PERCEIVED
With the Shannon’s Communication Model we are examining the complexity of the process and how it can be influenced. This primarily looking at the relationship from sender , message, and receiver.
Simply put- There needs to be some awareness to the probability of error in the communication process. This can be because of the ineffective types of communication, barriers, or a complete lack there of from a team.
Ask students the different types of communication and after compiling a list, than go to the next slide.
Message that Is Heard

51. Verbal, non-verbal, written, silence, electronic, graphic – Discuss examples, what works, what doesn’t, and why?

52. Use Common / Known Terminology Receivers Restate the Information
If Needed, Receivers Ask for Clarification
Senders Confirms Intended Info
Ask Questions to Clarify Information
“Roger” communications
Provide information per SOP
Provide information when asked
Repeat, as necessary
Use standard terminology
Request and provide clarification
Direct, unambiguous statements
Inform appropriate individuals when mission or plans change
Communicate all information needed by those external to team
Use appropriate nonverbal communication
Use proper order when communicating

53. Pre-occupation Anger or frustration Bias Priorities Rank/Structure
Team Diversity
Interruptions
Environment
Medical
Confidence
Background noise
When do these seem to arise as well?
Change in mission plan/ outcome
Change in leadership

54. CLASS EXERCISE:
Pre-communications (Was comms during the planning/pre-brief phase adequate?
Do you think roles were clearly communicated?
Discuss comms between boat crew and SSJCC.
Discuss proactive comms that may have helped avert this MISHAP, both external and internal.

55. Solicit for key words to define Situational Awareness from the class.
Situational Awareness is the ability to identify, process, and comprehend the critical elements of information in real-time regarding your surroundings and mission activities. Certain barriers reduce our ability to understand the situation and create a hazardous situation. Taking corrective action is the responsibility of all team members. The following factors negatively influence Situational Awareness.
Perception based on faulty information processing
Excessive motivation
Complacency
Overload
Fatigue
Poor communications

56. Knowing What is Happening
the Team*
the Unit
the Mission
Using those Team Coordination skills!
By using the quoted text, paraphrase the importance of knowing what is going (situational awareness) with your team, at the unit, and throughout the mission.
This is that extroverted process of being keenly aware of your surrounding. How do we obtain and sustain that?
Communication
Assertiveness
Adaptability/ Flexibility
Leadership
Make right decision
“ Ability to identify, process, and comprehend the critical elements of information about what is happening to the team with regards to the mission”

57. A collection of people assembled according to their technical abilities, pursuing a common purpose to successfully complete a mission.
Not always working by ourselves
How do we combine our shared mental model? Boat crew- Sectors- air crews
Working into Mission Planning blended mental model

58. Remain Alert to Mistakes and Crew Errors. Remain Vigilant to Changes
Understand
Mission Objective & Plan,
Known Hazards
Plan of Action.
Assigned Tasks.
Remain Alert to Mistakes and Crew Errors.
Remain Vigilant to Changes
Periodically Update Others on The Mission
What does your team need to be successful and cohesive?
- Without a clear and defined plan of action (Mission Analysis) a team can’t sustain Situational Awareness. This can be a mission briefs, updating when they can, conversation on what is going on, how people perceive the mission being accomplished, and attentiveness to change
Trap errors/ not people (again!) very important to “what if?” situation. Create conversation/ dialogue to enhance awareness
By conversing continuous on “what if” scenarios it will not only create a more alert and attentive crew that will more adaptable to change, but also allow for updates and changes in the mission to more easily recognized and processed.
Anticipate the needs of other team members
Predict the needs of other team members
Adapt to task demands efficiently

59. Confusion or gut feeling No one watching or looking for hazards
Use of improper procedures
Departure from REGS
Failure to meet planned targets/ briefed objective
Ambiguity
Lack of decisiveness/ clarity in making decisions
Fixation or Preoccupation
What are some of the personal experiences from the class?
List/ remember for future use
-One important part of losing situational awareness is that it become contagious practice, others will begin feeling the affects which can result in an entire team losing focus.
Team members need to trust their feelings
-Task direction and following through by fellow team members will ensure complete consciousness to the surrounding
-Departing from regs. and proper procedures is a very easy way to accelerate the loss of situation awareness for the entire team- stay away from this!
-Aspire to meet targets and goals previously briefed, and when they aren’t met don’t accept the circumstances without fully and systematically evaluating why
Ambiguity: a lack of decisiveness or commitment resulting from a failure to make a choice between alternatives.
Know your team, don’t allow preoccupation and/ or fixation tunnel their thoughts and task direction away from the mission! Try to detect early and correct quickly

60. Perception Excessive Motivation Complacency Overload Fatigue
Past Experiences
Expectations
Mindsets
Excessive Motivation
Complacency
Overload
Fatigue
Poor Communications
-Perception can be one of the most detrimental factors in barriers, especially in the climate we train and execute missions. Those key factors of expectations due to past experience, a predetermined expectation even before and during mission, can create a unrealistic mindset.
-Excessive motivation can provide blinders to the totality of a mission; safety, effectiveness/ resourcefulness of team, and objective you first set out for. Relate this to responding to a certain event and finding it be more complicated or dynamic than what was first perceived/ briefed.
-Complacency happens too often when task are routine, slow, or if you have achieved what you planned for. Example: most car accidents happen very close to home due to complacency
-Overload is an unfortunate element of our mission many will encounter. How we combat that and sustain situational awareness can be by prioritizing and delegating tasks to our team members on their abilities and capabilities at that moment. Don’t falter a team member if they are overload, but try to dial them back into the tasks at hand.
Fatigue can be controlled through monitoring, rotating, resting, and communicating with your team.
Poor comms= silence. Silence is dangerous in mission execution.

61. There are NO fail safe mechanisms
Evaluate judgments
Feedback and errors
Stress
Risks
When can human error occur?
Early and often = MISHAP
Team member must be able to I.D. ALL levels of human error and be EMPOWERED to take corrective actions!
Definition- Error chain is used to express the sequence (cluster) of actions or inactions that resulted in a MISHAP
This is where you will be evaluating judgments:
- Seek feedback and point out errors directly and promptly. Opinions matter!
- Assess stress levels: too little or too much. Adjust to that optimal level if you can.
- Manage possible risk: use your steps and break that error chain
Human errors can and will happen, what we want to do is identify and correct them before they compound into the inevitable= MISHAP

63. Recognize it as not deviant behavior
All team members have the right to participate:
Listened to and be taken serious/ can ask questions
Respect/ allowed to make mistakes
State Opinions- shared voice
Maintain a position
Until changed by the facts
Not by the authority or personality of another
Assertiveness should be expressed not as a defiant manner of a team member, but as an empowerment and right for member to state and maintain a position on an element of a mission and/or task. This obviously can be countered with factual information, but what we want to convey is that ability for member to speak, to express their thoughts and opinions
“Assertiveness is the most effective way of passing information and breaking the human chain of error that can affect safety and mission accomplishment”

64. Passive Behavior- They allow their ideas to be restricted by another individual or situation;
-excessive professional courtesy - express concerns in the form of a question, rather than a statement - avoid conflict - “along for the ride” - keep their feelings inside, can lead to unsafe levels
Aggressive Behavior- They usually invade another boundaries or right’s, dominating behavior to get their own way.
Excessive sarcasm and put-downs, belittling - behavior restricts comms. within team - synergy/ cohesiveness of team is lost - can be contagious to others
Assertive Behavior- They recognize boundaries between their ideas and those of others, and allow for communication and collective thinking
- Ask questions, suggest alternatives - maintain position when challenged, but respect factual info. - ask for help when overloaded - confront other types of behavior - use statements such as “I think” “what do you think” “lets work on this together” “what do you see”

65. Rank- can be a detrimental factor in someone feeling comfortable in being assertive. Team leaders need to ensure that junior members are empowered to be assertive, and that their voice is as important anyone else’s. This is a unfortunate barrier that can be hard to break through unless addressed from the beginning.
Perception- this can seen as a barrier in speaking up. A team member is reserved in being assertive due to the perceived reaction of others to the situation and/or being seen as defiant or anti-authority. This is a very common barrier; we encounter a potential hazard but before we take action or say something we contemplate how the others may react.
Mental Models/ Mindsets- Assertive behavior can be severely restricted if a shared mental model/ mindset is not apparent throughout a team. Even more detrimental is if a individual/ small group is not sharing the same ideas or perceived mission analysis and chooses to be passive in voicing their thoughts.

66. Each mental model comes with its own set of assumptions

67. Assumptions are valid only if based on Facts or Data
Can be mere opinions:
Ideas NOT PROVEN to be true, but sometimes thought to be true based on:
Past Beliefs
Past Knowledge
Past Experience
Assumptions are valid only if based on Facts or Data
So what are the pros and cons of Assumptions?

68. Know your Personality Trends (Mental Modeling).
Support Others Speaking Up.
Be Positive Even in Disagreement.
Avoid Conflict Creating Statements.
Reward Assertive Behavior by Others.
Goal of Assertiveness:
Clarity mission expect.
Point out a perceived problem

69. Who was or was not Assertive leading up to themishap?
Could the boat crewmen, coxswain, or unit command been more assertive? What about the Command Center?
Could assertiveness in the planning stages helped avoid this MISHAP?

71. OBJECTIVES: Be able to identify the signs or attitudes that may
affect a person’s or group’s ability to re-evaluate
or “change” a plan or action.
Describe options to prevent certain attitudes
from affecting Team Performance.

72. What is adaptability and flexibility?
Adaptability – ability to adjust oneself readily to different or changing conditions.
Flexibility - is being susceptible to that change.

73. Teams…
Ask for input and write them on the Board prior to going to the next slide.

74. Barriers to Adaptability
Individual Level
Group Level
Complacency
Stubbornness
Tunnel Vision
Fatigue
Stress*
Arrogance
Guilt
Peer Pressure
Group Think
Stress*
Fatigue
Invulnerability
Excitement
For individuals start the discussion relating to mission specific examples:
Mission repetition and complacency
Inability to break from the norm, seeing things only one way and not accepting the possibilities of change
Not assessing the fatigue factor, relating back to also an induced stubbornness and high level of stress
Don’t forget the overwhelming affect of stress- physically and mentally
Group resistance examples: (we speak more in-depth about stress in next module “Decision Making”
Peer pressure and stress can circulate very quickly, enabling that tunnel vision and sink hole effect
Fatigue is a large and contagious factor adding to resilience in changes to plans and/or adapting to change
Excitement: a group can become overly excited and eager to complete a mission and not allow for minor changes to be recognized or acted upon. This can start that error-chain effect!

75. Anti-authority- not wanting to conform. “No one tells me what to do
Anti-authority- not wanting to conform. “No one tells me what to do!” usually contrary to what they believe in their own better judgment. They need to be either reeled in by their leadership or the team.
Impulsiveness- sense of urgency when action doesn’t need to be taken immediately. “Do something quickly, anything” this is when actions/ decisions are made without stopping to think of the totality of the act. Their objective is do something, anything, and quickly. Can lead to not focusing on the changes in their surrounding and make poor decisions. They need to be stopped and dialed back in to the situation, offer them an outsides view and alternatives
Invulnerability- predisposition by a member or team that they cannot be harmed nor a unsafe condition/ MISHAP can happen to them. “It wont happen to me”. This can also be related to complacency, and usually is coupled with a denial of risk involved in a evolution.
Macho- “I can do it” attitude, fueled by the mindset of trying to prove themselves and impress others. This can be a teams thought pattern as well, and can result in pushing the envelope in operational capabilities and ignoring risk management.
Resignation- one of the more severe thought patterns in that the individual or team has the mindset that they cant effectively complete what they set out to accomplish or adjust to the changes they are presented “What’s the use”. In actuality what is happening is the denial of responsibility and wider mindset in problem solving and adapting to change.

76. Class Exercise Case Study:
Discuss the multitude of unique conditions that were
present that morning? Did tunnel vision play a factor at any level?
What obstacles did the boat crew face?
Did the perceived urgency of the mission serve as a barrier to the crew’s ability to remain flexible/adaptable?
How did the environment and communications promote or inhibit adaptability and flexibility?

78. Use the Information Available Apply:
Logical and Sound Judgment
A Systemic Approach
Define Actions to
Complete the Mission
Solve Problems
Ensure Timely & Effective Action by a Team

79. Minimize – Make the situation less important then it is.
Moralize – Make excuses to justify the actions or give it more priority than needed.
Muddle – Keep coming up with “what-if’s” to prolong the decision making process.
Scan – Constantly looking for way around making a decision or looking for endless alternatives.
Deny – Play down that there is even a problem or ignore that something needs to be done.
Optimize – Putting on a positive spin that it will work itself out; no action needed; taking action will only make it worse.

80. D E C I D E Estimate Significance of Change Choose Outcome
Detect Change
Estimate Significance of Change
Choose Outcome
I Identify Options
Do Best Option
Evaluate Results E C I D E

81. Stress is real. No one can leave their problems “at the brow” or “before they enter the building”. If your shipmates are not 100% “there”, than they won’t be 100% committed and alert at the task at hand. Talk about the importance of knowing your members, recognizing the signs of stress, and what help is out there. Help should be sited both through leadership and from resources through the CG (chaplain, Critical Incident Stress Management, CG Support, etc.)

84. In teams, develop a list of “WHAT CAN GO WRONG
In teams, develop a list of “WHAT CAN GO WRONG?” looking at Mission Analysis. Use the PEACE model on the Hazard Analysis Form using the provided case study. Pick your top concern for each dimension of the form, by using RAM/RAC and report the highest score found for each. Be prepared to discuss with class.
So for planning- What could or did go wrong with planning? Assign a number out of probability and severity from RAM, and the fill in report. Discuss and provide a control/ something to mitigate risk in last box.

85. What can we learn from this mission that will improve mission execution and crew safety?
Learn from successes and failures!

86. Conduct self-critique
Accept/encourage participation and feedback/suggestions from all crew
Focus on RM process to refine hazard awareness
Discuss what went well and what could be improved
Update RM artifacts (e.g., RAM)

88. THE END