ORM Fleet Brief 2012 - MCCS Cherry Point · 2014-02-14 · Risk Management is the process that assists organizations and individuals in reducing or offsetting . risk (by systematically

1

www.public.navy.mil/navsafecen

2

Were the following mishaps preventable?

Temporary Insanity II

Makes you wonder what happened to #1

Presenter

Presentation Notes

Makes you wonder what happened to #1.

Night Time, Weekend Alcohol, Speed are 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.

A look at the back of the trailer shows just what the impact did to both vehicles. As you can see the impact knocked the trailer section

off of its rear axles. One section of wheels are standing alone behind the trailer. The bottom of the trailer crushed the car like an egg carton.

Cars are not designed to with-stand this kind of impact.

Presenter

Presentation Notes

A look at the back of the trailer shows just what the impact did to both vehicles. As you can see the impact knocked the trailer section off of its rear axles. One section of wheels are standing alone behind the trailer. The bottom of the trailer crushed the car like an egg carton. Cars are not designed to with-stand this kind of impact.

April 2007, 1:00 am

Excess of 100 mph

Fatal Motorcycle Accident

July 2005 • Buckley Air National Guard Base – Denver • Lost hydraulics (nose wheel steering and brakes)

after landing when arresting gear doughnut bounced up and took out a brake line.

Presenter

Presentation Notes

July 2005 Buckley Air National Guard Base – Denver Lost hydraulics (nose wheel steering and brakes) after landing when arresting gear doughnut bounced up and took out a brake line.

8

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

Do you agree with this statement?

Presenter

Presentation Notes

Safety first Mission first� Explain the importance of the Navy’s mission and that we all understand the importance of it and that is why we are all here.

9

What’s the Most Important Take Away Today

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

Presenter

Presentation Notes

How do we get the mission done successfully? Correct application of ORM/TCRM Have them read the slide and understand the safety by-product and the successful mission completion again and again.� Ask: do we do the mission once or do we repeat the same type of mission again and again.

10

Overview

Operational Risk Management • Why ORM?

• Implementation Strategy

• Process

• Resources

• Summary

11

Why Risk Management?

12

Why Risk Management?

Cost Fatalities

PMV 73

Current as of 02 Oct 2012

AVIATION $791M

Total Cost: $865M

DoN – FY 2012

Total Fatalities: 122

Cost


Fatalities

PMV 42


AVIATION $448M

Total Cost: $496M

USN – FY 2012

Cost


Fatalities

PMV 31


AVIATION $343M

Total Cost: $369M

USMC – FY 2012

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

Presenter

Presentation Notes

Read Definition The process of dealing with risk associated with military operations, which includes risk assessment, risk decision making, and implementation of effective risk controls.

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

Completing the mission effectively is GOAL 1. this is why the Navy uses ORM.

Presenter

Presentation Notes

Explain the concepts…emphasize that completing the mission effectively is goal one. This is why the Navy uses ORM.

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.

Presenter

Presentation Notes

This is a good place in talk about Navy Core Values Honor Courage Commitment---Integrity Individual + supervisors + chain of command responsiveness Professional courtesies = qualification checkout and interview (Example… junior sailor checking in a senior sailor) you have done the job before/you have a higher rank You grant the qualification based on previously held certifications instead of following the JQR . Your busy-? Sign them off – you’ll be there and besides they have done the job before ( maybe 5+ years ago). And it all comes back to you on the day of the mishap…

19

Accident (aka “Mishap”)

An unplanned and unfortunate event that results in damage and/or injury.

So, what is an accident and are they preventable?

Presenter

Presentation Notes

So, what is an accident? Are they preventable?

20

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…

Presenter

Presentation Notes

Through our investigative and reporting process we know the causal factors of what lead to the mishap. However, even with this information we still manage to do the same things over and over again resulting in loss of life, limb and material. Every hand that flies, fixes and supports aircraft has the opportunity to introduce human error. ***** “Dirty Dozen” The Dirty Dozen was developed at Transport Canada, by Gordon Dupont. He was a licensed Aircraft Maintenance Engineer in Canada, the United States and Australia. He has also worked as a Technical Investigator for both the Canadian Aviation Safety Board and the Transportation Safety Board. After many years of aircraft accident investigation, Mr. Dupont developed a list of human factor error causes that were present with every mishap, which gave birth to “The Dirty Dozen”. Further, he notes that with each mishap, at least 3 of these human factor error causes were present. Errors, when they occur, will likely be found to be caused by one, or even more common, a combination of the following causes: Lack of: Communication, Resources, Assertiveness, Awareness, Teamwork, and Knowledge, and an… Abundance of: Pressure, Stress, Norms, Fatigue, Distraction, and Complacency. Review of NSC Mishap Database Poor Judgment / Decision Making - Failure to use proper PPE - Failure to adhere to proper procedures Complacency Loss of Situational Awareness Failure to adequately supervise Lack of communication Perceived pressure Not Qualified Attitude Poor organizational climate / culture

21

Are we learning?

Presenter

Presentation Notes

But, are we really learning. Are we passing on to those that replace us, what we have learned? Are they taking it on board? Photos taken during NSC Safety Survey

22

Are we learning?

Presenter

Presentation Notes

This Marine worked a 12 hour shift the day prior and stood a watch after that. The NCOIC for his work center throw a crainal at him to wake him up but it didn’t work. He was still tired. Youth… ten foot tall and bullet proof…. Fallon….Depot drinks etc aircrew good about observing 12 hour crew rest…..O’s or Sups buy everyone drinks and everyone is shit-faced…then up the next Am pre-flighting A/C.

23

Bottom-line

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

Presenter

Presentation Notes

ORM is applies to considerations with respect to “risk to force” and “risk to mission” whether the threat (hazards) are blue or red. However, statistics show us that the human in the loop is the biggest threat and is the focus of our discussion today.

24

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 - 562 Aircraft Destroyed

Reaching the War Fighter

Presenter

Presentation Notes

We know we are showing you a lot of aviation data and videos however there is a reason why. The aviation community operates a bit differently than our other navy communities. Aircraft go fast and the decision making must be made quickly and constantly . They also tell on themselves a lot along with pictures/video being taken constantly. Don’t let this fool you in thinking we don’t have the same problems in our other communities…we do it just doesn’t get the media attention unless its really bad. We all can learn from one another, we are one team in one fight. Take a look at this number (Red Threat). This is the number of aircraft we have lost to enemy action in twenty years. How many do you think we have lost to our own mistakes? NOTE: The number of aircraft lost does not reflect a component failure onboard the aircraft but due to maintenance, moving of aircraft, pilot error. ASK the class to give you numbers. You will get low numbers of around 100 – 250. Then show them the number and explain how many aircraft this would fill on our carriers today @8. Also ask how is your funding levels in your command? Taking a look at our number of aircraft and using a low number of 10 million per aircraft total cost would be @ 5 billion…could we use that money to complete our mission? The “war fighter” is not simply the one flying the aircraft…in this context the term is intended to encompass the team – support, maintenance, aircrew. The team faces the challenges of identifying and mitigating hazards and their associated risks in the accomplishment of the mission. ORM – Operational Risk Management: - The process to manage risk CRM – Crew Resource Management: - The skills to manage resources (man, machine, money, time, etc.)

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…

Integration Strategy

26

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

Presenter

Presentation Notes

How do we change the behavior / mindset of our sailor’s? With the understanding that there are some traits and behaviors that we specifically recruit, which we do not want to necessarily curtail. How do we instill in them the ability to make informed decisions? How do we instill in our sailor’s the integrity to make the right decision when no-one is there looking over their shoulders? What about the folks behind the camera!!!

27

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

Establishing an ORM Mindset

Goal: Risk Management is an integral part of Navy Culture

Presenter

Presentation Notes

The Secretary of Defense challenged the force to reduce accidents by 75% in 2008, with an ultimate goal of Zero preventable mishaps. As part of the effort to meet the Secretary’s challenge, senior Naval leadership identified Operational Risk Management (ORM) as an essential element to meeting the challenge. The Naval Safety Center was designated the Navy’s ORM Model Manager and general guidance was given to the Fleet to take action in order to revitalize and integrate ORM as part of every decision made and every action taken by every Sailor and DON Civilian employee – on and off duty. This is a very large task and obviously can not be accomplished overnight. Rather it will take a consistent effort over a generation of sailors. As the ORM Model Manager, NSC’s created a four pillar strategy to support the Fleet in accomplishing this task. Those pillars are: 1. Policy and leadership 2. Assessment and feedback 3. Training and education 4. Tools and resources In a nut shell…tell folks what they are required to do, hold them accountable for doing it, train them to be able to do it, and provide them the resources to do it. Each of the first three pillars are interdependent and are supported by the fourth. As a whole these pillars provide the foundation required in order to establish risk management as an integral part of Navy Culture. Policy and Leadership: Without engaged leadership at all levels, we will never achieve the task set before us. To help ensure visibility on associated requirements, initiatives, and resources; the NSC conducts ORM specific presentations, looks at application and integration of ORM during surveys and cultural workshops, supports conferences, provides information for executive level boards and committees, etc. For the long term, the guidance to the Fleet must be clearly articulated in writing. At present OPNAVINST 3500.39B and MCO 3500.27B are the USN and USMC ORM specific instructions. A revision of the OPNAVINST is underway in order to: - ensure alignment with SECDEF’s mishap reduction challenge and DON Objectives for FY 08 and beyond - provide better clarity on roles and responsibilities at all levels from the individual up through Echelon II commands - define NSC’s role as the Navy’s ORM Model Manager - include newly developed assessment processes - incorporate more detailed discussion on time critical risk management and associated tools - articulate the ORM learning continuum concept - re-organize to improve utility The draft has been delayed, but anticipate it to be available for Flag chop by end of April 2008. Additionally, discussion has begun with regards to feasibility of combining OPNAV INST and MCO, which would help standardize implementation across DON. In addition to the instruction and order, USFF and CPF continue to release periodic joint messages providing ORM guidance. Next message, currently in final chop, will articulate requirement for integration of in depth ORM assessment within all phases of the Fleet Response Plan (FRP). Assessment and Feedback: ‘Do not write a rule you are not willing to enforce.’ Although the ORM instruction and order have been on the street for many years, there was never a consistent or formal methodology to assess whether or not they were being implemented. Early FY07, the VCNO and CFFC task the Fleet and Force Providers working with the NSC to develop an ORM assessment process to measure risk management application and program compliance and capture and disseminate ‘best practices’. It was determined early on that the best course of action would be to tap into those evaluation and assessment commands that already exist (ATGP/L, TTGP/L, SFTP/L, TRE, etc.) and work collaboratively to tailor their processes to incorporate detailed assessment of application of ORM, to include feedback to those evaluated. The ultimate goal would be to permanently integrate ORM metrics into NMETLs, Pbviews, CV SHARP, TORIS/TFOM, STATS, etc. There is a training piece associated with conducting ORM assessments, as well. NSC currently provides training as needed to support this, but the long term goal is to get the training integrated into the evaluation commands’ existing efforts. The NSC also developed a program assessment checklist which can be utilized to check compliance with the existing instruction and guidance. The assessment process, both for program compliance and application of risk management concepts in execution, brings a level of accountability to the program, focuses leadership and remains a key element of ensuring risk management is integrated into Navy Culture.

28

Establishing an ORM Mindset

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

Goal: Risk Management is an integral part of Navy Culture

Presenter

Presentation Notes

Training and Education: A crucial piece of achieving the change in mindset is to ensure sailors, marines and civilians are exposed to / introduced to risk management from their first day in the Fleet and that ORM training remains a steady drum beat as they progress through their careers. To achieve this means building an ORM learning continuum (see next slide for graphic overview of the continuum) with targeted and relevant training based on one’s level of responsibility. The OSSC Safety and Training Working Group, chaired by NETC representative, supports this effort. Efforts currently underway: - NKO (Marine Net) courses: Material reviewed and found wanting. NETC estimated revision cost at $315. Unfunded to date. - DLA under contract with NSC to develop web-based, multimedia Time Critical Risk Management training module. Pending results of first module and available funding, DLA can provide further module develop to support entire continuum. - ORM Application & Integration Course: A 2-day traveling seminar intended to qualify ORM assistants at the unit level. Requires revision to focus on assistant duties, provide tools and resources for unit level integration and inclusion of assessment training. Funding expires end of FY09. - SWOS, ASO/ASC courses, SOAC: Provide similar material as 2 day A&I course and meet requirements for designating ORM assistants. - Recruits: Time Critical Risk Management trial in progress. Expect to use results to support expansion of training into other accession points (NROTC, OCS, Naval Academy, etc.) - Enlisted Exams: Initial review show ORM questions embedded into exams. Plan to participate in the next exam development cycle. - Future efforts: NAPS, Senior Enlisted Academy, Naval War College, Naval Academy, OCS, Direct Commissioning Programs Tools and Resources: Supporting the other pillars, it is essential that we provide the resources necessary for individuals and units to integrate risk management in all they do. This not only includes such things as developing new tools or sharing existing tools or best practices, but also being the advocate to find sponsors and funding to continue to support these tools and the overall ORM revitalization. - Web: NSC webpage provides the portal to an electronic library of risk management resources to include training material and best practices. Currently redesigning to improve user interface. Expect completion May 08. - Generic evolution and program assessment checklist available on-line - Publications: ORM Magazine (special issue) released 2007. Business cards, posters etc. available. ORM Flip guide to follow release of revise instruction - Software applications: TRIPS, TRACS, ORMAS - Provide support for unit level training such as Safety Standdowns or conferences.

29

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

30

• 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

31

• 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

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

Mishap

Remove one causal factor or

consequential error Failed or Absent

Controls

Presenter

Presentation Notes

It is known that mishaps are rarely due to a single cause, or in most instances, even a single individual. Rather, mishaps are caused by a chain of events, a series of latent conditions that “set the stage” for an active failure that leads to a mishap. The goal of a mishap investigation is to identify these conditions and failures in order to understand why a mishap occurred and how the chain can be broken to prevent the reoccurrence. This reactive approach provides lessons learned which we must then incorporate in a proactive manner to prevent a mishap the next time. The systematic approach of ORM is the tool to help do just that. It helps us identify the holes (hazards) in the “Swiss cheese” to which we may apply resources and controls in order to prevent the holes from aligning and thus prevent the mishap.

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

Presenter

Presentation Notes

What is our mitigation strategy to combat the causal factors that lead to degraded/failed mission, injury to force or self? Operational Risk Management is the process, when applied, leads to more effective mission success, reduction in loss to force and self. Remember the 4 principles are the foundation of ORM.

In-Depth Deliberate Time 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

Presenter

Presentation Notes

- Risk management is a continuous process that is integral from the strategic level planning thru the tactical level execution. It is a tool to help improve mission readiness and mission accomplishment. - A review of the attached figure shows the three levels of ORM are defined primarily by time. There is no definitive separating line between the three levels (in-depth, deliberate and time critical) – represented by the blurred transition in color; but in general: > If you have no time to plan and you are in the execution phase of the event or task, you are at the time-critical level of ORM. > If you have plenty of time to plan, to get the right answer, you are in the in-depth level of ORM. > The deliberate level lies between the two other levels, but is still focused on planning and preparation for execution. We don’t have unlimited time, yet we need to get the best answer. - We depict those levels in the shaded gradient because there are no definitive lines between the levels. You flow from one level to another as you approach the task or event. (Color selection rationale: Green was selected for the right as time and resources are available. Orange was selected for the left to infer potential increase in perceived or actual pressure due to lack of time and resources.) - It is important to know we have resources to tap into. At each level of the planning process hazards and associated risks are identified and appropriate controls are developed and implemented. These controls become resources upon which you can draw on for the next level of planning and ultimately for execution.

35

“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

Staff Recommend Options

Command Decisions

Identify Hazards

Assess Hazards

Make Risk Decisions

Supervise

Naval Operational Planning Process

Presenter

Presentation Notes

Emphasis on integrating into existing unit level / command planning processes, not a stand alone process.

36

“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.

37

“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.

38

“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?

39

5 Step Systematic Process

1. Identify Hazards

2. Assess Hazards



5. Supervise

40

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

Presenter

Presentation Notes

Operational analysis - A process to determine the specified and implied tasks of an evolution as well as the specific actions needed to complete the evolution. Ideally, the evolution should be broken down into distinct steps based on either time sequence or functional area. Specified task – A task that has been definitively directed by a superior (e.g., get underway on this date). Implied task – A task that indirectly accompanies one or more specified tasks but are not definitively directed (e.g., get underway with no personnel casualties, no damage to the vessel, and minimal environmental impact). Hazard/Threat – A condition with the potential to cause personal injury or death, property damage, or mission degradation Hazard root cause – The specific causal factor behind a hazard (e.g., inadequate rest, hydration or food intake; insufficient rudder input or authority to counter suction forces; or personnel intentionally violating procedures). A cause is more specific than a hazard. A method of clarifying if something is a hazard or a cause is to ask the question, “Is this specific enough to help identify a corrective control?” If the answer is ‘no’ it is a hazard, if the answer is ‘yes’ it is a cause. It is important to properly identify hazards and causes because there may be several causes associated with one hazard. If the more specific causes are not identified, necessary controls may be omitted resulting in the hazard not being eliminated or it’s risk inadequately reduced. Hazard symptom – An effect that can occur from one or more causal factors (e.g., fatigue, collision, explosion).

Stra

its T

rans

it R

isk

Ass

essm

ent

Hazard/Threat Effect Assess RAC Risk Control Action Re-assess Residual Supervision

Grounding/Flooding/ Navigation error C, II 3

SUWC: ensure ships' report RMD in effect, fixes every 2 min. w/ confidence & sources, OOD/Conn be proactive w/ identifying & communicating. D, II 4

CHENG: monitor from Control; CO/XO: monitor from bridge; GATOR: report & resolve discrepancies, provide recommendations to OOD

Blue/White Collision C, I 2

SUWC: pass shipping info., ships adhere to Rules of the Road, use Furuno/ARPA, dec. speed in strait, pass contacts to BWC/SUWC on net. D, II 4

CO/XO: monitor from bridge; OOD/CONN: resolve potential conflicts early & contact via radio; CICWO: backup OOD

Non-compliant, non-squawking low slow flyer B, I 1

ADC: proactively identify & resolve tracks; CFMCC: set weapons posture & status for threat; IWC: monitor & report I&W to BWC/ADC on net. C, II 3

ALL: report anything in water, wear PPE if topside; 1st LT: ensure proper PPE; LOOKOUTS: continually scan

Tide/current/waves A, III 2

SUWC: plan during favorable conditions, pass to restrict access to wx decks during high seas, update BWC on changes. A, IV 3

GATOR: determine impact if delayed; METOC: update emerging weather conditions

Fog/Reduced visibility/Inclement weather B, II 2

SUWC: ensure ships report restrictred visibility detail, use bell & horn, slow as needed. B, IV 4

METOC: report when below 3 NM visibility; OOD: backup METOC if visibility

Unknown submarine IVO PIM/Vital Area B, II 2

ASWC: notify BWC/SUWC of known/unknown sub location; BWC: launch alert ASW if needed. C, III 4

OOD: monitor bridge watch team and correct as necessary; CO/XO: monitor bridge team

Terrorist attack D, I 3

BWC: PPRs; SUWC: man ships' 50-cals.; ADC: direct ATFP/SAR helo D, III 5

GUN BOSS: monitor & quiz ATFP watches on PPRs

Inattention/ complacency A, III 2

SUWC: limit RMD watch duration; ALL: ensure rested & nourished B, III 3

atc es bac up e o watchstanders & supervisors relieve if needed

Deliberate ORM Example

Presenter

Presentation Notes

Here’s a sample Risk Assessment for a straits transit.

42

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


Presenter

Presentation Notes

Risk – An expression of possible loss in terms of severity and probability

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 1 1 2 3

II Significantly Degraded Mission Capability or Unit Readiness; Severe Injury or Damage

1 2 3 4 III Degraded Mission Capability or Unit

Readiness; Minor injury or Damage 2 3 4 5 IV

Little or No Impact to Mission Capability or Unit Readiness; Minimal Injury or Damage.

3 4 5 5 Risk Assessment Codes

1 – Critical 2 – Serious 3 – Moderate 4 – Minor 5 – Negligible

SEVE

RIT

Y E

ffect

of H

azar

d

Presenter

Presentation Notes

Here is the Risk Assessment Card from the instruction (in color) . Major difference in this card compared to cards that you may have used before is the note of Mission first then talking points on loss of assets, equipment, life.

44 44

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.

Stra

its T

rans

it R

isk

Ass

essm

ent


























= Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk


Presenter

Presentation Notes


Stra

its T

rans

it R

isk

Ass

essm

ent




























Presenter

Presentation Notes


Stra

its T

rans

it R

isk

Ass

essm

ent


























Identified Risk



Presenter

Presentation Notes


48

Assessment Pitfalls

• Over optimism • Misrepresentation • Alarmism • Indiscrimination • Prejudice • Inaccuracy • Complacency

Presenter

Presentation Notes

Over optimism: “It can’t happen to us. We’re already doing it.” This pitfall results from not being totally honest and not looking for root causes of the threats. Misrepresentation: Individual perspectives may distort data. This can be deliberate or unconscious. Alarmism: “The sky is falling” approach, or “worst case” estimates are used regardless of their possibility. Indiscrimination: All data is given equal weight. Prejudice: Subjectivity and/or hidden agendas are used instead of facts. Inaccuracy: Bad or misunderstood data nullify accurate risk assessment. Complacency: Enumeration: It is difficult to assign a numerical value to human behavior. • Numbers may oversimplify real life situations. • It may be difficult to get enough applicable data; this could force inaccurate estimates. • Numbers often take the place of reasoned judgment. • Risk can be unrealistically traded off against benefit by relying solely on numbers

49

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.


Presenter

Presentation Notes

Carefully evaluate the mission impact of the various risk control options. The most effective risk control may also be the one that has the most negative impact on other aspects of the mission. The objective is to choose the option(s) that has the best overall favorable impact on the mission. The best controls will be consistent with mission objectives and optimize use of available resources (manpower, material, equipment, money, time) Control – A method for reducing risk for an identified hazard by lowering the probability of occurrence, decreasing potential severity, or both by achieving one or more of the following: Avoid: Adjusted flight path to avoid known threat, change day mission to night to avoid specific hazard of day environment Delay: If not driven by specific timeline, delaying a task or mission may allow situation to change reducing or eliminating threat. Transfer: Reduce risk by transferring a mission or portion of a mission to another unit or platform that is better positioned or more survivable. UAV instead of manned aircraft. Spread: Compensate: To ensure success of critical missions or task, compensate with redundant capabilities. 2 aircraft to take out single target. Reduce: Examples of effective control criteria: Suitability: Control removes the threat or mitigates (reduces) the residual risk to an acceptable level. Feasibility: Unit has the capability to implement the control. Acceptability: Benefit gained by implementing the control justifies the cost in resources and time. Explicitness: Clearly specifies who, what, where, when, why, and how each control is to be used. Support: Adequate personnel, equipment, supplies, and facilities necessary to implement a suitable control is available. Standards: Guidance and procedures for implementing a control are clear, practical, and specific. Training: Knowledge and skills are adequate to implement a control. Leadership: Leaders are ready, willing, and able to enforce standards required to implement a control. Individual: Individual personnel are sufficiently self-disciplined to implement a control. Resource – A type of non-PPE control that can be used to mitigate risks; includes policies, tactics, procedures, processes, checklists, automation, briefings, external entities, knowledge, skills, and techniques. Residual risk - An expression of loss in terms of probability and severity after control measures are applied (i.e., the hazard's post-control expression of risk). - Overall residual mission risk should be determined based on the threat having the greatest residual risk. Determining overall mission risk by averaging the risks of all threats is not valid. If one threat has high residual risk, the overall residual risk of the mission is high, no matter how many moderate or low risk threats are present. Actionable solution – A solution that if enacted would likely prevent a particular failure from recurring. Definitions: - SOP – Standard Operating Procedures - ROE – Rules of Engagement

Stra

its T

rans

it R

isk

Ass

essm

ent




























Presenter

Presentation Notes


Stra

its T

rans

it R

isk

Ass

essm

ent




























Presenter

Presentation Notes


Stra

its T

rans

it R

isk

Ass

essm

ent




























Presenter

Presentation Notes


Stra

its T

rans

it R

isk

Ass

essm

ent


























Residual Risk



Presenter

Presentation Notes


54

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


Presenter

Presentation Notes

Involving subordinate units (stakeholders) in planning helps with user ownership – buy-in.

55

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


Presenter

Presentation Notes

Documented risk assessment – A documented five-step ORM process. Minimally, this involves a list of hazards assessed for risk with their risk controls, residual risks, and risk control supervision responsibilities noted. By using risk management whenever anything changes, we consistently control risks identified before an operation and those that develop during the operation. Addressing the risks before they get in the way of mission accomplishment saves resources and enhances mission performance.

Supervise, Monitor & use personal tool - ABCD

Action 1: Monitor

Action 2: Review

Action 3: Feedback

Assess Balance Resources Communicate Do – Debrief 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?

ABCD

Presenter

Presentation Notes

When we are supervising the developed deliberate ORM plan we are in TCRM which refers to applying ORM at the point of commencing or during execution of a mission or task, at the time critical level. However, the methodology of applying the deliberate 5- step process in a time critical situation has proven to be impractical. What is the method the ORM model manager implemented to assist the fleet during the execution of the mission or task? The ABCD Model The ABCD Model establishes a structure for individuals, teams, or crews to learn new or complex behaviors, skills, or values or gain understanding. The ABCD Model provides a common language and structure for a measured response when an individual, team, or crew is executing a routine task or when they are under duress from a more complex situation resulting from additive conditions, crew factors, or task loading.

Stra

its T

rans

it R

isk

Ass

essm

ent




SUWC: monitor all vessels & report when any vessel comes w/in 500 yds of shoal water; BWC: backup.



SUWC: monitor all vessels for CBDR or min range inside vital area; BWC/ASWC: backup.



ADC: monitor all tracks for possible low slow flyers; IWC: monitor I&W; BWC: backup ADC/IWC.



SUWC: monitor changing conditions; CSG OPS: call BWC if conditions become sig. different than forecast.



SUWC: report when vis<3NM & low visibility set, monitor speed.



ASWC: monitor all subsurface contacts & report possible locations for unknown; BWC/SUWC: backup.



SUWC/IWC: monitor I&W and use PPRs as required. BWC/ADC: backup.



ALL: backup watches & supervisors relieve if needed



Presenter

Presentation Notes


58

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.

Presenter

Presentation Notes

Risk management should be integral to operations from planning initiation to after action.

– 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

ORM Mind Set… Change the Perception of Risk Management

WDT ?

What’s Different Today?

Presenter

Presentation Notes

We are missing the ability or skills necessary to react and respond to … “What’s different today?” Time Critical Risk Management is the level of the established ORM process we as an organization fail to perform well. Whether during the mundane, routine task or the complex, multi-unit evolution (Red Threat or Blue Threat environment), we fail to adjust to what is different today. Managing risk does not stop after the brief is over. It is a continuous process. Yet it is at execution of the task or mission, where time and resources are most limited, the last slice of “cheese” so to speak, that we must learn to be proactive and responsive. As part of the Naval Safety Center’s effort to revitalize ORM, we are in the process of developing new tools and training to help address this issue across the Fleet.

5-Step ORM and ABCD

Time Critical Process and Mnemonic

A – Assess (your situation, your potential for error)

B – Balance Resources (to prevent and trap errors)

C – Communicate (risks and intentions)

D – Do and Debrief (take action and monitor for change)

5-Step Deliberate and

In-depth Process

1. Identify Hazards

2. Assess Hazards



5. Supervise (watch for changes)

Presenter

Presentation Notes

Automatic Build: The arrows from the ABCD to the 5 step ORM process build automatically. Intent of slide: First Line: The ABCD actually maps to the existing five-step ORM process, while at the same time being very easy to remember and working in the time-critical environment. Questions have been raised like: “What about what we are teaching now? What about a continuum of learning?” Our view is that we are not replacing what we have in our ORM kit bag, just augmenting it with what will help it stick in the minds of our people and bridge a vital gap that was never really addressed in the early stages. Our recommended changes to the ORM fundamentals will flow to a better understanding of the Deliberate process. ABCD is linked to the accepted and completely relevant 5-step process. We feel there is no need to memorize the five-step deliberate process. When you plan, why not have the steps in detail in front of you? The deliberate process would be introduced, but not be the focus until reaching a supervisory level.

of Risk Management

Where am I? What is going on? What will happen next?


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?

ABCD

Assess Balance Resources Communicate Do – Debrief

Presenter

Presentation Notes

Where am I? What is going on? What will happen next? Assess failure results: Mission Failure Mission Impact Danger Foul-up Unintended Consequences What seems to be only an individual “Foul-up” can lead to a chain reaction resulting in mission failure or danger to the team Falling asleep when watch standing You must think beyond yourself and communicate

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

Presenter

Presentation Notes

Gauging risk as you use the target: The green – I would like you to think the green as your comfort zone The yellow – is leaving your comfort zone due to unfamiliar situations, stress, task loading etc… The red – your uncomfortable and have become tunnel vision unable to see anything else that may be happening around you It follows the three colors of a traffic light and other programs such as sexual harassment. It permits you to visualize risk and communicate to others example… your in the red has immediate recognition by team members who have been trained in this concept.

of Risk Management





ABCD


Presenter

Presentation Notes

What are my options? How do I use them Balancing resources – controls in 5 steps of in-depth and deliberate become resources in execution.

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

Presenter

Presentation Notes

We will illustrate the Swiss cheese concept with this graphic Explain the resources available to them: Use examples Red block: Polices, Procedures, and Routines (We have) Green block: Checklist (We use) Aqua block: Automation (Alarms, sensors, etc.) Yellow block: Briefings and external resources (Supervisor, Shipmate, Chaplin, etc.) Gray block: Knowledge, Skill, and Technique (Training, practice, drills, etc.) Example: Driving 1. Recognizing Risk: Other Cars, Drivers, Passengers, radio, cell Phones, Distracted drivers 2. Create a habit: Seatbelts 3. Know what you're about to encounter: weather conditions 4. Know who to trust: You Who not to trust: other drivers 5. Write down things you might forget: Directions, trip to the supermarket 6. Give yourself an out: rules of the road. Show car / motorcycle crash video. Safety Center Facts: USN Introduction to ORM

of Risk Management





ABCD


Presenter

Presentation Notes

Who needs to know? Who can help? Who can provide backup? Communication is vitally important it extends to all steps in the 5 step process It is not all verbal It can be in any form – visual, verbal, feeling etc… If you expect something to happen and it doesn’t - you should investigate

Why a Common Language?

操作的风险管理

작전 위험 관리

تشغيل وإدارة المخاطرOperational

Risk

Management λειτουργική διαχείρηση κινδύνων

CVORRTTEX

SPOT

STORM

TRM

Navy Lingo

STAR

SOAP

R.I.T.E.

Presenter

Presentation Notes

We need a common language here are examples of why we need to standardize it. SPOT = Safely Professional On Time CVORRTTEX = Communicate, Visibility, Outside Support, Rest, Rehearsal, Threat, Training, Environment, Experience TRM = Tactical Risk Management STORM = Safety Training Operational Risk Management STAR= Stop, talk, act, restart SOAP = Stop, observe, act, proceed R.I.T.E.= R” - Risks vs. Rewards. Analyze the risks present and the value added by accepting those risks. “I” - Implement a well thought-out plan. “T” – Talk it over, ensure the entire team is on the same page. “E” – Execute the plan professionally. If the plan changes, stop and re-evaluate. �

of Risk Management





ABCD


Presenter

Presentation Notes

Carry out the plan Was mission successful? Did actions reduce the risk?

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

ABCD

Presenter

Presentation Notes

Yes, they are part of the team, but what does it mean to them? Make it personal - each member of the hose team is integral to its success in fighting a fire.

69

Put into Action

• Review of ABCD and Resources

• On duty • Off duty

• What can we do better tomorrow?

ABCD

Presenter

Presentation Notes

Carryout the mission/task on and off duty Provide feedback – critical to improving any process A complete loop – Assess, Balance Resources, Communicate, Do & Debrief - What went well/what was bad

70

Reconsider this situation…

Presenter

Presentation Notes

Let’s take a second look at this scene… - Did the rider consider this outcome? - Did his “backup” – friends consider this outcome? - Did they do anything about it? - What resources or options were considered to ensure success? - What are the chances the next rider down the street will learn anything from this?

71

Reconsider this situation…

72

It’s about informed decisions.

73

NSC Website:

a Valuable Resource

Resources & Tools www.public.navy.mil/navsafecen

Presenter

Presentation Notes

Designed so content is listed by both organizational structure (directorates and divisions and by content). Popular pages by content: Photo of the week Summary of Mishaps Safe Tips Traffic Safety Toolbox Seasonal Resources Magazines (Approach, Mech and Sea&Shore) Presentation (selection of over 300 briefs) Additional Resources: Web-Enabled Safety System (WESS) 50% Mishap Reduction Safetyline eNewsletter Safety Instructions Operational Risk Management (ORM) Printable ORM cards Magazine Special Features News and Articles Stats: The Naval Safety Center web site consists of approximately 20,000 files distributed over 17 sub-webs. Over 950,000 pages are viewed per month and usage is continuing on an upward trend. An average of 400 feedbacks are received per month via our website. There are over 1,800 people subscribed to receive our eNewsletter and 1,000 signed up to receive the Summary of Mishaps.

74

• 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

75

Risk management… It is a mindset

Presenter

Presentation Notes

Nod to our Traffic safety folks… But consider this – this is the generation (18-26 year olds) we need to reach out to, as it is the largest demographic of the service. 4 Principles of ORM: - They did not anticipate risks through planning – could have planned for designated driver or taxi - They accepted unnecessary, known risks – the girl is talking about them - They were willing to accept costs, far beyond the benefits of the “fun” – again the girl highlights some of the costs, as well as, demonstrated at the end. - They each individual made the decision to go along for the ride – they made a poor decision, because they did not understand the consequences of their actions.

76

We w ill manage risk to operate by follow ing 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…

77 77

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

78

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…

79

Congratulations!

You have completed your annual

Operation Risk Management Training

PRINT GIVEN NAME SIGNATURE

COMPLETION DATE NAF EMPLOYEE ID NUMBER

Fill in the required information above and get this certificate to your Department Training Liaison

By signing and submitting this certificate, I certify that I have read and understand the content in the training presentation.

No Nicknames

Documents

ORM Fleet Brief 2012 - MCCS Cherry Point · 2014-02-14 · Risk Management is the process that assists organizations and individuals in reducing or offsetting . risk (by systematically