Slide 1

1 www.public.navy.mil/navsafecen Slide 2 2 This presentation is designed to be tailored. Review the slides and select the ones that are appropriate for your audience and time allotted hide the rest. Hidden Slide Slide 3 3 Were the following mishaps preventable? Slide 4 Temporary Insanity II Slide 5 Night Time, Weekend Alcohol, Speed mix for Disaster Service member and cousin were killed when the Acura they were traveling in hit the semi-trailer truck. The Acura, which investigators said was going more than 80 mph, crumpled on impact. Slide 6 April 2007, 1:00 am Excess of 100 mph Fatal Motorcycle Accident Slide 7 Slide 8 Slide 9 Slide 10 10 Have you heard this? Safety First! Whats the Most Important Take Away Today Or this one Mission First! How do we get there? Correct application of ORM/TCRM Successful Mission Accomplishment Thru Correct Application Of ORM/TCRM Allows Safety to be a by-product Allowing us to Perform our task or mission again and again Do you agree with this statement? Slide 11 11 Overview Operational Risk Management Why ORM? Implementation Strategy Process Resources Summary Slide 12 12 Why Risk Management? Slide 13 13 Why Risk Management? Slide 14 CostFatalities PMV 73 Current as of 02 Oct 2012 AVIATION $791M Total Cost: $865M DoN FY 2012 Total Fatalities: 122 Slide 15 Cost Total Fatalities: 58 Fatalities PMV 42 Current as of 02 Oct 2012 AVIATION $448M Total Cost: $496M USN FY 2012 Slide 16 Cost Total Fatalities: 64 Fatalities PMV 31 Current as of 02 Oct 2012 AVIATION $343M Total Cost: $369M USMC FY 2012 Slide 17 Risk Management is the process that assists organizations and individuals in reducing or offsetting risk (by systematically identifying, assessing, and controlling risk arising from operational necessity, task loading, additive conditions and crew or human factors) and making decisions that weigh risks against mission or task benefits. The process can be used both on and off duty. Operational Risk Management Slide 18 ORM Concepts ORM is a decision making tool Reduce loss, increase success Ability to make informed decisions Minimizes risks to acceptable levels Same process in wartime or peacetime Efficient use of resources Slide 19 Cultural Challenges Can do anything, anywhere, anytime, at any cost mentality Do more with less mindset Reluctance to say no Making decisions based on the way weve 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. Slide 20 20 Accident (aka Mishap) An unplanned and unfortunate event that results in damage and/or injury. Slide 21 21 Why do mishaps occur? Lack of:Abundance of: - Communication+ Distraction - Awareness+ Complacency - Resources+ Norms - Assertiveness+ Stress - Teamwork+ Fatigue - Knowledge+ Pressure Over 85% of all mishap are attributable to human factors failures Mishap investigations (reactive approach) reveal causal factors Slide 22 22 Are we learning? On the job? Aircraft Movement: 2000: Tow tractor hit parked acft. Fatal injury. 2003: During acft towing, person fatally crushed between store & dolly 2004: Sqdn acft under tow direction of yellow shirt ran over ship's blue shirt. Permanent disability 2005: Wing walker's leg run over by acft during move permanent disability 2006: Acft ran over airman's right leg during taxi on flight deck permanent disability 2007: While towing acft airman caught and dragged under right wheel and suffered skin and muscle damage 2007: Wing walker injured while acft being towed. Lack of supervision guidance enforcement Complacency - Perceived Low Risk evolution Loss of Situational Awareness Lack of Time Critical RM Off-Duty? Slide 23 23 Are we learning? Slide 24 24 Are we learning? Slide 25 25 Bottom-line Red Threat Action / Inaction by own forces causing losses far exceeding those caused by Red Threat Degradation in mission readiness Impact to mission accomplishment Impact to the Team, Family & Friends ORM is a tactic to help reduce the Blue Threat Slide 26 26 Puts the concepts in to terms the War Fighter understands Hazards = Threats ORM = Tactics CRM = Skills The Blue Threat Threat Losses (FY Jan 91- Mar 11) Red Threat - 18 Aircraft Destroyed vs. Blue Threat - 562 Aircraft Destroyed Reaching the War Fighter Slide 27 Controls Controls derived from In-Depth & Deliberate ORM exist everywhere, in all activities throughout the unit maintenance programs, redundant systems, Standard Operating Procedures, checklists, flight briefs, Rules of Engagement, flight gear, survival equipment, etc. Recognize ORM Its Already in Place, but Its Already in Place, but Integration Strategy Slide 28 28 How do you change a mindset? ( Who is looking out for whom?) Slide 29 29 Policy & Leadership Focus all levels of leadership on key ORM implementation issues Develop and refine policy and guidance for the Fleet Assessment & Feedback Accountability Assist in development and integration of assessment process for the Fleet Partner with force commanders and readiness evaluators Institute vehicles for Best Practice dissemination Education & Training Implement an ORM Learning Continuum from accession to retirement Partner with training and accession commands Standardize training and education across the Fleet Resources & Tools Create and share tools to facilitate integration across the Fleet Establishing an ORM Mindset Goal: Risk Management is an integral part of Navy Culture Slide 30 30 ORM integration strategy 2 nd page of notes. Slide 31 31 ORM is a systematic approach to managing risks to increase mission success with minimal losses. This involves identifying and assessing hazards for risk, controlling risks, supervising and revising as needed. ORM Process Risk to Mission, Force, and Self Slide 32 32 About avoiding risk A safety only program Limited to complex-high risk evolutions Just another program Only for on-duty Just for your boss Just a planning tool Automatic or Static A replacement for: Sound tactical decision making Rehearsals and TTPs A zero defect mindset A fail-safe process A bunch of checklists A bullet in a briefing guide An excuse to violate the law, policies, directives, or procedures Someone elses job A well kept secret Difficult About limiting the commanders flexibility, initiative or accountability What ORM Is Not Slide 33 33 A methodology, applicable to any activity, to enhance decision- making skills Accomplishing the mission with acceptable risk Planning using a systematic, continuous and repeatable process Based on experience Following TTPs Watching for change Flexible and scalable Working as a team A mindset Asking "What's Different" Skill and knowledge dependent Sharing experience, lessons learned About Using available tools and resources Resource Management Applied, standardized "common sense" "Looking before you leap" As in-depth as time permits What ORM Is Slide 34 Organizational Factors Unsafe Supervision Unsafe Act Preconditions Preventing Mishaps A Proactive Approach Hazard Condition w/ potential to cause personal injury, damage to property, or mission degradation Unsafe Acts Misha p Remove one causal factor or consequential error Failed or Absent Controls Slide 35 ORM A systematic process 4 Principles Accept no unnecessary risk. Anticipate and manage risk by planning. Make risk decisions at the right level. Accept risks when benefits outweigh the costs. 3 Levels In Depth Long term process with extensive research and planning. Deliberate Pre-mission planning, time available for planning, recorded on paper. Time Critical Little time, done on the run, applied to control hazards introduced by unexpected events and changes to the plan. 1. Identify Hazards 2. Assess Hazards 3. Make Risk Decisions 4. Implement Controls 5. Supervise 5 Steps Slide 36 In-Depth DeliberateTime Critical Limited / No Time for Planning Time Available for Planning Controls from one level become resources for the next Mission & Task Success Charts/Flips Ship / Aircraft (Systems Safety) Instructions (3710, 5102, 4790) NATOPS Equipment (PPE) Training Ops Planning SOPs Briefings CO Guidance OJT Mission Execution Checklist Change Management (Environment, Mission, Emergency Procedures, Crew Change) Equipment / Systems Degradation Strategic Tactical Risk Management Levels Slide 37 37 Anticipate and manage risk by planning risks are more easily controlled when identified early in planning 4 Principles Integrate risk management into all levels of planning Dedicate time and resources to apply risk management effectively Include hazards in orders to assist subordinates Dont assume hazards away Implement Controls Receive Tasking & Analyze Staff Estimates Commanders Guidance StaffRecommend Options Command Decisions Identify Hazards Assess Hazards Make Risk Decisions Supervise Naval Operational Planning Process Slide 38 38 Accept risk when benefits outweigh the costs the goal is not to eliminate risk, which is inherent in what we do, but to manage it so that we can accomplish the mission with minimal losses. Leaders must consider benefits and costs associated with a hazards risks to make informed decisions. 4 Principles Sustaining a bold, risk-taking organization is always a challenge in peace and warORM helps. Slide 39 39 Accept no unnecessary risks only accept those risks that are necessary to accomplish the mission. 4 Principles If all detectable hazards and their associated causes have not been detected, then unnecessary risks are being accepted. ORM process provides a systematic, repeatable approach to identify hazards / threats that otherwise may go undetected. Slide 40 40 Make risk decisions at the right level risk management decisions should be made by the leader directly responsible for the operation. If the hazards 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? Slide 41 41 5 Step Systematic Process 1. Identify Hazards 2. Assess Hazards 3. Make Risk Decisions 4. Implement Controls 5. Supervise Slide 42 42 Identify Hazards Spend 30-40% of total ORM time List hazards for each step Use What if tool Focus on Whats 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 Slide 43 Straits Transit Risk Assessment Deliberate ORM Example Slide 44 44 Assess Hazards Whats 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 Whats the impact on mission, people, & things Involve Operators / Subject Matter Experts Slide 45 Risk Assessment Matrix The Risk Assessment Code (RAC) Matrix is used to determine the RAC for a hazard. You must cross probability and severity to obtain this code. Risk Assessment Matrix PROBABILITY Frequency of Occurrence Over Time A Likely B Probable C May D Unlikely I Loss of Mission Capability, Unit Readiness or Asset; Death 1123 II Significantly Degraded Mission Capability or Unit Readiness; Severe Injury or Damage 1 234 III Degraded Mission Capability or Unit Readiness; Minor injury or Damage 2345 IV Little or No Impact to Mission Capability or Unit Readiness; Minimal Injury or Damage. 3455 Risk Assessment Codes 1 Critical 2 Serious 3 Moderate 4 Minor 5 Negligible SEVERITY Effect of Hazard Slide 46 46 Severity and Probability SEVERITY Category I - The hazard may cause death, loss of facility/asset, or mission failure. Category II - The hazard may cause severe injury, illness, property damage, or serious mission degradation. Category III - The hazard may cause minor injury, illness, property damage, or minor mission degradation. Category IV - The hazard presents a minimal threat to personnel safety or health, property, or mission. PROBABILITY Sub-Category A - Likely to occur immediately or within a short period of time. Expected to occur frequently to an individual item or person or continuously to a fleet, inventory or group. Sub-Category B - Probably will occur in time. Expected to occur several times to an individual item or person or frequently to a fleet, inventory or group. Sub-Category C - May occur in time. Can reasonably be expected to occur some time to an individual item or person or several times to a fleet, inventory or group. Sub-Category D - Unlikely to occur. Slide 47 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 48 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 49 Straits Transit Risk Assessment Identified Risk = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 50 50 Assessment Pitfalls Over optimism Misrepresentation Alarmism Indiscrimination Prejudice Inaccuracy Complacency Slide 51 51 Make Risk Decisions Whats the impact on probability & severity Whats the risk control cost How do they work together Determine residual risk Make risk decisions at right level Ensure benefits outweigh costs Identify Control Options Determine Control Effects Make Risk Decisions Systems / Engineering: Material selection, Design Often not feasible Supervisory / Administrative: Instructions, Policies, SOPs, ROEs Flight briefs, checklists TTPs Training Effective if properly used / enforced Personal Protective Equipment: Eye & hearing protection Flight & survival Gear Least effective type of control - does not reduce the probability of a mishap occurring, it only reduces the severity when a mishap does occur. Involve Operators / Subject Matter Experts Slide 52 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 53 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 54 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 55 Straits Transit Risk Assessment Residual Risk = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 56 56 Implement Controls Assign individuals clear risk control responsibilities Command provide personnel & resources Make it sustainable Employ a feedback mechanism Integrate into plans Consider control conflicts Make Implementation Clear Establish Accountability Provide Support Use examples, pictures, or charts Describe expectations clearly Involve Operators / Subject Matter Experts Slide 57 57 Supervise Measure risk controls effectiveness Was mission successful Identify root causes of conditions that led to failures Implement new controls Save all documentation Recommend actionable solutions to prevent other failures Submit lessons learned Monitor Review Feedback Are the controls working Manage emerging changes (ABCD) Identify new hazards Involve Operators / Subject Matter Experts Slide 58 Supervise, Monitor & use personal tool - ABCD Action 1: Monitor Action 2: Review Action 3: Feedback A ssess B alance Resources C ommunicate D o D ebrief Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D Slide 59 Straits Transit Risk Assessment = Critical Risk = Serious Risk = Moderate Risk = Minor Risk = Negligible Risk Deliberate ORM Example Slide 60 60 In the bigger picture In planning we conduct risk assessment and develop controls. In operations we update risk assessment and implement controls. In sustainment we continue to update assessments and adjust controls. After action we provide feedback and capture lessons learned to integrate the next time. Slide 61 Technique to connect all three levels of ORM Spurs the use of Time Critical ORM during execution The missing piece in ORM understanding and proper application Change the Perception ORM Mind Set Change the Perception of Risk Management WDT ? Whats Different Today? Slide 62 5-Step ORM and ABCD Time Critical Process and Mnemonic Time Critical Process and Mnemonic A A Assess (your situation, your potential for error) B B Balance Resources (to prevent and trap errors) C C Communicate (risks and intentions) D D Do and Debrief (take action and monitor for change) 5-Step Deliberate and 5-Step Deliberate and In-depth Process In-depth Process 1.Identify Hazards 2.Assess Hazards 3.Make Risk Decisions 4.Implement Controls 5.Supervise (watch for changes) Slide 63 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o D ebrief Slide 64 Situational Awareness The Green You catch errors before they occur Good Situational Awareness Tools and Procedures in place to catch possible errors The Yellow Higher chance of errors Situational Awareness could be decreasing Tools and Procedures not in place to catch errors The Red Very high chance of consequential error Tasking and/or stress may be high, tunnel vision may occur Resources not effective to catch error Slide 65 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o D ebrief Slide 66 Understand your situation and required jobs Brief others, share your situational awareness Use automation to increase awareness Write things down; use a checklist or job aid Follow procedures and routines Policies, Tactics, Procedures and Processes Checklists Automation Briefings & External Resources Knowledge, Skills and Techniques Resources are Tools to get the Job done Balance your resources to catch possible errors Slide 67 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o D ebrief Slide 68 Why a Common Language? Gestione dei rischi operativa Delle operazioni Rischio Amministrazione Gestin de riesgos operacional Betriebsrisikomanagement Operational Risk Management CVORRTTEX SPOT STORM TRM Navy Lingo STAR SOAP R.I.T.E. Slide 69 of Risk Management Where am I? What is going on? What will happen next? What are my options? How do I use them? Who needs to know? Who can help? Who can provide back-up? Revise if necessary. Carry out the plan. Was mission successful? Did actions reduce the risk? ABC D A ssess B alance Resources C ommunicate D o D ebrief Slide 70 Your Part on a Team Know your duties and also duties of members on your team Maintain Situational Awareness for you and your Teammates Communicate clearly Be observant of stress levels for you and your Teammates ABC D Slide 71 71 Put into Action Review of ABCD and Resources On duty Off duty What can we do better tomorrow? ABC D Slide 72 72 Reconsider this situation Slide 73 73 Reconsider this situation Slide 74 74 Its about informed decisions. Slide 75 75 NSC Website: a Valuable Resource Resources & Tools www.public.navy.mil/navsafecen Slide 76 76 Web Enabled Safety System (WESS): Web-enabled reporting and data retrieval system Allows submission & routing of 5102 mishap / hazard notifications & 3750 hazard reports Provides real-time reporting Allows retrieval of data so activities can perform their own analyses (across DOD) Travel Risk Planning System (TRiPS): Provides ORM trip assessment and actual mishap cases relevant to planned trip Risk values / models based on National Transportation Safety Board (NTSB) data Trip map, times, distances and other products improve supervisor interaction Computer based training (CBT) course content designed to help change behavior Total Risk Assessment and Control System (TRACS): Evolution risk assessment tool Allows user to assess, manage and report on hazards, risks & controls Public library of completed assessments available for others to modify for their specific needs Resources & Tools Slide 77 77 Risk management It is a mindset Slide 78 78 We will manage risk to operate by following a standardized and institutionalized common model of ORM application and assessment across the fleet. Integrate risk management concepts across the fleet as part of every decision made and every action taken by every Sailor and DON Civilian employee on and off duty ORM Where we want to be Slide 79 79 Summary Humans are part of all Navy systems Managing the risk of human error improves capabilities and reduces losses ORM: A proactive, systematic tactic to defeat Blue Threats A leadership tool to assist in making informed risk decisions Should be integrated into your command planning, briefing, execution and after action processes Relies on education, training, experience and teamwork Requires outstanding communication skills at all levels Slide 80 80 The Challenge Engaged Leadership Support and actively promote integration of ORM On and Off Duty Use Deliberate Assessment Process Integrate TCRM - Whats 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 Slide 81 81 Questions? Thanks for your attention