www.safetycenter.navy.mil

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Were the following mishaps preventable?

Makes you wonder what happened to #1. Temporary Insanity II

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.

Operational Risk Management Implementation Strategy Overview Operational Risk Management Why ORM? Implementation Strategy Process Resources Summary

Why Risk Management?

DON’s Guidance “…Integrate Safety and Risk Management into all on and off-duty evolutions to maximize mission readiness and to establish DON as an organization with world class safety where no mishap is accepted as the cost of doing business…Establish a risk management training continuum to ensure all DON personnel receive targeted [ORM] training and that all formal professional training courses are infused with examples of how effective risk management improves both safety and mission readiness.” ) Director, Navy Staff issued “CNO Guidance for 2007-2008 Tasking” (05 Dec 07) in order to achieve the CNO’s intentions cited in his guidance for 2007-2008. Many of the tasks relate to risk and resource management such as: - “13.1.3. Navy identifies the expectations and accountability for each sailor’s and civilian’s contribution regarding individual readiness, to include risk management.” - “15.1.2. Incorporate risk assessment and mitigation in all decisions.” - “15.2.1. Determine and provide training for workforce on how to assess/balance risk.” “We manage risk: We will identify, analyze, mitigate and then accept risk, appreciating that we must always consider the risks in aggregate across the entire force. Zero risk is not achievable nor affordable. We must manage risk and move forward to accomplish the mission while safeguarding our people and infrastructure.”

Accident (aka “Mishap”) An unplanned and unfortunate event that results in damage and/or injury. So, what is an accident? Are they preventable?

Over 85% of all mishap are attributable to human factors failures Why do mishaps occur? Mishap investigations (reactive approach) reveal causal factors… Lack of: Abundance of: - Communication + Distraction - Awareness + Complacency - Resources + Norms - Assertiveness + Stress - Teamwork + Fatigue - Knowledge + Pressure 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 Over 85% of all mishap are attributable to human factors failures

Are we learning? On the job? Off-Duty? 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? But, are we really learning. Are we passing on to those that replace us, what we have learned? Are they taking it on board?

Are we learning? Photos taken during NSC Safety Survey

Are we learning? 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.

Bottom-line ORM is a tactic to help reduce the Blue 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 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. ORM is a tactic to help reduce the Blue Threat

Reaching the War Fighter The Blue Threat Puts the concepts in to terms the War Fighter understands Hazards = Threats ORM = Tactics CRM = Skills 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.) 16 16

Red vs Blue Aviation Box Score Ship/Sub Box Score Desert Shield /Storm Blue – 24 Class A mishaps resulting in 15 deaths Red – 6 combat losses with 6 deaths Since 9-11 Blue – 175 Class A mishaps resulting in 90 deaths Red – 1 combat losses with zero deaths Ship/Sub Box Score Since 30 July 1969 (earliest NAVSAFECEN data) and counting only mishaps involving 2 or more deaths: Blue – 90 incidents resulting in 286 deaths, 3 ships lost: USNS Sgt. Jack J. Pendleton (Grounding), USS La Moure County (Grounding), USS Guardian (Grounding) Red – 54 hostile deaths, zero ships lost: 17 deaths on USS Cole (Improvised Explosive Device), 37 deaths USS Stark (Anti-Ship Missile), No deaths on USS Samuel B. Roberts (Mine or USS Princeton (Mine)

It’s Already in Place, but… Integration Strategy Recognize ORM It’s Already in Place, but… 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.

Establishing an ORM Mindset 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 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. Goal: Risk Management is an integral part of Navy Culture

ORM Where we want to be… 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

Risk to Mission, Force, and Self ORM Process 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. Risk to Mission, Force, and Self

What ORM “IS NOT” About avoiding risk A ‘zero defect’ mindset 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” 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

ORM A systematic process 3 Levels Time Critical Little time, done on the run, applied to control hazards introduced by unexpected events and changes to the plan. Deliberate Pre-mission planning, time available for planning, recorded on paper. In Depth Long term process with extensive research and planning 5 Steps 1. Identify Hazards 2. Assess 3. Make Risk Decisions 4. Implement Controls 5. Supervise ORM 5-4-3 We will go in detail on each but here is the whole concept. Remember the 4 principles are the foundation of ORM. 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. 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.

Limited / No Time for Planning 3 Levels Strategic Tactical More Time Available for Planning Limited / No Time for Planning Mission Success In-Depth Deliberate Time Critical Publications Instructions Equipment (PPE) Training Programs - 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. Planning SOPs Briefings CO Guidance OJT / Maintenance Work Center Briefings Quality Assurance Mission Execution Checklist Change Management (Environment, Mission, Emergency Procedures, Crew Change) Equipment / Systems Degradation Controls from one level become resources for the next.

4 Principles “Anticipate and manage risk by planning” – risks are more easily controlled when identified early in planning 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 Emphasis on integrating into existing unit level / command planning processes, not a stand alone process.

4 Principles “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. Sustaining a bold, risk-taking organization is always a challenge in peace and war…ORM helps.

4 Principles “Accept no unnecessary risks” – only accept those risks that are necessary to accomplish the mission. 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.

4 Principles “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. 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?

5 Step Systematic Process 1. Identify Hazards 2. Assess Hazards 5. Supervise 4. Implement Controls 3. Make Risk Decisions

Involve Operators / Subject Matter Experts Identify Hazards List Hazards Operational Analysis Determine Hazard Root Causes Spend 30-40% of total ORM time List hazards for each step Use “What if…” tool Focus on “What’s different today?” Determine specified & implied tasks Break down into small steps Pull from lessons learned Target root causes vice symptoms Keep asking “Why?” until answered 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). Involve Operators / Subject Matter Experts

Involve Operators / Subject Matter Experts Assess Hazards Complete Risk Assessment Assess Probability Assess Severity What’s the probability of all factors Use past data Look at total exposure Use risk assessment matrix Rank hazards by risk level What’s the impact on mission, people, & things Risk – An expression of possible loss in terms of severity and probability Involve Operators / Subject Matter Experts

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 2 3 II Significantly Degraded Mission Capability or Unit Readiness; Severe Injury or Damage 4 III Degraded Mission Capability or Unit Readiness; Minor injury or Damage 5 IV Little or No Impact to Mission Capability or Unit Readiness; Minimal Injury or Damage. Risk Assessment Codes 1 – Critical 2 – Serious 3 – Moderate 4 – Minor 5 – Negligible Using the Risk Assessment Code (RAC) Matrix will determine the RAC for a hazard. You must cross probability and severity to obtain this code. Example: Hazard identified for a swim call was - Ship movement away from swimmers When we look at the severity we said that it was a I – loss of mission capability, unit readiness or asset, death (reduced manpower due to loss of personnel (death) impacting unit readiness. It not easy to get personnel replaced overnight is it?) When we look at the probability we said that it was a C – may occur (that the ship moved away from the swimmers due to anchor drag) We get an overall RAC of 2 with NO controls in place. SEVERITY Effect of Hazard

Severity and Probability 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. 34 6-3 34 3

Involve Operators / Subject Matter Experts Make Risk Decisions Identify Control Options Determine Control Effects Make Risk Decisions 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 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. 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 Involve Operators / Subject Matter Experts

Involve Operators / Subject Matter Experts Implement Controls Provide Support Make Implementation Clear Command provide personnel & resources Make it sustainable Employ a feedback mechanism Integrate into plans Consider control conflicts Establish Accountability Use examples, pictures, or charts Describe expectations clearly Assign individuals clear risk control responsibilities Involving subordinate units (stakeholders) in planning helps with user ownership – buy-in. Involve Operators / Subject Matter Experts

Involve Operators / Subject Matter Experts Supervise Feedback Review Implement new controls Save all documentation Recommend actionable solutions to prevent other failures Submit lessons learned Monitor Measure risk controls’ effectiveness Was mission successful Identify root causes of conditions that led to failures Are the controls working Manage emerging changes (ABCD) Identify new hazards 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. Involve Operators / Subject Matter Experts

WDT ? ORM Mind Set… Change the Perception of Risk Management What’s Different Today? 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. 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

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 Identify Hazards Assess Hazards Make Risk Decisions Implement Controls Supervise (watch for changes) 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.

Time Critical Risk Management TCRM is the level people use daily Developed experiences and pattern matching No time to plan – action orientated Influenced by time, experience, and acquired skills Mental analysis verses written problem solving techniques TCRM is established with tailored training e.g. - Emergency procedures Every community teaches what’s important to them The ABCD Model of TCRM establishes a common communication structure for all Navy personnel Interpreted by your knowledge, skills and abilities Using the ABCD Model daily creates a habit and trains the brain to continue thinking under duress or stress. The model is designed to assist when: 1. Working in a dynamic environment. 2. Monitoring a static or routine situation to capture errors. 3. Making a decision with partial information.

ABCD of Risk Management Assess Balance Resources Communicate Do – Debrief 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? Where am I? What is going on? What will happen next? What are my options? How do I use them? Explain the arrow…it is a constant loop but… it doesn’t always start at A but may start with C but must be executed until completion of the mission 41

Reconsider this situation… 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?

It’s about informed decisions.

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 44 44

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…

Thanks for your attention Questions?