NROTC PCO/PXO CONFERENCE 10 August 2001 MANAGING RISK CAPT GARY WILLIS DIRECTOR SHORE SAFETY NAVAL SAFETY CENTER

This is an F-14A, out of Fallon, NV During a 1V1 air combat maneuver, the pilot lost control, the aircraft crashed and was a total loss. 6 July 1998

Preparing for an UNREP off the coast of Hawaii, a Midshipman was the Officer of the Deck under instruction. USS DENVER, seen here, collided with USNS YUKON. Though no one was seriously injured, there were millions in damages to DENVER, while YUKON was nearly a complete loss due to significant keel damage. Significant, extensive and creative repair work was required to return her to operational status. 14 July 2000

USS LA MOURE COUNTY, collision with the continent of South America in the vicinity of Chile during a simulated night time amphibious assault. Navigation party using uncorrected charts with GPS, did not believe the RADAR display. Believe it, the ship was a total loss, and the crew flew home. Here’s a sequence of shots taken on 10 July providing a graphic explanation of what LMC is doing now. SINKEX, TICO BG 20 September 2000

NWS Yorktown, VA. Operating a forklift on an uneven surface NWS Yorktown, VA. Operating a forklift on an uneven surface. Installed seat belt not used. When forklift became unstable, the operator made a split second decision to jump. Vehicle rolled over on him and killed him. 2 November 1998

CORTRAMID East, NAB Little Creek, VA. Marine Corps orientation week, Confidence course cargo net. 18 year old female MDSN 3rd class, attending University of Pennsylvania, from VA Beach, my church, St. Matthews. Overweight, out of shape and tired from the previous obstacle. 35 feet from the ground. Tired, couldn’t traverse, couldn’t hold on, fell, dead. What could go wrong here and how could it be prevented? 13 July 1998

CORTRAMID West, Camp Pendleton. Marine Corps orientation week, several 5 tons in caravan, picking up NROTC midshipman and Marines who’d been out on early evening patrol. Driver starts vehicle, vehicle is in gear, driver doesn’t depress clutch, vehicle tires are not chocked as required by SOP, ergo it lurches forward pinning Marine and female midshipman. Cpl tried to get midshipman out of way, he was crushed to death, she barely survived, extensive debilitating injuries. What could go wrong here and how could it be prevented?

Cross country PCS move. Cibola County, NM, just outside Albuquerque Cross country PCS move. Cibola County, NM, just outside Albuquerque. High speed, Firestone tires, Ford Explorer - a dangerous trio. When a tire failed, the vehicle rolled several times. Driver and child passenger in seat belts were unhurt, Lieutenant passenger, unbelted, was ejected and killed. 30 June 1999

MISHAP COST 5 YEAR TOTAL: $3.9 BILLION & 1024 DEATHS

TRUE COST? Direct Cost Indirect Cost Litigation Loss of Manpower Delay in Doing Business Corporate Reputation Investigation Costs Loss of Assets

CORPORATE ENERGY COSTS Marines Ground Osprey After Crash Kills Crew of 19 U. S. Sub Collides With Japanese Training Vessel F-14 Crashes Into House Vice CNO Apologizes to Japanese Government Investigation Ordered 2 Crew and 3 Civilians Killed

CLASS A MISHAP RATE 5 year trends indicate declining mishap rate, but recent plateau 514 364 61

HOW SAILORS & MARINES DIED IN MISHAPS; FY96-00 Speed Kills! Deaths: FY 96-00: 1024 FY 01: 143 (31JUL01) Traffic 59% Recreation 14% Aviation 16% Afloat 1% Shore/Ground 10%

FATAL FACTORS IN TRAFFIC MISHAPS Percentage of Mishaps FY-98 to FY-00 339 DEAD! Fatigue: 18% 53% 65% 41% 32% 31% Weekend Night No Seat Belt Alcohol Speeding

PERSPECTIVE Robert B. Pirie Acting Secretary of the Navy “In 1968, we lost 99 American Sailors in USS SCORPION, which we think of as a national disaster. While we lost 103 Sailors and Marines in PMV accidents in 1998, and call it our “best year” !” Robert B. Pirie Acting Secretary of the Navy

RISK TAKING "It seems to be a truth, inflexible and inexorable, that he who will not risk cannot win." John Paul Jones

RISKY BUSINESS?

Feeling of Invincibility Speed, Tempo of Operations CAUSES OF RISK Personal Work Ethic Complex Evolutions High Energy Levels Stress CHANGE!! Environmental Influences Human Nature Resource Constraints New Technology Feeling of Invincibility Complacency Speed, Tempo of Operations

WRONG! HURT AT WORK I’ve carefully thought out all the angles I’ve done it a thousand times It comes naturally to me I know what I’m doing; its what I’ve been trained to do my entire life, I was born for this job Nothing could possibly go wrong RIGHT? WRONG!

OPERATIONAL TAPESTRY Investigations: Poor airmanship/seamanship Skill-based error rate Poor crew coordination Poor headwork CAS/MCAS/Surveys/Culture Workshops: Inadequate resources Command over-committed Manning/unavailable experience Cutting corners/PMS Poor communication Technical publications

HUMAN ERROR IN MISHAPS, FY 96-00 Aviation Afloat 79% 86% Shore 95%

YOU’VE GOTTA BE KIDDING?

THE CHALLENGE “ The success of naval operations is based upon a willingness to balance risk and taking the bold, decisive action necessary to triumph in battle. At the same time, commanders have a fundamental responsibility to safeguard highly valued personnel and material resources, and to accept only the minimal level of risk necessary to accomplish mission.” ADM Vern Clark, CNO

OPERATIONAL RISK MANAGEMENT What is ORM? A process to assist you in performing everyday tasks safely and efficiently! Modify the process to fit the situation while still identifying and assessing risks and developing controls to reduce the hazards.

ORM CONCEPTS All are responsible for using ORM Risk is inherent in all operations Risk can be controlled

ELEMENTS OF ORM 3 Levels of Application 4 Principles 5 Steps

3 LEVELS OF APPLICATION TIME CRITICAL DELIBERATE IN DEPTH 90% of ORM processes are “On the run” DELIBERATE Complete 5 step process IN DEPTH Other considerations outside local chain of command

3 LEVELS OF APPLICATION TIME CRITICAL DELIBERATE IN-DEPTH Little: - Time - Complexity Lot of: - Time - Complexity ORM is applied proportionate to operational complexity, criticality, and risk!

4 PRINCIPLES Accept risk when benefits outweigh cost Accept no unnecessary risk Anticipate and manage risk by planning Make risk decisions at correct level

5 STEPS Identify hazards Assess hazards Make risk decisions Implement controls Supervise

IDENTIFY HAZARDS Step #1: Analyze manageable pieces of an event Use experience as a guide “Experience is the name everyone gives to their mistakes” Oscar Wilde, 1892 Ask what if, use brainstorming, think cause and effect

ASSESS HAZARDS Prioritize identified hazards based on: Severity & Step #2: Prioritize identified hazards based on: Severity & Probability

Severity + Probability ASSESS HAZARDS Step #2: Severity + Probability of Occurrence = RAC

MAKE RISK DECISIONS Step #3: Consider risk control options, most serious risks first Risk versus benefit Communicate as required

IMPLEMENT CONTROLS Engineering Controls Administrative Controls Step #4: Engineering Controls Administrative Controls Personal Protective Equipment

SUPERVISE Step #5: Same as any other supervisory process: Assure controls effective and in place Maintain implementation schedules Correct ineffective risk controls Watch for change

WHY DO WE NEED IT?

WHY ELSE?

SCENARIO The Admiral has made it known that you will secure at 1500 on Friday (assume here in Pensacola), for a well-deserved 3 day weekend. Accordingly, you’re planning a trip to West Palm Beach to visit with family and friends, lounge and relax beach-side, and of course, to check into the local voting procedures and practices. Your plan is to leave as soon as possible after 1500 because the 610 mile trip will take at least 11 hours.

IDENTIFY HAZARDS Step #1: Fatigue Equipment breakdown Drunk drivers Speeding Directionally challenged Road construction Weather Orlando

ASSESS HAZARDS Step #2: Hazards Severity/Probability(RAC) I/C (2) Fatigue Equipment breakdown Drunk drivers Speeding Become directionally challenged Road construction Weather Orlando Severity/Probability(RAC) I/C (2) II/C (3) I/A (1) IV/C (5) III/C (4)

MAKE RISK DECISIONS Step #3: Hazard RAC Orlando 1 Speeding 1 Fatigue 2 Drunk drivers 2 Weather 3 Equipment breakdown 3 Road construction 4 Getting lost 5

IMPLEMENT CONTROLS Step #4: Controls Hazards Tactical nuclear device Know and obey limit Rest, adjust start time Leave early morning Monitor weather channel Inspect vehicle and make repairs before the trip Get a trip planner Carry a current map Hazards Orlando Speeding Fatigue Drunk drivers Weather Equipment b-down Construction Getting lost

LIMITS/WHY ORM?

SUPERVISE Step #5: Command sponsored vehicle inspection for those planning long distance trips. Mandatory completion of driver mishap risk indicator form Pre-holiday safety standdown Evaluate and adjust controls as the situation changes Ensure personnel are familiar with their situation Watch for changes

BENEFITS OF RISK MANAGEMENT Reduction in serious injuries and fatalities Reduction in material and property damage Effective mission accomplishment

REINFORCE GOOD ORM PRACTICES Provide Commander’s Intent re: acceptable risk and use of ORM. Benchmark ORM success. Should ORM fail, identify weak link. Enforce risk control standards as you would any other essential mission performance standard.

DOES ORM WORK? 9 Class A Mishaps 8 Lives $147 M Saved

ORM CAN MAKE A DIFFERENCE! 12 Class A’s 17 Lives $421 M Saved

SUMMARY ORM is a process ... NOT a program Decision making tool to: Increase ability to make informed choices Reduce risks to acceptable level ORM must become an inherent way of doing business

SUCCESS STORY

ORM TAKE AWAY Ask yourself three crucial questions: What can go wrong? What am I going to do about it? If I can’t do anything, who do I tell?

FROM THE SANDS OF IWO JIMA “Life is tough, but it’s tougher if you’re stupid” SGT John M. Stryker, USMC

ORM POCs DSN 564-3520 COML (757) 444-3520 FAX (757) 444-6044 CAPT Gary Willis Ext. 7166 Jim Wilder Ext. 7147 On the web: www.safetycenter.navy.mil