OPERATIONAL RISK MANAGEMENT INTRODUCE SELF & GIVE SHORT PERSONAL BACKGROUND * ORM IS NOT A SAFETY PROGRAM * ORM IS A TOOL TO ENHANCE YOUR OPERATIONAL READINESS YIELDING SAFETY AS A BY-PRODUCT * WE (THE SAFETY CENTER) ARE HERE BECAUSE WE HAVE THE TIME AND RESOURCES TO RAISE FLEET AWARENESS * ORM WORKS SO WHY ARE WE HERE TODAY????

OBJECTIVES Establish a common ORM language Train all hands on ORM basics: 3 application levels 4 ORM principles 5 steps of ORM process Group Sessions - ORM Scenario Applications SIMPLY READ THE SLIDE DURING THE COURSE OF THIS BRIEF WE WILL WORK THROUGH A SIMPLE SCENARIO. WHAT EXACTLY IS ORM….I OFFER THIS WORKING DEFINITION

WHAT IS ORM ? A leadership tool used to accomplish the mission with the least risk. NEXT SLIDE…ORM HAS A PROVEN TRACK RECORD . (THE AVIATION MISHPA RATE.)

ORM GOAL To strive for operational readiness & effectiveness by managing risk to accomplish the mission with minimal loss. READ THE SLIDE…. HOWEVER, WE HAVE A LONG WAY TO GO BEFORE REACHING THAT GOAL…… HIT THE NEXT SLIDES QUICKLY….. SHORE GROUND MISHAPS……….

USN & USMC SHORE/GROUND MISHAPS 108 DEAD OVER THE LAST 5 YEARS AVIATION MISHAPS……... 108 dead over last 5 years

USN & USMC AVIATION MISHAPS 133 DEAD OVER THE LAST 5 YEARS RECREATIONAL MISHAPS……... 133 dead over last 5 years

USN & USMC RECREATIONAL MISHAPS 157 DEAD OVER THE LAST 5 YEARS SUICIDES……….. 157 dead over last 5 years

? ? ? Why? 350 dead USN & USMC SUICIDES over last 5 years 350 DEAD OVER THE LAST 5 YEARS AND MOTOR VEHICAL MISHAPS……….. 350 dead over last 5 years

631 dead USN & USMC PMV MISHAPS over last 5 years 631 DEAD OVER THE LAST 5 YEARS THIS NEXT SLIDE IS INTERESTING….WOULD ANY ONE CARE TO GUESS HOW MANY SHIPMATES WE HAVE LOST IN THE LAST FIVE YEARS?????? 631 dead over last 5 years

TOP CAUSES OF DEATHS (1995-1999) RETORICAL CLICK MOUSE TO CONTINUE DEATHS FROM MISHAPS EXCEED ALL OTHER CAUSES OF DEATH COMBINED PMV MISHAPS 34% SUICIDES 19% There were 9,163 injuries attributed to mishaps resulting in multiple lost work days. Transition: What was the aviation piece of this mishap pie? 1,846 Deaths

NAVY/MARINE AIRCRAFT LOSSES FY 95-99 TYPE AIRCRAFT # LOST JETS 106 HELOS 37 PROPS 5 Type Aircraft # Lost AV-8 25 F-5 2 F/A-18 36 F-14 20 F-16 1 EA-6 6 S-3 7 T-2 1 T-34 7 T-44 1 T-45 7 H-1 13 H-3 1 H-46 9 H-53 3 H-60 11 P-3 2 WHAT DO THESE LOSSES EQUATE TO??? TOTAL LOST 148

ORM IN SIMPLE TERMS ORM can be as simple as taking a few seconds to review your current situation. READ THE SLIDE… LETS TAKE A LOOK AT A COUPLE OF GUYS WHO ARE DOING JUST THAT RUN THE BLUES BROTHERS VIDEO CLIP…..

ORM IS NOT NEW 776 aircraft destroyed in 1954 22 aircraft destroyed in 1999 Rate 1.44 Angled decks Aviation Safety Center Naval Aviation Maintenance Program (NAMP), 1959 RAG concept initiated NATOPS Program, 1961 Squadron Safety program System Safety Designated Aircraft ACT THOSE OF YOU THAT HAVE BEEN AROUND A FEW YEARS HAVE SEEN THIS SLIDE BEFORE. EACH MAJOR DECREASE IN THE AVIATION MISHAP RATE CAN BE ATTRIBUTED TO A CONCEPT THAT, WHEN EMBRACED, HELPED LOWER THE MISHAP RATE. TODAY WE ARE CONCERNED WITH THE PLATEAU TO THE RIGHT OF THE CURVE. FOR THE PAST FIVE YEARS WE HAVE NOT SEEN A DISTINCT DECREASE IN THE OVERALL AVIATION MISHAP RATE. TRANSITION: TO REVIEW, WHAT GOT US TO THIS PLATEAU? Aircraft Mishap rate 50 65 80 95 FY

WHAT GOT US TO THE PLATEAU? Tried and true principles: Leadership Accountability Creativity READ THE SLIDE WE BELIEVE THAT ORM IS A CONCEPT THAT WILL ENABLE US TO BREAK THROUGH TO NEW MISHAP RATE LOWS…. ADOPTING AN INSTITUTIONAL APPROACH TOWARD MANAGING RISK, A CLOSER EXAMINATION OF HUMAN FACTORS CONSIDERATIONS AND TECHNOLOGICAL ADVANCES WE SHOULD BE ABLE TO PRESERVE OUR ASSETS BETTER. LETS TAKE A CLOSER LOOK AT WHAT IS CONTRIBUTING TO THE MISHAP PLATEAU.

NAVAL FLIGHT MISHAP CONTRIBUTING CAUSE FACTORS FY RATE PER 100K FLT HRS CLICK THE MOUSE TO BRING PIECES OF THE CHART UP ONE AT A TIME. EVERYONE HERE OWNS A PIECE OF THE MISHAP RATE, MAINTAINERS, AIRCREW, SUPERVISORS. A RISK MANAGED APPROACH TO YOUR DAILY ROUTINE WILL NOT ONLY LOWER THIS MISHAP RATE, BUT KEEP YOU SAFER THROUGHOUT YOUR DAILY ACTIVITIES BOTH AT WORK AND AT HOME. SO MUCH FOR THE BACKGROUND…. WHY ARE WE HERE TODAY???

WHAT CAN WE DO TO IMPROVE? Concepts that will help us break through the plateau. Operational Risk Management Human Factors Considerations Technology WE BELIEVE THAT ORM IS A CONCEPT THAT WILL ENABLE US TO BREAK THROUGH TO NEW MISHAP RATE LOWS…. ADOPTING AN INSTITUTIONAL APPROACH TOWARD MANAGING RISK, A CLOSER EXAMINATION OF HUMAN FACTORS CONSIDERATIONS AND TECHNOLOGICAL ADVANCES WE SHOULD BE ABLE TO PRESERVE OUR ASSETS BETTER. NEXT SLIDE - 2YUTES LETS TALK A LITTLE ABOUT COMMUNICATION

NEXT SLIDE - THE THREE APPLICATION LEVELS OF ORM

ORM TERMS HAZARD HAZARD….. THINK ABOUT YOUR UP COMING DRIVE…. WHAT ARE SOME OF THE HAZARDS???? WHAT WILL THE WEATHER BE?? …..THE VISIBILITY??? IN WHAT CONDITION ARE THE TIRES ON YOUR CAR??? ARE YOU RESTED ENOUGH FOR THE DRIVE AFTER A FULL DAY’S WORK??? LETS LOOK AT A VIDEO CLIP OF SOMEONE THAT DID NOT CONSIDER THE HAZARDS BEFORE TAKING ON A TASK…… RUN CHEVY CHASE VIDEO….. A condition with potential to cause mission degradation, personal injury or death, or property damage.

potential impact of a hazard severity and probability. ORM TERMS RISK READ THE DEFINITION….. IN OUR EXAMPLE, A RISK WOULD BE SOMETHING LIKE THIS…. IF I DRIVE WHEN I’M TIRED, I COULD WRECK MY CAR IF I FALL ASLEEP AT THE WHEEL. OR MY TIRES ARE NOT IN THAT GOOD A SHAPE, SO IF IT RAINS HEAVILY DURING MY TRIP, THE CONTROLLABILITY OF MY CAR WILL BE DEGREDED. THE NEXT DEFINITION IS “SEVERITY” An expression of the potential impact of a hazard in terms of severity and probability.

ORM TERMS SEVERITY The worst credible consequence which can occur as a result of a hazard. READ THE SLIDE…………. ON MY TRIP THIS COMING WEEKEND, I COULD DIE IF I CRASH DUE TO POOR TRACTION OR IF I FALL ASLEEP AT THE WHEEL. IN THE ORM WORLD WE CAN ALSO CATEGORIZE LEVELS OF SEVERITY.

SEVERITY CATASTROPHIC CRITICAL MODERATE NEGLIGIBLE AS AN EXAMPLE, WE COULD CATEGORIZE THE SEVERITY OF A HAZARD IN THE FOLLOWING MANNER….. CATASTROPHIC…I FALL ASLEEP AT THE WHEEL AND DIE FROM A CRASH. CRITICAL…DUE TO WEATHER I FAIL TO BRAKE IN TIME TO STOP AND TOTAL MY CAR IN AN ACCIDENT. MODERATE…VISIBILITY IS POOR DUE TO RAIN AND I RUN INTO THE BACK OF THE GUY IN FRONT OF ME CAUSING A FENDER BENDER NEGLIGIBLE … WEATHER WAS POOR SO THE TRIP TOOK ME 2 HOURS LONGER THAN I EXPECTED. LETS LOOK AT ANOTHER ORM TERM… PROBABILITY...

PROBABILITY ORM TERMS An expression of the likelihood that a hazard READ THE SLIDE PROBABILITY IS EXPRESSED, MUCH LIKE SEVERITY, IN VARYING DEGREES. An expression of the likelihood that a hazard will cause mission degradation or result in a mishap or loss.

PROBABILITY DEFINITIONS Example Breakdown LIKELY to occur very soon PROBABLY will occur in time MAY occur in time UNLIKELY to occur READ THE SLIDE PROBABILITY AND SEVERITY CONVERGE TO YIELD WHAT WE CALL A RISK ASSESSMENT….

IN THAT SEGMENT GOOD OLD CLARK GRISWOLD SIMPLY WANTED TO HIDE SOME CHRISTMAS PRESENTS…BUT HE DID LITTLE IN THE WAY OF IDENTIFYING THE HAZARDS ASSOCIATED WITH VENTURING INTO HIS OWN ATTIC. THE NEXT DEFINITION WE WILL DISCUSS IS RISK…..

The process of evaluating ORM TERMS RISK ASSESSMENT READ THE SLIDE LETS LOOK AT ANOTHER VIDEO CLIP AND SEE IF YOU CAN SPOT THE RISK ASSESSMENT. HERE WE HAVE A MAN IN A SITUATION WHERE HE HAS TO MAKE AN ON THE SPOT RISK ASSESSMENT. RUN THE DIRTY HARRY VIDEO CLIP The process of evaluating the associated risks of identified hazards.

ORM TERMS CONTROL READ THE SLIDE….. IN OUR EXAMPLE, IF YOU FEEL THAT IT IS MISSION CRITICAL TO ARRIVE ON TIME AND YOU HAVE ASSOCIATED A HIGH RISK THAT THE WEATHER WILL IMPACT YOU, YOU MIGHT CONSIDER LEAVING EARLIER. (THIS IS A CONTROL) SUPPOSE IT HAS BEEN 18 MONTHS SINCE YOUR LAST TUNE UP, OR YOUR CAR HAS TWO BALD TIRES - WITH RESPECT TO ARRIVING ALIVE OR OF ARRIVING WITHOUT HAVING AN ACCIDENT MAY BE SUFFICIENTLY HIGH ENOUGH TO WARRANT THE PURCHASE OF NEW TIRES OR A TRIP TO THE SERVICE STATION FOR A TUNE UP. AGAIN…THESE ARE CONTROLS THAT YOU PUT IN PLACE TO LOWER THE RISK TO AN ACCEPTABLE LEVEL. CONTROLS CAN SOMETIMES BE AS SIMPLE AS A START UP CHECK LIST, OR A WALK AROUND BEFORE BACKING YOUR CAR OUT OF THE DRIVEWAY. TAKE A BUDDY TO HELP YOU STAY AWAKE….LEAVE WORK EARLY….INSPECT YOUR CAR BEFORE THE TRIP ORM IS APPLIED ON MANY DIFFERENT LEVELS……. A measure for reducing risk for an identified hazard by lowering the probability and/or severity.

Drive probability down Risk Control Desired Effect THIS IS AN EXAMPLE RISK ASSESSMENT MATRIX. AS YOU CAN SEE IT IS A CROSS BETWEEN SEVERITY AND PROBABILITY. THE WHITE ARROWS SHOW THE DESIRED EFFECT OF CONTROLS. A CONTROL IS SOMETHING YOU CAN DO TO LOWER THE SEVERITY, THE PROBABILITY, OR BOTH. Drive probability down NOW, FOR OUR WEEKEND TRIP EXAMPLE… YOU HAVE SEVERAL MISSION CRITERIA…. EACH HAZARD HAS A POTENTIAL IMPACT ON YOUR MISSION CRITERIA….THIS IS THE RISK. THE IDEA IS TO ASSESS WHAT COULD GO WRONG, AND ATTEMPT TO LOWER THE RISK BY EMPLOYING CONTROLS. NEXT SLIDE - THE CHALLENGES OF THE NAVAL CULTURE Drive Severity Down

3 APPLICATION LEVELS Time Critical Deliberate In Depth Little time, done on the run. Deliberate For situations that allow more planning. In Depth Long term process with extensive research and planning. HOWEVER, THERE ARE THREE GENERALLY ACCEPTED APPLICATION LEVELS OF ORM. READ THE SLIDE AND THERE ARE KEY PRINCIPLES OF ORM

4 KEY ORM PRINCIPLES 1. Accept risks when benefits outweigh costs. 2. Accept no unnecessary risk. 3. Anticipate and manage risk by planning. 4. Make risk decisions at the right level. THE 4 KEY ORM PRINCIPLES … READ THEM AS THEY APPEAR….. WE NEED TO GET EVERYONE THINKING IN THESE TERMS….. THESE 4 PRICIPLES AND 3 LEVELS OF ORM RESIDE WITHIN THE 5 STEP ORM PROCESS

5 STEP ORM PROCESS 1. Identify Hazards 2. Assess Risks 5. Supervise THE FIVE STEP ORM PROCESS IT BEGINS WITH IDENTIFY THE HAZARDS ASSESS THE RISKS MAKE CONTROL DECISIONS IMPLEMENT THE CONTROLS AND FINALLY SUPERVISE…. THE PROCESS IS CONTINUOUS…… IT IS THE HALLMARK OF PROFESSIONALS…. LETS LOOK AT THIS NEXT VIDEO CLIP. NOTICE THE FIVE STEP ORM PROCESS IN ACTION… SEE IF YOU CAN SPOT THE HAZARDS, THE CONTROLS, THE SUPERVISION……ARE THE CORRECT DECISIONS MADE AT THE APPRORIATE LEVELS??? RUN THE MISTER ROBERTS VIDEO CLIP 3. Make Control Decisions 4. Implement Controls

CAUSES OF RISK * Change - The “Mother” of Risk * Resource Constraints * New Technology * Complexity * Stress * Environmental Influences * Speed or Tempo of Ops * Societal Constraints * High Energy Levels * Human Nature THERE ARE MANY CAUSES OF RISK. CHANGE IS PROBABLY ONE OF THE MOST PREVALENT. RESOURCE CONSTRAINTS CAN BE $$, TIME, PEOPLE, EQUIPMENT, ETC. NEW TECHNOLOGY: V-22, NVG’S, LASER WEAPONS, JOINT STRIKE FIGHTER ENVIRONMENTAL INFLUENCES: HAZMAT RULES & MATERIALS, WEATHER IMPACTS ON OPS OPTEMPO - HIGH OPTEMPO CAN LEAD TO RUSHED WORK & ERRORS, STRESS, FATIGUE. LOW OPTEMPO - CAN LEAD TO FATIGUE, COMPLACENCY SOCIETAL CONTRAINTS - VIEQUES RANGE IMPACTS, AVIANO MISHAP, NOISE ABATEMENT ALL IMPACT ON EACH OF US AS HUMANS AND CAN RESULT IN ERRORS OR CHANGES IN BEHAVIOR. THERE ARE STILL HURDLES TO OVERCOME….MANY OF THESE ARE CULTRUAL..

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.” READ THE SLIDE AS THEY APPEAR. LUCKILY, THERE ARE MANY TOOLS THAT ARE AVAILABLE TO ASSIST US IN OUR ENDEAVOR.

ORM TOOLS SHARP/SARA/SQOM NAMP/NATOPS/SOP’S ACT/GCT HFC/HFB SURVEYS (SAFETY/MCAS/CSA) TRAINING (Standdowns, GMT, etc.) ORM Corner stories in magazines WE ARE MAKING INROADS WITH COMPUTER ASSISTED SCHEDULING. THERE ARE QUALITY PROGRAMS SUCH AS ….. WE HAVE COCKPIT COORDINATION TRAINING AND HUMAN FACTORS BOARDS. THE SAFETY CENTER CONDUCTS SAFETY SURVEYS. YOU CONDUCT SAFETY STANDDOWNS AND TRAINING. ADDITIONALLY, THE SAFETY CENTER HAS AN ORM WEB PAGE.

ORM Website IN SHORT, WE WANT TO MAKE ORM OUR WAY OF DOING BUSINESS.

Make ORM our ORM VISION: way of doing business Three Questions: What can happen that can hurt me or my mission? What am I going to do about it? If I can’t … who am I going to tell?

TOP CAUSES OF DEATHS (1995-1999) WE BELIEVE THAT IF YOU APPLY THIS FIVE STEP PROCESS TO YOUR DAILY ROUTINE, BOTH IN WORK AND AT HOME, THEN THE BARS ON THIS GRAPH WILL BEGIN TO SHRINK, OUR MISHAP RATE WILL DECLINE, AND VALUABLE ASSETS WILL BE PRESERVED. LETS LOOK AT ONE FINAL VIDEO CLIP. IT REQUIRES A BIT OF SET UP... IN THIS CLIP YOU WILL SEE AN INSTRUCTOR WATCHING HIS STUDENT DURING A PRACTICAL APPLICATION EXERCISE. THE STUDENT GETS A LITTLE COCKY AND THE INTRUCTOR CAUTIONS HIM THEN OFFERS SOME SAGE ADVICE. I THINK YOU WILL ENJOY IT. RUN THE BODY HEAT VIDEO CLIP. 1. Identify Hazards 2. Assess Risks 5. Supervise 4. Implement Controls 3. Make Control Decisions

“And...you gotta try not to get famous while you’re in the act.” If there is any doubt…then there is no doubt. Stop what you are doing and and brief it !!!! Any Questions???