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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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?

8. 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

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

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

13. 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

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

15. 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%

16. 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

17. 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

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

19. RISKY BUSINESS?

20. 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

21. 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!

22. 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

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

24. YOU’VE GOTTA BE KIDDING?

25. 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

26. 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.

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

28. ELEMENTS OF ORM
3 Levels of Application
4 Principles
5 Steps

29. 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

30. 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!

31. 4 PRINCIPLES Accept risk when benefits outweigh cost
Accept no unnecessary risk
Anticipate and manage risk by planning
Make risk decisions at correct level

32. 5 STEPS Identify hazards Assess hazards Make risk decisions
Implement controls
Supervise

33. 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

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

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

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

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

38. 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

39. WHY DO WE NEED IT?

40. WHY ELSE?

41. 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.

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

43. 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)

44. 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

45. 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

46. LIMITS/WHY ORM?

47. 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

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

49. 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.

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

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

52. 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

53. SUCCESS STORY

54. 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?

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

57. ORM POCs DSN 564-3520 COML (757) 444-3520 FAX (757) 444-6044
CAPT Gary Willis Ext. 7166
Jim Wilder Ext. 7147
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