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Operational Risk Management Operational Risk Management in the Navyin the Navy

Ken NeubauerKen NeubauerFutron CorporationFutron Corporation

Ted WirginisTed WirginisNaval Safety CenterNaval Safety Center

Managing the Human Component Managing the Human Component of an Operational Systemof an Operational System

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Navy SystemsNavy Systems

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The Biggest ChallengeThe Biggest Challenge

4 of Every 5 4 of Every 5 Mishaps Involve Mishaps Involve

Human ErrorHuman Error

– Operator Error– Supervisory Error– Supporting Personnel

Error– Poor Decision Making– Poor Planning– Organizational Failures– Etc.

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OVERVIEWOVERVIEW

• Background– History– ORM Elements

• Foundations– Revitalization– Targets for success

• Strategy– Initiatives– Tools

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Watershed Event

- January 1996, Nashville, TN- Navy F-14 crashes into local neighborhood killing:

-- Two aircrew-- Three local residents

- Mishap investigation opens the eyes of Navy leadership….

History of Navy ORMHistory of Navy ORM

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ORM FundamentalsORM Fundamentals

ORM PrinciplesORM 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

3 Levels3 Levels

4 Principles4 Principles

55 Steps Steps

InDepth

Deliberate

Time CriticalTime Critical

5. Supervise

4. Implement Controls

1. Identify Hazards

2. Hazard Assessment

3. Make Risk Decisions

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Military PlanningMilitary Planning

ImplementControls

Receive Tasking &

Analyze

Staff

Estimates

Commander ’sGuidance

Staff Recommend

Options

Command

Decisions

Identify Hazards

Assess Hazards

Make RiskDecisions

Supervise

Naval OperationalPlanning Process

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Unit Risk ManagementUnit Risk Management

CO

Unit Unit PersonnelPersonnel

ORM ORM InstructorsInstructors

• Strategic planning

• Deliberate ORM

• On-Line Training

• Subject Matter Expert

• Formal Classroom training

• Mission Execution

• Change Management

• On-Line Training

No change in the approach for a decadeNo change in the approach for a decade

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The Status QuoThe Status Quo

Solid Concepts but Solid Concepts but Little Change to ---Little Change to ---

GuidanceGuidance

ApproachApproach

ApplicationApplication

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Why Revitalize ORM?Why Revitalize ORM?

Secretary of Defense MemoSecretary of Defense Memo

Reducing Preventable Reducing Preventable AccidentsAccidents

“ “ I have set some very I have set some very specific mishap reduction specific mishap reduction

goals for the department to goals for the department to achieve. . . . There is no achieve. . . . There is no

excuse for losing lives given excuse for losing lives given proper planning, attention to proper planning, attention to

detail, and the active detail, and the active involvement of the chain of involvement of the chain of

command.” command.”

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$316 Million$316 Million12 Aircraft Lost12 Aircraft Lost28 Lives Lost28 Lives Lost

The Cost of RiskThe Cost of Risk

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The Cost of RiskThe Cost of Risk

326 Lives Lost326 Lives Lost

Crew of 1 DestroyerCrew of 1 DestroyerOrOr

1 F/A-18 Squadron1 F/A-18 Squadron

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Continuing the ChargeContinuing the Charge

Secretary of Defense MemoSecretary of Defense Memo

Zero Preventable Zero Preventable AccidentsAccidents

““We can no longer tolerate We can no longer tolerate the injuries, costs and the injuries, costs and capability losses from capability losses from preventable accidents. preventable accidents.

Accidents cost the Accidents cost the Department about $3 billion Department about $3 billion per year, with indirect costs per year, with indirect costs

up to four times that up to four times that amount.”amount.”

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ORM RevitalizationORM Revitalization

Why the reattack on ORM?

– Provide a needed course correction for an initiative stagnant for a decade

– Fully infuse Navy Culture with a proven process to manage risk

– Proactive tactic to attack mishap reduction– Standardize widely varied views of ORM and how

to support it– Bridge a vital gap in decision making skills for our

Sailors

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NSC Strategic PrinciplesNSC Strategic Principles

• Shaping Navy culture is key to safety and all dimensions.

• ORM accepted as the primary tool for achieving mishap reduction and cultural change.

• ORM integral to Navy operational planning and a routine aspect of both team execution and individual decision making.

Safety Center adapting processes to meet today’s demands --- organizing around ORMorganizing around ORM

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A Revised Strike PlanA Revised Strike Plan

OUR TARGETSOUR TARGETS

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Reaching the War FighterReaching the War Fighter

Puts the concepts in to Puts the concepts in to terms the War Fighter terms the War Fighter

understandsunderstands

Hazards = ThreatsHazards = Threats

ORM = TacticsORM = Tactics

The The Blue ThreatBlue Threat

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Blue Threat OriginsBlue Threat Origins

WTI 2-06Operationalizing Safety for WTIs

Col J.M. Davis

“Dog”

TRMTRMTactical Risk ManagementTactical Risk Management

• Partnership between Partnership between Operational Experts and Operational Experts and Safety ExpertsSafety Experts

• MAWTS-1MAWTS-1

• School of Aviation SafetySchool of Aviation Safety

• Leadership InspiredLeadership Inspired

• Looking for mishap reduction Looking for mishap reduction answersanswers

• Calling on all resources Calling on all resources within the organization . . . Not within the organization . . . Not just the just the “Safety Guys”.“Safety Guys”.

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Leadership SupportLeadership Support

Leadership Leadership Driving the Driving the

RevitalizationRevitalization

Navy ORM Support StructureNavy ORM Support Structure

• Key leaders with buy-in Key leaders with buy-in influence acceptance of the influence acceptance of the processprocess

• Institutionalizing the mindset Institutionalizing the mindset and the forcing/accountability and the forcing/accountability elements is key with frequent elements is key with frequent leadership turnoverleadership turnover

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ORM AssessmentORM Assessment

FFC/CPF&

TYCOM

UNITS• Application• Mentoring

• Reinforce Training• Expand understanding on the job

• Expand application off duty

ASSESSMENT

•SFTG – COMTUEX

•NSC – Safety Surveys

•NSAWC – AIRWING Fallon

•ATG – TSTA

•TACTRAGRU – BG Staff

Others

IG

INSERV

ASSESSMENTUNITS

NSC

Feed

back

Feedback/Best Practices

• Use teams already in place

• Provide assessors with specific ORM training

• Identify exemplars and disseminate best practices

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ORM AssessmentORM Assessment

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Retained ORM risk assessments, lessons learned, and/or best practices for this evolution in a centralized, readily accessible location at the unit/group. 10

20Shared ORM risk assessments, lessons learned, and/or best practices for this evolution with relevant external 10

Maximum Possible Additional Comments, Lessons Learned, or Best Practices continued on reverse

Lessons Learned / Best Practices

Evolution Score

Max. Pts.

1

Identified and incorporated lessons learned, best practices, ORM risk assessments or other data from previous or similar evolutions during planning. 10

2 Involved operators from every functional area necessary to conduct the evolution in planning. 10

3 Conducted and documented a Deliberate or In-Depth ORM risk assessment during planning. 10

Evolution ORM Assessment SheetUnit/Group:__________________________ Assessor:___________________Evolution:___________________________ Date/Time:__________________

CommentsPlanning

USS SAMPLE (CVN- X) LCDR Carlson, NSCGetting U/W, NAV Dept. 05 Feb 07, 0900L

230 197

7

9

Kept in NAV safe butANAV- only access

Used TRACS for ORM

NOBX8 5 of 6 areas: no CS Dept.6 Poor documentation (over )

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Retained ORM risk assessments, lessons learned, and/or best practices for this evolution in a centralized, readily accessible location at the unit/group. 10

20Shared ORM risk assessments, lessons learned, and/or best practices for this evolution with relevant external 10

Maximum Possible Additional Comments, Lessons Learned, or Best Practices continued on reverse

Lessons Learned / Best Practices

Evolution Score

Max. Pts.

1

Identified and incorporated lessons learned, best practices, ORM risk assessments or other data from previous or similar evolutions during planning. 10

2 Involved operators from every functional area necessary to conduct the evolution in planning. 10

3 Conducted and documented a Deliberate or In-Depth ORM risk assessment during planning. 10

Evolution ORM Assessment SheetUnit/Group:__________________________ Assessor:___________________Evolution:___________________________ Date/Time:__________________

CommentsPlanning

USS SAMPLE (CVN- X) LCDR Carlson, NSCGetting U/W, NAV Dept. 05 Feb 07, 0900L

230 197

7

9

Kept in NAV safe butANAV- only access

Used TRACS for ORM

NOBX8 5 of 6 areas: no CS Dept.6 Poor documentation (over )

O1 is >=90%, “Exceptional”

O2 is 80-89.9%, “Proficient”

O3 is 70-79.9%, “Needs improvement”

O4 is <70%, “Not proficient”

ORM Proficiency LevelsORM Proficiency Levels

240 208

O2

Maximum Possible Overall Score

ORM Proficiency Level Proficient86.7%

240 167

O4

Maximum Possible Overall Score

ORM Proficiency Level Not proficient69.6%

240 229.8

O1

Maximum Possible Overall Score

ORM Proficiency Level Exceptional95.8%

240 181.4

O3

Maximum Possible Overall Score

ORM Proficiency Level Needs improvement75.6%

O1 is >=90%, “Exceptional”

O2 is 80-89.9%, “Proficient”

O3 is 70-79.9%, “Needs improvement”

O4 is <70%, “Not proficient”

ORM Proficiency LevelsORM Proficiency Levels

240 208

O2

Maximum Possible Overall Score

ORM Proficiency Level Proficient86.7%

240 167

O4

Maximum Possible Overall Score

ORM Proficiency Level Not proficient69.6%

240 229.8

O1

Maximum Possible Overall Score

ORM Proficiency Level Exceptional95.8%

240 181.4

O3

Maximum Possible Overall Score

ORM Proficiency Level Needs improvement75.6%

O1 is >=90%, “Exceptional”

O2 is 80-89.9%, “Proficient”

O3 is 70-79.9%, “Needs improvement”

O4 is <70%, “Not proficient”

ORM Proficiency LevelsORM Proficiency Levels

240 208

O2

Maximum Possible Overall Score

ORM Proficiency Level Proficient86.7%

240 167

O4

Maximum Possible Overall Score

ORM Proficiency Level Not proficient69.6%

240 229.8

O1

Maximum Possible Overall Score

ORM Proficiency Level Exceptional95.8%

240 181.4

O3

Maximum Possible Overall Score

ORM Proficiency Level Needs improvement75.6%

ORM Program AssessmentORM Program Assessment• Evaluates ORM instructional compliance• Gives an indication of the relative unit ORM program strength

ORM Application AssessmentORM Application Assessment

• Evaluates operational planning, briefing, execution, debriefing, and lessons learned/best practices• Only provides a snapshot of ORM use during evolutions observed

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ORM Guidance and SupportORM Guidance and Support

Naval Safety Naval Safety Center ORM Center ORM

WebsiteWebsite

• Process and Process and Model ManagementModel Management

•Tools for Leaders Tools for Leaders

• Examples for Examples for SailorsSailors

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ORMASORMAS

Operational Risk Operational Risk Management Management Assessment SystemAssessment System

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ORMASORMAS

• Compare disparate data elements with a safety and risk bias

• Provide unit commanders / decision makers with a view of present risk

• Focus leaders on weak areas needed a concentration of resources to manage risk

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Unit Applicatio

n

Model Management

Enterprise Support

ORM Elements and Standards

Best Practices Collection and Dissemination

Guidance

Training and Education

Assessment

Operational

Off-Duty

Cycle

Of

Application

And

Assessment

ORM ModelORM Model

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Shaping a Risk Managing CultureShaping a Risk Managing Culture

• Demonstrate & Mentor New Accessions• Boot Camp• USNA• ROTC

• Educate the Leaders• Leadership Schools• Instructor Courses• Learning Continuum

An

alyt

ical

Del

iber

ate

Tim

e C

riti

cal

Tim

e

Criticality, People, Tools

™

Shaping the BaseShaping the Base

Where the Majority of Navy Personnel Operate

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Time Critical Risk ManagementTime Critical Risk Management

Skills Process1. Situational Awareness• I know my environment

• I can see changes

2. Mission Analysis• I can assess the changes

• I can see how they affect my job/mission

3. Assertiveness• I have confidence in myself, my team, and my

leadership to bring new threats to their attention

4. Communication• I need to let my teammates or others involved

know what I know

5. Leadership• My leaders accept my plan for action or know

how to act to manage new risk

6. Adaptability/Flexibility• The plan is flexible and we can adapt to

changes

7. Decision Making• We have enough information, time and a good

plan of action, or we need help

ABCABCDD for for Decision MakingDecision Making

AAssess the mission for potential adverse consequences

BBalance the use of Resources to minimize risk

CCommunicate Risks and Intentions

DDo (and debrief to improve future performance)

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NIGHT UNREPNIGHT UNREP• Routine Evolution• Time Constrained• Supply ship committed (perceived)

Time Critical ScenariosTime Critical Scenarios

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What’s Different?• Late at night start

(2300)• Winds and seas

different than forecast• Maintaining station

difficult• Keeping fuel hoses

seated very difficult

Decision Distractions• Desire to get the job

done now• Fatigue• Routine Evolution

Option A• Continue with evolution• Risks – damage to

equipment, peopleOption B• Breakaway and

reassess hazards and controls

• Risks – delay, lower than normal fuel

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™

RETURN FROM LEAVERETURN FROM LEAVE• Routine Drive of 300 miles• End of Major Holiday Weekend• Muster at 0730• Getting underway in two days

What’s Changed?• Family early PM dinner

runs late• Rear tire deflated (slow

leak from nail puncture)• Light fog forms (not

forecasted)

Decision Distractions• Never been late from

leave• New Division CPO• Made this drive many

times before

Option A• Continue with Drive• Risks – fatigue, flat tire,

heavy trafficOption B• Call ship and speak to

OOD• Risks – Angry CPO,

miss underway briefs

Time Critical ScenariosTime Critical Scenarios

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Influ

ence

on

Dec

isio

n M

aker

s

Time

Design Design Test

OTE Fleet Introduction

- Engineers

- Operators / Maintainers

React

ive

React

ive

ProactiveProactive

Systems

Human

Source of Safety Input in the Source of Safety Input in the Birth of a Navy AircraftBirth of a Navy Aircraft

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SummarySummary

• Humans are part of all Navy systems

• Managing the risk of human error improves capabilities and reduces losses

• ORM for the Navy is:– A tactic to defeat Blue Threats– A leadership tool – A decision making process for our

youngest people

• Partnering systems designers and safety professionals makes saving lives and assets easier in the operational world

Special Edition MagazineSpecial Edition Magazine

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Questions ???Questions ???

Ken NeubauerKen NeubauerTechnical Director, Technical Director, Aerospace SafetyAerospace SafetyFutron CorporationFutron Corporationkneubauer@futron.comkneubauer@futron.com  (757) 262-2074, x317(757) 262-2074, x317

Ted WirginisTed WirginisExecutive Assistant,Executive Assistant,ORM DivisionORM DivisionNaval Safety CenterNaval Safety Centertheodore.wirginis@navy.miltheodore.wirginis@navy.mil  (757) 444-3520, x7271(757) 444-3520, x7271