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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
2
Navy SystemsNavy Systems
3
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.
4
OVERVIEWOVERVIEW
• Background– History– ORM Elements
• Foundations– Revitalization– Targets for success
• Strategy– Initiatives– Tools
5
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
6
44
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
8
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
9
The Status QuoThe Status Quo
Solid Concepts but Solid Concepts but Little Change to ---Little Change to ---
GuidanceGuidance
ApproachApproach
ApplicationApplication
10
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.”
11
$316 Million$316 Million12 Aircraft Lost12 Aircraft Lost28 Lives Lost28 Lives Lost
The Cost of RiskThe Cost of Risk
12
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
13
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.”
14
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
15
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
16
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
20
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
21
ORM AssessmentORM Assessment
19
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 )
19
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
22
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
23
ORMASORMAS
Operational Risk Operational Risk Management Management Assessment SystemAssessment System
24
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
25
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
27
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)
28
NIGHT UNREPNIGHT UNREP• Routine Evolution• Time Constrained• Supply ship committed (perceived)
Time Critical ScenariosTime Critical Scenarios
™
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
29
™
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
30
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
31
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
32
Questions ???Questions ???
Ken NeubauerKen NeubauerTechnical Director, Technical Director, Aerospace SafetyAerospace SafetyFutron CorporationFutron [email protected]@futron.com (757) 262-2074, x317(757) 262-2074, x317
Ted WirginisTed WirginisExecutive Assistant,Executive Assistant,ORM DivisionORM DivisionNaval Safety CenterNaval Safety [email protected]@navy.mil (757) 444-3520, x7271(757) 444-3520, x7271