U.S. Coast Guard Safety and Environmental Health - Way Ahead -

1. U.S. Coast Guard Safety and Environmental Health - Way Ahead - Leslie H. Holland, MS, CSP, CIH CG-113 January 2011

2. - Current Program State - Prevention • Systems Safety • Operational Risk Management • Operational Hazard Analysis • Near-miss/HIPOs/Human Factors • Team Coordination Training • Crew Endurance Management • Crew Resource Management • Trend Analysis • Safety Climate Surveys • Education & Training Response Compliance • Policy • Programs • OSHA • Inspections • Mishap Investigations/ • Human Factors • Incident Response

4. - The Risk Continuum - • Increase in Diversity/Complexity of Missions • CG is moving along the risk continuum from SAR to LE to tactical ops • Loss of life approaches certainty as we move along the risk continuum • Less experience in new missions, and rate consolidations • No and/or underdeveloped doctrine, guidance, TTP • Aging Fleet and infrastructure concurrent with significant fiscal constraints • New airframes, platforms, new technologies, new rates • OPTEMPO • Political and funding realities • SemperParatus safety climate/culture/attitude • Supervisory/leadership oversight/accountability

5. “The Coast Guard, like most dynamic organizations, is ever adapting to political, funding, and mission demands that expose it to dynamic and unknown safety challenges. These safety challenges can only be resolved with adaptive and dynamic risk management systems that identify and mitigate hazards ahead of mishaps.”

6. - To Err is Human - • Humans by their very nature make mistakes • It is unreasonable to expect error-free human performance Human error is implicated in 60-90% of all accidents Rate of human error accidents has remained relatively stable over the past 20 years, whereas accidents associated with mechanical failures have been virtually eliminated.

7. - Way Ahead - Prevention • Systems Safety • Operational Hazard Analysis • Operational Risk Management • Near-miss/HIPOs/Human Factors • Safety Climate Surveys • Team Coordination Training • Crew Resource Management • Crew Endurance Management • Trend Analysis • Education & Training Compliance Response • Policy • Programs • OSHA • Inspections • Mishap • Investigations/ • Human Factors • Incident Response

8. - Objective - Ensure that each person will live and work under conditions in which hazards are known and controlledto an acceptable level of potential harm.

9. Systems Approach – • Focus on proactive risk reduction ahead of mishaps • MAB findings indicate the need for systems thinking/tools • Shift compliance to unit level Systems thinking will transform how we identify and mitigate hazards in CG work environments. Technology/ Infrastructure People Doctrine

10. Compliance in the New World Order • Unit - safety compliance • Compliance trend analysis • Coordination with HSWL SC Compliance Verification Supervisor HSWL Oversight/ USAT Administrator/ Consultation USC** Supervisor USAT* Supervisor *Unit Safety Assessment Tool **Unit Safety Coordinator

11. Operational Hazard Analysis(OHA) A quantitative tool to proactively identify mission hazards • Operational Hazard Analysis (OHA) • HQ Level • HSWL Level (“OHA-lite”) • Systems evaluation approach • ID system deficiencies that pose risk to mission success • ID system leverage points with the greatest potential to control/mitigate risk • Recently employed to evaluate special ops capabilities

13. Operational Risk Management (ORM) • ORM is not understood and confused with GAR(General Assessment of Risk) • GAR is too general, too subjective, static, haphazard, and misrepresents exposure to risk Result: Risks may not be identified and false sense of security is created “you don’t know what you don’t know” • Mishap analysis verifies need for change to fit operator needs • New GAR tool in development ORM Policy update - based on field requirements!

14. GAR Tool

15. Mishap Analysis - Moving Forward - • > Emphasis on High Potential (HIPO), low consequence mishaps • Much more numerous to provide more statistically viable data • Prevent more serious mishaps • Verify implementation of actionable items Example: Small Boat Ejections • Since FY99, 34 small boat ejections reported • March 2007 – ejection fatality, numerous actionable items • October 2008 - Class “C” HIPO double ejection, investigated to verify fatality mishaps actionable items more work required!

16. HFACS*: Approach What Happened? Why it Happened? *Human Factors Analysis and Classification System

17. Safety Climate/Culture –

18. Hazard Identification Hazard Inventory and Assessment Endurance State Integrated Hazard Monitoring Hazard Mitigation Mishap Data Mission Capability/Capacity Gap Analyses Integrated Hazards Mitigation Program Hazards-Based Risk Assessments

19. SG 1.0. Provide direction and oversight for the Coast Guard’s Safety and Environmental Health Program. SG 2.0. Ensure that CG-113 policy and programs effectively improve Coast Guard mission readiness and execution. SG 3.0. Develop and establish proactive and progressive safety programs to identify and control operational hazards and risks. SG 4.0. Oversee and manage mishap investigations and analysis. SG 5.0. Maintain a highly motivated, professionally competent and productive workforce. SG 6.0. Ensure effective internal and external communications. SG 7.0 Develop a strategic business plan delineating specific program objectives and initiatives that ensure accountability.

20. Operational • - Health, Safety & Work-Life Service Center • - Safety & Environmental Health Officers • Safety Officers (XO) • - Flight Safety Officers • Sector Safety Managers • Safety Managers (eg., ALC, Yard, DOG) • Unit Safety Coordinators POLICIES & PROGRAMS FEEDBACK/ REALITY CHECKS HQ • - Safety & Environmental Health Program • Tri-Partite (ops/eng/safety) • CG Safety & Occupational Health Council