Operational Risk Management in the Navy

1. Operational Risk Management in the Navy Managing the Human Component of an Operational System Ken Neubauer Futron Corporation Ted Wirginis Naval Safety Center

2. Navy Systems

3. The Biggest Challenge 4 of Every 5 Mishaps Involve Human Error • Operator Error • Supervisory Error • Supporting Personnel Error • Poor Decision Making • Poor Planning • Organizational Failures • Etc.

4. OVERVIEW • Background • History • ORM Elements • Foundations • Revitalization • Targets for success • Strategy • Initiatives • Tools

5. History of Navy ORM 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….

6. In Depth Deliberate Time Critical 1. Identify Hazards 5. Supervise 2. Hazard Assessment 4. Implement Controls 3. Make Risk Decisions ORM Fundamentals 3 Levels 4 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 4 Principles 5 Steps

7. Identify Hazards Receive Tasking & Assess Analyze Supervise Hazards Staff Command Naval Operational Estimates Decisions Planning Process Commander ’ s Staff Recommend Guidance Options Make Risk Implement Decisions Controls Military Planning

8. CO Unit Personnel ORM Instructors Unit Risk Management • 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 decade

9. The Status Quo Solid Concepts but Little Change to --- Guidance Approach Application

10. Why Revitalize ORM? Secretary of Defense Memo Reducing Preventable Accidents “ I have set some very specific mishap reduction goals for the department to achieve. . . . There is no excuse for losing lives given proper planning, attention to detail, and the active involvement of the chain of command.”

11. The Cost of Risk $316 Million 12 Aircraft Lost 28 Lives Lost

12. The Cost of Risk 326 Lives Lost Crew of 1 Destroyer Or 1 F/A-18 Squadron

13. Continuing the Charge Secretary of Defense Memo Zero Preventable Accidents “We can no longer tolerate the injuries, costs and capability losses from preventable accidents. Accidents cost the Department about $3 billion per year, with indirect costs up to four times that amount.”

14. ORM 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 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 ORM

16. Tactics Tools Training WAR FIGHTER LEADERSHIP SAILORS A Revised Strike Plan OUR TARGETS

17. Reaching the War Fighter The Blue Threat Puts the concepts in to terms the War Fighter understands Hazards = Threats ORM = Tactics

18. WTI 2-06Operationalizing Safety for WTIs Col J.M. Davis “Dog” Blue Threat Origins • TRM • Tactical Risk Management • Partnership between Operational Experts and Safety Experts • MAWTS-1 • School of Aviation Safety • Leadership Inspired • Looking for mishap reduction answers • Calling on all resources within the organization . . . Not just the “Safety Guys”.

19. Leadership Support Navy ORM Support Structure Leadership Driving the Revitalization • Key leaders with buy-in influence acceptance of the process • Institutionalizing the mindset and the forcing/accountability elements is key with frequent leadership turnover

20. ORM Assessment • Use teams already in place • Provide assessors with specific ORM training • Identify exemplars and disseminate best practices ASSESSMENT • SFTG – COMTUEX • NSC – Safety Surveys • NSAWC – AIRWING Fallon • ATG – TSTA • TACTRAGRU – BG Staff • Others • IG • INSERV ASSESSMENT UNITS FFC/CPF & TYCOM • UNITS • Application • Mentoring • Reinforce Training • Expand understanding on the job • Expand application off duty Feedback NSC Feedback/Best Practices

21. ORM Assessment • ORM Program Assessment • Evaluates ORM instructional compliance • Gives an indication of the relative unit ORM program strength • ORM 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 Support • Naval Safety Center ORM Website • Process and Model Management • Tools for Leaders • Examples for Sailors

23. ORMAS Operational Risk Management Assessment System

24. ORMAS • 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. ORM Model Enterprise Support Guidance Training and Education Assessment Cycle Of Application And Assessment Model Management ORM Elements and Standards Best Practices Collection and Dissemination Unit Application Operational Off-Duty

26. Analytical Deliberate Time Critical Shaping the Base Criticality, People, Tools • Shaping a Risk Managing Culture • Demonstrate & Mentor New Accessions • Boot Camp • USNA • ROTC • Educate the Leaders • Leadership Schools • Instructor Courses • Learning Continuum Time Where the Majority of Navy Personnel Operate ™

27. Time Critical Risk Management SkillsProcess • 1. 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 ABCD for Decision Making • Assess the mission for potential adverse consequences • Balance the use of Resources to minimize risk • Communicate Risks and Intentions • Do (and debrief to improve future performance)

28. ™ Time Critical Scenarios • NIGHT UNREP • Routine Evolution • Time Constrained • Supply ship committed (perceived) • What’s Different? • Late at night start (2300) • Winds and seas different than forecast • Maintaining station difficult • Keeping fuel hoses seated very difficult • Option A • Continue with evolution • Risks – damage to equipment, people • Option B • Breakaway and reassess hazards and controls • Risks – delay, lower than normal fuel • Decision Distractions • Desire to get the job done now • Fatigue • Routine Evolution

29. ™ Time Critical Scenarios • RETURN 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) • Option A • Continue with Drive • Risks – fatigue, flat tire, heavy traffic • Option B • Call ship and speak to OOD • Risks – Angry CPO, miss underway briefs • Decision Distractions • Never been late from leave • New Division CPO • Made this drive many times before

30. Source of Safety Input in the Birth of a Navy Aircraft Reactive Human Influence on Decision Makers Proactive Systems Design Design Test OTE Fleet Introduction Time - Engineers - Operators / Maintainers

31. Summary • 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 Magazine

32. Questions ??? Ken Neubauer Technical Director, Aerospace Safety Futron Corporation kneubauer@futron.com  (757) 262-2074, x317 Ted Wirginis Executive Assistant, ORM Division Naval Safety Center theodore.wirginis@navy.mil  (757) 444-3520, x7271