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Meeting the Safety Needs of a Dynamic Organization

Meeting the Safety Needs of a Dynamic Organization. RADM Mark Tedesco, MD, MPH, FS, USPHS Director, Health, Safety and Work-Life U. S. Coast Guard. The Risk Continuum. Increase in Diversity/Complexity of Missions Aviation Rotary Wing Aerial Intercept Expansion of Airborne Use of Force

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Meeting the Safety Needs of a Dynamic Organization

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  1. Meeting the Safety Needs of a Dynamic Organization RADM Mark Tedesco, MD, MPH, FS, USPHSDirector, Health, Safety and Work-Life U. S. Coast Guard

  2. The Risk Continuum • Increase in Diversity/Complexity of Missions • Aviation • Rotary Wing Aerial Intercept • Expansion of Airborne Use of Force • Decrease in standardization of airframes • Arctic domain supremacy • Maritime Safety and Security • New rates, new platforms – temporary mismatch • Inadequate platforms/equipment for missions • Incident Response esp. Maritime Environmental • Aging Fleet and infrastructure concurrent with significant fiscal constraints • OPTEMPO This dynamic operational environment, coupled with funding constraints, raises mishap potential.

  3. Aviation Mishap Rate(FY99 –FY09 as of 3/31/09) Flight Hours (Bars) Mishap Rate per 100,000 Flt Hrs (Line)

  4. Small Boat Mishap Rate(FY99 – FY09 as of 3/31/09) Mishap Rate per 100,000 Op Hours Total Small Boat Op Hours Fiscal Year

  5. Cutter Mishap Rates(FY00 – FY09 as of 3/31/09) Total Cutter Op Hours Mishap Rate per 100,000 Op Hrs Fiscal Year

  6. Cutter Mishap Rate by Class of Cutter (FY08) Number of Mishaps Rate of Occurrence per 100,000 Op Hrs

  7. WHEC 378 Mishap Rate by Class (FY99-2nd Qtr FY09) Rate of Occurrence per 100,000 Op Hrs

  8. WHEC Number of Fires and Rate* of Occurrence (FY01 - FY09 as of 3/31/09) * Per 100K ophours

  9. Fires by Cutter Class (FY08) Number of Fires Cutter Class

  10. Military Class A Mishaps • by Count • On and Off-Duty* – • (FY99 – FY09 projected) projected *includes all off-duty activities

  11. Off-Duty PMV Mishap Rate*(FY04 - FY09 Projected) Private Motor Vehicle (PMV) vs. Motorcycle (MC) Class A Rates* Rate per 100,000 employees Rate per 100,000 Persons • MC Class A rate: • consistently higher than PMV • increasing over time, steady in FY 06 - 08 • FY 09 decline projected *assumes 100% PMV; 10% M/C

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

  13. The Future Prevention • Systems Safety • Operational Risk Management • Near-miss/HIPOs/Human Factors • Safety Climate Surveys • Job Hazard Analysis • Crew Endurance Management • Crew Resource Management • Trend Analysis • Education & Training Compliance Response • Policy • Programs • OSHA • Inspections • Mishap • Investigations/ • Human Factors • Incident Response

  14. Challenge • Humans by their very nature make mistakes, therefore, • 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.

  15. HFACS: Benefits • Structured analysis of human error • Sophisticated, complete…yet operational • Detects error patterns current methods miss • Get to the “why”… not just the “what” happened • More insightful root cause determination • Better CO decisions… more effective ORM • A new, data-driven approach • Common methodology across the Services • Easily applied to large body of existing data • Easily applied to new incidents and mishaps • Can be used for more than Operational purposes • Can be a Risk Management tool • Applies to both on-duty and off-duty evolutions

  16. HFACS: Approach What Happened? Why it Happened? Source: U.S. Naval Safety Center

  17. Organizational HFACS: Tiers Latent Failures/Conditions Supervision Preconditions Acts Active Failures Deficient or Immature Conditions Accident & Injury Adapted from Reason (1990)

  18. HFACS: Analysis Limited Recent Experience (SP003) Workspace Incompatible with Human (PE206) Get There It Is (PC213) Negative Transfer (PC105) Local Training Issue (SI003) Complacency (PC208) Overcontrol/ Undercontrol (AE104) Distraction (PC106) Risk Assessment – During Ops (AE204) Breakdown of visual scan (AE105) Inattention (PC101) Capsize Necessary Action Delayed (AE204) Fatigue (PC307) Ops Tempo/Workload (OP001) Cross-Monitoring Performance(PP102) Unit/Org Values/ Culture (OC001) Risk Assessment – Formal (SP006) Red HFACS = Causal Black HFACS = Contributory 18

  19. Mishap Analysis - Moving Forward - More emphasis on HIPO mishaps to prevent more serious mishaps and to verify implementation of actionable items Example: Small Boat Ejections • Since FY99, 34 small boat ejections reported • March 2007 – ejection resulting in fatality with numerous actionable items from the investigation • October 2008 - Sand Key, FL Class “C” HIPO double ejection • provided the MAB an opportunity to review and verify actionable items from March 2007 ejection fatality mishap investigation • findings indicate more work must be done

  20. Value of Mishap Analyses

  21. Questions?

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