SAFETY BRIEF MAY 2012 ORM ANNUAL LESSON PLAN PCR-PAE-049
GAINING ATTENTION
Final Action On Administrative Investigation Into The Crash of CG-6017 That Occurred On
07JUL2010; Total equipment loss (an MH-60T helicopter) and loss of life, near La Push, WA. http://www.uscg.mil/foia/docs/CG%206017%20FAM.pdf
(Available on-line, public record)
The US Coast Guard, like USAF and CAP, has a well developed system of operational risk management designed to mitigate the effects of operating in high risk environments, doing dangerous missions and working in complex equipment. Although skilled and professional aviators, ORM didn’t work because of a failure to follow policy and procedure, and
complacency in planning and conduct of the flight.
OBJECTIVE(S)
Given a CAP ACTIVITY ORM ANALYSIS WORKSHEET, have a basic understanding of ORM concepts and steps to complete the form, in accordance with CAPR 62-1, SAFETY
RESPONSIBILITIES AND PROCEDURES. (Additional references: AFI 90-901 and AFP 90-902)
RECALL PRE-REQUISITS
 Definitions:

HAZARD – simply a condition that could cause mission degradation or loss.

RISK – the potential impact from exposure to the hazard

MISHAP – any unplanned, undesired, operational occurrence that results in or has potential to cause death, injury, or damage to equipment or property.

ACCIDENT – means a mishap that results in death, serious bodily injury, or major damage to, or loss of, equipment or property

SITUATIONAL AWARENESS – Perception > Processing > Projecting >>> Action
 RISK ASSESSMENT—The process of detecting hazards and their causes, and systematically assessing the associated risks.
 CAPR 62-1 25 MARCH 2011
3. Organization and Responsibilities.
(4)Every CAP member is responsible to ensure they receive an Operational Risk
Safety Briefing for all activities or sub-activities that they participate in...Participation in an activity without completing a required Operational Risk
Safety Briefing is prohibited.
5. Operational Risk Safety Briefing Requirements. b. CAP commanders, activity directors, safety directors, and/or safety officers, shall reference the list of Operational Risk Management analyses for CAP activities available on the National CAP Safety web page [Authorized Activities ORM
Worksheets] at http://members.gocivilairpatrol.com/safety/. CAP leaders are
required to use these forms to quantify and mitigate risk during CAP activities in conjunction with required Operational Risk Safety Briefings. d. Operational Risk Safety Briefings. At the start of each new day, operational risk safety briefings must be accomplished to ensure all participants are briefed on the
risks of the day. Additionally, new participants that arrive throughout an activity or sub-activity must receive a mandatory operational risk safety briefing pertaining to their roles and responsibilities before participating.
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SAFETY BRIEF MAY 2012 ORM ANNUAL LESSON PLAN PCR-PAE-049
PRESENT INFORMATION / PROVIDE LEARNING GUIDANCE, PRACTICE and FEEDBACK
 Question: When do most mishaps occur in CAP (what time of year)? June, July, August.
These mishaps occur to both the cadet participants and the senior member support personnel at the activity. Having a mishap prevention program is vital to reducing or eliminating these occurrences during our busy missions and activities. We use ORM analysis and briefings to help identify and reduce those mishaps.
 CRITICAL MISSION COMPONENTS: the 5 M’s that CAP uses to ensure we think about all areas of the activity or mission:
Man (IMSAFE + fitness + crew selection), Media (environment), Machine (equipment),
Management (Standard Operating Procedure), Mission (defined)
HANDOUT: Sample ORM Worksheet, prefilled Driving to CAP Squadron Meeting
 SAMPLE ORM WORKSHEET ( SAMPLE ORM HANDOUT)
Using this ORM Analysis Worksheet is required (remember CAPR 62-1).
We’ll use this as an example of how ORM is performed for the most simple and routine tasks, such as driving to a CAP meeting. Let’s use this sheet to look at how to use the designated ORM document to capture our risk assessment and briefings.
Explain overall rows and columns.
 SPE Model – CAP ( ref HIGH-LOW Matrix SLIDE)
Risk is assessed based on the order of a hazards that are most likely to least likely to happen.
We can use the SPE Model to rank the hazards that we identify.
SEVERITY: Severity is the estimate of the extent of loss that is likely (What if...?)
PROBABILITY: the estimate of the likelihood that a hazard will cause a negative event (Dominoes
falling on the next, in a row)
EXPOSURE: the number of personnel or resources affected by a given event or, over time, by repeated events
Problem with HIGH-LOW Matrix model? SUBJECTIVE
So we have a Modified Matrix that can give a number to a risk – allows for more OBJECTIVE view
 ORM Matrix – Six Step Process ( SAMPLE ORM HANDOUT)
1.
Identify the Hazards: the application of appropriate hazard identification techniques.
2.
Assess the Risk: quantitative or qualitative measures to determine the probability and
severity of ill effects potentially resulting from exposure to a hazard.
3.
Analyze Risk Control Measures: the evaluation of specific strategies and controls that reduce or eliminate risk. Effective mitigation measures reduce one of the three components of risk. (Probability, Severity or Exposure)
4.
Make Control Decisions: Decisions are made at the appropriate level and are based upon analysis of overall costs and benefits.
 Basic risk control options: Spread, Transfer, Avoid, Reject, Delay, Compensate, Reduce, Accept
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SAFETY BRIEF MAY 2012 ORM ANNUAL LESSON PLAN PCR-PAE-049
5.
Implement Risk Controls: Once control measures have been selected, an implementation
strategy must be developed and carried out.
6.
Supervise and Review: Risk management is a process that continues throughout the life
cycle of the system, mission, or activity. Leaders at every level must fulfill their respective roles ensuring controls are sustained over time.
 Leaders manage risk by:
 having the right combination of well-trained, disciplined, and well-equipped forces.

issuing clear guidance to minimize risk.

determining and implementing risk controls for carrying out the mission.

maintaining situational awareness, especially of vulnerabilities.

avoiding unnecessary accident risk.
 When ORM can, and should, be accomplished (at three levels):

Strategic - long term planning of complex or large operations

Deliberate - by an experienced group coming together and brainstorming

Time Critical - done on the fly to deal with unplanned or quickly changing events
Remember: ORM is a fluid, dynamic process that requires keen Situational Awareness and continues through the full life cycle of the activity or mission.
 ASSIGNING RISK TO APPROPRIATE LEVEL:
RISK LEVEL
Low
Medium
High
Extremely High
DECISION LEVEL
Any person in a leadership position
Flight leader, or senior leader on the scene
Group Commander or specifically authorized designee
Wing Commander or specifically authorized designee
Accept the Mission.
Continue to monitor.
Make necessary changes and adapt.
Accept the Mission.
Continue to monitor.
Employ Control
Options when available.
Accept the Mission only with Command endorsement.
Communicate Risk vs.
Gain to Chain of
Command. Actively pursue Control
Options to reduce Risk .
Accept the Mission.
Continue to monitor.
Make necessary changes and adapt.
Accept the Mission.
Continue to monitor.
Employ Control
Options when available.
Accept the Mission only with Command endorsement.
Communicate Risk vs.
Gain to Chain of
Command. Actively pursue Control
Options to reduce Risk.
Accept the Mission. Reevaluate Risk vs. Gain, should Risk Factors change.
Accept the Mission.
Continue to monitor.
Actively pursue
Control Options to reduce Risk.
Do not Accept the
Mission.
Communicate to Chain of Command. Wait until Risk Factors change or Control
Options warrant .
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SAFETY BRIEF MAY 2012 ORM ANNUAL LESSON PLAN PCR-PAE-049
 Four ORM Principles—
1.
Accept No Unnecessary Risk
2.
Make Risk Decisions at the Appropriate Level
3.
Accept Risk When Benefits Outweigh the Costs
4.
Integrate ORM into Operations and Planning at all Levels
ASSESSMENT
HANDOUT:BLANK ORM ANALYSIS WORKSHEET
HANDOUT: Severity + Probability = Exposure Model
HANDOUT: ORM Job Aid
Using the BLANK WORKSHEET, walk thru some possible CAP activities where ORM would be required:
Examples: Rappelling, Refueling an a/c, land navigation, making a stew, marshalling a/c
ENHANCED RETENTION
CG-H60 aircrew: Had a verbal ORM briefing, but filed no ORM worksheet.

A Time Critical analysis was not done on the fly to deal with unplanned or quickly changing events
Did this crew operate under the FOUR ORM PRINCIPALS?
1.
Did they Accept Unnecessary Risk?
2.
Did they Make Risk Decisions at the Appropriate Level
3.
Did they Accept Risk When Benefits Outweigh the Costs
4.
Did they Integrate ORM into Operations and Planning at all Levels
**NO ONE SPOKE UP or CHALLENGED THE OPERATION at any time during the flight**
 They had the right combination of well-trained and well-equipped crew. Were they disciplined?
 Operational complacency (due in part to a permissive climate of the Air Station crews to fly at low levels to train for bad weather familiarity, even when not in inclement weather) resulted in failure to issue clear guidance to minimize risk.
 The crews complacency in verbalizing changes in the operation of the flight at low level and high speed flight resulted in failure to determine and implement risk controls for carrying out the mission.
 This resulted in a severe loss of situational awareness, especially of CATASTROPHIC and
FREQUENT vulnerabilities.
 As a worst case scenario, ORM didn’t work because of a failure to follow policy and procedure,
and complacency in planning and conduct of the flight, and failure to avoid unnecessary
accident risk.
Various CAP (and USAF) Activities
As a CAP member, you have an inherent responsibility to minimize the risks faced by our membership in
the performance of their volunteer duties. Every day. Everywhere.
Read ADM Papp’s final comments: email
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