www.public.navy.mil/navsafecen
1
Were the following
mishaps preventable?
2
Makes you wonder what happened to #1
Temporary Insanity II
A look at the back of the trailer
shows just what the impact did to
both vehicles. As you can see the
impact knocked the trailer section
off of its rear axles. One section of
wheels are standing alone behind
the trailer. The bottom of the trailer
crushed the car like an egg carton.
Cars are not designed to withstand this kind of impact.
Night Time, Weekend Alcohol, Speed
are mix for Disaster
Service member and cousin were killed when the Acura they were traveling in hit the semi-trailer
truck. The Acura, which investigators said was going more than 80 mph, crumpled on impact.
Fatal Motorcycle
Accident
April 2007, 1:00 am
Excess of 100 mph
July 2005
•
•
Buckley Air National Guard Base – Denver
Lost hydraulics (nose wheel steering and brakes)
after landing when arresting gear doughnut
bounced up and took out a brake line.
What’s the Most Important
Take Away Today
Have you heard this?
Safety First!
Do you agree with this statement?
Or this one
Mission First!
How do we get there?
Correct application of
ORM/TCRM
8
What’s the Most Important
Take Away Today
Successful Mission
Accomplishment
Thru
Correct Application Of
ORM/TCRM
Allows
Safety to be a by-product
Allowing us to
Perform our task or mission again
and again
9
Overview
Operational Risk Management
• Why ORM?
• Implementation Strategy
• Process
• Resources
• Summary
10
Why Risk Management?
11
Why Risk Management?
12
DoN – FY 2012
Cost
AVIATION
$791M
Total Cost: $865M
Current as of 02 Oct 2012
Fatalities
PMV
73
Total Fatalities: 122
USN – FY 2012
Cost
AVIATION
$448M
Total Cost: $496M
Current as of 02 Oct 2012
Fatalities
PMV
42
Total Fatalities: 58
Cost
USMC – FY 2012
Fatalities
AVIATION
$343M
Total Cost: $369M
Current as of 02 Oct 2012
PMV
31
Total Fatalities: 64
Operational Risk Management
Risk Management is the process that assists
organizations and individuals in reducing or offsetting
risk (by systematically identifying, assessing, and
controlling risk arising from operational necessity, task
loading, additive conditions and crew or human
factors) and making decisions that weigh risks against
mission or task benefits. The process can be used
both on and off duty.
ORM Concepts
• ORM is a decision making tool
• Reduce loss, increase success
• Ability to make informed decisions
• Minimizes risks to acceptable levels
• Same process in wartime or peacetime
• Efficient use of resources
Completing the mission effectively is GOAL 1. this is why the Navy uses ORM.
Cultural Challenges
• Can do “anything, anywhere, anytime, at any cost” mentality
• “Do more with less” mindset
• Reluctance to say “no”
• Making decisions based on “the way we’ve always done it”
• Letting others worry about our mission hazards
• Doing only what we “have to” and not what we “should do”
• Taking advantage of professional courtesies.
Accident (aka “Mishap”)
So, what is an accident and are they preventable?
An unplanned and unfortunate event that
results in damage and/or injury.
19
Why do mishaps occur?
Mishap investigations (reactive approach) reveal causal factors…
Lack of:
Abundance of:
- Communication
- Awareness
- Resources
- Assertiveness
- Teamwork
- Knowledge
+ Distraction
+ Complacency
+ Norms
+ Stress
+ Fatigue
+ Pressure
Over 85% of all mishap are attributable to
human factors failures
20
Are we learning?
21
Are we learning?
22
Bottom-line
Action / Inaction by own forces
causing losses far exceeding
those caused by Red Threat
• Degradation in mission readiness
• Impact to mission accomplishment
• Impact to the Team, Family & Friends
ORM is a tactic to help reduce the Blue Threat
23
Reaching the War Fighter
The Blue Threat
Puts the concepts in to
terms the War Fighter
understands
Hazards = Threats
Threat Losses (FY Jan ‘91- Mar ‘11)
Red Threat - 18 Aircraft Destroyed
vs.
Blue Threat - 562 Aircraft Destroyed
ORM = Tactics
CRM = Skills
24
Integration Strategy
Recognize
ORM
It’s Already in Place,
but…
Controls derived from In-Depth & Deliberate ORM exist everywhere,
in all activities throughout the unit
maintenance programs, redundant systems, Standard Operating Procedures, checklists,
flight briefs, Rules of Engagement, flight gear, survival equipment, etc.
How do you change a mindset?
(Who is looking out for whom?)
26
Establishing an ORM
Mindset
Policy & Leadership
• Focus all levels of leadership on key ORM implementation
issues
• Develop and refine policy and guidance for the Fleet
Assessment & Feedback
• Accountability
• Assist in development and integration of assessment process
for the Fleet
• Partner with force commanders and readiness evaluators
• Institute vehicles for “Best Practice” dissemination
Goal: Risk Management is an integral part of Navy Culture
27
Establishing an ORM
Mindset
Education & Training
• Implement an ORM Learning Continuum from accession to
retirement
• Partner with training and accession commands
• Standardize training and education across the Fleet
Resources & Tools
• Create and share tools to facilitate integration across the Fleet
Goal: Risk Management is an integral part of Navy Culture
28
ORM Process
ORM is a systematic approach to
managing risks to increase mission
success with minimal losses. This
involves identifying and assessing
hazards for risk, controlling risks,
supervising and revising as needed.
Risk to Mission, Force, and Self
29
What ORM Is Not
• About avoiding risk
• A ‘zero defect’ mindset
• A safety only program
• A fail-safe process
• Limited to complex-high risk
evolutions
• A bunch of checklists
• Just another program
• A bullet in a briefing guide
• Only for on-duty
• An excuse to violate the law,
policies, directives, or procedures
• Just for your boss
• Someone else’s job
• Just a planning tool
• A well kept secret
• Automatic or Static
• Difficult
• A replacement for:
• About limiting the commander’s
flexibility, initiative or
accountability
– Sound tactical decision making
– Rehearsals and TTPs
30
What ORM Is
• A methodology, applicable to any
activity, to enhance decisionmaking skills
• A mindset
• Accomplishing the mission with
acceptable risk
• Skill and knowledge dependent
• Planning using a systematic,
continuous and repeatable
process
• Based on experience
• Following TTPs
• Watching for change
• Flexible and scalable
• Asking "What's Different"
• Sharing experience, lessons
learned
• About Using available tools and
resources – Resource
Management
• Applied, standardized "common
sense"
• "Looking before you leap"
• As in-depth as time permits
• Working as a team
31
Preventing Mishaps
A Proactive Approach
Organizational
Factors
Unsafe
Supervision
Hazard – Condition w/
potential to cause personal
injury, damage to property,
or mission degradation
Unsafe Act
Preconditions
Unsafe
Acts
Failed or
Absent
Controls
Remove one
causal factor or
consequential error
Mishap
ORM
A systematic process
3 Levels
In Depth
5 Steps
Long term process with extensive research and planning.
Deliberate
1. Identify
Hazards
Pre-mission planning, time available for planning, recorded on
paper.
Time Critical
Little time, done on the run, applied to control hazards
introduced by unexpected events and changes to the plan.
4 Principles




Accept no unnecessary risk.
Anticipate and manage risk by planning.
Make risk decisions at the right level.
Accept risks when benefits outweigh the costs.
5. Supervise
4. Implement
Controls
2. Assess
Hazards
3. Make Risk
Decisions
Risk Management Levels
Strategic
Tactical
Limited / No Time
for Planning
Time Available for
Planning
In-Depth
• Charts/Flips
• Ship / Aircraft
(Systems Safety)
• Instructions
(3710, 5102, 4790)
• NATOPS
• Equipment (PPE)
• Training
Deliberate
•
•
•
•
•
Ops Planning
SOPs
Briefings
CO Guidance
OJT
Time Critical
• Mission Execution
Checklist
• Change Management
(Environment, Mission,
Emergency Procedures,
Crew Change)
• Equipment / Systems
Degradation
Controls from one level become resources for the next
Mission &
Task
Success
4 Principles
 “Anticipate and manage risk by planning” – risks are
more easily controlled when identified early in planning
Identify Hazards
Receive Tasking
&
Analyze
Supervise
Command
Decisions
Hazards
Staff
Naval Operational Estimates
Planning Process
StaffRecommend
Options
Implement
Controls
Assess
Commander’s
Guidance
Make Risk
Decisions
• Integrate risk management into
all levels of planning
• Dedicate time and resources to
apply risk management
effectively
• Include hazards in orders to
assist subordinates
• Don’t assume hazards away
35
4 Principles
 “Accept risk when benefits outweigh the costs” – the
goal is not to eliminate risk, which is inherent in what we
do, but to manage it so that we can accomplish the
mission with minimal losses. Leaders must consider
benefits and costs associated with a hazard’s risks to
make informed decisions.
Sustaining a bold, risk-taking organization is always a
challenge in peace and war…ORM helps.
36
4 Principles
 “Accept no unnecessary risks” – only accept those risks
that are necessary to accomplish the mission.
• If all detectable hazards and their associated causes
have not been detected, then unnecessary risks are
being accepted.
• ORM process provides a systematic, repeatable
approach to identify hazards / threats that otherwise
may go undetected.
37
4 Principles
 “Make risk decisions at the right level” – risk management
decisions should be made by the leader directly responsible
for the operation. If the hazard’s risk cannot be controlled at
his level, leaders shall elevate the risk decision to their chain
of command.
•
•
•
•
•
Who has the legal / organizational authority to make the decisions?
Who has the maturity and experience to make the decisions?
Who has on-scene knowledge?
Who has the resources to mitigate the risk?
Who will answer in the event of a mishap?
38
5 Step Systematic Process
1. Identify
Hazards
5. Supervise
4. Implement
Controls
2. Assess
Hazards
3. Make Risk
Decisions
39
Identify Hazards
Operational
Analysis
Determine
specified &
implied tasks
Break down into
small steps
Pull from
lessons learned
List Hazards
Spend 30-40% of
total ORM time
Determine Hazard
Root Causes
List hazards for
each step
Use “What if…”
tool
Focus on “What’s
different today?”
Target root
causes vice
symptoms
Keep asking
“Why?” until
answered
Involve Operators / Subject Matter Experts
40
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
Assess Hazards
Assess Probability
Assess Severity
What’s the
impact on
mission, people,
& things
Complete Risk
Assessment
What’s the
probability of all
factors
Use past data
Look at total
exposure
Use risk
assessment
matrix
Rank hazards by
risk level
Involve Operators / Subject Matter Experts
42
Risk Assessment Matrix
The Risk Assessment Code (RAC) Matrix is used to determine the RAC for a hazard.
You must cross probability and severity to obtain this code.
PROBABILITY
SEVERITY
Effect of Hazard
Risk Assessment Matrix
Frequency of Occurrence Over Time
A
Likely
B
Probable
C
May
D
Unlikely
I
Loss of Mission Capability, Unit
Readiness or Asset; Death
1
1
2
3
II
Significantly Degraded Mission
Capability or Unit Readiness; Severe
Injury or Damage
1
2
3
4
III
Degraded Mission Capability or Unit
Readiness; Minor injury or Damage
2
3
4
5
IV
Little or No Impact to Mission
Capability or Unit Readiness; Minimal
Injury or Damage.
3
4
5
5
1 – Critical
2 – Serious
Risk Assessment Codes
3 – Moderate
4 – Minor
5 – Negligible
Severity and Probability
SEVERITY
PROBABILITY
Category I - The hazard may cause
death, loss of facility/asset, or
mission failure.
Sub-Category A - Likely to occur
immediately or within a short period of
time. Expected to occur frequently to an
individual item or person or continuously
to a fleet, inventory or group.
Category II - The hazard may
cause severe injury, illness,
property damage, or serious mission
degradation.
Category III - The hazard may
cause minor injury, illness, property
damage, or minor mission
degradation.
Category IV - The hazard presents
a minimal threat to personnel safety
or health, property, or mission.
Sub-Category B - Probably will occur in
time. Expected to occur several times to
an individual item or person or frequently
to a fleet, inventory or group.
Sub-Category C - May occur in time.
Can reasonably be expected to occur
some time to an individual item or person
or several times to a fleet, inventory or
group.
Sub-Category D - Unlikely to occur.
44
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Identified Risk
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Assessment Pitfalls
•
•
•
•
•
•
•
Over optimism
Misrepresentation
Alarmism
Indiscrimination
Prejudice
Inaccuracy
Complacency
48
Make Risk Decisions
Identify Control
Options
Determine
Control Effects
Systems / Engineering:
• Material selection, Design
• Often not feasible
Supervisory / Administrative:
• Instructions, Policies, SOPs, ROEs
• Flight briefs, checklists
• TTPs
• Training
• Effective if properly used / enforced
Personal Protective Equipment:
• Eye & hearing protection
• Flight & survival Gear
• Least effective type of control - does not
reduce the probability of a mishap
occurring, it only reduces the severity
when a mishap does occur.
What’s the
impact on
probability &
severity
What’s the risk
control cost
How do they
work together
Make Risk
Decisions
Determine
residual risk
Make risk
decisions at
right level
Ensure benefits
outweigh costs
Involve Operators / Subject Matter Experts
49
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
CHENG: monitor from Control;
CO/XO: monitor from bridge;
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
Unknown submarine
IVO PIM/Vital Area
= Critical Risk
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
= Moderate Risk
= Minor Risk
= Negligible Risk
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Assess RAC Risk Control Action
C, II
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
2 BWC/SUWC on net.
D, II
CO/XO: monitor from bridge;
OOD/CONN: resolve potential
conflicts early & contact via
4 radio; CICWO: backup OOD
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
ALL: report anything in
water, wear PPE if topside;
1st LT: ensure proper PPE;
3 LOOKOUTS: continually scan
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
Terrorist attack
D, I
Inattention/
complacency
A, III
2 ALL: ensure rested & nourished
= Critical Risk
CHENG: monitor from Control;
Residual
Risk
CO/XO: monitor from
bridge;
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
Unknown submarine
IVO PIM/Vital Area
Re-assess Residual Supervision
B, II
C, II
C, III
GATOR: determine impact if
delayed; METOC: update
3 emerging weather conditions
METOC: report when below 3
NM visibility; OOD: backup
4 METOC if visibility
OOD: monitor bridge watch
team and correct as
necessary; CO/XO: monitor
4 bridge team
D, III
GUN BOSS: monitor & quiz
5 ATFP watches
on PPRs
atc es bac
up e o
B, III
watchstanders & supervisors
3 relieve if needed
SUWC: limit RMD watch duration;
= Serious Risk
GATOR: report & resolve
discrepancies, provide
4 recommendations to OOD
= Moderate Risk
= Minor Risk
= Negligible Risk
Implement Controls
Make
Implementation
Clear
Use examples,
pictures, or charts
Describe
expectations
clearly
Provide
Support
Establish
Accountability
Assign individuals
clear risk control
responsibilities
Command provide
personnel &
resources
Make it sustainable
Employ a feedback
mechanism
Integrate into plans
Consider control
conflicts
Involve Operators / Subject Matter Experts
54
Supervise
Feedback
Review
Monitor
Measure risk
controls’
effectiveness
Are the controls
working
Manage emerging
changes (ABCD)
Identify new
hazards
Was mission
successful
Identify root
causes of
conditions that
led to failures
Implement new
controls
Save all
documentation
Recommend
actionable
solutions to
prevent other
failures
Submit lessons
learned
Involve Operators / Subject Matter Experts
55
Supervise, Monitor &
use personal tool - ABCD
Action 1:
Monitor
Assess
Action 2:
Review
Balance Resources
Where am I?
What is going on?
What will happen
next?
ABCD
What are my options?
How do I use them?
Communicate
Who needs to know?
Who can help?
Who can provide back-up?
Revise if necessary.
Action 3:
Feedback
Do – Debrief
Carry out the plan.
Was mission successful?
Did actions reduce the
risk?
Straits Transit Risk Assessment
Deliberate ORM Example
Hazard/Threat Effect
Grounding/Flooding/
Navigation error
Blue/White Collision
Non-compliant, nonsquawking low slow
flyer
Tide/current/waves
Fog/Reduced
visibility/Inclement
weather
Unknown submarine
IVO PIM/Vital Area
Terrorist attack
Inattention/
complacency
= Critical Risk
Assess RAC Risk Control Action
Re-assess Residual Supervision
C, II
SUWC: ensure ships' report RMD
in effect, fixes every 2 min. w/
confidence & sources, OOD/Conn
be proactive w/ identifying &
3 communicating.
D, II
SUWC: monitor all vessels &
report when any vessel
comes w/in 500 yds of shoal
4 water; BWC: backup.
C, I
SUWC: pass shipping info., ships
adhere to Rules of the Road, use
Furuno/ARPA, dec. speed in
strait, pass contacts to
D, II
2 BWC/SUWC on net.
SUWC: monitor all vessels for
CBDR or min range inside
vital area; BWC/ASWC:
4 backup.
B, I
ADC: proactively identify &
resolve tracks; CFMCC: set
weapons posture & status for
threat; IWC: monitor & report
1 I&W to BWC/ADC on net.
C, II
3
A, III
SUWC: plan during favorable
conditions, pass to restrict
access to wx decks during high
2 seas, update BWC on changes.
A, IV
3
B, II
SUWC: ensure ships report
restrictred visibility detail, use
2 bell & horn, slow as needed.
B, IV
4
B, II
ASWC: notify BWC/SUWC of
known/unknown sub location;
BWC: launch alert ASW if
2 needed.
C, III
4
D, I
BWC: PPRs; SUWC: man ships'
50-cals.; ADC: direct ATFP/SAR
3 helo
D, III
5
A, III
SUWC: limit RMD watch duration;
2 ALL: ensure rested & nourished B, III
= Serious Risk
= Moderate Risk
ADC: monitor all tracks for
possible low slow flyers; IWC:
monitor I&W; BWC: backup
ADC/IWC.
SUWC: monitor changing
conditions; CSG OPS: call
BWC if conditions become
sig. different than forecast.
SUWC: report when vis<3NM
& low visibility set, monitor
speed.
ASWC: monitor all subsurface
contacts & report possible
locations for unknown;
BWC/SUWC: backup.
SUWC/IWC: monitor I&W and
use PPRs as required.
BWC/ADC: backup.
ALL: backup watches &
3 supervisors relieve if needed
= Minor Risk
= Negligible Risk
In the bigger picture
• In planning
– we conduct risk assessment and develop controls.
• In operations
– we update risk assessment and implement controls.
• In sustainment
– we continue to update assessments and adjust controls.
• After action
– we provide feedback and capture lessons learned to integrate the
next time.
58
ORM Mind Set… Change the
Perception of Risk Management
W DT ?
What’s Different Today?
– Technique to connect all three levels of ORM
– Spurs the use of Time Critical ORM during execution
– The missing piece in ORM understanding and proper application
5-Step ORM and ABCD
Time Critical Process
and Mnemonic
A – Assess (your situation, your
potential for error)
B – Balance Resources (to
prevent and trap errors)
C – Communicate (risks and
intentions)
D – Do and Debrief (take action
and monitor for change)
5-Step Deliberate and
In-depth Process
1. Identify Hazards
2. Assess Hazards
3. Make Risk Decisions
4. Implement Controls
5. Supervise (watch for
changes)
ABCD
Assess
Where am I?
What is going on?
What will happen
next?
of Risk Management
Balance Resources
What are my options?
How do I use them?
Communicate
Who needs to know? Who
can help?
Who can provide back-up?
Revise if necessary.
Do – Debrief
Carry out the plan.
Was mission
successful?
Did actions reduce
the risk?
Situational Awareness

The Green – You catch errors before they occur
•
Good Situational Awareness
•
Tools and Procedures in place to catch possible errors

The Yellow – Higher chance of errors
•
Situational Awareness could be decreasing
•
Tools and Procedures not in place to catch errors

The Red – Very high chance of consequential error
•
Tasking and/or stress may be high, tunnel vision may occur
•
Resources not effective to catch error
ABCD
Assess
Where am I?
What is going on?
What will happen
next?
of Risk Management
Balance Resources
What are my options?
How do I use them?
Communicate
Who needs to know? Who
can help?
Who can provide back-up?
Revise if necessary.
Do – Debrief
Carry out the plan.
Was mission
successful?
Did actions reduce
the risk?
Resources are Tools to get
the Job done
Balance your resources to catch possible errors
Knowledge, Skills and Techniques
Understand your situation and required jobs
Briefings & External Resources
Brief others, share your situational awareness
Automation
Use automation to increase awareness
Checklists
Write things down; use a checklist or job aid
Policies, Tactics, Procedures and Processes
Follow procedures and routines
ABCD of Risk Management
Assess
Where am I?
What is going on?
What will happen
next?
Balance Resources
What are my options?
How do I use them?
Communicate
Who needs to know? Who
can help?
Who can provide back-up?
Revise if necessary.
Do – Debrief
Carry out the plan.
Was mission
successful?
Did actions reduce
the risk?
Why a Common
Language?
Navy Lingo
SPOT
‫ﺗﺷﻐﻳﻝ ﻭﺇﺩﺍﺭﺓ ﺍﻟﻣﺧﺎﻁﺭ‬
TRM
Operational
R.I.T.E.
STORM
λειτουργική διαχείρηση
κινδύνων
SOAP
Risk
STAR
操作的风险管理
Management
CVORRTTEX
작전 위험 관리
ABCD of Risk Management
Assess
Where am I?
What is going on?
What will happen
next?
Balance Resources
What are my options?
How do I use them?
Communicate
Who needs to know? Who
can help?
Who can provide back-up?
Revise if necessary.
Do – Debrief
Carry out the plan.
Was mission
successful?
Did actions reduce
the risk?
Your Part on a Team
• Know your duties and also duties
of members on your team
• Maintain Situational Awareness
for you and your Teammates
• Communicate clearly
• Be observant of stress levels for
you and your Teammates
ABCD
Put into Action
•
Review of ABCD and Resources
ABCD
•
•
•
On duty
Off duty
What can we do better tomorrow?
69
Reconsider this situation…
70
Reconsider this situation…
71
It’s about informed decisions.
72
Resources & Tools
www.public.navy.mil/navsafecen
NSC
Website:
a Valuable
Resource
73
Resources & Tools
• Web Enabled Safety System (WESS):
–
–
–
–
Web-enabled reporting and data retrieval system
Allows submission & routing of 5102 mishap / hazard notifications & 3750 hazard reports
Provides real-time reporting
Allows retrieval of data so activities can perform their own analyses (across DOD)
• Travel Risk Planning System (TRiPS):
–
–
–
–
Provides ORM trip assessment and actual mishap cases relevant to planned trip
Risk values / models based on National Transportation Safety Board (NTSB) data
Trip map, times, distances and other products improve supervisor interaction
Computer based training (CBT) course content designed to help change behavior
• Total Risk Assessment and Control System (TRACS):
– Evolution risk assessment tool
– Allows user to assess, manage and report on hazards, risks & controls
– Public library of completed assessments available for others to modify for their specific
needs
74
Risk management…
It is a mindset
75
ORM
Where we want to be…
W e w ill m anage risk to
operate by follow ing a
standardized and
institutionalized
com m on m odel of ORM
application and
assessm ent across the
fleet.
Integrate risk management concepts across the fleet as part
of every decision made and every action taken by every
Sailor and DON Civilian employee – on and off duty
76
Summary

Humans are part of all Navy systems

Managing the risk of human error improves capabilities and
reduces losses

ORM:
• A proactive, systematic tactic to defeat Blue Threats
• A leadership tool to assist in making informed risk decisions
• Should be integrated into your command planning, briefing,
execution and after action processes
• Relies on education, training, experience and teamwork
• Requires outstanding communication skills at all levels
77
The Challenge
 Engaged Leadership
 Support and actively promote integration of ORM
•
•
•
•
On and Off Duty
Use Deliberate Assessment Process
Integrate TCRM - “What’s different today?”; “ABCD”
Support ORM Assessment at all levels
 Use the resources and tools available
 Establish an environment where hazards can be identified by
anyone at any time
 Provide feedback and share
 Work together to lookout for our shipmates (on and off duty)
and preserve DOD resources in order to ensure mission
readiness and help eliminate these…
78
Congratulations!
You have completed your annual
Operation Risk Management Training
PRINT GIVEN NAME
SIGNATURE
No Nicknames
COMPLETION DATE
NAF EMPLOYEE ID NUMBER
By signing and submitting this certificate, I certify that I have read and
understand the content in the training presentation.
Fill in the required information above and get this certificate to your Department Training Liaison
79