Operational Risk Management
in the Navy
Managing the Human Component
of an Operational System
Ken Neubauer
Ted Wirginis
Futron Corporation
Naval Safety Center
1
Navy Systems
2
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.
3
OVERVIEW
• Background
– History
– ORM Elements
• Foundations
– Revitalization
– Targets for success
• Strategy
– Initiatives
– Tools
4
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….
5
ORM Fundamentals
In
Depth
Deliberate
Time Critical
4
3 Levels
ORM Principles
1. Accept risks when benefits outweigh costs
4 Principles
2. Accept no unnecessary risk
3. Anticipate and manage risk by planning
4. Make risk decisions at the right level
5. Supervise
4. Implement
Controls
1. Identify
Hazards
3. Make Risk
Decisions
5 Steps
6
Military Planning
Identify Hazards
Receive Tasking
&
Analyze
Supervise
Command
Decisions
Naval Operational
Planning Process
Staff Recommend
Options
Implement
Controls
Assess
Hazards
Staff
Estimates
Commander ’s
Guidance
Make Risk
Decisions
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Unit Risk Management
CO
• Strategic planning
• Deliberate ORM
• On-Line Training
ORM
Instructors
• Subject Matter Expert
• Formal Classroom training
Unit
Personnel
• Mission Execution
• Change Management
• On-Line Training
No change in the approach for a decade
8
The Status Quo
Solid Concepts but
Little Change to --Guidance
Approach
Application
9
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.”
10
The Cost of Risk
$316 Million
12 Aircraft Lost
28 Lives Lost
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The Cost of Risk
326 Lives Lost
Crew of 1 Destroyer
Or
1 F/A-18 Squadron
12
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.”
13
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
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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
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A Revised Strike Plan
OUR TARGETS
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Reaching the War Fighter
The Blue Threat
Puts the concepts in to
terms the War Fighter
understands
Hazards = Threats
ORM = Tactics
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Blue Threat Origins
TRM
WTI 2-06
Operationalizing Safety for WTIs
Tactical Risk Management
• Partnership between
Operational Experts and
Safety Experts
• MAWTS-1
• School of Aviation Safety
• Leadership Inspired
Col J.M. Davis
“Dog”
• Looking for mishap reduction
answers
• Calling on all resources within
the organization . . . Not just
the “Safety Guys”.
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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
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ORM Assessment
• Use teams already in place
• Provide assessors with specific ORM training
• Identify exemplars and disseminate best practices
ASSESSMENT
ASSESSMENT
UNITS
FFC/CPF
&
TYCOM
•SFTG – COMTUEX
Feedback
•NSC – Safety Surveys
•NSAWC – AIRWING Fallon
•ATG – TSTA
•TACTRAGRU – BG Staff
Others
NSC
UNITS
• Application
• Mentoring
• Reinforce Training
• Expand understanding on the job
• Expand application off duty
IG
INSERV
Feedback/Best Practices
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ORM Assessment
ORM Program Assessment
Evolution ORM Assessment Sheet
Unit/Group:__________________________
Assessor:___________________
USS SAMPLE (CVN-X)
LCDR Carlson, NSC
Evolution:___________________________
Getting U/W, NAV Dept. Date/Time:__________________
05 Feb 07, 0900L
Planning
1
Identified and incorporated lessons learned, best
practices, ORM risk assessments or other data
from previous or similar evolutions during
planning.
X
10
Involved operators from every functional area
2 necessary to conduct the evolution in planning.
3
Conducted and documented a Deliberate or In-Depth
ORM risk assessment during planning.

Lessons Learned / Best Practices
Retained ORM risk assessments, lessons
learned, and/or best practices for this
evolution in a centralized, readily
accessible location at the unit/group.
Shared ORM risk assessments, lessons
20 learned, and/or best practices for this
evolution with relevant external
Comments
Max. Pts.
10
10

19
10
10
NOB
8 5 of 6 areas: no CS Dept.
6 Poor documentation (over )

7
Kept in NAV safe but
ANAV-only access
9
Used TRACS for ORM
• Evaluates ORM instructional
compliance
• Gives an indication of the
relative unit ORM program
strength
ORM Proficiency Levels
O1 is >=90%, “Exceptional”
230 197
Maximum Possible  
 Evolution ScoreMaximum Possible 240
Additional Comments, Lessons Learned, or Best Practices continued on reverse 
O1
ORM Proficiency Level 
ORM Application Assessment
• Evaluates operational planning,
briefing, execution, debriefing, and
lessons learned/best practices
• Only provides a snapshot of ORM
use during evolutions observed
O2 is 80-89.9%, “Proficient”
Maximum Possible 240
O2
ORM Proficiency Level 
229.8
 Overall Score
Exceptional
95.8%
 Overall Score
86.7%
Proficient
208
O3 is 70-79.9%, “Needs improvement”
Maximum Possible 240
O3
ORM Proficiency Level 
 Overall Score
75.6% Needs improvement
181.4
O4 is <70%, “Not proficient”
Maximum Possible 240
O4
ORM Proficiency Level 
167
 Overall Score
Not proficient
69.6%
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ORM Guidance and Support
Naval Safety
Center ORM
Website
• Process and
Model Management
•Tools for Leaders
• Examples for
Sailors
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ORMAS
Operational Risk
Management
Assessment System
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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
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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
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Shaping the Base
Criticality, People, Tools
Shaping a Risk Managing Culture
Time Critical
Time
• Demonstrate & Mentor New Accessions
• Boot Camp
• USNA
• ROTC
• Educate the Leaders
• Leadership Schools
• Instructor Courses
• Learning Continuum
Where the Majority of
™ Navy Personnel Operate
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Time Critical Risk Management
Skills
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
Process
ABCD for
Decision Making
Assess the mission for potential
adverse consequences
3. Assertiveness
•
I have confidence in myself, my team, and my
leadership to bring new threats to their
attention
4. Communication
•
Balance the use of Resources to
minimize risk
I need to let my teammates or others involved
know what I know
5. Leadership
Communicate Risks and
•
Intentions
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
Do (and debrief to improve
future performance)
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Time Critical Scenarios
NIGHT UNREP
™
• Routine Evolution
• Time Constrained
• Supply ship committed (perceived)
What’s Different?
Decision Distractions
Option A
• Late at night start
(2300)
• Winds and seas
different than forecast
• Maintaining station
difficult
• Keeping fuel hoses
seated very difficult
• Desire to get the job
done now
• Fatigue
• Routine Evolution
• Continue with evolution
• Risks – damage to
equipment, people
Option B
• Breakaway and
reassess hazards and
controls
• Risks – delay, lower
than normal fuel
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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?
Decision Distractions
Option A
• Family early PM dinner
runs late
• Rear tire deflated (slow
leak from nail puncture)
• Light fog forms (not
forecasted)
• Never been late from
leave
• New Division CPO
• Made this drive many
times before
• Continue with Drive
• Risks – fatigue, flat tire,
heavy traffic
Option B
• Call ship and speak to
OOD
• Risks – Angry CPO,
miss underway briefs
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Influence on Decision Makers
Source of Safety Input in the
Birth of a Navy Aircraft
Proactive
Design
Design
Test
OTE
Time
Fleet
Introduction
- Engineers
- Operators / Maintainers
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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
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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
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