OPERATIONAL RISK MANAGEMENT

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					   OPERATIONAL
RISK MANAGEMENT
“ Commanders have a fundamental
  responsibility to safeguard highly valued
  personnel and material resources, and to
  accept only the minimal level of risk
  necessary to accomplish an assigned
  mission.”


  From OPNAVINST 3500.39          Photo of an LHA
  (Operational Risk Management)
  signed on 3 April 1997.
   Operational Mishap Rates
                Navy Class A’s, FY88-4/15/97
 15.02                14.91 14.76                                           14.52
         14   14.15
                                    13.53
                                                            12.72                   12.48
                                                    10.81                                   11.14
                                            10.03                   10.19




  89     83    82      85    80      69      47      47      53      23      339    296      147


   88    89    90      91    92      93      94      95      96      97      88-     92-     94-
                                                                             91      96      96
Rate per 100,000 people per year
Number in bar = number of mishaps
                                                                                             6001N
    Afloat Class A Mishap Rates
                                   FY87-4/15/97

   4.52                      4.73
                 4.12 4.24                                                    4.11
                                                         3.42
          2.97                      2.96                               2.96
                                                                2.43                 2.52 2.48
                                           2.18
                                                  1.68



    24    16     22    22    24     14     10      7     13      9      5     108     53   29
    87     88     89   90     91     92     93     94     95     96     97    87-    92-   94-
                                                                              91     96    96

 Rate per 100 ships & submarines



Formal Afloat Mishap Investigations Started                                                 2001
    What Causes Afloat Mishaps?

 Procedures        475


    Material         1,293
                                    The dominant factor!

Environment          1,533


  Personnel                                            16,125


               0             5000      10000   15000            20000

                         Number of mishaps, FY87-96             2002
       USS Abraham Lincoln &
          USS Sacramento
Note: Background is a photo of a CVN underway



                  5 Jun 95 - Collision During UnRep
                  Rigs Tensioned
                  AOE Suspected Steering Problems
                  Shifted Control to After Steering
                  Rudder Amidships - Distance Opened
                  CVN Followed Guide Right
                  AOE After Steering Came Left to R Corpen
                                                        3003.PPT
 Where Fatalities Occurred
               Navy, FY92-96


                       PMV
                       58%
 FY92-96                             Recreation
                                        18%
Total: 834                      Aviation
                                 14%
             Other
              2%
                Surface Ship   Shore/Ground
                     3%         Operational
                                    4%
                                                  6003N
       Top Ten Causes of
             Death
   Navy & Marine Corps Enlisted, 5/1/94 – 2/12/97
     Alcohol    12
        Gun     16
     Aviation    23
                                34 Months
         Fall    24
    Exercise         36        1,088 Deaths
      Drown          40
       Crime              79
      Natural                   150
     Suicide                            245
Motor vehicle                                  370
                                                     3001
            Top Ten Causes of
                  Death
     Navy & Marine Corps Officers, 5/1/94 – 2/12/97
        Guns     1
    Drowning     2
        Crime        3
                                       34 Months
          Fall       3
     Exercise        4                 125 Deaths
Motor vehicles           9
      Suicide                15
       Natural                    21
      Aviation                                      56
                                                    3002A
     The Cost of Mishaps
                    Navy, FY92-4/15/97
     FY92-96                         FY97
   Total: $3.25 B                Total: $165 M
         Aviation
                                  Aviation
           84%
                                    77%




                                                    Other
                                                     3%
                       Other
Afloat    PMV Ground              Afloat         Ground
                        3%                   PMV
 5%        4%   4%                 13%             3%
                                              4%
                                                       6002N
                Naval Aviation
                 Mishap Rate
      776 aircraft
     destroyed in                     FY 50-96
         1954
60                   Angled decks
                          Aviation Safety Center                              39 aircraft
50                                                                          destroyed in
                                 Naval Aviation Maintenance Program              1996
                                 established in 1959 (NAMP)
40
                                        RAG concept initiated
30                                            NATOPS Program initiated 1961
                                                    Squadron Safety program
20                                                        System Safety
                                                          Designated Aircraft
10                                                                      ACT      2.35
 0
FY 50                            65                        80                       96
             All Services
     Class A Flight Mishap Trend
     7
     6
     5                                                         (14) 3.92 USMC
     4                                                         (21) 1.80 NAVY
     3                                                         (26) 1.20 USAF
     2                                                         (7) 0.64 ARMY
     1
     0
         90    91       92          93     94   95     96

                             Fiscal Year

US Army ORM training                             US Army attains lowest flight
reached the majority of operators                mishap rate for last 2 years
         Human Factors QMB
Reducing Human Error in Naval Air Operations:
         “Risk management is our doctrine”

        Dissect mishap data
        Safety culture assessment
        Benchmark successful programs
        Recommend process improvements
           • Leadership
           • Training
           • Operational Risk Management
           • Information management
           • Investigations
Organizational Culture
“The way we do things here”

 * Fundamental building blocks
 * Group values and standards
 * Medium for growth
 * Shaped by leadership

  Drives Key Decisions
ORM

      Process ...

           NOT Program!
    Implementing ORM in Your
           Command

   Incorporate Risk in Decision
     Making at All Levels
   Operational Risk Management
     Makes Everyone a Risk Manager
ORM - Levels of Training

•Indoc

     •User

             •Advanced

                   •Leader

                             •Senior Leader
        Indoctrination Training
            Course Outline
 PURPOSE: To provide students with a basic understanding of
 what Risk Management is, the benefits derived from it, the
 concepts that apply to it, and how to do Time Critical ORM.
CONTENT:
    ORM terms and definitions
    ORM introduction/concept
    Four Principles of ORM
    ORM vs. traditional approach
    Benefits of ORM
    Three Levels of ORM
    Time Critical ORM, examples and demonstration
    Specific applications (connection to existing
   processes/procedures)
 LENGTH: 1 hour
AUDIENCE: E-1 through E-4; O-1/2
               User Training
               Course Outline
PURPOSE: To teach the student how to work through the
deliberate five step process and use previously developed,
application specific techniques

CONTENT: Indoctrination Training plus:
    Deliberate ORM process and demonstration
    Basic hazard identification, tools and examples
    Hazard assessment tools and examples
    Risk assessment tools and examples (command worksheets/tools)
    Deliberate ORM practical exercise
    Specific applications (connection to existing processes/procedures)

LENGTH: 4 hours
AUDIENCE: E-5 through E-7; O-2/3
               Advanced Training
                Course Outline
PURPOSE: To teach students how to apply any level of
ORM and provide the tools necessary for implementing ORM
at their command. This course can be combined with a Tiger
Team site visit to set up proven ORM techniques.
CONTENT: User Training plus:
    In-depth hazard identification tools and examples
    Risk assessment tools and examples (cross section of available tools)
    Communication/presentation approaches
    Command implementation and leadership concepts
    Specific applications (connection to existing processes/procedures)
    On-site application of ORM techniques (Tiger Team site visit only)

LENGTH: 2 days classroom; 1 day on-site
AUDIENCE: E-8/9; O-4/5
               Leader Training
               Course Outline
PURPOSE: To give squadron leadership enough knowledge
to understand in-depth and deliberate ORM, what ORM can
provide and how to implement it within their units.

CONTENTS: Abbreviated User Training plus:
      Synopsis of In-depth hazard identification tools
      Risk assessment tools and examples
      Command implementation and leadership concepts
      Specific applications

LENGTH: 4 hours
     Senior Leader Training
        Briefing Outline
PURPOSE: To provide senior leaders (flag officers and O-6
COs) with a basic understanding of the ORM process, the
benefits derived from it, the three levels and some of the
applications of ORM.
CONTENT:
    Background
    Three Levels of ORM
    Five Step Process
    ORM vs. traditional approach
    Specific fleet applications
    Benefits of ORM
    ORM implementation status and goals

LENGTH: 2 hours
         Vision of ORM Expertise

FLAG OFFICER       LEADER     PREVIOUS TRAINING

MAJOR COMMAND      LEADER     PREVIOUS TRAINING

CO/XO              LEADER     LEADERSHIP CONTINUUM


DEPARTMENT HEAD    ADVANCED   LEADERSHIP CONTINUUM
                              DEPT HEAD SCHOOL

DIVISION OFFICER   USER       LEADERSHIP CONTINUUM
                              DIVISION OFFICER CSE

MAINTENANCE        USER/      LEADERSHIP CONTINUUM
PERSONNEL          INDOC        “A” / “C” SCHOOLS
        “Safety is built on integrity,
       trust and leadership, created
         and sustained by effective
             communication.”



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