NROTC PCO/PXO CONFERENCE 10 August 2001 MANAGING RISK CAPT GARY WILLIS DIRECTOR SHORE SAFETY NAVAL SAFETY CENTER
MISHAP COST 5 YEAR TOTAL: $3.9 BILLION & 1024 DEATHS
Direct Cost TRUE COST? • Indirect Cost • Litigation • Loss of Manpower • Delay in Doing Business • Corporate Reputation • Investigation Costs • Loss of Assets
Marines Ground Osprey After Crash Kills Crew of 19 CORPORATE ENERGY COSTS U. S. Sub Collides With Japanese Training Vessel F-14 Crashes Into House Vice CNO Apologizes to Japanese Government Investigation Ordered 2 Crew and 3 Civilians Killed
CLASS A MISHAP RATE 5 year trends indicate declining mishap rate, but recent plateau 514 364 61
HOW SAILORS & MARINES DIED IN MISHAPS; FY96-00 Speed Kills! Deaths: FY 96-00: 1024 FY 01: 143 (31JUL01) Traffic 59% Recreation 14% Aviation 16% Afloat 1% Shore/Ground 10%
FATAL FACTORS IN TRAFFIC MISHAPS Percentage of Mishaps FY-98 to FY-00 339 DEAD! Fatigue: 18% 53% 65% 41% 32% 31% Weekend Night No Seat Belt Alcohol Speeding
PERSPECTIVE “In 1968, we lost 99 American Sailors in USS SCORPION, which we think of as a national disaster. While we lost 103 Sailors and Marines in PMV accidents in 1998, and call it our “best year” !” Robert B. Pirie Acting Secretary of the Navy
RISK TAKING "It seems to be a truth, inflexible and inexorable, that he who will not risk cannot win." John Paul Jones
CAUSES OF RISK Personal Work Ethic Complex Evolutions High Energy Levels CHANGE!! Stress Environmental Influences Human Nature Resource Constraints New Technology Feeling of Invincibility Complacency Speed, Tempo of Operations
HURT AT WORK • I’ve carefully thought out all the angles • I’ve done it a thousand times • It comes naturally to me • I know what I’m doing; its what I’ve been trained to do my entire life, I was born for this job • Nothing could possibly go wrong RIGHT? WRONG!
OPERATIONAL TAPESTRY Investigations: • Poor airmanship/seamanship • Skill-based error rate • Poor crew coordination • Poor headwork CAS/MCAS/Surveys/Culture Workshops: • Inadequate resources • Command over-committed • Manning/unavailable experience • Cutting corners/PMS • Poor communication • Technical publications
HUMAN ERROR IN MISHAPS, FY 96-00 Aviation Afloat 79% 86% Shore 95%
THE CHALLENGE “ The success of naval operations is based upon a willingness to balance risk and taking the bold, decisive action necessary to triumph in battle. At the same time, 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 mission.” ADM Vern Clark, CNO
OPERATIONAL RISK MANAGEMENT What is ORM? A process to assist you in performing everyday tasks safely and efficiently! Modify the process to fit the situation while still identifying and assessing risks and developing controls to reduce the hazards.
ORM CONCEPTS • All are responsible for using ORM • Risk is inherent in all operations • Risk can be controlled
ELEMENTS OF ORM • 3 Levels of Application • 4 Principles • 5 Steps
3 LEVELS OF APPLICATION • TIME CRITICAL 90% of ORM processes are “On the run” • DELIBERATE Complete 5 step process • IN DEPTH Other considerations outside local chain of command
3 LEVELS OF APPLICATION TIME CRITICALDELIBERATEIN-DEPTH Little: - Time - Complexity Lot of: - Time - Complexity ORM is applied proportionate to operational complexity, criticality, and risk!
4 PRINCIPLES • Accept risk when benefits outweigh cost • Accept no unnecessary risk • Anticipate and manage risk by planning • Make risk decisions at correct level
5 STEPS • Identify hazards • Assess hazards • Make risk decisions • Implement controls • Supervise
IDENTIFYHAZARDS Step #1: • Analyze manageable pieces of an event • Use experience as a guide “Experience is the name everyone gives to their mistakes” Oscar Wilde, 1892 • Ask what if, use brainstorming, think cause and effect
ASSESS HAZARDS Step #2: Prioritize identified hazards based on: Severity & Probability
ASSESSHAZARDS Step #2: Severity + Probability of Occurrence = RAC
MAKE RISK DECISIONS Step #3: • Consider risk control options, most serious risks first • Risk versus benefit • Communicate as required
IMPLEMENTCONTROLS Step #4: • Engineering Controls • Administrative Controls • Personal Protective Equipment
SUPERVISE Step #5: Same as any other supervisory process: • Assure controls effective and in place • Maintain implementation schedules • Correct ineffective risk controls • Watch for change
SCENARIO The Admiral has made it known that you will secure at 1500 on Friday (assume here in Pensacola), for a well-deserved 3 day weekend. Accordingly, you’re planning a trip to West Palm Beach to visit with family and friends, lounge and relax beach-side, and of course, to check into the local voting procedures and practices. Your plan is to leave as soon as possible after 1500 because the 610 mile trip will take at least 11 hours.
Step #1: IDENTIFY HAZARDS • Fatigue • Equipment breakdown • Drunk drivers • Speeding • Directionally challenged • Road construction • Weather • Orlando
ASSESS HAZARDS Step #2: Severity/Probability(RAC) Hazards • Fatigue • Equipment breakdown • Drunk drivers • Speeding • Become directionally challenged • Road construction • Weather • Orlando I/C (2) II/C (3) I/C (2) I/A (1) IV/C (5) III/C (4) II/C (3) I/A (1)
MAKE RISKDECISIONS Step #3: HazardRAC Orlando 1 Speeding 1 Fatigue 2 Drunk drivers 2 Weather 3 Equipment breakdown 3 Road construction 4 Getting lost 5
IMPLEMENT CONTROLS Step #4: Controls Tactical nuclear device Know and obey limit Rest, adjust start time Leave early morning Monitor weather channel Inspect vehicle and make repairs before the trip Get a trip planner Carry a current map Hazards Orlando Speeding Fatigue Drunk drivers Weather Equipment b-down Construction Getting lost
SUPERVISE Step #5: • Command sponsored vehicle inspection for • those planning long distance trips. • Mandatory completion of driver mishap risk • indicator form • Pre-holiday safety standdown • Evaluate and adjust controls as the situation • changes • Ensure personnel are familiar with their • situation • Watch for changes
BENEFITS OF RISK MANAGEMENT • Reduction in serious injuries and fatalities • Reduction in material and property damage • Effective mission accomplishment
REINFORCE GOOD ORM PRACTICES • Provide Commander’s Intent re: acceptable risk and use of ORM. • Benchmark ORM success. • Should ORM fail, identify weak link. • Enforce risk control standards as you would any other essential mission performance standard.
DOES ORM WORK? 9 Class A Mishaps 8 Lives $147 M Saved