Title: Operational Risk Management - The Air Force Way
1Operational Risk Management - The Air Force Way
Headquarters Air Force Safety Center Lt Col Denny
Peeples Ms. Karen Kinkle
2Who, Why , What ?
- Who
- Denny F-15, 10 yrs safety experience, CSP
- Karen ORM manager for USAF
- Why are we here ?
- MG McFann believes in Military / Civilian cross
talk - Lessons learned for both take something home
- What are we going to cover ?
- Background
- How does the AF teach / use ORM ?
- How can you integrate ORM into your organization
?
3Rules of Engagement
- Call us Denny or Peeps and Karen
- Lots of material, 5 day class, in 90 minutes but
- Ask questions as we go along
- We will answer them directly, quickly or
- Well follow-up with emails, calls
- Exchange our increase mission effectiveness for
your civilian world make more, save more money - Make sure you leave with handouts, cards,
websites - Call , email us with follow-ups, well do same
- The question left UNASKED is the dumb question
4Background info on AF Safety
- 1947 USAF started from US Army Air Corps of WWII
- Traditionally more people killed in training than
war, recently off duty vs. on duty - Grouped into flight, ground, weapons
- s have generally plateaued the past decade
- Sec Def Rumsfield initiative to reduce mishaps by
50 in two years
5Air Force mishap rate history
6Wheres your office ? What is your risk ?
7Note to Peeps slide
- 8/6/04 Update the following 2 slides with the
latest information prior to NSC 9/13/04
8ORM at home 101 Critical Days Fatality Summary
Week 1 2 3 4 5
6 7 8 9 10 11
12 13 14 15
Total Fatals 19 65
PMV
Through Current Week
FY 04 to Date
MC
PMV
2004
MC
PMV
MC
MC
PMV
PMV
PMV
MC
MC
PMV
PMV
S/R
MC
MC
PMV
PMV
PMV
Total Fatals 21 63
S/R
2003
FY 03 thru 4 Aug 03
PMV
PMV
Through Current Week
MC
S/R
PMV
PMV
PMV
PMV
MC
MC
MC
MC
MC
MC
MC
PMV
MC
PMV
PMV
MC
MC
ON
PMV
PMV
PMV
PMV
MC
MC
PMV
MC
PMV
MC
PMV
PMV
Total Fatals 19
78
PMV
PMV
Through Current Week
FY 02 thru 4 Aug 02
2002
PMV
MC
PMV
PMV
MC
PMV
MC
PMV
S/R
ON
MC
PMV
PMV
MC
PMV
S/R
MC
PMV
PMV
S/R
PMV
PMV
S/R
ON
PMV
MC
On-Duty
ON
Off-Duty
Alcohol
Vehicle
Motorcycle
Sports/Rec
Misc.
MC
S/R
PMV
As of 4 Aug 04
9Our biggest Threat .
10Lost Workday Injury Rates USAF vs Alcoa
USAF data as of 4 Aug 04 ALCOA data as of 4 Aug
04
LWI Rate/100 employees
FY91 FY92 FY93 FY94 FY95 FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04
MIL 0.16 0.14 0.11 0.13 0.11 0.13 0.12 0.11 0.09 0.14 0.15 0.11 0.10 0.12
Civ 0.92 0.83 0.80 0.91 0.74 0.74 0.55 0.55 0.53 0.59 0.50 0.38 0.31 0.33
USAF 0.41 0.35 0.31 0.35 0.29 0.30 0.24 0.23 0.21 0.26 0.24 0.19 0.16 0.18
ALCOA 0.99 0.81 0.77 0.75 0.46 0.49 0.46 0.36 0.23 0.18 0.16 0.15 0.12 0.07
USAF mil civ injuries are on-duty, ground only
(aviation excluded).2002 includes USAF
occupational illness data
UNCLASSIFIED
11 Overview
- What is ORM? Why ORM?
- ORM - The Key Principles
- How the USAF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
12What is ORM ?
ORM The Air Forces six-stepdecision-making
processwith specific tools designed
tosystematically identifyrisks and benefitsand
determine the best course of actionfor any
given situation
Fundamental GoalEnhance mission effectiveness
by optimizing risk
13What is ORM?(Informal Definition)
- Simply applying common sense on- and off-duty
- Dont Do Stupid Things!
- Rubber Meets the Road Language
- What can go wrong?
- How bad can it be?
- What can we do about it?
14Achieving the Goal . . .
Requires A Cultural Shift
- Traditional Safety
- Reactive
- Evaluates compliance
- Focuses on performance
- Inspections/evaluations
- Risk Management
- Proactive
- Evaluates risk
- Focuses on mission
- Everyone involved
15What are the goals of ORM ?
- Enhance mission effectiveness at all levels.
- Integrate ORM into mission processes.
- Create an Air Force in which every leader,
airman, and employee is trained and motivated to
manage risk in all their on- and off-duty
activities. - Identify opportunities to increase USAF
warfighting effectiveness.
16MISHAP RATE VS ANNUAL COSTCLASS A FLIGHT
ONLY(Why do we need ORM?)
17 Why ORM - Know The Threats
The Safety Pyramid
1 Fatality
30 Lost-Time Injuries
300 Recordable Injuries
1,000 to 1
30,000 Near Misses
300,000 At-Risk Behaviors
18KC-135 Overpressurization(Tinker AFB - Depot)
19Note Where Aft Hatch Landed
20 Overview
- What is ORM?, Why ORM?
- ORM - The Key Principles
- How the AF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
214, (no 5) Key ORM Principles
- 1. Accept no unnecessary risks.
- 2. Make risk decisions at the appropriate level.
- 3. Accept risks when benefits outweigh costs.
- Integrate ORM into planning, operations and
education at all levels. - Make it second nature, on duty and off
22 Overview
- What is ORM?, Why ORM?
- ORM - The Key Principles
- How the AF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
23Man your cheat sheet !!!
AF ORM Cheat Sheet
1
6
2
5
Ms Karen Kinkle 505 246 1386
karen.kinkle_at_kirtland.af.mil Lt Col Denny Peeples
505 246 0714 denny.peeples_at_kirtland.af.mil
3
4
HAZARD SEVERITY CATEGORIES I
Catastrophic - Complete mission failure, death,
or system loss. II Critical - Major mission
impact, severe injury, or major system
damage. III Moderate - Minor mission impact,
injury, or system damage. IV Negligible - Little
mission impact, injury, or damage.
HAZARD PROBABILITY CATEGORIES A Frequent -
Item occurs often. Fleet continuous.
Individual occurs often. All
continuous. B Likely - Item occurs
several times. Fleet frequently.
Individual occurs several times. All
frequently. C Occasional - Item will occur.
Fleet several times.
Individual will occur. All sporadic. D Seldom
- Item could occur. Fleet will occur.
Individual could occur.
All seldom. E Unlikely - Item will not
occur. Fleet could occur.
Individual will not occur. All very rarely.
Event Probability
Frequent
Likely
Occasional
Seldom
Unlikely
A
B
C
D
E
6
12
8
SEVERITY
I
Catastrophic
4
7
11
15
II
Critical
10
14
9
16
5
III
Moderate
17
18
19
20
13
IV
Negligible
24The ORM 6-Step Process
25Step 1 Identify the Hazards
Process Emphasize hazard ID tools. Adds rigor
and early detection. Output Significant
improvement in the detection of hazards (50) .
26Step 1 Identify the Hazards
- Operation/task analysis provides basis for
systematic approach - Sequence of events
- Hazards identified in each step
27Step 1 Identify the Hazards
- Hazard - Any real or potential condition that can
cause mission degradation, injury, illness, or
death to personnel or damage to or loss of
equipment or property - Hazard ID tools Over 25 Available
- What-Ifs, Scenarios, 5Ms, etc
- Early detection leads to significant
improvement
What Bad Things Can Happen?
28Identify the Hazard, all the Hazards
29Dont Jockey Throttles With Engines Running
30Flight 357, Now Arriving at Gate 114
31Step 2 Assess the Risks
- Process All hazards evaluated for mission or
activity impact. Root causes determined and risk
levels assigned. - Output Personnel know the priority risk issues
of the organization and of their function.
32Assess the Risk
- Associates hazards with level of risk
33What is the worse alternative ?Can you accept
the risk ?
34What is the worse alternative ?Can you accept
the risk ?
35Step 3 Analyze Control Measures
- Process Comprehensive risk control options
developed on a worst-first basis. - Output A full range of cost effective, mission
supportive, risk controls for the decision-maker.
36Macro Options
Step 3 Analyze Control Measures
- Reject Risk outweighs the benefit, so dont do
it - Avoid Go Around the Risk/Do it a Different
Way - Delay New technology/need may no longer exist
- Transfer UAV/contract the operation
- Spread Make a bigger target/reduce exposure
- Compensate Create redundancies
- Reduce Use the control options matrix
- to suggest reduce options
37Step 3 Analyze Control Measures
Action 1 Identify Control Options
Action 3 Prioritize Risk Control Measures
Action 2 Determine Control Effects
38Note Position of Jack Pads
39Just Missed a Parked Jet
40Step 4 Make Control Decisions
- Process Gets risk decisions to the right person,
at the right time, with the right support. - Output Personnel know their decision-making
authority and limitations.
41Step 4 Make Control Decisions
42KC -10 Towing Accident
43OOPS! That Isnt Gonna Buff Out
44Step 5 Implement Risk Controls
- Process Leaders lead, operators involved,
accountability known. - Output Controls approved by decision-maker are
implemented.
45Step 5 Implement Risk Controls
Action 1 Make Implementation Clear
Action 3 Provide Support
Action 2 Establish Accountability
46Is your risk control effective ?
47Step 6 Supervise and Review
- Process Measures mission effectiveness and
direct indicators of risk. - Output Real time status. Proactive, not
reactive.
48Step 6 Supervise and Review
49Review Measures to Avoid This!
Example of Aircraft Foreign Objects Found
during periodic inspections
50In the end have an honest assessment
51Using the 6-Step Process THE RISK MANAGEMENT
CONTINUUM
52Using the 6-Step Process LEVELS OF EFFORT
53F-15 Fuel Purge Requirements
- AF required fuel purge during certain F-15
maintenance - ORM assessment revealed
- Airflow required for worker evacuates fuel
vapors - Residual atmosphere too lean for explosion
- Results
- Eliminated fuel purge requirement
- Significant cost savings
- AF-wide applicability--potentially other systems
too - Previously Depot work may be done locally
54Do you practice RM at home ?
55 Overview
- What is ORM?, Why ORM?
- ORM - The Key Principles
- How the AF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
56USAF ORM Maturation
- USAF Approach, Vision
- Background
- Strategy
- The leaders role will be a decisive factor in
the success or failure of ORM
57USAF Approach
- Top-Down Approach
- Strong Senior Leader Backing
- Decentralized Implementation
- Moderate Implementation Tempo
- Safety Lead Role for Cross-Functional
Implementation
58Vision
- Macro Every Leader, Airman, Employee Manages
Risk in All They Do... On- Off-Duty - Micro
- On-Duty - Every Organization Manages
Normal Operational Risk Profile - - Unique Operations Identified
Assessed - Off-Duty - Every Individual Applies Risk
Management Process to Activities
59Background
- CSAF Formally Approved ORM Implementation,
- 2 Sep 96
- AFI 91-213, Operational Risk Management Program
(ORM), 1 Nov 96 - Initial Implementation Plan
- CSAF Memo, 1 Jul 97
- ORM Moved From 91 Series (Safety) to 90 Series
(Command Policy), Apr 00
60Strategy
- Education and Training
- Tools and Information
- Continuously improve ORM support
- Synthesize into loss control functions
- Integrate into all USAF operations - -
- on- and off-duty
- Provide Oversight and Sustainment
61ORM Strategy Education and Training
- Short Term
- Executive Level - Senior Leaders
- Applications Integration - Focal
Points/Planners - Essentials - Mid-level Managers/Supervisors
- Fundamentals - Working Level
- Introduction - All
- (Available at http//afsafety.af.mil)
- Long Term
- Institutionalized into all Training Education
-
62AF Risk Management CBT
http//afsafety.af.mil/AFSC/RDBMS/Training/SEME_h
ome.htm
63 Overview
- What is ORM?, Why ORM?
- ORM - The Key Principles
- How the AF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
64Its Just Common Sense Why Do We Need ORM?
- You know what you're doing, its what you've been
trained to do your whole life. - You've carefully thought out all the angles.
- You've done it a thousand times.
- It comes naturally to you.
- Nothing could possibly go wrong right?
65Think Again!
66Roadblocks during integration Culture of
Assumptions?
- Potential Individual Assumptions
- Actions Briefed Actions Accomplished
- Missions Executed as Planned
- Issued Equipment is Suitable for Mission
- Supervisors Know all the Facts
- Potential Corporate Assumptions
- Requirements are Valid and Resources are
Sufficient - Individuals are Appropriately Trained
- Information Flow is Adequate
- Procedures Work and are Followed
- Lower Level Supervisors are Effectively
Managing - Individuals Will Speak Up
67ORM Integration
68Integrating the ORM Process
- Why integration is critical?
- 12 Strategies for ORM integration.
- The importance of pace.
69Why Integration is Critical ?
- Integration
- Forces balancing of loss control and other
mission needs - Captures more of the knowledge and experience of
large numbers of operators - Reduces the number and diversity of references
needed to do the job right - Eliminates redundancy and gaps between loss
control functions - Strengthens accountability
- Reduces costs and workloads (in plans, materiel
development cycles, etc.)
70The Twelve Strategies for Integration into your
Company
- Accountability
- Teaming
- Partnership
- Integrate in Training
- Risk Decision Points
- Organization Policy Structure
- Employee Activities
- Process Integration
- Direct Change
- Gain a Champion
- Integrate in Strategic Planning
- Integrate into Measurement
71The Importance of Pace
- Dont use the shotgun
- Dont get out in front of the organization - too
far - Dont inspect-in ORM
- Do focus on targets
- Do expect crawl, walk, run
- Patience, patience, patience
72The Way Ahead
- Make ORM a Core Competency for all Air Force
personnel - Meet the Challenges
- Cell Phonesdistractions
- Generation X - The Risk Takers
73Who-would-a-thunk ?(Policeman on a cell phone)
74Questions/Comments
Its time to move forward in making ORM
the natural way for our people to conduct their
professional and personal activities. --General
John P. Jumper, Chief of Staff
75Note to Peeps slide
- 8/12/04
- See how the time and questions and answers go
with the previous slides - Present the JSAT process brief as an advanced
example of Step 2, Assess the risk, in the 6 step
ORM model
76 Overview
- What is ORM?, Why ORM?
- ORM - The Key Principles
- How the AF teaches ORM The 6-step process
- USAF ORM Maturation
- How to integrate ORM into your company
- ORM Process example
77Joint Services Analysis Team Process Example
Maj Bob Baker Col Donald Pitts
78SECDEF Challenge
- SECDEF Memo Dated 19 May 03
- Cut number of mishaps accident rates 50
- Accomplish 50 goal in next two years
- DoD wide effort managed by USD (PR)
- Defense Safety Oversight Council (DSOC)
79ORM Steps In A Nutshell
- Identify Hazards
- Analysis, What-Ifs, Scenarios, 5Ms
- Assess Risks
- Severity and Probability
- Analyze Control Measures
- Avoid, Delay, Transfer, Spread, Compensate,
Reduce - Make Control Decisions
- Accept, Reject, Modify, Elevate
- Implement Controls
- Clear, Accountability, Support
- Supervise and Review
- Effective, Feedback
80CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 1 Individually review the mishap
81CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 2 Identify the hazards or, in other words,
what happened that was hazardous - Hazard Any real or potential condition that can
cause mission degradation, injury, illness, or
death to personnel or damage to or loss of
equipment or property.
82CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 2 Identify the hazards or, in other words,
what happened that was hazardous
83CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 2 Identify the hazards or, in other words,
what happened that was hazardous - Solely watching wingman for spatial orientation
(man) - Solely relying on aural warnings for altitude
reference (man) - Commencing maneuvering near the floor / hard deck
(man) - Tactical maneuvering in degraded / limited visual
conditions (media) - Too complex a mission after a long layoff
(mission) - Failure to identify and correct weaknesses in
performance among aircrew (management)
84CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 3 Assign a Power (P1) and Applicability (A)
value to each hazard (discuss as group but assign
own, will average) - P1 Hazard Importance Rated 0-6
- 0 - No Influence 3 - Moderate
Influence 6 - Completely Influential - 1 - Little Influence 4 - Quite
Influential - 2 - Slight Influence 5 - Highly
Influential - Hazard
- Solely relying on aural warnings for altitude
reference (man)
85CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 3 Assign a Power (P1) and Applicability (A)
value to each hazard (discuss as group but assign
own, will average) - P1 Hazard Importance Rated 0-6
- 0 - No Influence 3 - Moderate
Influence 6 - Completely Influential - 1 - Little Influence 4 - Quite
Influential - 2 - Slight Influence 5 - Highly
Influential - Hazard
- Solely relying on aural warnings for altitude
reference (man) - P1 6
86CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 3 Assign a Power (P1) and Applicability (A)
value to each hazard (discuss as group but assign
own, will average) - P1 Hazard Importance Rated 0-6
- 0 - No Influence 3 - Moderate
Influence 6 - Completely Influential - 1 - Little Influence 4 - Quite
Influential - 2 - Slight Influence 5 - Highly
Influential - P1 6
- Applicability based on Risk Assessment Matrix
- Using professional judgment (absent historical
data) how applicable will this hazard be in
future mishaps without mitigation
87Risk Assessment Matrix
Probability
Frequent Probable Occasional Remote Improbable
Catastrophic 6.0 5.7 5.1 4.8 3.9
Critical 5.4 4.2 3.3 2.7 2.1
Marginal 4.5 3.0 1.8 1.5 0.9
Negligible 3.6 2.4 1.2 0.6 0.0
Severity
Values here are used to help score hazards
Table derived from DoDI 6055.1 E7, Mil-Std 882,
and Joint MTTP on Risk Management
88CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Mishap severity categories
- CATASTROPHIC - Complete mission failure, death,
or loss of system - CRITICAL - Major mission degradation, severe
injury, occupational illness, or major system
damage - MARGINAL - Minor mission degradation, injury,
minor occupational illness, or minor system
damage - NEGLIGIBLE - Less than minor mission degradation,
injury, occupational illness or minor system
damage
89CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Mishap probability categories
- FREQUENT
- Individual item - Occurs often in the life of the
system - Fleet or inventory - Continuously experienced
- Individual Airman - Occurs often in career
- All Airmen exposed - continuously experienced
- PROBABLE
- Individual item - Occurs several times in the
life of the system - Fleet or Inventory - Occurs often
- Individual Airman - Occurs several times in a
career - All Airmen exposed - Occurs often
- OCCASIONAL
- Individual item - Will occur in the life of the
system - Fleet or Inventory - Occurs several times in the
life of the system - Individual Airman - Will occur in a career
- All Airmen exposed - Occurs sporadically
90CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Mishap probability categories
- REMOTE
- Individual item - Could occur in the life of the
system. - Fleet or Inventory - Can be expected to occur in
the life of the system. - Individual Airman - Could occur in a career.
- All Airmen exposed - Seldom occurs.
- IMPROBABLE
- Individual item - So unlikely you can assume it
will not occur in the life of the system. - Fleet or Inventory - Unlikely but could occur in
the life of the system. - Individual Airman - So unlikely you can assume it
will not occur in a career. - All Airmen exposed - Occurs very rarely.
91Risk Assessment Matrix
Probability
Frequent Probable Occasional Remote Improbable
Catastrophic 6.0 5.7 5.1 4.8 3.9
Critical 5.4 4.2 3.3 2.7 2.1
Marginal 4.5 3.0 1.8 1.5 0.9
Negligible 3.6 2.4 1.2 0.6 0.0
Severity
92CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 3 Assign a Power (P1) and Applicability (A)
value to each hazard (discuss as group but assign
own, will average) - P1 Hazard Importance Rated 0-6
- 0 - No Influence 3 - Moderate
Influence 6 - Completely Influential - 1 - Little Influence 4 - Quite
Influential - 2 - Slight Influence 5 - Highly
Influential - P1 6
- Applicability based on Risk Assessment Matrix
- A 5.2
93CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 4 Assign / develop a control measure for
each hazard considering the control measure
options - Note There may be multiple control measures for
each hazard -
- Hazard
- Solely relying on aural warnings for altitude
reference (man)
94CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 4 Assign / develop a control measure for
each hazard considering the control measure
options - Note There may be multiple control measures for
each hazard -
- Hazard
- Solely relying on aural warnings for altitude
reference (man) - Control measure
- Allow PGCAS to get pilot attention in another way
such as a stick - bump
95CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 5 Assign a Power (P2) and Confidence (C)
value to each control measure (discuss as group
but assign own, will average) - P2 Control measures ability to mitigate hazard
Rated 0-6 - 0 - No ability 3 - Moderate
ability 6 - Completely able - 1 - Little ability 4 - Quite able
- 2 - Slight ability 5 - Highly able
- C Confidence that implementation measure will
perform as expected Rated 0-6 - 0 - No Confidence 3 - Moderate
Confidence 6 - Completely Confident - 1 - Little Confidence 4 - Quite Confident
- 2 - Slight Confidence 5 - Highly Confident
96CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- Step 5 Assign a Power (P2) and Confidence (C)
value to each control measure (discuss as group
but assign own, will average) - P2 Control measures ability to mitigate hazard
Rated 0-6 - 0 - No ability 3 - Moderate
ability 6 - Completely able - 1 - Little ability 4 - Quite able
- 2 - Slight ability 5 - Highly able
- P2 5.5
- C Confidence that implementation measure will
perform as expected Rated 0-6 - 0 - No Confidence 3 - Moderate
Confidence 6 - Completely Confident - 1 - Little Confidence 4 - Quite Confident
- 2 - Slight Confidence 5 - Highly Confident
- C 4.2
97CFIT JSAT ProcessControlled Flight Into Terrain
Joint Service Analysis Team
- What we do with the numbers
-
- Results of example
- P1 6, A 5.4, P2 5.5, C 4.2
- Power 5.7 Overall Effectiveness 3.6
- Results evaluated, sorted and sent to JSIT for
further evaluation
98This is what we strive to avoidQuestions ??
99Operational Risk Management - The Air Force Way
Headquarters Air Force Safety Center Lt Col Denny
Peeples Ms. Karen Kinkle