ORM Civil Air Advanced Patrol ADVANCED LEVEL OPERATIONAL RISK

ORM Civil Air Advanced Patrol ADVANCED LEVEL OPERATIONAL RISK MANAGEMENT ADV ORM Version 2 12.9.2010 1

Advanced ORM IMPORTANT The NOTE! material in this presentation provides some worthwhile information on risk management. However, the content is dated and does not necessarily reflect the current guidance found in CAPR 1601 and CAPR 160-2, and should be considered informational only ADV ORM Version 2 12.9.2010 2

Advanced ORM In CAP’s Basic and Intermediate course you learned that Operational Risk Management is a logic-based, common sense approach to making calculated decisions on human, material and environmental factors associated with any type of activity. Or simply put, it’s a methodical, six-step process to manage inherent risk. ORM does not replace regulations or allow CAP officers and cadets to disregard existing regulations. ORM fills the gap between real-world conditions and scenarios which are not already covered under regulation or law. Use of ORM does not guarantee mission success, but provides a standard methodology for avoiding or reducing mishaps. If your have forgotten certain aspects of ORM, go back over the two previous courses before proceeding. ADV ORM Version 2 12.9.2010 Otherwise here is a refresher of the main points of ORM.

Advanced ORM The four principles of ORM The six-steps of ORM are: are: 1. Identify the Hazards 1. Accept no unnecessary risks 2. Assess the Risks 2. Make risk decisions at the 3. Analyze the Risk Control appropriate level Measures 3. Accept risk when benefits 4. Make Control Decisions outweigh the cost 5. Implement Risk Controls 4. Integrate ORM into CAP at 6. Supervise and Review all levels The 5M Model The three levels of ORM 1. Man 1. Time-Critical 2. Media 2. Deliberate 3. Machine 3. Strategic 4. Management 5. Mission ADV ORM Version 2 12.9.2010

Advanced ORM This advanced course will enhance mission success by increasing your knowledge of the ORM process with the addition of some new items. Ten hazard identification tools are presented to guide you in uncovering areas of potential hazards as you work through ORM’s first step. The course will also explore steps two through six in greater detail. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards To identify the hazards, you analyze the mission, list the hazards and list the causes. Perform hazard ID on all of CAP’s assets: Aircraft Vehicles Personnel Equipment Apply hazard ID to all operational levels: National Region Wing Group Squadron & Flights ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards These seven primary tools are the backbone in identifying hazards in any CAP operation. The Seven Primary Hazard ID Tools: A. Operations Analysis B. Preliminary Hazard Analysis C. “What If” Tool D. Scenario Process Tool E. Logic Diagram F. Change G. ADV ORM Version 2 12.9.2010 Analysis Cause & Effect Tool

Advanced ORM Step 1. Identify Hazards Operations Analysis Tool Used mostly by planners. Big picture look at what is expected to happen. Evaluates all elements of operation for potential sources of risk. Overcomes focusing on only a few intuitively identified risky operational areas. Itemizes chronological or sequential list of major events of an operation. Key to understanding which event(s) pose the highest level of risk. Each ADV ORM Version 2 12.9.2010 event can be broken down into sub-events.

Advanced ORM Step 1. Identify Hazards Operations Analysis Tool Key to understanding flow of events. Overcomes major weakness of only focusing on a few intuitively identified risky operational areas. Pen & Paper: Put steps of process on index cards or “sticky” notes. Can rearrange as necessary. Easily add or eliminate areas or events. Computer: Use project management software or create simple flow chart. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Preliminary Hazard Analysis Tool Provides initial or broad overview of hazards present in overall operational flow. Briefly considers risk in every aspect. Can serve as only hazard ID tool if risk is low or routine. In higher risk operations, used to focus and prioritize risk issues. Used in virtually all ORM except time critical operations. Usually based on the operational analysis tool results ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Preliminary Hazard Analysis Tool Used to identify hazards requiring more in-depth hazard ID Easy to use and takes very little time Activity or Event Hazard Step 1 Hazard 1 Hazard 2 Step 2 Hazard 1 Step 3 Hazard 1 Hazard 2 ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards “What If” Tool One of the most powerful hazards ID tools. Designed to add structure to the intuitive and experiential expertise of operational personnel. Especially effective in capturing hazard data about failure modes. Typically used after the operations analysis and preliminary hazard analysis. Can be used on time critical applications. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards “What If” Tool Captures input of operational personnel in brainstorming–like environment. Participants should have through operation flow knowledge. Visualize expected operational flow in chronological order from beginning to end. Select Use a segment to focus on. “Murphy’s Law” to anticipate failures and worsecase scenarios. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Scenario Process Tool Identify hazards using imagination and visualization to reveal unusual hazards. Construct a mental movie to walk thru events immediately ahead of and of the actual hazard. Visualize twice; once as they should be, then with worse credible scenarios. Ability to link two or more individual hazards makes it one of the best tools. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Scenario Process Tool Entertaining, dynamic and motivating for even the most junior personnel. Best to follow flow of events outlined in the operational analysis tool. Can be only tool needed in time critical events. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Logic Diagram Provides the maximum structure and detail of the primary hazards identification tools. It’s graphics captures and correlates the hazards data produced by the other tools. Tree-like structure establishes the connectivity and linkages that may exist between hazards. Most effective with complicated operations where hazards are interlinked in various ways. Excellent place to use the 5M Model – Interaction between Man, Machine, Media, and Management to produce Mission success. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Logic Diagram The most comprehensive of the primary hazard identification tools. Three major types of logic diagrams Positive diagram. Highlights factors that must be in place if risk is to effectively controlled. Event diagram. Focuses on one event, often a failure identified with “what if” tool, and examines possible outcomes. Negative diagram. Selects a loss event and analyses various hazards that could combine to produce that loss. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Logic Diagram Generic Logic Diagram ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Logic Diagram s Successful drive to SAREX Man Physically Ready Mentally Ready Example of Positive Logic Diagram Emotionally Ready Legally Ready Machine Mechanically Ready Safety Equipment Ready Media Weather Conditions Road Conditions Road Structure Management Traffic Rules Enforcement ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Logic Diagram Example of Negative Logic Diagram Speeding Road Rage Weather Automobile Accident Inattention Road Conditions Reckless Driving Mechanical Failure Falling Asleep ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Change Analysis Used to analyze the hazard implications of planned or unplanned changes. Focuses only on the changed aspect of event. Compare the current situation with the previous one. Only tool needed if operation has been subjected to in-depth hazard analysis. Best accomplished using a simple worksheet. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Change Analysis Worksheet Factors Evaluated Situation What Equipment Building Safety issues Where In the process Location When In time In sequence Who Personnel Customer ADV ORM Version 2 12.9.2010 Comparable Situation Difference Significance

Advanced ORM Step 1. Identify Hazards Change Analysis Worksheet Factors Evaluate Comparabl d e Situation Situation Differenc e Significanc e Task Procedure Goal Working Conditions Duty day Weather Trigger Event Managerial Controls Chain of Command Hazard Analysis Risk Monitoring To use the worksheet: Start at the top of the left column and work across. Consider the current situation. Compare it to a previous situation in a similar operation. Identify differences and determine if changes will cause any ADV ORM Version 2 12.9.2010 significant hazards. Modify worksheet to operation specifics.

Advanced ORM Step 1. Identify Hazards Cause & Effect Tool Brainstorming is used to identify causes, using the 5M Model, that may lead to a hazard. Uses the “Fishbone” or Ishikawa Diagram, after inventor Professor Kaoru Ishikawa of Tokyo University, a highly regarded expert in quality management. Illustrates hierarchical relationships between possible causes according to their level of importance. Can be drawn on flip chart or whiteboard. Variation ADV ORM Version 2 12.9.2010 of the Logic Diagram.

Advanced ORM Step 1. Identify Hazards Cause & Effect Tool “Fishbone” Diagram ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Cause & Effect Tool “Fishbone” Diagram ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool USAF identifies 14 specialty hazard ID tools used to augment the primary tools. Three are covered here: A.The Mapping Tool B.The Interface Analysis C.Mission ADV ORM Version 2 12.9.2010 Protection Tool

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool A. The Mapping Tool Involves using road maps, terrain maps, airport diagrams, facility blueprints and system schematics to identify sources of hazards. Potential hazards are steep terrain, creeks and streams, winding mountainous roads, desert areas, flammables, and high voltage areas. Locate energy sources and other hazards on the map and note distance to operation and resources. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool A. The Mapping Tool Someone who has seen the map object is an invaluable resource to consult. An on-site inspection should occur before the operation begins. Incorporate these hazards into other Primary Hazard ID Tools ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool B. The Interface Analysis Used to uncover potentially hazardous linkages or interfaces between unrelated activities. A SAR/SAREX at a local airport may impose hazards to the local airport operations, facilities and pilots. CAP operations at a airport not used before is a good cue to use the interface analysis and the Primary Hazard ID Change Analysis. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool The Interface Analysis Example Matrix Energy Interface Generators Personnel Interface Mission Base Personnel Flight line Personnel Airport Personnel Equipment Interface Aircraft Trailers Supply Interface Food Product Interface Mission Information Interface ATC FBO Bio-Material Interface None ADV ORM Version 2 12.9.2010 Trailers for Communication Antenna Vehicles Catering Base Equipment

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool C. Mission Protection Tool Designed to focus on protection of the mission rather than on protection of personnel or other assets. Mitigates partially or completely stopping the mission by events that injure no one or cause no damage. Identify key components of mission continuity and success and what could interrupt them. Has no specific method or worksheet and is characterized by its focus. ADV ORM Version 2 12.9.2010

Advanced ORM Step 1. Identify Hazards Specialty Hazard ID Tool C. Mission Protection Tool Examples to consider that may prevent missions from proceeding are: Computers or Internet service not available. CAP Forms, weather reports, personnel contact information Spare parts not available for resources. Aircraft & vehicle tires, backup radios Emergency at intended airport or FBO preventing setting up mission base. ADV ORM Version 2 12.9.2010

Advanced ORM Step 2. Assess the Risk Risk is assessed based on exposure, severity, and probability in the order of most likely to least likely to happen using the risk assessment matrix. ADV ORM Version 2 12.9.2010

Advanced ORM Step 2. Assess the Risk Three Problems with Standard Matrix Subjectivity in the two dimensions of the matrix due to individual interpretation of Severity and Probability. Inconsistency because of subjectivity. Problem arises if the two hazards are competing for same risk control resource. Only four ranges with most falling in the medium and high risk level. ADV ORM Version 2 12.9.2010

Advanced ORM Step 2. Assess the Risk Modified Risk Matrix ADV ORM Version 2 12.9.2010

Advanced ORM Step 2. Assess the Risk Modified Risk Matrix 20 levels of risk, using a top-down order of priority. Highest risk is number 1. Helps Can to prioritize risk control efforts. be used to group risks into clusters of related risks. Does it. ADV ORM Version 2 12.9.2010 not replace the standard matrix but augments

Advanced ORM Step 3. Analyze Risk Control Measures Analyzing Risk Control Measures involves three actions. Identify Control Options Determine Prioritize Control Effects Control Measures Important to keep risk at the best acceptable level using control options, even if risk seems to be at an acceptable level. ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Identify Control Options Eight major risk control options are designed to have the broadest application: Reject the Risk Avoid the Risk Delay the Risk Transfer the Risk Spread the Risk Compensate for the Risk Accept the Risk Reduce the Risk ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Identify Control Options Reject the Risk if overall risks exceed benefits. It is the correct option if you do not have the authority to put proper controls in place. Avoid the Risk by going around it or by performing the operation in another way. Delay the Risk is the right answer if there is no urgency to perform the operation. The hazard could go away or the operation may not needed. ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Identify Control Options Transfer the Risk to another individual or operation. The hazard is not eliminated but may be better controlled with a different operator and/or equipment. Spread the Risk by increasing the exposure distance or increase the time between exposure events. Compensate for the Risk by having redundant capabilities; extra resources or parts. Accept the Risk if benefits exceed the cost in personnel and resources. Use risk controls to reduce the risk to it’s lowest possible level. ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Identify Control Options Reduce the Risk is the most widely used option. Brainstorm to come up with ideas or use the Risk Control Options Matrix. Risk Control Options Matrix uses 46 proven ways to reduce risk from most preferred to least preferred control area ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Risk Control Options Matrix Options ENGINEER/ENERGY MANAGEMENT Limit Energy Substitute Safer Form Prevent Buildup Prevent Release Provide Slow Release Re-channel/Separate in Time/Space Provide Special Maintenance of Controls GUARD On Source Barrier Between On Human or Object Raise Threshold (Harden) ADV ORM Version 2 12.9.2010 Examples Reduce speeds, reduce heights Less hazardous chemicals Automatic cutoffs, limit momentum Containment, chock A/C & vehicles Use energy absorbing materials Barriers, launch A/C farther apart Special procedures, checklists Fire suppression, energy absorption Walls, distance Personal protective equipment Reinforce, physical conditioning

Advanced ORM Step 3. Analyze Risk Control Measures Risk Control Options Matrix (Cont’d) IMPROVE TASK DESIGN Sequence of Events/Flow Timing (within/between tasks) Man-Machine Interface/ Ergonomics Simplify Tasks Reduce Tasks Loads Physical, Mental, Emotional Backout Options LIMIT EXPOSURE Number of People/Items Time Interactions SELECTION OF PERSONNEL Mental Criteria Emotional Criteria Physical Criteria Experience ADV ORM Version 2 12.9.2010 Toughest task first, only a few in a row Allow enough time, don’t rush Proper fitting equipment, good design Provide job aids, safely reduce steps Set weight limits, use automation Avoid excessive stress, provide breaks Stop process if new hazards observed Only expose essential personnel & things Minimize time of exposure Limit repeat exposures Essential skills,proficiency,common sense Essential stability and maturity Essential strength,endurance,motor skills Demonstrate performance abilities

Advanced ORM Step 3. Analyze Risk Control Measures Risk Control Options Matrix (Cont’d) TRAIN AND EDUCATE Core Tasks (especially critical tasks) Leader Tasks Emergency Contingency Tasks Safety Tasks Rehearsals Define min abilities: train, test, score Define leader standards: train,test,score Define, assign, train, verify ability Hazard ID, risk controls, standards Validate process, skills, verify interfaces WARN Signs/Color Coding Audio/Visual Alarms Briefings Warning, instruction and traffic signs Bells, flares, flashing lights, whistles Refresher training, demonstrate hazards MOTIVATE Measurable Standards Essential Accountability Positive/Negative Incentives Competition Demonstrations of Effects Define min acceptable risk controls Check performance at essential levels Meaningful awards or punishment Healthy competition on a fair basis Graphic, dynamic, tasteful demos of effects of unsafe acts ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Risk Control Options Matrix (Cont’d) REDUCE EFFECTS EMERGENCY Equipment Rescue Capabilities Emergency Medical Care Emergency Damage Control Procedures Backup/Redundant Capabilities REHABILITATE Personnel Facilities/Equipment Mission Capabilities ADV ORM Version 2 12.9.2010 Fire Extinguishers, first aid materials Rescue squad, equipment, 911 Quality first aid personnel and facilities Emergency responses, co-agencies Alternate ways to perform mission Rehabilitate to restore confidence Return key elements back to service Focus on restoration of mission

Advanced ORM Step 3. Analyze Risk Control Measures Determine Control Effects. From the control matrix, determine what effect each option will have on the associated hazard. Prioritize Risk Controls. Controls must be chosen and prioritized that make the most effective and efficient use of mission available resources. Establish guidelines that will direct which control measure to recommend and implement. ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Guidelines for selecting risk control measures Follow all published directives. Select combinations yielding the most missionsupportive risk level; not necessary the lowest risk as there is a risk of mission ineffectiveness with not taking risks. Avoid incompatible risk controls. Do not have only Gatorade available to combat dehydration if persons are allergic to food additives; have water available also. Choose risk controls that reinforce each other. Discipline safety rule violators and have a special awards program for following safety procedures and being accident free. ADV ORM Version 2 12.9.2010

Advanced ORM Step 3. Analyze Risk Control Measures Guidelines for selecting risk control measures Evaluate full costs versus full benefits, not isolated areas. Apply controls to activities and personnel actually at risk. Choose redundant risk controls when it is mission supportive, practical and cost effective, but do not waste resources. The goal is optimum risk control. ADV ORM Version 2 12.9.2010

Advanced ORM Step 4. Make Control Decisions Develop a decision making process and system that establishes who will select the risk controls to implement and who determines the final go/no-go decision. EXAMPLE of Risk Decision Making Personnel for Risk Level Decision Level SAREX 01-03, 04-08, 09-13, 14-20, Extremely High High Medium Low ADV ORM Version 2 12.9.2010 Wing Commander Incident Commander Mission Safety Officer Operations/Planning Section Chief

Advanced ORM Step 4. Make Control Decisions The decision maker Must pick the controls. Oversee Decide how much to spend. Be responsible for the outcome of the operation. Be able to obtain resources needed. Be in control of the resources. Have their implementation. authority in the chain of command. Implement a good decision making process by using a decision matrix. ADV ORM Version 2 12.9.2010

Advanced ORM Step 4. Make Control Decisions Rank each risk control option considering on a scale of 1 to 10, 1 being the lowest and 10 the highest, on a list of chosen desirable characteristics. Add up each risk’s score. The option with the highest score is chosen. An example of decision matrix follows: ADV ORM Version 2 12.9.2010

Advanced ORM Step 4. Make Control Decisions Example of Decision Matrix Characteristics Control Option: 1 2 3 4 5 6 7 Low Cost 5 8 6 1 0 4 9 9 Easy to Implement 8 8 5 9 9 5 7 Positive Operator Involvement 7 4 7 1 0 6 4 8 Consistent with Culture 5 7 6 7 6 3 6 Easy to Integrate 1 6 2 1 0 5 9 7 Easy to Measure 8 4 9 5 8 7 9 Low Risk/Sure to Succeed 8 1 0 7 9 1 0 8 9 ADV ORM Version 2 12.9.2010

Advanced ORM Step 5. Implement Risk Controls Once the risk control decision is made, assets must be made available to implement specific controls. To implement risk controls Develop a complete action plan Establish Provide ADV ORM Version 2 12.9.2010 accountability a means of resource support

Advanced ORM Step 5. Implement Risk Controls Develop an action plan to manage the control options: Determine Estimate Set all manpower and resources needed. cost to implement each control. a timeline that clearly sets milestones and goals. Assign Enlist tasks and due-dates to specific personnel. user input to establishment ownership. Provide job aids, tools and examples to make implementation clear to everyone. Measure performance. Document ADV ORM Version 2 12.9.2010 any outside support given.

Advanced ORM Step 5. Implement Risk Controls Establish levels of accountability: Identify person responsible for successful implementation of each control measure. Identify unit or operations level person responsible for the implementation as a whole. Combine the power of command with leadership to maintain accountability. Establish motivation and create meaningful and positive incentives for success. Involve persons affected by the controls during implementation. ADV ORM Version 2 12.9.2010

Advanced ORM Step 5. Implement Risk Controls Resource support includes six components: Policy support with operating instructions, technical orders, and any standard operating procedures. Command support showing the absolute backing of the leadership. Training support for personnel implementing controls. Tools support including job aids, checklists, decision guides and instructions. Measurement support to determine if timelines, schedules and standards are being met. Motivation support providing the positive and negative incentives for a successful risk control. ADV ORM Version 2 12.9.2010

Advanced ORM Step 6. Supervise and Review Determining the effectiveness of risk control involves setting a goal, knowing where you are in relation to the goal, and a plan in place to reach the goal. This last step of ORM involves Supervise Review Feedback ADV ORM Version 2 12.9.2010

Advanced ORM Step 6. Supervise and Review Supervise the implementation plan, insure all are in place, monitor all controls, and make certain they are effective. Controls are effective if they bring about favorable changes to the physical condition or personal behavior. If control is ineffective, correct or discontinue. Can use the Change Analysis Tool from Step 1 to reevaluate any changes that require further risk management. ADV ORM Version 2 12.9.2010

Advanced ORM Step 6. Supervise and Review Review the total cost verses total benefits the controls provide; for each control consider both physical and behavioral changes. Costs should be in line with expectations. The benefits in risk reduction should be greater than the cost of the control measure. Benefits or effectiveness of controls should be compared to forecasted goals. A simple cost vs. benefit matrix is recommended. ADV ORM Version 2 12.9.2010

Advanced ORM Step 6. Supervise and Review Feedback is the essential element in Step 6. It provides the ability to share success and failure. One of the basic rules of ORM is to stop reinventing the wheel and learn from past practices and from the mistakes of others. Feedback should go to all personnel; from new cadets to commanders. Effective risk controls that increase the overall mission success should be a part of every CAP member’s lessons learned file. ADV ORM Version 2 12.9.2010

Advanced ORM Conclusion To fully realize all the benefits from ORM, it must be integrated into every aspect of CAP’s organization and it’s missions. All levels of CAP should proactively promote and use ORM. It’s use will benefit everyone by improving mission capability, enhancing better decision making, reducing accidents and injuries, preserving our assets. ADV ORM Version 2 12.9.2010

Advanced ORM References Air Force Policy Directive 90-9, Operational Risk Management Air Force Instruction 90-901, Operational Risk Management Air Force Pamphlet 90-902, Operational Risk Management (ORM) Guidelines and Tools ADV ORM Version 2 12.9.2010

Advanced ORM Civil Air Patrol wishes to thank the USAF Safety Center for the use of their information in the creation of this presentation. ADV ORM Version 2 12.9.2010 64

Advanced ORM Close the presentation. Verify that you have read the required material then click the “Start Quiz” button. Thank your for your support of CAP’s safety program. ADV ORM Version 2 12.9.2010 65