210 likes | 216 Views
Minnesota Wing Safety Meeting July 2010. Lt Col Larry Brockshus MN Wg /SE. Overview. ORM review June Safety Beacon Lessons learned from a mishap Cadet injuries on the RISE Tire Pressure. Civil Air Patrol ~ Air Force Auxiliary.
E N D
Minnesota Wing Safety MeetingJuly 2010 Lt Col Larry Brockshus MN Wg/SE
Overview • ORM review • June Safety Beacon • Lessons learned from a mishap • Cadet injuries on the RISE • Tire Pressure
Civil Air Patrol ~ Air Force Auxiliary I n t e g r i t y - S e r v i c e - E x c e l l e n c e Operational Risk Management Lt Col Brillo Macklin CAP-USAF SWLR/DO 16 Oct 2003
What is ORM? Poor Judgment . . . Leads to accidents I n t e g r i t y - S e r v i c e - E x c e l l e n c e
What is ORM? • Natural Evolution From Traditional Risk Management • Systematic Decision-Making Tool • All Dimensions of Risk Considered “First reckon, then risk” Field Marshall Helmuth Von Moltke I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Why ORM? • Ensure Necessary Risks are Taken • An Important Tool for Realistic Training • Significant Potential to Expand Capabilities I n t e g r i t y - S e r v i c e - E x c e l l e n c e
4 Key Principles • Accept No Unnecessary Risks • Make Risk Decisions at Appropriate Level • Accept Risks When Benefits Outweigh Costs • Integrate ORM into Doctrine and Planning at all Levels I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Implement Risk Controls 3. Analyze Risk Control Measures 4. Make Control Decisions 6 Step Process I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Implement Risk Controls 3. Analyze Risk Control Measures 4. Make Control Decisions Step 1 Identify the Hazards Process: Emphasize hazard ID tools. Adds rigor and early detection Output: Significant improvement in the detection of hazards (50%+) I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 5. Implement Risk Controls 3. Analyze Risk Control Measures 4. Make Control Decisions 2. Assess the Risks Step 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. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Implement Risk Controls 4. Make Control Decisions 3. Analyze Risk Control Measures Step 3 Analyze Risk 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 I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Implement Risk Controls 3. Analyze Risk Control Measures 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. Step 4 Make Control Decisions I n t e g r i t y - S e r v i c e - E x c e l l e n c e
1. Identify the Hazards 6. Supervise and Review 2. Assess the Risks 5. Implement Risk Controls 3. Analyze Risk Control Measures 4. Make Control Decisions Step 5 Implement Risk Controls Process: Leaders lead, operators involved, accountability known Output: Controls approved by decision-maker are implemented I n t e g r i t y - S e r v i c e - E x c e l l e n c e
6. Supervise and Review 1. Identify the Hazards 2. Assess the Risks 5. Implement Risk Controls 3. Analyze Risk Control Measures 4. Make Control Decisions Step 6 Supervise & Review Process: Measures mission effectiveness and direct indicators of risk. Output: Real time status. Proactive NOT reactive. I n t e g r i t y - S e r v i c e - E x c e l l e n c e
USAF APPROACH • Top-Down • Strong Senior Leader Backing • Decentralized Implementation • Safety Lead Role for Cross-Functional Implementation I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Education & Training • Short Term • Executive Level - Senior Leaders • Applications & Integration - Focal Points/Planners • Essentials - Mid-level Managers/Supervisors • Fundamentals - “Working” Level • Introduction – All • Long Term - Institutionalized into all Training & Education I n t e g r i t y - S e r v i c e - E x c e l l e n c e
FLY SAFE! I n t e g r i t y - S e r v i c e - E x c e l l e n c e
Lessons learned from a mishap • Safety consciousness does not make you invulnerable • If you have not done it in a while, rethink it • Watch how a person does something, not just that they are doing something • When tired, slow down
Cadet Injuries on the RISE! • Pre-existing conditions • Non-reported condition aggravated by CAP activity • Horseplay • Goofing off, rough housing • CPFT • No warm up or enforcement of proper exercise • Team sports • Not appropriate or unsupervised (tackle football) • New members • No safety education • Passing out in formation • Hydration, nutrition, locked knees
Tire pressure • Several tire related mishaps • Tire integrity • Pilot technique • Tire pressure • NTSB report on a Learjet mishap in 2008 • All four mains severely under inflated • Under inflation compromised tire integrity • Tire failed after V-1 (S-1 for military); pilot attempted abort • Failed tire also damaged sensor which retracted thrust reversers resulting in takeoff thrust during abort • Aircraft departed runway…Four killed, two injured