Risk Perspectives in Marine Corps Aviation Training and Operations Presented to the 5th International High-Reliability Organizing Conference by Major Randy Cadieux, USMC, M.S., MEng *Note, this material represents the views of the author and does not imply DoD, USMC, or USN endorsement

Overview • Overview of risk components • Risk perspective in basic core skills competency training, Deployments For Training, and Combat Operations • Production pressure • Overall risk planning considerations – Impacts – Routine vs. Non-Routine Operations

• Conclusions

Risk Components • Risk = Hazard + Probability + Severity • Hazard-A condition that can cause harm to personnel, equipment, or the environment – “Aircraft flies under it’s own power and crashes into mountain”

• Probability-the likelihood that a hazard will actually occur, often expressed in frequency – “Likely to occur in the next several days”

• Severity-The level of injury or damage experienced if the hazard occurs – “Permanent partial disability, fatality, total loss of aircraft”

ORM Risk Assessment Codes • Initial RAC – Risk Assessment Code combines probability and severity to obtain a RAC before the introduction of hazard controls

• Implementation of Hazard Controls – Hierarchy of Controls (Z10-elimination, substitution, engineering controls, warnings, admin cntrls, PPE)

• Final RAC – Risk Assessment Code with a reduction in probability and/or severity (often difficult unless a combination of controls used (ex: engineering controls and PPE)

• Residual Risk – The remaining risk (accept or iterate the process)

Hazard Relationships • Hazard-Cause-Effect • Hazard-the event that actually harms personnel, equipment, or environment • Cause (initiating mechanism) – “Aircrew descended below minimum altitude as a result of a failed ADHRS.”

• Effect-Level of injury or damage

Hazard Relationships • Risk reduction can be accomplished in several ways – 1) Reducing the probability of hazard occurrence • Implement controls to reduce likelihood of cause • Reduce exposure levels, duration

– 2) Limit the severity of damage/injury • Implement controls to protect personnel/equipment (barriers, PPE) • Implement ways to recover from adverse event – Business Continuity Management, alternate supply chains, warehouses, information backup

– 3) Using a combination of controls, may be possible to reduce both probability and severity (PRCS + SAR or SCBA/EOD robots with suit)-limit exposure and protect employee

Risk PerspectiveNaval Aviation Training Command • Typically training with one qualified instructor and an unqualified student aviator • Primary flight training – Single-engine aircraft – T-34C has no ejection seat (T-6 ejection seat) – Often includes training with one Instructor Pilot and a student aviator with limited flight time and very little time in the aircraft

• Risk perspective is conservative • Primary vs. advanced phase of training – More experience overall, but new to aircraft

Risk PerspectiveNaval Aviation Training Command • Considerations (I’MSAFE Checklist) – Illness – Medicine – Stress – Alcohol – Fatigue – Eating

• Preparation • Attitude • Weather-“Even if it’s legal, does it make sense?”

Risk PerspectiveBasic Core Skills Training • Basic level training (100 level codes) typically conducted in CONUS in Fleet Replacement Squadron • Often conducted with crewmembers attempting to become qualified in the aircraft with very limited experience – Qualified instructors – Replacement Pilots, often fresh out of flight school

• Risk perspective is slightly less conservative than primary flight training – The likelihood of mission execution and potential mishap occurrence must be balanced against the capabilities of the crew and the production requirements

Risk PerspectiveBasic Core Skills Training • Considerations – Weather minimums – Maintenance requirements (FMC vs. PMC Aircraft) – Fatigue – Code level completion requirements and aviator time-to-train – Experience level of crew

• Even if it is “legal” (falling within the rules or guidelines) does it make sense to perform the mission? – 4 Principles of ORM

Risk PerspectiveDeployments for Training (DFT) Advanced level of core skills training Often training involves advanced combat tactics Training often linked to combat deployments Level of integration with other units higher than basic core skills training • More capable crews • Risk perspective generally less conservative than during basic core skills training (100 level codes), but more conservative than during combat operations • • • •

Risk PerspectiveDeployments for Training (DFT) • Considerations – Weather minimums – Maintenance requirements (PMC vs. FMC aircraft) – Fatigue – Impact to unit readiness if mission not performed – Experience level of crew and level of interaction with other units – Planning and communications clarity

• How will cancelling or not completing the mission affect the crew’s ability or the unit’s ability to effectively operate in combat?

Risk Perspective-Combat Ops • Tight integration with ground and other air units • Fully combat-capable aircrew • Attempt to deploy with armor and other active and passive hazard controls/threat reduction technology • Mission requirements often driven by other supported units • Risk perspective is less conservative than basic core skills training or DFT’s • Supported unit’s risk level often drives risk-based decisionmaking – Troops In Contact (KC-130 AAR example)

Risk Perspective-Combat Ops • Considerations – Supported unit requirements – Threat and tactics – Weather requirements – Maintenance Requirements (PMC vs. FMC Aircraft) – Level of unit integration into overall plan

• “What is the impact to the supported unit if we fail to complete the mission?” – Lives lost? – Overall mission failure? – Big picture

Risk Perspective Overall • Although risk perspective and level of acceptance or aversion on the risk continuum may shift, Operational Risk Management is applied during all operations – “…the goal of ORM is not to eliminate risk, but to manage the risk so the mission can be accomplished with the minimum amount of loss.”

• The 4 Principles of ORM and the 5-step planning process is used in all operations to achieve acceptable levels of risk

4 Principles of ORM • 1) Accept No Unnecessary Risk – Risks are only taken when necessary for mission accomplishment

• 2) Anticipate and Manage Risk through Planning – Proactive identification makes risks easier to control

• 3) Accept Risk When Benefits Outweigh the Costs • 4) Make Risk Decisions at the Right Level – Decisions made by those in charge of operations – If it is determined that leaders cannot control risk at their level, the decision is raised to higher levels of authority

Production Pressure • Operators, supervisors, and (most importantly) leaders must be aware of the organizational pressures placed on personnel • Actual pressure – Explicit stated goals require line operators to make tradeoffs and sacrificing judgments

• Perceived pressure – Often felt by operators due to statements or actions by senior personnel even if they are not specifically told to execute a mission, operation, procedure, or task – End-state is often the same; line operators execute as if there were explicit instructions to meet mission or performance requirements

Risk Planning Considerations • Risk is often thought of in terms of: – – – –

Injuries Fatalities Damage to equipment Damage to the environment

• Consider the impact to: – Reputation (once damage is done, it can be hard to recover) – Ability to continue to meet stakeholder requirements – Ability to support employees – Less visible impacts (invisible wounds affect morale and production) – Long-term sustainability and survivability of organization

Risk Planning Considerations • Low-Probability/High-Severity possibilities should be considered – “Just because it hasn’t happened doesn’t mean it won’t happen.”

• High-Frequency/Low-Severity events can still have a major impact and need to be considered • Non-Routine Ops vs. Routine Ops – Change: “The mother of all risk” – Management of Change (MOC) is essential • Detailed risk assessments using a diverse team with effective communication

– Marine Corps aviation mishaps during routine ops • It is easy to be lulled into a false sense of security

Conclusions • Risk considerations should include assessing hazards in terms of probability and severity • Leaders should understand that dynamic environments will change risk perspective and possibly risk appetite – Risk ALARP and tolerance may be different depending on the industry and operation, and requires leadership oversight

• Consider the potential impact on personnel and the organization • Consider risk perspective during routine and unique events

References • MCO 3500.27B. Operational Risk Management • Ericson II, Clifford. Hazard Analysis Techniques for System Safety. 2005. • safetycenter.navy.mil • MIL-STD-882D, Department of Defense Standard Practice on System Safety