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