2.11 Attachment 11 NAVAVSCOLSCOMINST 5100.1 Chapter 25 SAFETY AND OCCUPATIONAL HEALTH AND HIGH-RISK TRAINING SAFETY PROGRAMS.pdf

NAVAVSCOLSCOMINST 5100.1E

N7

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CHAPTER 25

RISK MANAGEMENT

25.01 General. Following the guidelines of reference (k), this instruction establishes the ORM program.

a. Uncertainty and risk are inherent in all military training. Success of the Naval Service is based upon a willingness to balance risk with opportunity for successful mission completion.

Commanders have a fundamental responsibility to safeguard the personnel and material resources entrusted to their care and to accept only the minimal level of risk necessary to accomplish the assigned mission.

b. Applying risk management principles in the training setting helps minimize the risk of negligence. Applying these principles throughout the organization can decrease risk, minimize loss and improve mission effectiveness.

c. The following program describes a systematic organization-wide program that focuses on all aspects of command operation. It is characterized by a system that provides both a decision making tool and the means to identify and initiate a response to hazards and adverse events. It also provides an opportunity to analyze data, which could indicate a negative trend or potential of risk/harm to staff, students, visitors, or the potential to degrade the mission.

25.02 Responsibilities.

a. Risk Management Manager. Per reference (k) the CO will appoint (in writing) the XO as the Operational Risk Management Manager (ORMM) and the outlying swim site OICs as the site

Assistant Operational Risk Management Manager (AORMM). NAVAVSCOLSCOM notice

1301 (Collateral Duty List) will satisfy this requirement. The ORMM shall implement and coordinate the ORM Program for NAVAVSCOLSCOM. The ORMM assistances assistants shall be appointed in writing using the Collateral Duty List.

b. Command Safety Officer/Training Safety Administrator. The CSO/TSA shall act as the

ORM program coordinator. Additionally, the CSO/TSA shall:

(1) Implement and coordinate the ORM Program organization-wide.

(2) Provide education and training to personnel.

(3) Maintain the ORM database.

(4) Investigate potential risk areas/issues and assist the department with the Operational

Risk Management Assessments (ORMA).

(5) Maintain a close liaison with the XO.

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(6) Ensure the appropriate documentation is completed per reference (k) of this manual.

(7) Maintain the ORM Quality Assurance documents in a secure location for three years prior to disposal per reference (k).

c. Role of Command Personnel. Every member of the command is a front line risk manager.

All personnel are responsible for accomplishing their mission in a safe, secure, and courteous environment. The should integrate ORM principles into all their daily routines and participate in

ORM activities. All staff members are encouraged to use the CSO/TSA to identify a process or event that has the potential for risk to personnel, material, or mission.

25.03 Metrics.

a. ORMA sheets in Appendix K are the data collection/reporting tools. They are also available from the CSO/TSA or DSR.

b. The ORMA should be completed under the following circumstances:

(1) To report events that are not consistent with normal operations.

(2) To report any sentinel event resulting in adverse consequences.

(3) To report a disturbance, environment factor, or unfavorable circumstance that increases the likelihood or severity of an adverse event, disrupts command function, or damages the command’s reputation.

c. Risk Management Data. The CSO/TSA acts as the central data collection and evaluation point for command adverse reporting. The ORM data will be collected, analyzed, and reported quarterly at the command safety committee meeting as needed. Any immediate concerns will be forwarded to the CO/XO.

d. Sentinel Event (SE). SEs are risk management occurrences which are severe in nature.

Examples of SEs are death, loss of limb, or limb function as a result of training provided by

NAVAVSCOLSCOM. An SE will be documented using the ORMs and immediately (within 25 hours) forwarded to the CSO/TSA to initiate investigation. All ORM occurrences that meet the

SE definition and/or a Risk Assessment Code of 1-2 will generate a Root Cause Analysis (RCA) and may require higher authority reporting.

e. Root Cause Analysis. RCA is a process identifying the basis or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.

The RCA focuses primarily on systems and processes, not individual performance. It progresses from common and/or special causes in processes to potential improvements that would decrease the likelihood of such events in the future. After analysis, it may determine that an improvement opportunity doesn’t exists. The RCA worksheet is available from the CSO/TSA or DSR.

f. Root Cause Analysis Team. The RCA team shall consist of:

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(1) Team Leader. The Team Leader shall possess leadership skills which shall allow them to implement improvement changes identified by the team. The Team Leader will organize the team and meetings, work with the facilitator, lead the team through the RCA process, compile and prepare the RCA and action plan for presentation, ensure the RCA summary report is timely, credible, and thorough, and keep leadership informed of the team’s progress.

(2) General Members. Staff involved with the processes and procedures or who have knowledge of the events that lead to the adverse outcome.

(3) Ad Hoc Members. Members that have expertise and experience with a specific event or who can affect improvement changes within the command.

(4) Resources. The team will be provided the necessary resources (time, records, personnel, meeting room, etc.) needed to complete a thorough and credible investigation within the time-frames required.

g. Action Plan. The RCA will produce an action plan identifying strategies the organization intends to implement to reduce the risk of future occurrences. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions. Examples are available from the

CSO/TSA.

25.04 Communication.

a. ORMAs are available in each department from the CSO/TSA.

(1) The individual possessing the most knowledge of the event should complete the

ORMA. If that party is not present when the event is discovered, the individual who discovers the event assumes the duty to submit an ORMA using Appendix K. Complete the front page of the screen. The back page is optional if comfortable assessing hazard severity and mishap probability.

(2) The information on the screen is confidential and should be handled expeditiously. The original report is forwarded to the CSO/TSA within 24 hours. Copies are never made.

(3) The ORMAs and any addendum reports of follow-up, including the RCA and action plan are considered confidential quality assurance documents. Any department manager can review an original screen by contacting the CSO/TSA.

(4) The ORMA is not used as a punitive measure. It cannot be used against a staff member during a disciplinary procedure. It is a factual accounting of the event that answers the questions: WHO, WHAT, WHEN, WHERE, WHY, and HOW the event occurred. It should also reflect what actions/procedures were initiated. Do not finger point, use accusatory language, or assign blame or guilt.

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(5) Local area generated ORMAs should be hand-delivered to the CSO/TSA (never guard mail).

b. Reporting Requirements. All information generated by the occurrence of sentinel events will be managed per Reference (k). NETC via CNATT will be notified within five days that a potential SE has occurred. If CNATT verifies it to be a SE, then a RCA will be initiated and completed within 45 days after notification. NETC requires submission of the original RCA and

Action Plan.

(1) A written report will be submitted to the CO twice per year.

(2) ORM data will be collated, graphically displayed, and presented to the senior leadership as required for trend analysis on a regular basis. This data will be accompanied by recommendations for action(s).

25.05 Education and Training.

a. Mandatory General Training. All staff and students shall at a minimum complete the following courses:

(1) Individual

(a) Initial. Managing Your Risk (CPPD-ORM-MYR-1.0).

(b) Annual. Command Provided Training (GMT/Safety stand-downs).

(2) Supervisor

(a) Initial. Managing Your Teams Risk (CPPD-ORM-MYTR-1.0)

(b) Annual. Command Provided Training (GMT/SafetyStand-downs).

(3) ORM Assistant. Leading Risk Management Integration (CPPD-ORM-LRMI-1.0).

(4) ORM Manager. Directing Your Command’s Risk Management (CPPD-ORM-

YCRM-1.0).

b. Education and training opportunities will be offered to all personnel during command check-in, quarterly training topics, and electronic training briefs shall be made available on a quarterly basis.

c. The ORM Reference Guide provides detailed directions for staff on the five-step process that can be used as a decision-making tool. This process includes hazard identification and hazard assessment in terms of risk probability and severity for each step. The Risk Assessment

Code can then assist the decision-making process and the establishment of controls.

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d. Training topics will minimally cover:

(1) Principles of Risk Management (on and off duty).

(2) Risk Management Screen/Submission Process.

(3) The Decision Making Tool – ORM Reference Guide.

(4) Examples of Military and Civilian ORM data from pertinent operational and training programs “Lessons Learned.”

e. All training topics and opportunities will be coordinated with the CSO/TSA.