EDITORIAL STAFF

Head, Media Division Derek Nelson

Editor Evelyn Odango

Art Director Allan Amen

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EDITORIAL OFFICE

Commander, Naval Safety Center

Attn: Sea Compass

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Norfolk, VA 23511-4399

Telephone: 757-444-3520, ext. 7220 (DSN 564-3520) / Fax: 757-444-6791

General email: safe-seacompass@navy.mil

Editor's email: evelyn.odango@navy.mil

AFLOAT SAFETY PROGRAMS DIRECTORATE

Commander, Naval Safety Center

Attn: Code 30

375 A Street

Norfolk, VA 23511-4399

Afloat mishap line: DSN 564-1562 / 7130; Fax: DSN 564-8636

Afloat safety email: safe-afloat@navy.mil

SUBMISSIONS 

Submit your stories or news items to safe-seacompass@navy.mil. E-mail letters to: 

evelyn.odango@navy.mil or write to: Commander, Naval Safety Center, Attn: Sea 

Compass, 375 A Street, Norfolk, VA 23511-4399. 

Contents and opinions expressed are not necessarily the official views of, or endorsed 

by, the U.S. Navy, the Department of Defense, or the U.S. Government. Photos 

and artwork are for illustrative purposes only, unless otherwise noted. Reference to 

commercial products or links to non-DoD resources do not imply Department of the Navy 

endorsement. Unless otherwise stated, material in this publication may be reprinted 

without permission; please credit the magazine and author. We reserve the right to edit all 

submissions for clarity and applicability. 

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Postmaster: Send address changes to Commander, Naval Safety Center, Attn: Sea 

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The Naval Safety Center Magazine for Surface, Submarine and Diving Operations

2014, Vol. 4, Issue 2

ORM Issue

Back to Basics

Commander, Naval Safety Center RDML Christopher J. Murray

Deputy Commander Col Glen Butler, USMC

Command Master Chief CMDCM (AW/SW) Paul Kingsbury

Department Head, Media and Public Affairs Margret Menzies

MAGAZINE ADVISORY BOARD 

SAFETY CULTURE AND ORM DIVISION Ext. 7816

CDR Rudolph Ohme rudolph.ohme@navy.mil

Division Head

Ted Wirginis theodore.wirginis@navy.mil

ORM Manager (Policy)

Denis Komornik denis.komornik@navy.mil

ORM Training and Education

AFLOAT SAFETY PROGRAMS

CDR Rosario McWhorter rosario.mcwhorter@navy.mil

Director, Afloat Safety Programs

Ron Keim ronald.keim@navy.mil

Deputy, Afloat Safety Programs

CDR Jason Eaton jason.c.eaton@navy.mil

Assistant, Afloat Safety Programs

Steve Scudder steve.scudder1@navy.mil

Afloat Safety Analyst/Publications Review

SAFETY ANALYSTS

To contact a safety analyst by phone, call the main number (757) 444-3520 and dial the 

extension at any time during the greeting.

SURFACE Ext. 7831

CDR Atkins Jinadu atkins.jinadu@navy.mil

Surface Division Head

LCDR James Bostick james.c.bostick@navy.mil

Safety Admin/Deck Analyst

LT Danveco Carter danveco.carter@navy.mil

Safety Admin/Combat Systems

CWO4 Don McDougal donald.mcdougal@navy.mil

Aux Analyst

ETCS Charles Gauntt charles.m.gauntt@navy.mil

Combat Systems Analyst

HMCS (SW) Angela Hussey angela.hussey@navy.mil

Medical/NAVOSH Analyst

GSCS (SW) Noah Lopez noah.lopez@navy.mil

Main Propulsion Analyst

DCC (SW) Justin Jones justin.m.jones1@navy.mil

Damage Control Analyst

EMC (SW) Michael Lavergne michael.lavergne@navy.mil

Electrical Analyst

GMC (SW) Barry Cramer ramiro.salas@navy.mil

Weapons

DIVING Ext. 7837

CWO3 William Turner william.r.turner@navy.mil

Diving Officer

HMC (EXW/SW) Christopher Precht christopher.precht@navy.mil

Diving Medical Technician

NDCM David Schoephoerster david.schoephoerster@navy.mil

Master Diver

MKC Charles Sowers, USCG charles.sowers@navy.mil

Diving Analyst, Damage Control

SUBMARINE Ext. 7838

LT John Oravitz john.oravitz@navy.mil

Submarine Division Head

LT Michael Lopez michael.lopez@navy.mil

Safety Analyst/Scheduler

EMC (SS) Louie Belk louie.belk@navy.mil

Support Systems/Electrical

ETC (SS) Adam Kingsley adam.kingsley@navy.mil

Support Systems/Electrical/Mechanical

MMC (SS/SW) Kamil Chayim kamil.chayim@navy.mil

Support Systems/Damage Control

FTC (SS) David Macon david.macon@navy.mil

CS/Weapons/Deck Analyst

HMC (SS) Francis Thomas francis.thomas@navy.mil

Submarine Medical

Join us on the web or your mobile device through these social networks:

CONNECT WITH US

The Anymouse program provides an outlet for safety concerns 

that have been submitted to the chain of command but remain 

unresolved. You can find the Anymouse icon on the main page 

of the Naval Safety Center web site.
Vol. 4, Issue 2 / 2014

STATUS

2 Editor's Note: Balancing Resources

3 Building a Culture of Operational Excellence BY APRIL PHILLIPS

4 A Supervisor's Investment BY GREGG GILLETTE

5 Fitness Matters to Mission Readiness BY CMDCM (AW/SW) PAUL KINGSBURY

THE BASICS

6 Ten Steps to the ORM Mindset

7 ORM 101 By DENIS KOMORNIK 

8 What ORM Is and Isn't 

9 Organizing Your Local Program: Roles and Responsibilities

TCRM

10 What's the Science Behind TCRM BY KD VANDRIE

12 TCRM Down Below: Do You Know Your Dive Emergency Procedures? BY LT JOHN ORAVITZ

14 Set Condition 1A for Wet Well Operation BY LCDR JAMES BOSTICK and BMCS MICHAEL SWEITZER

CASE STUDIES

16 Lessons from Miami BY LT JOHN ORAVITZ 

18 They Do Sometimes Get Hurt BY EILEEN CHOLLET, PH.D.

BEST PRACTICES

20 Honor Thy Prop Arc Safety Chain BY LCDR JASON D. WELLS

22 USS Germantown Sets the Bar in Safety BY LT JESSE JOHN ROND

24 Momsen's Journey BY ENS KRISTIN WIHERA

26 Visual Aids Get Sailors Talking About Safety BY CDR DEREK ATKINSON

28 Tracking Down Mishaps and Hazards BY LT MICHAEL LOPEZ

OFF DUTY

29 TCRM in the Real World BY DEREK NELSON

TOOLS AND REFERENCES

30 Assessment Tools

31 Frequently Asked Questions

32 Training and Web Resources

33 Anatomy of The ABCD Model

About the Cover: LCDR James Bostick, senior deck analyst in the Naval Safety Center's 

Afloat Safety Programs Directorate, performs 

an assessment of a rigid inflatable boat (RIB) 

aboard USS Barry (DDG 52) during a safety 

survey. U.S. Navy photo by Dan Steber

This page: Sailors from the deck department 

aboard USS Kitty Hawk (CV 63) heave on 

mooring lines as they prepare for departure. 

U.S. Navy photo by PHAN Adam York

SEA COMPASS SEA COMPASS II 2014 2014 II VOL. 4, ISSUE 2 VOL. 4, ISSUE 2 ORM: BACK TO BASICS ORM: BACK TO BASICS 1
NAVAL SAFETY CENTER WELCOMES NEW COMMANDER

In October, Rear Admiral Christopher J. Murray took over from 

Rear Admiral Kenneth Norton as Commander, Naval Safety Center.

RDML Murray has served tours with VF-1, VF-124, VF-111, and VF-14, 

culminating this phase of his career as commanding officer of VF-143. 

He served as Commander of Carrier Air Wing Nine from November 

2006 to December 2009. 

EDITOR’S NOTE

Balancing Time, Energy With ORM Tools and Resources

This issue of Sea Compass is about going back 

to basics — learning more about operational risk 

management and time-critical risk management, that 

is. If you're an afloat safety officer, you know about 

making ORM an integral part of on-duty operations. 

You might even use it to manage risks associated with 

off-duty activities. 

My first introduction to ORM was more than 14 

years ago when I became part of a marketing team 

that designed posters and publications promoting 

operational risk management. I've since learned how 

to apply the ORM deliberate and in-depth fivestep process to almost everything I do, whether I'm 

rearranging furniture at home or going on long road 

trips. I also worked for a company where I designed 

graphics pertaining to risk and resource management.

So it's almost second-nature for me to–as most 

safety professionals would say–“ORM it” (whatever 

“it” is). But I'm still learning; as you probably are 

as well. Demands from work and personal lifestyles 

are such that every day becomes a balancing act. 

Resources like this magazine come in handy in 

aligning strategies for managing time and energy to 

accomplish a task or mission.

The subject-matter experts in the Afloat Safety 

Programs Directorate and contributing writers from the 

fleet offer resources to help you get an overview of the 

Navy’s safety culture, understand ORM and its basic 

principles, learn from past mistakes and new ideas, stay 

safe off duty, and use the right tools for your program. 

Consider their contributions as components for your 

safety toolbox. After all, you’re not just balancing time 

and energy; you’re creating an arsenal of strategies to 

attack the enemy: human error.

This is the third installment of ORM-centric 

publications we've produced at the Naval Safety 

Center (ORM-The Essentials in 2007 and Leadership 

Essentials in 2012). In this issue, you’ll relearn the 

basics of ORM and get an introduction to the ABCD

Model and the science behind TCRM — how it helps 

mitigate operational and personal risks by improving 

situational awareness. 

For starters, April Phillips gives us an overview of 

the Fleet Safety Campaign Plan, which examines our 

safety culture (Page 3). Viewpoints from a former Navy 

chaplain and the Naval Safety Center CMC address risk 

mitigation through personal involvement (starting on 

Page 4). Beyond the basics of ORM, you can read about 

the science behind TCRM as explained by KD Van 

Drie (Page 10). There are also scenarios that emphasize 

time-critical and crew resource management: diving 

emergency procedures (Page 12) and wet well operation 

(Page 14). You'll read about case studies such as lessons 

from the USS Miami (SSN 755) fire and CSG-2’s 

analysis of how Sailors get hurt on ships (Page 18). 

Most importantly, take note on best practices from the 

fleet and see how you can contribute to creating a more 

engaged workforce and a much safer workplace. 

Risk will be present all the time, but it can be 

managed. ORM reduces risks and helps us make the 

right decisions. Use it as a tool to not let human error 

diminish personal capabilities and degrade mission 

readiness.

Evelyn Odango

evelyn.odango@navy.mil

2 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
When Adm. Bill Gortney, Commander, U.S. Fleet 

Forces Command, and Adm. Harry Harris, 

Commander, U.S. Pacific Fleet, signed the Fleet 

Safety Campaign in June, they were very clear 

about the campaign’s end state: A culture of 

operational excellence where risk management 

is second nature and safety practices are 

embedded in mission accomplishment.

The campaign plan, 

available for download on the 

Naval Safety Center’s website, 

acknowledges that the vast majority 

of Sailors and Marines do a great job 

of managing risk both on and off the 

job. However, it is also true that about 80 

percent of mishaps are the result of human 

error – someone cut a corner, rushed through 

a routine maintenance job, let DC training 

lapse, or drove distracted or recklessly. Even small 

errors in judgment can have huge consequences. The 

Navy’s overall mishap costs for both people and materiel 

resources between fiscal years 2011 and 2014 exceeded 

$1 billion with 116 fatalities. That’s billion, with a B, and 

more importantly, 116 trained-and-ready shipmates who are 

no longer with us or their families.

The impact doesn’t end there. Mishaps have forced some 

ships to delay deployments which means another crew had to 

get underway early to take up the slack. Safety isn’t just good for 

keeping Sailors and Marines attached to all their fingers and toes. 

It’s crucial for maintaining adequate rest, training, and maintenance 

between deployments. It’s good warfighting, and it’s inseparable 

from readiness.

For many, this type of thinking requires a mind shift. Be honest 

– have you ever thought the ORM brief before an evolution was just 

keeping you from getting at the job you needed to be doing right then? If 

so, it probably means the brief could have benefited from more interactive 

content, but it also potentially points to a culture where safety is seen as a 

barrier to the mission rather than an active part of it.

As the Fleet Safety Campaign begins to attack the enemy centers of gravity 

(complacency, inattention, fatigue, stress, and many other causes of human 

error) the culture will begin to shift. It won’t happen overnight, so don’t expect 

any drastic changes that can be stressful in and of themselves. Everyone has a role 

to play in the campaign effort. Remember that everyone is a leader, and your risk 

management attitudes – both positive and negative – are contagious. 

Ms. Phillips is the Naval Safety Center’s strategic communications planner and a member of the 

Fleet Safety Campaign Operational Planning Team.

Building a Culture of Operational Excellence

Fleet Safety Campaign Plan Overview

By April Phillips

ON THE WEB: Fleet Safety Campaign Plan http://www.public.navy.mil/

comnavsafecen/Documents/instructions/Safety_Campaign_Plan_INST.pdf

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 3
By Gregg Gillette 

I

n life, we protect that which 

we deem valuable. This isn’t 

just professionally speaking, 

but even more so in our 

personal lives. Nevertheless, our 

level of protection is subjectively 

based upon our perceived value 

of what we are “protecting” and 

our understanding of the threat 

level in the area of protection. 

As such, some of us have 

chosen to invest in a constantly 

monitored motion-detector and 

camera-equipped home-security 

system while others feel at 

ease, safe, and protected with 

nothing more than a deadbolt 

on their doors. 

In the context of safety and 

mishap prevention, personal 

protective equipment (PPE) 

is the lowest form. It is used 

when performing a task involving an identified hazard that 

cannot be removed through engineering or administrative 

controls, or when another process can’t be substituted. For 

some tasks, PPE will always be required. But simply making 

PPE usage a requirement should not be a supervisor’s sole 

involvement in the OSHA requirement to ensure a safe 

work place. OSHA regulations state that every employer 

shall furnish to each of their employees “a place of 

employment free from recognized hazards,” including the 

tasks that the employee performs and the worksite itself. 

The employer is required to protect their workers from 

recognized hazards; however, all hazards aren’t always 

easily recognizable. 

The very first step in operational risk management 

(ORM) is to recognize the hazards associated with the task 

or the site. This requirement covers all known hazards, but 

how are new hazards identified? In many cases they can 

be identified after a mishap with a thorough investigation. 

An investigator’s primary objective is to find out what 

happened in order to prevent recurrence. However, even 

trained investigators appreciate support from employees.

After a mishap, the injured worker’s supervisor can 

help by performing basic steps. Seeking immediate medical 

attention, if needed, is the first step. Just as crucial; getting 

an idea of what happened and why. The supervisor may 

perform the initial inquiry or designate a competent coworker who knows the injured worker and the task that 

was being performed when the mishap occurred. 

This same-day proactive identification of the causal 

factor(s) may prevent others from getting hurt doing the 

same task. The action suggests that the workers’ current 

well-being and future safety is worth the supervisor’s time 

and effort. 

Information obtained at the scene is crucial. It can 

help identify causal factors that should eventually lead 

to a newly recognized or identified hazard, or it can be 

used to rule out that any of the work process was unsafe. 

Unfortunately safety representatives are often viewed 

as outsiders rather than co-workers. That misplaced 

perception could prevent the safety investigator from 

learning all the facts necessary to correctly determine the 

cause of the injury. Not knowing the cause equates to 

the hazard remaining unidentified and workers remaining 

vulnerable. Therefore, the supervisor’s investment shown 

by their personal involvement as an attempt to prevent 

recurrence of such suffering will hopefully be understood 

as a statement of value and worth to their co-workers. 

Mr. Gillette, a retired U.S. Navy chaplain, is a safety specialist and 

mishap investigator at NAS Jacksonville. 

A Supervisor's Investment

Photo by MC3 Juan M. Pinalez Jr.

4 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 

viewpoint Reader commentary, opinion and point of view
Fitness Matters to Mission Readiness

Suggested Readings 

Power: Why Some People Have It and Others Don’t by 

Jeffrey Pfeffer

The 7 Types of Power, Using Power Effectively in 

Organizations by Sharlyn Lauby (eBook)

By CMDCM (AW/SW) Paul Kingsbury

While staying fit does not involve making 

complex decisions in a matter of minutes, 

it directly affects your ability to contribute 

to mission readiness. As a leader, you can 

influence your Sailors’ attitudes toward physical readiness. 

For most tasks, we apply standard operating procedures to 

minimize preventable errors, maximize crew coordination and 

optimize the use of ORM. One such task demands dedication 

and weeks (sometimes months) of personal assessment and 

work. This task is expected, and it is unavoidable: the semiannual physical fitness assessment (PFA).

Just as our ships must be fully mission-capable and combatready, Sailors must ensure they are physically and mentally 

mission-ready as well. One of the reasons we conduct the PFA is 

to evaluate your functional fitness: cardiovascular fitness, upper 

body and core strength. The jobs we do often require a lot of 

physical exertion or require some amount of stamina. 

In some warfare communities, specialties and ratings, 

physical fitness correlates directly to job performance (SEALs, 

EOD, divers, pilots, rescue swimmers). But how about the 

command career counselor, information systems technician, 

supply officer, operations specialist, or command master chief? 

Just as we invest time maintaining our ships, submarines, 

aircraft and other weapon platforms to ensure high levels of 

combat readiness, we all need to invest the same amount 

of attention to the combat readiness of our bodies — to our 

personal well-being. 

In conjunction with the annual physical health assessment, 

the Navy performs periodic checks of fitness level as well. 

Perhaps you’ve heard of the term “trust but verify.” The PFA 

is the Navy’s method of verifying you meet a basic level of 

functional fitness and professionalism. Your physical readiness has 

direct impact on your ability to contribute to mission readiness 

and your leadership effectiveness. 

Life on a ship exposes you to many hazards. We endure 

long periods of standing (or sitting), often in extreme 

environmental conditions. Watchstanding requires mental 

alertness, as well. It is affected by the level of your physical 

readiness. Going up and down the ladders all day or stabilizing 

your body in periods of extreme sea states all require some 

amount of physical fitness. Many Sailors perform maintenance 

or operations which require functional fitness to perform 

heavy lifting, pushing or pulling. We must all be physically 

prepared to endure the challenges that combat and damage 

control may bring. Long periods of firefighting, handling heavy 

damage control gear such as shoring and dewatering pumps, 

and transporting injured Sailors and rendering first aid require 

minimum standards or functional fitness. 

When faced with the prospect of surviving at sea and 

treading water for days, how long could you survive? A few 

minutes? Hours? Days? The higher your state of physical fitness, 

the better your odds of survival. Physical fitness also improves 

your internal health and gives you more energy, which can help 

you deal more effectively with mental and physical stress day-today and in combat situations. 

When preparing for the semi-annual PFA, consider how 

your level of physical readiness and your personal appearance 

also affect your leadership effectiveness. It strengthens your 

ability to motivate and influence others to increase their levels 

of fitness and inspire them to work together as a crew. When 

leaders don’t appear physically fit, their subordinate’s sense that 

they subscribe to double standards. Their credibility drops and 

their ability to effectively lead is compromised. The crew may not 

perform as well as expected. 

So how does risk management and crew resource 

management (CRM) relate to fitness? As long as you are part 

of the Navy and Marine Corps team, it is your responsibility to 

take physical fitness seriously. After all, you could face some 

risks to your career if you don’t manage your mental, health 

and physical readiness. 

CRM refers to effective use of all available resources by 

individuals, crews and teams to safely and effectively accomplish 

a mission or task. By applying CRM to physical readiness, you 

can learn skills that will enable you and your team to identify and 

manage conditions that may otherwise lead to human errors.

Two of the seven behavioral skills of CRM apply to the 

PFA: leadership and situational awareness. As a leader, it is 

your responsibility to be aware of crew factors that may impact 

everyone’s ability to perform the task at hand. This includes such 

things as attitudes, personalities, level of training, experience, 

fatigue, and physiological issues. Everyone on your watch team 

must be able to maintain awareness of what is happening 

around them and their primary duties.

So as your prepare for your next PRT cycle, take some time 

to reflect on how the process contributes to risk mitigation. 

More importantly, reflect on how you can improve your level of 

physical readiness. Investing time and resources in your crew’s 

physical fitness will have a direct impact on the degree of mission 

readiness and accuracy in which they operate. 

CMDCM Kingsbury is the Naval Safety Center’s command master chief.

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 5
E BASICS THE BASICS THE BASICS THE BASICS

Ten Steps to the ORM MINDSET

ORM should be a vital part of a unit’s culture: the way things are done by the leaders and members, something that is at 

the forefront of all activities. Here are the vital elements of this shared mindset:

Leaders know that managing risk is an integral part of mission success.

Everyone understands that any loss of personnel (on duty or off), equipment or capability degrades the unit’s ability 

to accomplish its missions.

Everyone recognizes the factors that might lead to loss or mission failure. They view these factors as threats.

Everyone understands that ORM is a tactic to defeat these threats.

Everyone abides by the principles of ORM. They accept risk when the benefits outweigh the cost. They accept 

no unnecessary risk. They make risk decisions at the proper level. And they anticipate and manage risk through 

planning.

Everyone realizes that they may not know whether an associated risk is acceptable. Therefore, they need to ask their 

immediate supervisor or higher so the decision to accept risk can be made at the proper level.

Everyone understands that they already use ORM every day through such risk controls as standard operating 

procedures, personal protective equipment, seat belts, speed limits, and qualification standards.

Unit planning includes deliberate risk assessments, using assessments previously developed for recurring events, as 

well as developing new assessments for new tasks.

Before executing a plan or an evolution, unit members ask “What’s different today?” This is time-critical ORM: a way 

to recognize last-minute changes to a “routine” evolution and identify any new hazards.

ORM isn’t seen as an administrative burden that is only applied when time allows. Personnel are constantly aware, 

watching for change and putting controls in place to ensure success.

6 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
THE BASICS

ORM

 hat’s more important: safety or the 

mission? I ask officers and enlisted 

Sailors this question during our 

assist visits. As a warfighter, mission 

accomplishment is our primary goal. But does that 

mean safety takes a backseat? Let’s see how we can 

answer this question.

First, we all recognize that we have a mission or 

task to perform no matter how seemingly minimal. 

Second, to accomplish this mission or task we must 

make informed risk decisions that affect everyone. 

Understanding our decision-making responsibilities 

includes using the ORM process to ensure mission 

success by weighing the risks with the benefits. Correct 

ORM execution results in safety as a by-product and the 

ability to accomplish missions or tasks. 

About Those Principles

The starting point for learning about ORM is the 

understanding and application of the four principles: 

making risk decisions at the right level, accepting 

risks when benefits outweigh the costs, accepting no 

unnecessary risks, and anticipating and managing risks 

by planning. These principles are the foundation of the 

five-step process and the rationale behind the ORM 

program. 

When one understands these principles, the 

remainder of the ORM process of three-levels (indepth, deliberate and time critical) and five-step process 

(identify hazards, assess hazards, make risk decisions, 

implement controls, and supervise) makes a lot more 

sense. Just how easy is it to understand ORM and its 

principles? Let’s look at an incident that happened not 

too long ago. 

Aboard a U.S. Navy ship, a LTJG was in the midst 

of a zone inspection. He opened a fan room hatch and 

found a discrepancy: hazardous material and rags were 

stored improperly. The Sailor pointed out his discovery 

to the division chief, but was told, “We need those extra 

supplies; we are headed out on cruise and it’s hard to get 

the stuff to do our jobs. On top of that, hazmat has no 

more room for storage.” The LTJG ignored the discovery 

and moved on. 

What happened next is general “crew” knowledge 

of personnel illegally smoking in the fan room and 

accidentally leaving the area with smoldering cigarette 

embers. This caused a large fire with extensive ship 

damage and injuries to personnel. 

Now imagine that you are the LTJG and found this 

issue. Which principle would you apply to the situation? 

Anticipating and managing risk by planning could help 

identify this mission shortfall and allow you to provide 

your command proper risk management measures. 

If the Sailor had identified these shortfalls using the 

ORM principles, the issue could have been addressed 

using the deliberate five-step process. The crew could 

have planned for acquisition of the required material to 

meet mission requirements. It’s important to know that 

the ORM five-step process assists in documenting the 

mission, identifying the hazards and collecting lessons 

learned and best practices. Equally as important is 

having trained subject-matter experts (SMEs) in your 

command to assist in making decisions at the right level. 

Informed Decision Makers

ORM reduces or offsets risks by systematically 

identifying hazards, and assessing and controlling 

the associated risks. It allows you to make decisions 

that weigh risks against mission or task benefits. Navy 

personnel are responsible for managing risk in all 

tasks, while leaders at every level are responsible for 

ensuring proper procedures are in place and appropriate 

resources are available for their personnel to perform 

assigned tasks. 

We have to work toward an environment in which 

every officer, enlisted, or civilian person is trained and 

motivated to personally manage risk in everything they 

do at work and off-duty. If it doesn’t look or feel right, it 

probably isn’t. Stop what you’re doing and ask the ORM 

SME. Managing risk is everyone’s responsibility and is a 

continuous process that pervades our warfighting strategy; 

it must be integrated in our Navy culture. It is our approach 

to problem solving and decision making. 

Mr. Komornik is the Naval Safety Center’s ORM training and education 

specialist. 

 Make risk decisions at the right level. Risk-management decisions should be made 

by the leader directly responsible for the operation. If the risk cannot be controlled 

at that level, that leader must elevate the decision to their chain of command.

 Accept risk when benefits outweigh the costs. The goal is not to eliminate risk, 

which is inherent in what we do, but to manage it so that we can accomplish the 

mission with minimal losses. Leaders must consider benefits and costs associated 

with a hazard’s risks to make informed decisions.

 Accept no unnecessary risks. Accept only those risks that are necessary to accomplish the mission.

 Anticipate and manage risk by planning. Risks are more easily controlled when 

By Denis Komornik identified early. 

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 7
THE BASICS

• A way to avoid risk

• A safety-only program

• Limited to complex, high-risk evolutions

• A program rather than a process

• Only for on-duty tasks

• Just for your boss

• Just a planning tool

• Automatic

• Static

• Difficult

• Someone else’s job

• A fail-safe process

• A bunch of checklists

• A bullet in a briefing guide

• TQL

• A mindset and methodology that applies to any activity

• Accomplishing the mission with acceptable risk

• Planning using a standard, five-step process

• A continuous process

• Based on people’s experiences

• Following procedures

• Watching for change

• Flexible

• Best when applied as a team

• Asking “What’s different today?”

• A process that depends on skill and knowledge

• Sharing experiences and lessons learned

• Using available tools and resources

• Applied, standardized common sense

• “Looking before leaping”

• As in-depth as you have time for

What ORM Is What ORM Isn't

● Navy and Marine Corps ORM instructions

● Evolution ORM assessment sheet

● ORM program assessment checklist

● Risk matrix postcard

● ORM courses on NKO

● Web tools and resource links

● Email updates

browse

preview

download 

sign up

OPERATIONAL RISK 

MANAGEMENT is a tool for 

making smart decisions at all levels. 

Each person has a role to play 

in managing risk for the unit, and 

each role is vital to success. These 

roles require different skills and 

knowledge.

• Leaders use the ORM process 

to plan unit operations.

• Junior personnel manage risk 

while they’re actually doing 

tasks.

You already use ORM every day. 

When you follow a checklist, 

you’re doing step four ("Implement 

Controls"). When you watch for 

changes, you’re doing step five 

("Supervise"). There are many other 

ways to apply ORM – both at the 

deliberate and time-critical levels.

8 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
THE BASICS

 Establish command policy and expectations for on- and off-duty ORM.

 Designate your command ORM manager. This person will oversee command ORM implementation and training, and will measure ORM 

effectiveness within the unit. Recommend the XO or department head fill this role.

 Address the ORM process in mission, training, safety, and lessons-learned reports. Reports should comment on hazards, risk 

assessments, and effectiveness of risk-mitigation efforts.

 Inform the chain of command of hazards identified by the ORM process that cannot be controlled at the command level.

 Ensure ORM risk decisions are being made at the appropriate level within the command.

 As the command’s subject matter experts (SMEs), the ORM assistants assist command personnel in doing risk assessments. They also 

train command personnel using resources such as ORM assessments, general military training (GMT), ORM training, videos, and lesson 

guides and materials provided by the ORM model manager, school houses, or other sources. Suggested venues for this training include 

training in work centers, at standdowns, indoctrination classes, and training syllabus events.

 Direct the use of tools and resources such as Total Risk Assessment and Control System (TRACS) or its equivalent. Assist with hazard 

identification and risk prioritization. Assist with hazard controls for ORM assessments on common tasks and evolutions. Help develop 

ORM assessments for unique tasks or evolutions.

 Include ORM in the orientation and training of all military and civilian command personnel. The level of training should be commensurate 

with rank, experience and leadership position.

 Include ORM training in individual development training course plans and individual development plans for civilian personnel.

 Incorporate identified hazards, assessments, and controls into briefs, notices and written plans.

 Conduct a thorough risk assessment for all command operations, tasks, and activities including new or complex evolutions, 

defining acceptable risk, and possible contingencies for the evolution.

 Ensure periodic command ORM evolution and program evaluations are completed and logged.

 Submit ORM lessons learned and best practices to the ORM model manager for annual dissemination.

 Ensure the ORM process is applied to all aspects of command operations and activities.

 Designate at least one officer and one senior enlisted person (or a civilian equivalent) as ORM assistants. Additional senior 

personnel may be designated based on command mission or unit size. 

		  Ensure the command ORM assistants complete (at least one of the following): the instructor-led ORM Application 

and Integration Course, Aviation Safety Officer Course, Aviation Safety Command Course, Surface Warfare Officer School, or 

the Submarine Officer Advanced Course.

ORM Manager:

ORGANIZING YOUR LOCAL PROGRAM:

Roles and Responsibilities

ORM Assistants:

Commanders, Commanding Officers and Officers in Charge:

(Reference OPNAVINST 3500.39 series)

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 9
TIME-CRITICAL TIME-CRITICAL TIME-CRITICAL

What’s the Science Behind TCRM?

KD VanDrie, developer of the ABCD Model explains

Figure 2: TCRM link to the 5-Step ORM Process

Time-critical risk 

management, or TCRM, 

refers to the application 

of ORM at the execution 

level of a mission or 

task: the time-critical 

point. However, the 

methodology of applying 

the deliberate five-step 

process of ORM in a 

time-critical situation has 

proven to be impractical. 

The Naval Safety 

Center, with its ORM 

division, serves as the 

model manager and subject-matter expert for the Navy's 

ORM program. The ORM model manager has chosen 

the A-B-C-D mnemonic as the scheme to use based on 

its scientific foundation. 

The ABCD Model (Figure 1) is not a replacement 

for the five-step ORM process or a different process of 

risk management. It is the practical application of the 

five-step process in a time-critical environment. 

Figure 1 shows the graphic representations or icons 

that illustrate how a set of recognizable patterns can help 

individuals recall a set of actions to counter risk even 

when distracted.

The ABCD Model is a visual reminder to assist in 

remembering and applying the principles of ORM and 

improve communications during an event, a task, or a 

mission. The model helps raise situational awareness 

and improve skills and knowledge.

Figure 2 shows the relationship between the fivestep ORM process and TCRM using the ABCD Model. 

The following breakdown explains each letter and 

expected action. See page 33 (inside back cover) for a 

detailed illustration of the ABCD Model.

10 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
Research related to risk management has grown 

by leaps and bounds in the past decade and has led to 

the development of our ABCD Model which consists 

of icons – a mnemonic, resource blocks and a threecolored target. We refer to the ABCD Model as a set of 

tools because it’s a framework to help managers ensure 

that they don’t expose their organization to any more 

risk than is acceptable.

Behind the A-B-C-D mnemonic and icons 

(which captures the basic skills 

of situational awareness, decision 

making, communications and 

active learning), there is a wealth 

of science. This includes the 

phases of situational awareness, 

complexity theory, risk assessment, 

development of expertise, habit 

formation, decision making styles, 

communication and education. 

The ABCD Model toolbox is 

there to help mitigate the effects of 

stress on the brain and to provide a 

mental model that can be shared by 

everyone.

The A-B-C-D mnemonic 

represents TCRM. Each letter 

represents an action to be taken by 

an individual to mitigate personal or 

mission-related risk by improving 

situational awareness (Assess 

the situation, Balance resources, 

Communicate to others, Do and Debrief the event).

The Resource Blocks icon is based on extensive 

experience in the design and development of 

operational guidance, instructional design, use of 

automation, and operations research in both civilian and 

DoD applications. Additionally we have drawn from 

NASA human factors research. The model has been 

used extensively in the design of scenario-based training 

and was further validated through data collection 

and analysis of those events. The resource blocks are 

consistent with widely accepted mishap causal-factor 

research and exist to visually show how to stop a chain 

of errors before it becomes a consequence, even if we’ve 

lost track of the errors.

The Target icon helps to quickly evaluate and 

communicate your level of risk, from the green area where 

everything is optimal, through the yellow area where 

A wealth of science ...

stress begins to take its toll, or in the red area where there 

is a significant chance goals may not be met, or where the 

risk exceeds the reward. It can also be used as a lens for 

situational awareness from green (good) to red (poor). 

The swooping arrow represents the return to good SA.

The framework of the ABCD Model is meant to 

make all of this science easily accessible, in real-time, to 

people that need to get a job done in a dynamic, timecritical, and often high-risk environment. At its core, 

the ABCD Model is about dealing 

with the physical and psychological 

effects of stress on the brain. When 

we are under stress from any source, 

it affects our ability to effectively 

manage risk. 

We designed the ABCD Model 

to make complex ideas intuitive, 

to get the core concepts into the 

habit and instinct part of the brain 

as quickly as possible. With the 

A-B-C-D mnemonic loop, we 

built a continuous improvement 

process that is just as instinctive as 

the rest of the tools, and effective 

whether done informally with 

personal evaluation or formally with 

organization wide data collection 

and analysis.

The solution begins here 

and now with you. What is your 

knowledge of TCRM? Have you 

provided your people with the necessary resources, 

tools and training to successfully do their jobs? The 

leader’s role is a decisive factor in the successful 

integration of time-critical risk management. This is a 

Navy-Marine Corps team effort. Everyone must know 

their responsibilities and the consequences of a loss of 

a teammate. We still have to measure up and TCRM 

assists us. TCRM, it’s for on- and off-duty. Learn it. 

Use it. 

Ms. VanDrie is the president of Volant Systems, LLC, and has taught 

risk and resource management strategies to a variety of audience 

groups including the Navy, Marine Corps, commercial airlines, and 

other industries including medical and educational institutions.

The original interview appeared in the Leadership Essentials issue of 

ORM magazine (2012).

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 11
TCRM Down Below

TIME-CRITICAL

e are all becoming very familiar 

with ORM and we are getting better 

at understanding time-critical risk 

management (TCRM), but our goal is 

to be outstanding at TCRM. Why? A 

diver’s life may depend on it.

Diving operations must revolve around operational 

and time-critical risk management because the 

environment in which the work is being done can be 

very unforgiving. Whether it’s a single dive or a group 

dive (divers descend, or often descend, in pairs), using 

TCRM can improve awareness. This is essential in 

executing the mission and returning to the surface. 

During diving operations, communication 

between the diver(s) and the supervisor is critical. 

However, circumstances may arise when there isn’t 

time for the diving supervisor to analyze the situation 

and recommend an action for the diver. A basic 

understanding of the purpose and functionality of 

TCRM could be a lifesaver.

ORM is typically applied in advance and there is a 

direct correlation between the time invested in ORM 

and the success of the evolution. Prior to that evolution, 

there is unlimited access to resources for planning (indepth). It is at the task execution level (time-critical) 

when the ability to reach out for resources is much more 

limited. Knowing how to apply TCRM at this stage will 

help you the most. 

Do you know your dive emergency procedures?

By LT John Oravitz

Implementing TCRM in a diving emergency 

revolves around knowing and balancing resources; 

those established resources all divers know and love: 

emergency procedures. Every evolution begins with a 

safety brief, which always includes a discussion of the 

emergency procedures. If divers didn’t pay attention to 

the brief before executing a dive or simply don’t know 

the emergency procedures, their execution of TCRM 

will be much less successful. 

Let me sell it to you another way, if what you are 

doing has an emergency procedure, it is most likely 

dangerous. It is in your best interest to know those 

emergency procedures and know how to apply them 

using TCRM. 

LT Oravitz is the submarine division head for NAVSAFECEN’s Afloat 

Safety Programs Directorate.

TCRM AT ITS BEST – Underwater 

operations (this page and opposite) 

are especially fluid and require 

strong situational awareness and a 

clear understanding of all emergency 

procedures. U.S. Navy photos

12 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
How do you do that for deep-sea diving? It is as simple as applying the easy-to-remember 

A-B-C-D time critical risk management scheme (Assess risks, Balance your resources, 

Communicate, Do and debrief).

A - Assess the situation: You may only have a split second to assess the situation; you may have 

lost your primary air supply, dropped a tool, or found a live suction where there shouldn’t be one. 

B - Balance your resources: Balancing resources can be difficult unless your dive buddy is right 

there with you and even more difficult if you are diving alone. Knowing your emergency procedures 

inside and out ahead of time will really help you balance those resources. 

C - Communicate to others: Communicating may not be the easiest thing to do, especially 

if you don’t have air or don’t have time to make a line pull signal, but once you are safe, establish 

communication with the supervisor and let him know what happened.

D - Do and debrief the event: If you have been following the scenario, Do may already have been 

done and debrief will take place after the dive. 

TIME-CRITICAL

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 13
Set Condition 1A for Wet 

Well Operation

By LCDR James Bostick and BMCS Michael Sweitzer

The well deck control officer, ship’s bo’s’n, and first 

lieutenant were not on station in the well deck but left 

instructions to complete shoring on the LCU with the 

shoring team. The shoring team consisted of six Sailors 

and one safety observer. 

Their objective was to move the 12” x 12” x 10’ pieces 

of shoring from the upper vehicle storage to the well deck. 

During the brief, the safety observer ordered all personnel 

to be on the same side of the shoring while carrying it to 

the well deck. The safety observer , however, did not walk 

with the personnel nor 

monitor the movement of 

the shoring. 

During the operation, 

four Sailors were on one side 

of the shoring and two were 

on the other side. As the 

Sailors were getting ready to 

set the shoring down, one 

of the Sailors devised a plan 

to just throw the shoring off 

their shoulder to the left. 

This unknowingly caused 

the shoring to drag one of 

the Sailors who was on the 

opposite side, crushing his head between the shoring and 

the deck. The Sailor sustained fatal head injuries.

There are many questions that surround this 

scenario. Did everyone – individuals, crews and teams 

– effectively use all available resources to safely and 

effectively accomplish the mission or task?

Did supervisors do anything, prior to the task, to 

minimize the crew's preventable errors, maximize crew 

coordination and optimize/enhance the use of ORM?

Understanding the threats and hazards – the things that 

stand in the way of the successful accomplishment of 

Sailors from deck department of an amphibious 

assault ship remove shoring in the well deck. Photo by 

MC3 J. Michael Schwartz

CREW RESOURCE MANAGEMENT

14 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
CREW RESOURCE MANAGEMENT

task/mission – allows personnel to execute, sometimes 

under extreme stress. Crew resource management 

training teaches skills that enable individuals to identify 

and manage conditions that may otherwise lead to 

human errors.

The outcome could have been different if everyone 

applied the A-B-C-D of time-critical risk management 

and asked these important questions:

A - Assess the situation: Is this what we planned 

for? What’s different? What are the changes? Are the 

environmental conditions correct for this evolution?

B - Balance your resources: Is this the right 

number of personnel for the task? Are there qualified 

personnel on station to ensure the task is completed 

safely and in accordance with all applicable instructions?

C - Communicate to others: Did the petty officer 

in charge (POIC), safety observer, and well deck control 

officer (WDCO) all communicate what was required of 

the shoring team and ensure the team comprehended 

the instructions? Did the officer of the day (OOD) 

know that the craft was not secured yet?

D - Do and Debrief the event: Did the CO and 

everyone down to the junior personnel know what was 

planned? Was a debrief planned and conducted at the 

end of the event? 

An LCU enters a well deck. U.S. Navy photo

Editor’s Note: Condition 1A is to set well deck operations 

and involves additional watchstanders on the bridge and in 

combat information center as well as manning well deck and 

ballast control stations.

Photos used in this article are for illustration only.

LCDR Bostick is the lead deck and seamanship analyst and BMCS 

Sweitzer is the deck and seamanship analyst at NAVSAFECEN's 

Afloat Safety Programs Directorate. They each have served multiple 

tours on amphibious, carrier and surface combatant ships.

What Should Have Happened?

 Once the LCU was in the correct position 

in the well deck, and the ship completed deballasting, the WDCO should have communicated 

the assessment of the de-ballasting and shoring 

requirements to the OOD in the pilot house:

 that they were commencing shoring of 

the LCU, and

 to ask permission to turn on the white 

lights in the upper vehicle and the well deck. 

The ship’s bos’n should have been on station 

along with the safety observer and a POIC to conduct 

a shoring brief with the shoring team. 

The ship should have maintained a safe 

speed and not conducted any maneuvering until 

shoring was completed (Assess the situation). 

The POIC and safety observer should have 

walked with the shoring team as they were carrying 

the shoring to the well deck (Balance resources), 

ensuring they properly put the shoring in place. 

GAUGING RISK

Were the Sailors in the Yellow? 

In the Green? 

In the Red?

See page 33 (inside back cover) for a detailed illustration 

of the ABCD Model.

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 15
US Navy handout (Reuters / Handout)

ES CASE STUDIES CASE STUDIES CASE STUDIES

By LT John Oravitz 

S

ubmarine life is difficult and complex in many 

ways. The mission is inherently dangerous while 

operating underwater, and when you are not at 

sea, you may be at a shipyard or an intermediate 

maintenance facility. Submarine maintenance at a 

shipyard also has its share of danger and complexities.

On May 15, 1969, USS Guitarro (SSN 665) sank 

pierside during a maintenance period. It prompted 

the development and implementation of the NAVSEA 

6010 Manual, “Industrial Ships Safety Manual for 

Submarines,” which formalized and codified shipyard 

maintenance practices to prevent future incidents. 

Fast forward to May 23, 2012. A Naval Sea Systems 

Command (NAVSEA) shipyard worker had set fire to 

rags onboard USS Miami (SSN 755) because he wanted 

to go home (he was subsequently sentenced to 17 

years in federal prison for arson). Intense heat caused 

suspended temporary services to collapse and severely 

hindered damage control efforts, which lasted 12 hours. 

The fire injured seven people, caused $450 million in 

damage, and resulted in the decommissioning of the 

vessel 10 years ahead of schedule. The mishap resulted 

in a series of investigations and the implementation of 

the “NAVSEA Industrial Ship Safety Manual for Fire 

Prevention and Response” (NAVSEA 8010 Manual). 

Four working groups, led by the Quality Programs 

and Certification Office (NAVSEA 04XQ), immediately 

identified the need for a formal document to capture all 

industrial fire safety aspects. But until the 8010 Manual 

could be assembled and rolled out, Fire Serial 009 

(COMNAVSEASYSCOM 211050Z May 2013) was 

released as a temporary measure. It referenced 46 CFR 

Part 164 Subpart 164.009, “Non-Combustible Materials 

for Merchant Vessels.” This new CFR (Code of Federal 

Regulations) requirement mandated the use of metal 

wire or strapping to suspend temporary services during 

any submarine maintenance period to prevent a similar 

incident. 

During maintenance, only a few hatches are 

available for entry and exit. To accommodate the flow 

Lessons from Miami

of work, temporary services are put in place, such 

as ventilation (in and out), power sources, high and 

low pressure air, and temporary lighting. According 

to NAVSEA 04XQ, “metal straps would survive the 

temperatures associated with a rolling overhead fire 

and/or flashover situation ... as fire is darkened with 

firefighter hose team advancement, the firefighters 

do not become encumbered by collapsed temporary 

services, slowing their response or, worse yet, 

entrapping them.” 

NAVSAFECEN’s submarine safety survey team 

included this new requirement in the “General 

Departmental” category of the submarine safety 

checklist (a department head and XO walkthrough 

inspection). On several surveys, the team found that 

some NAVSEA shipyards were not in compliance 

with the Fire Serial 009/8010 Manual requirement: 

they were using Kevlar-reinforced synthetic line and/

or Nomex fireproof line instead of metal. One of the 

reports from surveys conducted onboard two units 

noted that the NAVSAFECEN survey team interacted 

with NAVSEA shipyard to rectify the discrepancy. The 

report further stated that personnel who were installing 

shipyard temporary services (e.g., the Kevlar line) 

admitted that “they knew of the metal wire requirement 

and they knew that there was metal wire in the shop.” 

Even though the 8010 Manual references the same 

CFR requirement as the interim Fire Serial 009, two 

different NAVSEA shipyards repeatedly stated that they 

could use the Kevlar. Their rationale was that the 8010 

Manual had a 180-day implementation period (which 

was true). But they had completely ignored the fact that 

the requirement was the same. 

NAVSEA 04XQ finally intervened. “...The 

requirement in Chapter 10 of 8010 Manual is clear 

that the material used to suspend temporary services 

is required to meet the non-combustibility testing 

requirements (164.009-15) in Occupational Safety 

and Health Standards for Shipping, 46 CFR Part 164 

Subpart 164.009, “Non-Combustible Materials for 

16 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
From NAVSEA Letter 9077, dated Feb. 6, 2014:

“On 23MAY2012, a major fire occurred on board 

USS Miami (SSN 755) during her overhaul at Portsmouth Naval Shipyard, which caused major damage to the forward compartment of the submarine 

and resulted in her inactivation from the Fleet 10 

years before scheduled. The fire burned for nearly 

12 hours, and required extensive effort by Ship’s 

Force (SF), Navy’s Fire and Emergency Services 

(F&ES), local mutual aid fire departments (20 companies), and the shipyard to extinguish. The fire 

was started intentionally in the forward compartment, spread rapidly to cleaning supplies that had 

been stored onboard, and flashed over and spread 

to the upper level and forward and aft before SF 

and F&ES could establish an effective fire-fighting 

response. Initial efforts were also hampered by 

conflicting reports with regards to the location of the 

fire, difficulties in getting hoses and sufficient water 

on the fire, interferences from temporary services, 

and air flow patterns due to hull cuts, vertical fire 

spread, and ventilation paths.”

Photo by MC2 Benjamin Crossley

CASE STUDIES CASE STUDIES CASE STUDIES CA

Merchant Vessels” (e.g., 750° ±10 °C).”

NAVSEA 04XQ further explained that “the 

(metal) tie downs survive the temperatures associated 

with a rolling overhead fire, flashover, or chimneying 

situation. Copper does not melt until about 1950 F 

and steels are 2500 to 3000 F. This means that any 

copper, steel, or steel-reinforced services will longsurvive the 1300 F tie material. 

Emphasizing that this was a significant lesson learned 

from the Miami fire (key vertical accesses were not usable 

for firefighter advancement due to dropped services), 

NAVSEA 04XQ had disseminated this information to 

ensure the other three naval shipyards were aware of this 

non-compliance and that they thoroughly implement use 

of correct material at their facilities. 

Reduce the potential for shipboard fire by 

following these simple precautions:

Minimize accumulation of combustible material, particularly in unoccupied spaces and spaces 

with limited or restricted access aboard ships and 

buildings. Try to store combustible material in a 

metal container to minimize the chance of ignition 

from external sources.

Make sure people know that vacuum cleaners 

can catch fire. Empty all vacuum cleaners at the 

end of each shift. Recommend storage off-hull or 

in a separate steel container as mitigation for the 

potential delayed ignition of the filter and contents.

If a vacuum cleaner is being used to collect 

debris after the completion of hot work, ensure it 

doesn’t contain other combustible material prior 

to such use. Wait 30 minutes after hot work is 

completed, and ensure hot work debris are cool 

to touch before vacuuming. Vacuum cleaners intended for such service should be clearly labeled 

to indicate their use in support of hot work and not 

used in other applications.

Remove excessive or adrift combustibles from 

vessels.

Route temporary services so that ingress and 

egress accesses are safe and support potential 

firefighting requirements. Remove temporary 

services that are no longer in use.

Inspect hot-work sites to ensure combustibles 

are protected or removed and that operations are in 

accordance with NSTM 074 (Vol. 1, Welding and 

Allied Processes), OSHA and local instructions.

What did we learn from this evolution? From 1915 

to 1963, the U.S. Navy lost 16 submarines to noncombat related causes. Since the 1963 establishment of 

the Submarine Safety Program (SUBSAFE), the Navy 

has lost only two vessels: the non-SUBSAFE-certified 

USS Scorpion (SSN 589) and USS Miami (SSN 755). 

If you are involved with submarine maintenance in any 

way, think about that statement. Protocols and standard 

requirements are there for a reason. Know them, 

understand them, and practice them. 

LT Oravitz is the submarine division head at the Naval Safety Center.

REFERENCE:

Fire Message Serial 009 (COMNAVSEASYSCOM 

211050Z May 2013)

ORM: BACK TO BASICS 17
CASE STUDIES

They Do Sometimes Get Hurt

By Eileen Chollet, Ph.D. 

Since an aircraft carrier is such an 

obviously dangerous place, the results 

of the injury study were all the more striking: afloat 

personnel are four times less likely to get seriously 

injured than civilians back in CONUS. According to 

2010 Centers for Disease Control statistics, the rate of 

emergency room visits for injuries for males 15-24 years 

old is 19.7 visits per 100 persons per year [1], equivalent 

to about 22 trips to the medical department per week 

for a carrier with an embarked air wing. The medical 

department on GHWB saw an average of 21 Sailors per 

week for injuries, but 75 percent of those injuries were 

far too minor to send someone to the ER, requiring 

only minor treatment or no treatment at all. The CDC 

statistics show that most injuries treated in the ER come 

from traffic accidents and brawls; neither is common 

at sea. Though Sailors are doing dangerous work, their 

procedures, protective equipment and robust health are 

working to keep them safe from injury afloat. 

Still Sailors do sometimes get hurt. During GHWB’s 

deployment, Sailors accumulated over four personyears of light duty. Surprisingly, about half of injuries 

occur from just walking around the ship, and only one 

in three injuries was from industrial work like doing 

maintenance. About one in five of the shipboard injuries 

were slips and trips, often while carrying gear up and 

down ladders. Safety officers can make the ship safer by 

When the USS George H.W. Bush (CVN 77) carrier strike 

group turns west after a successful Middle East deployment, 

those aboard will be thinking about heading home, sitting 

down for turkey and pie with their loved ones. While a safe 

homecoming is every commander’s priority, Carrier Strike 

Group 2 (CSG-2) decided to go beyond the usual lessons 

learned and take a rigorous, data-driven approach to 

safety, with some unexpected results.

18 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
CASE STUDIES

tracking exactly where people 

get hurt and investigating 

hazards (such as condensation 

from the ever-present Middle 

East humidity.) One in four 

injuries arose from Sailors 

catching fingers in doors, 

hatches, and racks, and broken 

fingers required about half of the 

light duty that was accumulated 

on the ship. 

It’s worth stressing an old, 

familiar lesson – the most 

dangerous task is the one the Sailor has not done 

recently. This issue is well-understood in the aviation 

community; pilots, no matter how experienced or 

talented, are much more likely to have a mishap if they 

haven’t flown much in the previous month [2]. 

Life at sea is no different: when GHWB CSG first 

arrived in the Middle East, the injury rate spiked to 

twice the rate seen during the rest of the deployment. 

The data also show that junior enlisted Sailors (E-3 

and below) were five times more likely to get hurt than 

senior enlisted and officers, in part because they are 

not as familiar with the shipboard environment. When 

conducting safety training, a focus on junior enlisted 

and newly-arrived sailors will have the biggest impact on 

risk management.

Though life in the Navy is 

never risk-free, commanders 

should be encouraged that the 

procedures already in place are 

keeping their Sailors pretty safe, 

and that minding the simple 

things like hatches and ladders 

can help them stay even safer. 

The strike group hopes our 

lessons learned give future 

deploying strike groups plenty 

of reason to be thankful. 

Dr. Chollet is CNA Corp.'s Center for Naval Analyses representative 

to the George H. W. Bush carrier strike group. As the Department of 

the Navy's federally funded research and development center, CNA 

reps have been doing field-based, data-driven operations analysis for 

more than 70 years. Dr. Chollet has been in the field with the strike 

group since November 2013, working a diverse set of projects including safety, coalition integration, and Operation Inherent Resolve.

REFERENCES

[1] Centers for Disease Control. “National Hospital 

Ambulatory Medical Care Survey”, accessed Oct. 21, 2014 at 

http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_

ed_web_tables.pdf.

[2] W. Brobst, K. L. Thompson, and A. C. Brown. Air Wing 

Training Study: Flight Hours, Mishap Rates, and Tactical 

Proficiency. CRM D0018776.A2/Final, October 2008.

Illustrations courtesy of Dr. Chollet. Study data as of Oct. 27, 2014

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 19
Best Practices

or “ORM in the Fleet”

LEET IN THE FLEET IN THE FLEET IN THE FLEET

Every member of our team understands the 

intricacies of E-2D maintenance, practices, and the 

gotchas that can arise in a VAW squadron. We have 

developed a strong safety culture; but what happens 

when conditions change? The VAW-125 “Tigertails” 

safety team raised this concern when embedding in 

USS Theodore Roosevelt (CVN 71) for a three-week, 

at-sea period. We were entering a new environment with 

Sailors on an aircraft carrier who weren’t accustomed to 

the complexities and safety concerns of two 13.5-foot 

propellers turning at 1106 RPMs. We put the five-step 

process of ORM to work.

IDENTIFY THE HAZARDS

The propeller arc (the circle described by a propeller 

when it is moving or static) presents a severe risk on 

By LCDR Jason D. Wells

V AW-125, an E-2D advanced Hawkeye squadron, strives to build a culture 

where every member creates and maintains a safe and professional 

aviation environment. We make every effort to ingrain the concepts of risk 

management into each Sailor’s thought process. While achievable, this 

remains a challenge with each day presenting new and interesting issues as we change 

environments during our work-up cycle.

a carrier flight deck. No one would intentionally walk 

into a propeller arc. However, when you add stress, 

fatigue, wind, and low visibility to the equation, 

accidentally walking into a moving propeller becomes 

a real possibility.

Using the first step of ORM, we identified two 

hazards. 1) Many Theodore Roosevelt Sailors had not 

spent “quality” time operating around the E-2D 

Hawkeye. 2) VAW-125 “Tigertails” had not operated 

recently in the high-paced environment of flight-deck 

operations. 

ASSESS THE HAZARD

The probability of an incident on the flight deck rises 

when you have inexperienced personnel operating in an 

unfamiliar environment or around unfamiliar aircraft.

Honor Thy Prop Arc 

Safety Chain

20 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
IN THE FLEET

MAKE RISK DECISIONS

We had to prevent a propeller incident. Using 

available time, we were able to deliberately plan a 

response and came up with several solutions. In 

addition to our mandatory flight deck familiarization 

and shipboard safety discussion, Theodore Roosevelt

Sailors provided a ship safety brief for VAW-125 

personnel. We also discussed an entertaining way to 

get Sailors’ attention about the seriousness of prop arc 

safety. Our resident video expert, LT Adrian Kellgren, 

and our very own voice talent, LT Dartenya Santana 

(who dubbed the voice of a young James Earl Jones), 

developed a plan. An humorous video will get the 

attention of Sailors but still emphasize the serious 

nature of operating around propellers, especially on 

the flight deck. We want to provide personnel an 

engaging medium that also serves as an “edutainment” 

during the upcoming underway period.

IMPLEMENT CONTROLS

The video will emphasize the following do’s and 

don’ts:

1. Always honor the prop safety chain. This is 

group of personnel forming an arc designed to keep 

people out of the prop arc during engine starts and 

shutdowns. Anyone needing to enter this arc must get 

the attention of the plane captain (PC). You will be 

challenged for your own protection, regardless of rank, 

if trying to enter the prop safety chain without getting 

the attention of the PC.

2. Treat every prop as if it is spinning. This instills 

the habits and respect necessary to prevent accidentally 

walking into a spinning propeller.

3. Don’t ever walk into the prop arc of a moving or 

static prop. 

4. When operating around E-2/C-2 aircraft, 

approach the aircraft from behind the nacelle.

5. Never walk between the propeller and the 

fuselage of the aircraft.

SUPERVISE

The previously applied steps were designed 

to build and reinforce safe habits while operating 

around a moving propeller afloat and ashore. The 

air wing safety officer of the day (and during E-2D 

events) is required to make observations and provide 

feedback to ensure the message is being disseminated 

properly. 

LCDR Wells is the safety officer for the VAW-125 Tigertails.

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 21

The human prop arc safety chain surrounds 

aircraft 600 after arrested landing.
IN THE FLEET Developing an effective safety program aboard 

a U.S. naval warship is never an easy task. 

It often requires years of instilling safety in 

the command culture and a highly focused 

organization to manage complex programs with only 

one chance to demonstrate their effectiveness during 

inspections.

While this task is an uphill battle, the officers and 

crew of USS Germantown (LSD 42) achieved several 

incredible accomplishments in the area of occupational 

health and safety. They have maintained a flawless safety 

record despite a relentless schedule of certifications, 

inspections, and operations. In the Navy Occupational 

Safety and Health (NAVOSH) functional area, they far 

exceeded the average scores in their recently completed 

Type Commander Material Inspection (TMI), safety 

assessment, and Board of Inspection and Survey 

(INSURV) Material Inspection. These accomplishments 

are even more profound in light of their recent schedule 

where they completed a compressed Surface Force 

Readiness Manual (SFRM) certification cycle. USS 

Germantown truly has set a new standard in encouraging 

other ships to “Follow in Our Footsteps.”

Its respiratory protection program far exceeded 

Navy standards. During TMI, the inspector credited the 

respirator locker as the most organized locker he had 

ever seen and requested to use pictures the ship’s locker 

in training slides for the rest of the fleet. 

The outstanding quality of this program is managed 

and maintained by Seaman Lauren Smalley. SN Smalley 

is no ordinary deck seaman. Her meticulous attention 

to detail and relentless work ethic was the driving force 

behind an impeccable respirator program.

“I have been involved in the respirator program for a 

year and had to build the program up from scratch,” said 

Smalley. She credited this significant accomplishment to 

simple training.

“It wasn’t until I attended the respiratory protection 

manager course that I finally understood what I needed 

to do and felt I had the tools to do it,” she said. Once 

equipped with the appropriate knowledge, she passed it 

on to the rest of the crew by teaching them the proper 

way to fit a respirator, the correct usage, and why it can’t 

be left adrift. 

“When I started with the program, respirators were 

adrift everywhere,” Smalley added. “It was a crew-wide 

effort to hunt them all down. Even one adrift respirator 

can fail the entire program.”

USS Germantown attained outstanding assessments 

in all of her medical NAVOSH programs as well. During 

the recent INSURV and TMI, all seven NAVOSH 

programs received a score of over 90 percent and 

the Medical Readiness Inspection (MRI) score was 

an exceptional 100 percent. Petty Officer 1st Class 

Shannon Ramsden, a hospital corpsman and the ship’s 

NAVOSH programs manager, said a key component to 

her success was asking questions to off-ship experts. 

“I would email and communicate with the base 

industrial hygienist,” said Ramsden. With subject matter 

experts backing her up, Ramsden was able to develop a 

USS Germantown 

Sets the Bar in Safety

By LT Jesse John Rond

Exceeding Navy Standards

 Respiratory Protection Program

 All Seven NAVOSH Programs

 Medical Readiness

 HAZMAT Program

This page: SN Lauren Smalley ensures her 

fellow shipmate has a properly fitting respirator. 

Opposite from top: HT2 Ernest Page instructs 

a fellow shipmate on proper use of HAZMAT. 

HM1 Shannon Ramsden organizes her 

NAVOSH program binder in preparation for 

INSURV. Photos courtesy of USS Germantown

22 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
IN THE FLEET

“Overall the ship did very well,” said LT Dave Smith, 

the ship’s safety officer. “Safety is a culture and we should 

always be inspection-ready. This is an effort made by the 

entire crew. Everyone worked really hard to do well on 

the inspections. We performed better than average for 

our class of ship, and that wouldn’t have been possible 

without the hard work and dedication from our Sailors.”

Now that USS Germantown is one of the safest ships 

on the waterfront, one might think the crew would be 

content to rest on their laurels. Nothing could be farther 

from the truth. The safety team is never satisfied with 

the status quo and has already identified additional areas 

to improve upon. 

SN Smalley has aspirations for a more efficient 

method of organizing her respirator paperwork to 

streamline the documentation process. She also wants 

to have a respirator bulletin board to better inform the 

crew about the program. 

HT2 Page has found ways to best inventory the 

hazmat onboard. He also wants to incorporate a more 

user-friendly automated system that can help order 

hazmat quickly when supplies get low. 

With this kind of dedication and passion for safety, 

it is no surprise that USS Germantown is elevating the 

bar for ship safety. 

LT Rond is USS Germantown’s assistant safety officer.

clear understanding of expectations and what would be 

required during all inspections.

High safety standards are also evident in the 

hazardous material (hazmat) program, which is often a 

very difficult program to manage and maintain. During 

supply department’s recent Supply Management 

Certification (SMC), the hazmat program was assessed 

at a flawless 100 percent with the inspector even 

commenting that he honestly couldn’t find anything to 

“hit.” Their outstanding performance continued with a 

100 percent score during TMI and 92 percent during 

INSURV. 

The program manager credits much of the score to 

the hard work and dedication of his team. “I have 12 

personnel within the division and six hazmat assistants 

that have all helped build the program,” said Petty 

Officer 2nd Class Ernest Page, a hull maintenance 

technician. “While I’ve had this NEC for 10 years, I 

had to recognize that they weren’t at the same level just 

yet. I had to slowly motivate and train them in order to 

implement required changes.” HT2 Page sat down with 

each member of his hazmat crew. “Only then could I 

get to know them on a personal level and be able to 

employ them most effectively.”

All the accomplishments of USS Germantown are 

more profound when one realizes just how far the safety 

programs have come. 

HM1 Ramsden had many challenges when she 

became the ship’s NAVOSH program manager a year 

ago. 

“The lead safety, sight conservation, and asbestos 

programs weren’t implemented and I had to build 

them from nothing,” said Ramsden. “It was a lot of 

work. I had to personally assess every eyewash station 

on the ship. I then worked with the divisions who 

owned the eyewash stations to ensure they had the 

exact tools needed to fix them.”

HT2 Page couldn’t believe the state of the hazmat 

program when he first arrived.

“At one point there were 50 pallets of excess 

hazmat sent off the ship. The program didn’t follow the 

references, the crew wasn’t trained on proper handling, 

the hazmat wasn’t inventoried and didn’t match up with 

the logs, and a lot of money was wasted on expensive 

hazmat that we didn’t even need.”

Despite starting out so far behind, Germantown’s 

safety team managed to pull together and overcome 

these obstacles. The workload was incredibly high 

considering the ship had to respond to several 

contingencies the previous year, complete SFRM 

mission certifications and then culminate with three 

extremely rigorous inspections in a six-week period: 

TMI, Safety Survey and INSURV. 

”It took a lot of extra work and keeping personnel 

late into the evening,” said Page. “But it was all worth it. 

All it takes is dedication and passion to be the very best.”

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 23
IN THE FLEET

Dedicated to increasing mission effectiveness, the 

safety team leaders decided to attack the problem in 

three parts: education, participation, and evaluation. 

Applying the second level of the ORM process 

(deliberate ORM), the team’s goal while in DSRA was to 

implement detailed planning of our mission. 

Before relocating to the shipyard, Momsen held a 

safety standdown in Everett to educate the crew on what 

to expect during DSRA. We invited the shipyard safety 

team to come and assist us with the standdown. The 

team covered important topics such as environmental 

protection, work-authorization forms, tag-out procedures, 

electrical safety, and crane safety. We wanted to ensure 

that the entire crew, both those who have been to 

shipyards before and those who were seeing a shipyard 

for the first time, were briefed on what to expect and what 

was expected from them. By bringing on subject-matter 

experts and experienced personnel, we were able to 

brainstorm and performed effectively as a team.

MOMSEN’S JOURNEY

Our main objective was to enable our Sailors and 

crew to identify and manage conditions that may 

otherwise lead to human errors. To keep safety fresh on 

everyone’s minds, we held another safety stand down 

two months into our DSRA. This time we focused on 

trends and observations from our first 60 days in the 

yards. This helped cultivate a culture of safety within the 

crew. We continued to remind the crew of these safety 

lessons with rotating safety notes in the Plan of the Day 

and safety posters hung in crew living spaces. 

Consistent participation has had the most impact 

on safety of the crew. Every day, designated members 

of the ship’s safety team and shipyard safety personnel 

tour the ship to identify hazards. Following every safety 

walkthrough, a list of the identified safety concerns is 

disseminated to the crew and shipyard personnel for 

action. We rely on the crew to fix concerns found by the 

safety team and, more importantly, to identify hazards in 

their own spaces. 

By ENS Kristin Wihera

USS Momsen (DDG 92) left her homeport of Everett, Washington, in 

February 2014. She headed to Vigor Shipyard in Seattle to be drydocked 

for her scheduled CNO availability (DSRA). The most significant concern 

on everyone’s mind was safety. The industrial shipyard environment 

presented a unique challenge for Momsen’s safety team: an unfamiliar work 

environment, thousands of contract workers who follow different safety standards, and 

a demanding and ambitious work schedule. 

Cultivating a culture of safety through education, 

participation and evaluation.

24 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
IN THE FLEET

Creating a safe work environment has required 

all hands’ attention and understanding of operational 

risk management. It has been extremely beneficial 

involving the division safety petty officers (DSPO) 

in this process. Each division has their own qualified 

and designated SPO who assists in the walkthroughs, 

helping take the safety message down to the 

deckplates. The SPOs get regular training to better 

understand the safety program, DSRA safety, and 

hazard control. With this knowledge, they are able to 

be true safety leaders within their divisions. 

We have continued to improve our safety program with 

constant self-evaluation. When a safety concern is set to be 

corrected, the safety team returns within 24 hours to make 

certain it has been fixed. This process allows us to know 

if the crew and shipyard workers understand the concern 

and the proper action. At the completion of every month, 

the government conducts a trend analysis of the safety 

concerns found during that month. The results help us 

understand what types of mishaps we are most susceptible 

to and how we can prevent them.

USS Momsen in drydock. Photo by ENS Vanessa Berry

In the event of a mishap, we investigate and report 

the factors that led to the mishap. Discovering the 

causes of the mishap help us avoid similar mishaps in 

the future and create recommendations for other ships 

entering DSRA.

Safety and risk management continue to be a 

daily focus. Crew members understand what makes 

a workspace unsafe and know who to report it to. 

They are consistently reminded of the importance of 

risk management and their role in keeping everyone 

out of harm’s way. We’ve documented more than 500 

corrective safety actions and fixed even more items 

on the spot. Some of these actions have been minor, 

others more significant, but each one is part of creating 

a safe working environment for the Momsen crew and 

contract workers. As a safety team, we now recognize in 

what ways we are most vulnerable and how to avoid or 

minimize those mishaps. 

ENS Wihera is the assistant safety officer on USS Momsen (DDG 92).

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 25
One of the many challenges of being an afloat 

safety officer is how to effectively leverage 

your limited resources in order to realize 

the commanding officer’s safety vision. In 

response to the Naval Safety Center fleet wide need to 

“operationalize” the principles of risk management at the 

deck plate level or execution phase of the evolution, the 

USS John C. Stennis (CVN 74) safety department got 

creative. Our team has worked diligently on building up 

needed resources that did not previously exist to shape 

behavior, drive down injuries and ensure procedural 

compliance. 

The second step (B) of the ABCD Model is to 

“Balance Resources.” During an all-hands safety training, 

the command focused on the Sailor’s level of knowledge 

as a resource. To put it another way, not all resources will 

be contained in a continuity binder or be issued through 

supply department neatly packaged. 

Your level of knowledge and “muscle memory” 

will be the resources you must rely on in a dynamic 

environment. You won’t have time to fetch a binder from 

the workshop when you are in extremis. The resources 

you need will be your application of knowledge through 

rehearsal, job aids and visual management. In the 

aviation profession these are known as critical memory 

items, or CMI.

In naval aviation the term “chair flying” is a method 

to habitualize performance to drive critical memory 

tasks to the subconscious, freeing the brain to process 

what is unique, different and potentially dangerous. 

Olympic athletes know this process as visual motor 

rehearsal and its proven link to increasing human 

performance. For this to be effective, resources must 

be tailored to drive the performance toward the goal. 

During the dry docking planned incremental availability, 

(DPIA) the safety department created a number of 

visual job aids to foster an enviable safety culture for the 

ship and shipyard team.

Manning and the work required for the DPIA 

project was not static; rather the manning peaked 

about 10 months into the project, as did the complexity 

of the work. The Stennis safety team and its civilian 

counterparts in the environment, safety and health 

(ESH) department worked together to pre-empt 

IN THE FLEET

By CDR Derek Atkinson 

Visual Aids Get Sailors 

Talking About Safety

From left: Rob Pommier, an environmental safety 

and health manager, Chief Aviation Boatswain's Mate 

(Handling) Jason Garcia, department leading chief petty 

officer of safety, and Joe Wright, an environmental safety 

and health manager, pose for a photograph in front of a 

ladder well safety poster aboard USS John C. Stennis

(CVN 74). U.S. Navy photo by MCSN Christopher Frost

26 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
IN THE FLEET

hazardous behaviors and created high-impact safety 

posters. Their goal was to get the attention of the 

combined team of the ship’s force, shipyard civilian and 

contractors ... in effect, to get them talking about safety 

on the work sites. 

The team decided to use graphic images of injuries 

related to the type of work being performed and bridge 

that graphic to a proper hazard control. For example, 

the machine shop had images of an amputated hand 

while HAZMAT issue showed severe burns over a 

woman’s head and neck to emphasize proper PPE wear. 

In areas where the safety team knew power tools were 

being used with power sourced from either a higher 

or lower deck, images of bodily damage from runaway tools were displayed to drive behavior to prevent 

unattended power tools.

Far and away the most successful posters were 

related to incline ladder safety. Two posters were created 

to curb injuries from inattention on incline ladders. The 

first featured an archetype character, a Sailor named I.M. 

Inarush and it displayed an X-ray of a broken tibia and 

fibula with the time to heal the broken bones under the 

title, “Sliding Down Ladders is Not Faster!” Another 

featured poster was called “The Crumpled Man.” It 

showed a man at the bottom of a ladder with tools, 

arms and legs akimbo, suggesting poor technique on 

descending the ladder.

The response was immediate and as desired.

The analysis of the types of bodily injury, location of 

injury and phase of work is an example of performing 

deliberate ORM with the goal of preventing hazardous 

behavior at the execution stage. At a peak of 1,600 

civilian and contractor workers plus the 2,900 ship’s 

force crew, we achieved an impressive reduction in 

incline ladder injuries of 78 percent overall and zero 

ladder injuries for Stennis Sailors. 

Word about the graphic posters filtered through 

the shipyard and another project requested the files 

for immediate implementation. As we’ve recently 

completed sea trials and formally ended our DPIA, 

the posters were in place and despite 18-foot seas in 

a very light aircraft carrier with no aircraft, ordnance 

and little fuel, we experienced zero ladder incidences 

during this underway.

Behaviors are shaped through repetition and 

rehearsal ... think chair flying or visual motor 

rehearsal. Applying tailored resources at the final 

moments of decision making and during execution 

can influence those behaviors to support your 

command’s safety vision.

In these times of budget constraints, a safety 

department must take seriously its role in enhancing 

mission readiness through conservation of assets. 

The takeaway is that a safety department needs to 

understand its operating environment and tailor 

its efforts to generate maximum effect in fostering 

an effective safety culture. Our decision to go with 

graphic imagery was calculated and, for a limited 

time, designed to affect our culture to get people 

talking and thinking about risk. In our case it was a 

high payoff effort. 

CDR Atkinson is the safety officer aboard USS John C. Stennis

(CVN 74).

TCRM Visual Aid and Safety Brief 

Discussion Points

We learn and think with the front part of our brain. Which 

in turn we bury in our brain stem in the back of our brain. 

When something puts us under stress our brain shuts 

down from the front to the back and we react pulling the 

information we have stored in our brain stem from previous 

drills we have performed. The question is ... what happens 

when the reaction that we developed doesn’t work? Do we 

complete the mission? Lose our equipment? Possibly lose 

lives? This is why the ABCD Model is such a critical part 

of the process: When under stress you react the way you 

train! The goal of TCRM is to teach the brain to continue to 

think by using the ABCD Model.

Courtesy of Surface Warfare Officers School ORM A&I courseware.

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 27
uring a recent submarine safety survey at 

Joint Base Pearl Harbor/Hickam, the 

Naval Safety Center (NAVSAFECEN) 

team came back with more than just survey 

results. Two safety officers stood out in the 

spotlight primarily because of their innovative use of 

electronic mishap and hazard tracking systems. 

LTJG Luis Wu, the safety officer (SO) of USS 

Olympia (SSN 717) had an outstanding and easy 

to use safety discrepancy tracker that met all of the 

NAVSAFECEN requirements. His system tracked 

hazards and mishaps and showed when corrective 

actions were completed, allowing him to trend the data. 

Another SO, ETCM Christian Newkirk from USS Santa 

Fe (SSN 763), developed a safety discrepancy tracker 

that presented trends in various graphic formats.

Both systems allowed the user to track mishaps 

(cuts, shocks, sprains, even items dropped on body 

parts) and hazards (sharp objects, broken lights, trip 

hazards, loose/exposed wires). These innovative ideas 

facilitated discussions during Safety Council meetings 

and resulted in NAVSAFECEN Submarine Division's 

development of a universal safety officer tracker. The 

“SO Tracker” Excel spreadsheet, which is now available 

online, combines both of the safety officers’ systematic 

data-collection method into a single program. 

The SO Tracker has three main areas: mishaps, 

hazards and traffic. Each area has its own tracker, data 

tables, and graph worksheets. This program is easy to 

use and is also customizable. As it evolves, we expect 

users to maximize its functionality and recommend 

updates and changes.

This tracker will not replace WESS reporting 

requirements, but will serve as an additional resource 

for tracking and analyzing trends. Since its inception, 

the SO Tracker has gone through a number of updates 

to ensure that it complies with INSURV and NSC 

safety survey requirements. Standardizing how 

safety officers track and trend their data is highly 

recommended by the Naval Safety Center and U.S. 

Naval Submarine Forces. 

By LT Michael Lopez 

“The tracker is thorough enough for them [safety 

officers] to use on a daily basis and especially to formally 

track safety survey and INSURV discrepancies,” said 

LCDR Brent Levingston, a safety and environment 

compliance officer from Submarine Atlantic Force. 

Levingston is also optimistic that this tracker will make 

it easy for the SO to analyze trends and to hopefully use 

it for their Safety Council and committee briefings. 

Our survey team assesses how effectively the SO 

manages data and trends, how those trends are presented 

to the CO at the Safety Council meeting, and how 

effectively the safety team acts to mitigate potential 

discrepancies based on existing trends. NAVSAFECEN 

safety experts intend for this document to evolve into a 

fleet-wide resource and to standardize the administrative 

submarine safety program. Generally, the submarine 

community is trending in a positive direction with regard 

to safety. Resources like this will further improve safety 

programs and safety climates aboard submarines. 

LT Lopez is the submarine safety analyst and scheduler at the Naval 

Safety Center. 

BRIGHT 

IDEA 

● Required data includes date, location, description, classification, 

corrective actions, completion date, and more. 

● The data worksheet displays tables of classifications and totals of 

all data points. 

● The graphs worksheet displays graphical charts for the data point 

tables and breaks down the results quarterly and by mishap/

hazard type.

● Everything in the worksheets is unified (data will automatically 

populate in the graphs and tables) for easy presentation.

● A hints worksheet is provided to help with any problems with the 

data and graphs worksheets. 

● A list source worksheet will allow the user to add mishap types to 

the drop-down lists. 

● The change worksheet shows all updated items or functions in the 

latest version.

● Available online, under the NAVSAFECEN's "Afloat" tab, 

"Submarine" quick launch, and "Resources."

SO Tracker Download:

http://www.public.navy.mil/comnavsafecen/Documents/afloat/Submarines/Safe_Officer_Gen_Depart/SO_tracker_V4.1.xlsx

Tracking Down 

Mishaps and Hazards

THE SO TRACKER

IN THE FLEET

28 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
OFF DUTY

By Derek Nelson

T

he first piece of good news is that most of us do 

a good job of managing risk most of the time 

(usually without even noticing it). If we didn’t, 

we’d spend a lot more time on crutches and in 

bandages. So I don’t need to waste a lot of ink and time 

giving you an intro or pep talk.

The second piece of good news is that when we 

focus on managing risk, we do a decent job of planning. 

So you don’t need the blah-blah about that part, either.

The problem is when plans start to fall apart. Like 

the Sailor I once interviewed about his DUI. He’d had 

a designated driver (a young woman that he knew). 

She’d abstained, he had a few drinks. She was driving 

them home, so far so good. Then they approached a 

road block. Instantly distraught, she confessed that she 

didn’t have a license and had some other legal problems 

lurking in the background. He, chivalrously, slid over to 

take the wheel and the heat.

If you’ve had your quota of ORM training, you’ve 

heard this phrase: “Change is the mother of all risks.” 

Granted, that’s an exaggeration. Inexperience and 

complacency, to name two factors, put plenty of 

unsuspecting Sailors and Marines in high-risk situations. 

One of the reasons that off-duty/recreational mishaps 

take so many personnel away from the mission is that, 

off-duty, there’s a lack of supervision. On the job, 

experienced people can at least try to keep subordinates 

from learning the hard way.

So that everyone can learn to look out for 

themselves, we teach the theory of risk management. 

But theory is boring. The real world is tangible and 

vivid. So, apply the easy-to-remember A-B-C-D timecritical risk management scheme (Assess risks, Balance 

your resources, Communicate, Do and debrief) to an E-5 

who headed out to hoist a few.

Yes, picking on drunk guys stacks the odds in our 

favor, because they are much more likely to fail when it 

comes to managing risk. However, the following tale is 

too good of a bad example to ignore.

We don’t know how he did on “A,” but under “B” he 

did have money (to buy numerous drinks), didn’t have 

a driver’s license (it had been yanked after a DUI), and 

did have a spouse. He had checked the block for “C” by 

arranging to have her pick him up, by which time he had 

been drinking for four and a half hours.

When he got home, alas, he had to start the alphabet 

all over again, because his neighbor wanted to look at 

the Harley Sportster that the E-5 wanted to sell. The 

TCRM in the Real World

E-5 then flunked “A” by deciding to give the neighbor a 

demonstration.

He also did a terrible job on “B” this time, because 

his resources included zero PPE (he was clad in that 

ever-popular protective ensemble of cotton shorts, 

cotton t-shirt and sneakers). His helmet was inside and 

apparently too hard to fetch. His BAC of 0.33 qualifies 

as an anti-resource. He took off down the street. The “C” 

part of this iteration was limited to “Hey, watch this” and 

“Don’t tell my wife.”

“D” involved him riding a third of a mile and reversing 

course. Coming around a sharp turn, he thought that an 

oncoming car was in his lane. He swerved off the road, 

hit some gravel, lost control and took a swan dive. He 

rolled about 20 feet, accruing a textbook assortment of 

road rash, cuts and bruises on three-quarters of his body, 

starting with the top of his head.

The neighbor then did some late communicating by 

calling 9-1-1, and perhaps some debrief by yelling, “Hey, 

I don’t think I want to buy that motorcycle any more” as 

the ambulance pulled away.

Crappy decisions aren’t a seasonal thing, and plenty of 

sober Sailors and Marines make them during a spectrum 

of activities. Everybody’s vision is perfect when it comes to 

20:20 hindsight. The goal is 20:20 foresight. 

Mr. Nelson has been writing the Friday Funnies since 2002. He also 

creates the Photo of the Week feature and writes the NSC blog, 

“Beyond the Friday Funnies” for the Naval Safety Center website. 

He has authored more than 200 freelance magazine articles and 10 

books about American and military history.

Photo by Alexander Steven, Wikimedia.

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 29
We’ve partnered with the fleet assessment 

commands to develop two tools to help evaluate 

your programs. These tools help measure 

the implementation of your program and 

provide feedback on the effectiveness of your 

command’s ORM training. They were designed 

to be integrated within existing commandlevel assessments and to be used by outside 

evaluation commands. 

The Evolution ORM Assessment Sheet 

(Figure 1) looks at how well a unit applies 

the ORM process during operations. The 

assessment sheet is an evaluation of your 

unit, staff, or group’s application of the ORM 

principles and processes during execution of 

a complex event. A tailorable evolution ORM 

assessment sheet is also available to focus on 

your command’ individual requirements.

The ORM Program Assessment Sheet 

(Figure 2) measures how well a unit complies 

with the guiding OPNAVINST 3500.39 series. 

This assessment sheet is an evaluation of ORM 

integration of your command’s policies, training 

and the compliance of OPNAVINST 3500.39 

series. 

These assessment sheets enable you to 

analyze your command’s program strengths 

and weaknesses. The Naval Safety Center and 

the assessment commands have found a strong 

correlation between the task scores for ORM 

planning and the scores for execution. The 

better you plan, brief and use ORM, the more 

likely your performance will improve. 

TOOLS AND REFERENCES

ASSESSMENT TOOLS

RISK MATRIX CARD

This familiar card has been around 

a long time, but this current version 

addresses a major change to the way 

we look at risk management. It’s 

the MISSION and how severity 

and probability impacts the 

accomplishment of it.

Risk Assessment Matrix

PROBABILITY

1

1

2

3

1

2

3

4

2

3

4

5

3

4

5

5

SEVERITY

Effect of Hazard

Frequency of Occurrence Over Time

A

Likely

B

Probable

C

May

D

Unlikely

1 - Critical 2 - Serious 3 - Moderate 4 - Minor 5 - Negligible

Risk Assessment Codes

Loss of Mission Capability, Unit

Readiness; Asset, Fatality

IV

Significantly Degraded Mission

Capability or Unit Readiness; Severe

Injury or Damage

Degraded Mission Capability or Unit 

Readiness; Minor Injury or Damage

Little or No Impact to Mission 

Capability or Unit Readiness; Minimal 

Injury or Damage

I

II

III

These ORM assessment sheets are available at: https://navalforms.

documentservices.dla.mil. Click the tab for “Forms” in the top nav 

bar, select “Keyword Search,” and enter the form name in the box for 

“Search Criteria.” Local reproduction of the forms is authorized.

(1) OPNAV 3502/1 (JAN 2010) Evolution ORM Assessment Sheet

(2) OPNAV 3502/2 (JAN 2010) Tailorable Evolution ORM Assessment Sheet

(3) OPNAV 3502/3 (JAN 2010) ORM Program Assessment Sheet

30 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
FREQUENTLY ASKED QUESTIONS

Who is responsible for ORM in my unit?

Commanding officers and OICs are responsible for 

ORM within their commands. The executive officer, 

chief of staff, or civilian equivalent is the unit ORM 

manager and primary agent of ORM implementation.

What’s the best way to implement ORM at my 

command?

Make sure you meet the existing requirements of 

OPNAVINST 3500.39 series. You need at least 

one officer and one senior enlisted trained as ORM 

assistants (we previously called them “instructors”). 

Train all command personnel commensurate with 

their rank and experience. Identify new and complex 

evolutions at your command, assemble a planning team 

made up of operators from the various functional areas 

necessary to complete the evolution, and conduct a 

deliberate or in-depth risk assessment. Brief the hazards, 

controls and individual risk-control supervision 

responsibilities to all evolution participants prior to 

execution. Identify root causes of conditions that led to 

failures, recommend actionable solutions to the chain 

of command to prevent future failures, then retain 

internally and disseminate externally lessons learned, 

best practices, and the risk assessments for future 

planners.

How do I sign up for ORM training? 

The ORM training is available on Navy Knowledge 

Online (NKO). There is also the ORM Application 

and Integration (A&I) course, which is two days long 

and led by an instructor. You can also sign up for the 

A&I course on ENTRS. It is intended for your ORM 

manager and assistants. 

I’ve heard ORM described as both a program and 

a process. What exactly is it?

ORM is both a program and a process. An ORM 

program refers to a command’s compliance with ORM 

instructions directives, with regard to its organization, 

training, implementation, and feedback mechanisms. 

The ORM process is a systematic approach to managing 

risks to increase mission success with minimal losses. 

This involves identifying and assessing hazards, 

controlling risks, supervising and revising as needed. 

When commands are assessed for ORM, it will either be 

an ORM program assessment (compliance-based) or an 

ORM application assessment (process-based).

How should I document my ORM training?

Document ORM training in both individual training 

jackets [or Relational Administration (RADM) folders] 

and at the command-level. A typical entry might be 

“Last ORM GMT training occurred on ...”

How often should service members and civilian 

employees receive ORM training?

At least annually, commensurate with their rank or 

experience level, according to OPNAVINST 3500.39 

series. ORM training is also directed to be included in 

command orientation, as well. Currently, everyone is 

required to receive annual refresher training. 

What is a risk assessment?

A risk assessment is a documented five-step ORM 

process. Minimally, this involves a list of hazards 

assessed for risk, the risk controls for those hazards, the 

residual risks, and who is responsible for supervising the 

risk controls. 

What is time-critical risk management? 

This level of ORM is when you are in the execution of 

the event or do not have time to plan. You have to make 

risk decisions on the fly. It is using the ORM process 

when limited by time constraints.

How do you order ORM business Cards?

You may download the files off of our website at www.

public.navy.mil/comnavsafecen/pages/orm/orm_

businesscards.aspx. 

CONTROLS BECOME RESOURCES DURING EXECUTION

In-Depth

Time available for planning Limited/No time for planning

Deliberate Time-Critical

STRATEGIC TACTICAL

• charts

• ship/aircraft

• systems safety

• instructions

• operational planning

• mission briefs

• CO standing orders

• safety equipment

• team/crew

• mission execution checklist

• change management

• equipment degradation

MISSION

& TASK

SUCCESS

TOOLS AND REFERENCES

SEA COMPASS I 2014 I VOL. 4, ISSUE 2 ORM: BACK TO BASICS 31
TRAINING & WEB RESOURCES

 ORM Application and Integration Course (2 Days)

Course Registrations: All Quota requests are made in the ENTRS System. Access to ENTRS may be obtained by 

logging onto: https://main.prod.cetars.training.navy.mil. Select ENTRS then request accress from the initial login 

screen and fill out the application. For ENTRS training, email cetarstraining_reque@navy.mil. When requesting a 

seat for the ORM A&I course CIN: A-570-0100, use CDP 09GE for Dam Neck, Va., use 09GJ for San Diego, Calif., 

and use 03PS for all other locations.

 eLearning Courses

First, register for an online account at https://wwwa.NKO.navy.mil/. Follow the instructions for “New Users.” 

Then select “Navy e-Learning” under the horizontal “Learning” tab at the top of the page, On that page, in the left 

navigation bar under “Content,” select “Browse Categories,” then select “Department of the Navy,” then “ORM” 

(in the right-hand column). Other ORM training is available by selecting the “Personal Development” tab along 

the top, then clicking “Risk Management/Safety” in the left navigation bar (the fourth item down). You will find 

eight traffic-safety items (two are specifically ORM-related), as well as two ORM topics (FY05 GM Topic 1-1, an 

introduction to the operational risk management process and principles, with a practical application to a longdistance driving scenario), with a facilitator’s guide and a large zip file to download.

 ORM Courses (on the Navy e-Learning)

Operational Risk Management - Time-Critical Risk Management CPPD-GMT-ORMTC-1.0

Manager - Directing Your Command Risk Management CPPD-ORM-DYCRM-1.0

Assistant - Leading Risk Management Integration CPPD-ORM-LRMI-1.0

Individual - Managing Your Risk CPPD-ORM-MYR-1.0

Supervisor - Managing Your Team’s Risk CPPD-ORM-MYTR-1.0

Time Critical Risk Management CPPD-TCRM09-02

Note: Refer to OPNAVINST 3500.39C, Encl (3) for periodicity.

 Naval Safety Center Website

http://www.public.navy.mil/comnavsafecen/Pages/orm/ORM.aspx

 ORM Model. This is a multi-faceted explanation of ORM, with expanded versions of many of the sections 

contained in this magazine, as well as others (for example, tools and methods). These web pages will continue to be 

updated and to grow.

http://www.public.navy.mil/comnavsafecen/Pages/orm/ExplanationofORM.aspx

 OPNAVINST 3500.39C. The online documents in the Department of the Navy Issuances System have been 

grouped by instruction. On the navigation menu, go to the “Directives” tab, and click on “All Instructions.”

http://doni.daps.dla.mil 

 Presentations. The ORM Fleet Brief is a customizable presentation which includes various types and levels of 

training.

http://www.public.navy.mil/comnavsafecen/Documents/presentations/orm/ORM_general.pptx

 Application and Integration Training

http://www.public.navy.mil/comnavsafecen/Documents/ORM_data/ORM_Applic_Integ_Info/FY12_ORM_AI_Alsafe.docx

 Safety Center Links to the Army and Air Force ORM sites, as well as the Army, Air Force and Coast Guard 

RMIS (risk management information system) sites.

http://www.public.navy.mil/comnavsafecen/Documents/ORM_data/ORM_Tools_and_Resources/ORM_

WEB_SITES.doc

 Army CRM site. The Army calls it “Composite Risk Management.” This site contains basic information, 

training tools, traffic-safety initiatives and news. It contains a PDF version of its 108-page Field Manual 5-19 

(“Composite Risk Management”); an appendix contains some excellent examples of applying risk management to 

specific kinds of operations.

https://safety.army.mil 

 Air Force ORM site. The Air Force Safety Center offers the ORM A&I (Course Number WCIP 05E, PDS Code 

WEI). The course provides “how-to” instruction in applying primary and select ORM tools and techniques. In addition, the integration of ORM into organizational activities is covered. The course is intended for personnel serving as 

organizational ORM focal points, ORM trainers, lead planners and others requiring a more in-depth understanding 

of ORM principles, tools and application. The site also has sections devoted to ORM training, guidance, media, 

tools and lessons learned. 

 http://www.afsec.af.mil/organizations/education/rm.asp.

TOOLS AND REFERENCES

32 ORM: BACK TO BASICS VOL. 4, ISSUE 2 I 2014 I SEA COMPASS 
ANATOMY OF THE ABCD MODEL