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Accountability actions and follow up
Follow up inquiries by phone & during visits
Verbal support in staff meetings
Sign directives
Figure 15-8. Levels of Command Involvement
Procedures for Sustaining Risk Control Effectiveness
To be fully effective, risk controls must be sustained. This means maintaining the responsibility
and accountability for the long haul. If the risk control has been well designed for compatibility
with the organization operation and culture this should not be difficult. Managers must maintain
accountability and yet provide a reasonable level of positive reinforcement as appropriate.
Supervise and Review
The sixth step of ORM, Supervise and Review, involves the determination of the effectiveness of
risk controls throughout the operation. This step involves three aspects. The first is monitoring the
effectiveness of risk controls. The second is determining the need for further assessment of either
all or a portion of the operation due to an unanticipated change as an example. The last is the need
to capture lessons-learned, both positive and negative, so that they may be a part of future
activities of the same or similar type. Figure 15-9 depicts the actions necessary to complete this
step.
Figure 15-9: Supervise and Review Actions
ACTION 1:
SUPERVISE
ACTION 2:
REVIEW
ACTION 3:
FEEDBACK
ACTIONS FOR STEP 6 - SUPERVISE AND REVIEW
Action 1—Supervise
Monitor the operation to ensure:
FAA System Safety Handbook, Chapter 15: Operational Risk Management
December 30, 2000
15 -
21
· The controls are effective and remain in place.
· Changes, which require further risk management, are identified.
· Action is taken when necessary to correct ineffective risk controls and reinitiate the
· Risk management steps in response to new hazards.
Any time the personnel, equipment, or tasking change or new operations are anticipated in an
environment not covered in the initial risk management analysis, the risks and control measures
should be reevaluated. The best tool for accomplishing this is change analysis.
Successful performance is achieved by shifting the cost versus benefit balance more in favor of
benefit through controlling risks. By using ORM whenever anything changes, we consistently
control risks, those known before an operation and those that develop during an operation. Being
proactive and addressing the risks before they get in the way of operation accomplishment saves
resources, enhances operational performance, and prevents the accident chain from ever forming.
Action 2—Review
The process review must be systematic. After assets are expended to control risks, then a cost
benefit review must be accomplished to see if risk and cost are in balance. Any changes in the
system (the 5-M model, and the flow charts from the earlier steps provide convenient benchmarks
to compare the present system to the original) are recognized and appropriate risk management
controls are applied.
To accomplish an effective review, supervisors need to identify whether the actual cost is in line
with expectations. Also the supervisor will need to see what effect the control measure has had on
operational performance. It will be difficult to evaluate the control measure by itself so focus on
the aspect of operational performance the control measure was designed to improve.
A review by itself is not enough, a feedback system must be established to ensure that the
corrective or preventative action taken was effective and that any newly discovered hazards
identified during the operation are analyzed and corrective action taken. When a decision is made
to assume risk, the factors (cost versus benefit information) involved in this decision should be
recorded. When an accident or negative consequences occur, proper documentation allows for the
review of the risk decision process to see where errors might have occurred or if changes in the
procedures and tools lead to the consequences. Secondly, it is unlikely that every risk analysis
will be perfect the first time. When risk analyses contain errors of omission or commission, it is
important that those errors be identified and corrected. Without this feedback loop, we lack the
benefit of knowing if the previous forecasts were accurate, contained minor errors, or were
completely incorrect.
Measurements are necessary to ensure accurate evaluations of how effectively controls eliminated
hazards or reduced risks. After action reports, surveys, and in progress reviews provide great
starting places for measurements. To be meaningful, measurements must quantitatively or
qualitatively identify reductions of risk, improvements in operational success, or enhancement of
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System Safety Handbook系统安全手册上(64)
