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capabilities.
FAA System Safety Handbook, Chapter 15: Operational Risk Management
December 30, 2000
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22
Action 3—Feedback
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. Feedback informs all
involved as to how the implementation process is working, and whether or not the controls were
effective. Whenever a control process is changed without providing the reasons, co-ownership at
the lower levels is lost. The overall effectiveness of these implemented controls must also be
shared with other organizations that might have similar risks to ensure the greatest possible
number of people benefit. Feedback can be in the form of briefings, lessons learned, cross-tell
reports, benchmarking, database reports, etc. Without this feedback loop, we lack the benefit of
knowing if the previous forecasts were accurate, contained minor errors, or were completely
incorrect.
Monitoring the Effectiveness of Implementation
This aspect of the supervise and review step should be routine. Periodically monitor the progress
of implementation against the planned implementation schedule that should have been developed
during the third and fifth ORM steps. Take action as necessary to maintain the planned
implementation schedule or make adjustments as necessary.
Monitoring the Effectiveness of Risk Controls
If the risk control has been well designed, it will favorably change either physical conditions or
personnel behavior during the conduct of an operation. The challenge is to determine the extent to
which this change is taking place. If there has been no change or only minor change, the risk
control is possibly not worth the resources expended on it. It may be necessary to modify it or
even rescind it. At first thought it may seem obvious that we need only determine if the number
of accidents or other losses has decreased. This is only practical at higher levels of management.
Even at those levels of management where we have sufficient exposure to validly assess actual
losses, it may be a year or more before significant changes actually occur. This is too long to wait
to assess the effectiveness of risk controls. Too much effort may have been invested before we
can determine the impact of our proposals. We need to know how we are doing much sooner. If
we can’t efficiently measure effectiveness using accident rates, how can we do it? The answer is
to directly measure the degree of risk present in the system.
Direct Measures of Behavior. When the target of a risk control is behavior, it is possible to
actually sample behavior changes in the target group. Making a number of observations of the use
of restraints before initiating the seat belt program and a similar sample after, for example, can
assess the results of an effort to get personnel to wear seat belts. The change, if any, is a direct
measure of the effectiveness of the risk control. The sample would establish the percent of
personnel using belts as a percentage of total observations. Subsequent samples would indicate
our success in sustaining the impact of the risk control.
Direct Measures of Conditions. It is possible to assess the changes in physical conditions in the
workplace. For example, the amount of foreign objects found on the flight line can be assessed
before and after a risk control initiative aimed at reducing foreign object damage.
FAA System Safety Handbook, Chapter 15: Operational Risk Management
December 30, 2000
15 -
23
Measures of Attitudes. Surveys can also assess the attitudes of personnel toward risk-related
issues. While constructing survey questions is technical and must be done right, the FAA often
conducts surveys and it may be possible to integrate questions in these surveys, taking advantage
of the experts who manage these survey processes. Nevertheless, even informal surveys taken
verbally in very small organizations will quickly indicate the views of personnel.
Measures of Knowledge. Some risk controls are designed to increase knowledge of some hazard
or of hazard control procedures. A short quiz, perhaps administered during a safety meeting
before and after a training risk control is initiated.
Safety and Other Loss Control Reviews Procedures. Programmatic and procedural risk control
initiatives (such as revisions to standard operating procedures) can be assessed through various
kinds of reviews. The typical review involves a standard set of questions or statements reflecting
desirable standards of performance against which actual operating situations are compared.
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