BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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A2.A.8. <strong>THE</strong> CHANGE ANALYSIS A2.A.8.1. FORMAL NAME. The change analysis A2.A.8.2. ALTERNATIVE NAMES. None A2.A.8.3. PURPOSE. Historically change has been an important source of risk in operational processes. Figure A2.15 illustrates this causal relationship. Figure A2.15. Change Causation. Introduce System Stress is Risk controls Risk Losses change impacted created overcome Increases Increase A2.A.8.3.1. Some of these changes are planned, but many occur incrementally over time without any intentional or conscious direction. The change analysis is intended to analyze the hazard implications of either planned or unplanned changes. Properly used, the change analysis allows the risk management process to focus only on the changed aspects of the operation. This eliminates the need to reanalyze the total operation just because a change has occurred in one area. The change analysis is also used to detect the occurrence of change. By periodically systematically comparing current procedures with previous procedures, unplanned changes are identified and clear defined. Finally, change analysis is an important mishap investigation tool. Because many mishaps are due to the injection of change into systems, an important investigative objective is to identify these changes using the change analysis procedure. A2.A.8.4. APPLICATION. Change analysis should be routinely used in the following situations. A2.A.8.4.1. Whenever significant changes are planned in operations in which there is significant mission risk of any kind. A typical example is the decision to conduct a certain type of operation at night that has only been done in daylight previously. A2.A.8.4.2. Periodically, perhaps once a year, in any mission important operation to detect the occurrence of unplanned changes. A typical example is the many different types of maintenance procedures. A2.A.8.4.3. As a mishap investigation tool. A2.A.8.4.4. As the only hazard ID tool required when an operational area has been subjected to in-depth hazard analysis. The change analysis tool will reveal if any elements exist in the current operation that were not considered in the previous in-depth analysis. A2.A.8.5. METHOD. The change analysis is best accomplished using a format such as the sample worksheet shown at Figure A2.16. The factors in the column on the left side of this tool are intended as a comprehensive change checklist. 52
Figure A2.16. Sample Change Analysis Worksheet. Target: ______________________________________ Date: ________________________________ FACTORS EVALUATED COMPARABLE DIFFERENCE SIGNIFICANCE SITUATION SITUATION WHAT Objects Energy Defects Protective Devices WHERE On the object In the process Place WHEN In time In the process WHO Operator Fellow worker Supervisor Others TASK Goal Procedure Quality WORKING CONDITIONS Environmental Overtime Schedule Delays TRIGGER EVENT MANAGERIAL CONTROLS Control Chain Hazard Analysis Monitoring Risk Review To use the worksheet: The user starts at the top of the column and considers the current situation compared to a previous situation and identifies any change in any of the factors. When used in a mishap investigation, the mishap situation is compared to a previous baseline. The significance of detected changes can be evaluated intuitively or they can be subjected to what if, logic diagram, or scenario, other specialized analyses. A2.A.8.6. RESOURCES. A key resource for the change analysis tool is experienced operational personnel who have long term involvement in an operational process. These personnel must help define the “comparable situation.” Another important resource is the documentation of process flows and task analyses. Large numbers of such analyses have been completed in recent years in connection with quality 53
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SECTION A4.B. THE RISK CONTROL OPTI
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Figure A5.2. Example Maximizing Ban
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Attachment 6 RISK CONTROL IMPLEMENT
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Attachment 7 SUPERVISE AND REVIEW D
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BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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