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

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improvement and reengineering projects. These materials are excellent definitions of the baseline against which change can be evaluated. A2.A.8.7. COMMENTS. The change analysis is one of the most important hazard analysis tools. In organizations with mature ORM processes, most, if not all, higher risk activities will have been subjected to thorough ORM applications and the resulting risk controls will have been incorporated into operational guidance. In this situation, the vast majority of day-to-day ORM activity is the application of change analysis to determine if this particular operation has any unique aspects that have not been previously analyzed. Only if specific changes are detected will it be necessary to apply any ORM procedures. If there is no change, optimum procedures will already have been fully integrated in the established operational guidance. A2.A.8.8. EXAMPLES. An example of a change analyses is illustrated at Figures A2.17 and A2.18. Figure A2.17. Example of Change Analysis. Situation: The DO of an Air Force Reserve flying organization has observed evidence of what he considers “loose” flying over the last several days. He decides to use a change analysis to assess changes in the unit that may have led to this deterioration in flying performance He uses the change analysis worksheet illustrated earlier (Figure A2.16) to make this assessment. Result: Notice how the change analysis (Figure A2.18) reveals both planned and unplanned changes. Notice also how the worksheet brings all the changes into focus in context with each other. Any one of these changes are significant but not particularly unusual. When all of them are viewed in the context of the worksheet, the cumulative impact of all of the changes becomes apparent. The very probable cause of the “loose” flying is the optempo and resulting mental and physical stress on pilots. It is likely that a DO would intuitively be aware of many, if not all, of these factors. The role of the change analysis is to assemble the changes in a format where their cumulative impact is readily apparent. This situation is a good example where the impact of the individual changes is considerably greater than the sum of their individual impacts and only by considering all of the changes at one time can the real risk issue be understood. 54
Figure A2.18. Example of Change Analysis. Target: _Unit flying operations___________________ 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 25% plus up Baseline Major plus up Stress In the process optempo (mental & physical) WHO Operator Avg crew Baseline Major decrease Significant Fellow worker flt hrs exper level Supervisor 30%reduction decrease Others TASK Goal Procedure Estimate Baseline Significant Stress Quality current task increase flight profile 15% harder WORKING CONDITIONS Environmental 2 months Good weather Tougher flying Stress Overtime bad weather Schedule Avg week Was under Major Stress now 62 hrs 50 increase (mental Delays & physical) TRIGGER EVENT MANAGERIAL CONTROLS Control Chain Current Cdr Easygoing More command Stress Hazard Analysis hard driver, pressure Monitoring demanding Risk Review 55
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BY ORDER OF THE AIR FORCE PAMPHLET
Page 3 and 4: Figure 14. Levels of Command Involv
Page 5 and 6: levels while preserving assets and
Page 7 and 8: Section B—The ORM Process 5. Intr
Page 9 and 10: 8.2. Identified Risk is risk that h
Page 11 and 12: 10.3.12. There are no “safety pro
Page 13 and 14: 12.3.3.2. Maintenance: Availability
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Page 23 and 24: 32.3. The feasible alternatives mus
Page 25 and 26: 36.3. When notified of a situation
Page 27 and 28: Section G—Step 5—Implement Risk
Page 29 and 30: It is usually a good idea to signal
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Page 33 and 34: Section I—Conclusion 54. Operatio
Page 35 and 36: HAZOP—Hazard operability Hrs—Ho
Page 37 and 38: Risk—An expression of consequence
Page 39 and 40: A2.A.3. THE OPERATIONS ANALYSIS AND
Page 41 and 42: A2.A.3.8.2. Any one event of the ab
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Page 45 and 46: the involvement of operators and th
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Page 59 and 60: A2.B.3. THE HAZARD AND OPERABILITY
Page 61 and 62: A2.B.4. THE MAPPING TOOL A2.B.4.1.
Page 63 and 64: A2.B.5. THE INTERFACE ANALYSIS A2.B
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Page 67 and 68: A2.B.7. THE SAFETY QUIZ A2.B.7.1. F
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Figure A4.2. Example Risk Control O
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elatively small investments in risk
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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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