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

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A2.C.8.8. EXAMPLES. The top blocks of the MORT diagram are displayed at Figure A2.45. Figure A2.45. Example MORT Section. Oversights & Omissions Operational System Factors LTA Accidental Losses 96 Assumed Risk Management System Factors LTA
Attachment 3 RISK ASSESSMENT TOOLS, DETAILS, AND EXAMPLES A3.1. Introduction. There are many ways to assess risk, but the easiest and most effective for routine risk management applications is the risk assessment matrix introduced in Section D. The easiest way to understand the application of the matrix is to apply it. Follow the reasoning of the matrix user in the example below as he applies the matrix to the assessment of the hazards associated with the movement of a heavy machine from point A to point B. A3.1.1. Example. The example below demonstrates the application of the matrix to a hazard associated with moving a heavy piece of machinery. A3.1.1.1. Hazard to be assessed: The hazard of the machine falling over and injuring personnel. A3.1.1.2. Probability assessment: The following paragraphs illustrate the thinking process that might be followed in developing the probability segment of the risk assessment: A3.1.1.2.1. Use previous experience and the database, if available. “We moved a similar machine once before and although it did not fall over, there were some close calls. This machine is not as easy to secure as that machine and has a higher center of gravity and poses an even greater chance of falling. The base safety office indicates that there was a mishap about 18 months ago that involved a similar operation. An individual received a broken leg in that case.” A3.1.1.2.2. Use the output of the hazard analysis process. “Our hazard analysis shows that there are several steps in the machine movement process where the machine is vulnerable to falling. Furthermore, there are several different types of failures that could cause the machine to fall. Both these factors increase the probability of falling.” A3.1.1.2.3. Consider expert opinion. “My experienced NCOs feel that there is a real danger of the machine falling” A3.1.1.2.4. Consider your own intuition and judgment. “My gut feeling is that there is a real possibility we could lose control of this machine and topple it. The fact that we rarely move machines quite like this one increases the probability of trouble.” A3.1.1.2.5. Refer to the matrix terms. “Hmmm, the decision seems to be between likely and occasional. I understand likely to mean that the machine is likely to fall, meaning a pretty high probability. Certainly there is a real chance it may fall, but if we are careful, there should be no problem. I am going to select Occasional as the best option from the matrix.” A3.1.1.3. Severity assessment. The following illustrates the thinking process that might occur in selecting the severity portion of the risk assessment matrix for the machine falling hazard: A3.1.1.3.1. Identify likely outcomes. “If the machine falls, it will crush whatever it lands on. Such an injury will almost certainly be severe. Because of the height of the machine, it can easily fall on a person’s head and body with almost certain fatal results. There are also a variety of different crushing injuries, especially of the feet, even if the machine falls only a short distance. A3.1.1.3.2. Identify the most likely outcomes. “Because of the weight of the machine, a severe injury is almost certain. Because people are fairly agile and the fact that the falling machine gives a little warning that it is falling, death is not likely.” 97
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BY ORDER OF THE AIR FORCE PAMPHLET
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Figure 14. Levels of Command Involv
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levels while preserving assets and
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Section B—The ORM Process 5. Intr
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Section G—Step 5—Implement Risk
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BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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