Naval Safety Center

School Of Aviation Safety

Presentation Time: 1.5 Hours

Welcome to this Risk Assessment presentation. Our goal is to teach you how to analyze hazards for
their potential risk to cause future accidents.

With this knowledge, you will be able to prioritize corrective actions to prevent those future
accidents.

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 Risk Assessment

The process of
detecting hazards and
assessing associated risks

What is Risk Assessment?

The process of detecting hazards and assessing associated risks.

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 Hazards and Risks

Hazard – A condition with the potential to

cause personal injury or death, property damage,
or operational degradation

Risk - An expression of possible loss in terms

of probability and severity

Hazards and Risks are not the same!

Hazard – A condition with the potential to cause personal injury or death, property damage, or
operational degradation

Risk – An expression of possible loss in terms of probability and severity

Example: Driving on icy roads is a hazardous condition.

- Risk is lessened by driving slow while using snow tires or chains (less probability of slipping and
less damage if you go in the ditch at a slower speed).
- Risk is increased with speed or bald tires (higher probability of slipping and greater damage on
impact).
- Risk is zero if you don’t drive at all, even though the hazard still exists! However, if we don’t drive
at all, we won’t “get the job done” either!

Risk Management allows us to still do the job, but with the safest (less risk) method.

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 Intervention Development
Operational Risk Management

Assess Make
Hazards Decisions

Identify Implement
Hazards Controls

Supervise

Operational Risk Management is a method of identifying and controlling risks.

This lesson will focus on the first two steps of Risk Management…the Identification of Hazards and
Assessing Hazards.

(Quickly go to next slide)

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 Assessing Hazards by Probability
Probability
How often will a certain
hazard lead to an accident?

Frequent: Probably will occur very often

Likely: Probably will occur often
Occasional: Expected to occur occasionally
Seldom: Expected to occur on a rare basis
Unlikely: Unexpected, but might occur

Probability is the likelihood of an accident with a given hazard.

This can happen on a:

Frequent, Likely, Occasional, Seldom, or Unlikely basis.

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 Assessing Hazards by Severity
Severity
When that hazard does cause an accident,
how severe will the outcome be?

Catastrophic: Loss of life; complete equipment

loss
Critical: Accident level injury and
equipment damage
Moderate: Incident to minor accident damage
Negligible: Damage probably less than
accident or incident levels

Severity describes the highest level of damage possible when an accident occurs from a
particular hazard.

Damage can be:

Catastrophic, Critical, Moderate, or Negligible

For example: Ergonomic hazards may result in Negligible, Moderate, or even Critical levels of
accidents, depending on tasks (e.g., typing or lifting heavy materials). But using inadequate tools
when jacking an aircraft may result in Catastrophic aircraft damage or death.

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 Combining Probability and Severity

RISK
Extremely High Risk:
A hazardous condition may cause frequent accidents
which may result in catastrophic equipment losses,
injury, or death.

Low Risk:
A hazardous condition is unlikely to cause accidents,
and even if it does, results in only negligible damage.

So Risk is a combination of Probability and Severity.

Risks can range from Low to Extremely High Levels.

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 Risk Elimination?

All accident causal factors (hazards) should

be eliminated, however, we may not have the
resources to immediately accomplish it.

We must then prioritize our corrective actions

by addressing High Risks before Low Risks.

But why bother to classify risks at all? Shouldn’t we just eliminate all hazards and their
associated risks?

If it were possible yes, but sometimes we don’t have the resources (authority, personnel, equipment,
support, budget, etc.) to accomplish it.

If we don’t have infinite resources, we must then prioritize our actions by identifying and
eliminating the higher risks before we devote too many resources to the lower risks.

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 Risk Assessment

But, how can we systematically classify and

prioritize risks?

Answer: Risk Assessment Codes or (RACs).

They provide a simple method to prioritize
intervention strategies.

But, how can we systematically classify and prioritize risks?

Answer: Assign Risk Assessment Codes (RACs). RACs provide a simple method to prioritize
intervention strategies.

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 Risk Assessment Matrix
RAC PROBABILITY

Codes Frequent Likely Occasional Seldom Unlikely

A B C D E

I II B
B
Catastrophic Extremely
S
High
E
V II HighHigh
Critical II
IIDD
E
R
I Moderate III III
IIIAA
Medium Low
T
Y
Negligible IV IV
IVBB IV
IVEE

Facilitator: Click for each “slide build”

The Risk Assessment Matrix is really quite easy to use. It illustrates the relationship between Probability, Severity,
Risk Levels, and RAC Codes.

Probability vs. Severity

- First, notice the “boxed” section along the top of the Matrix for Probability (Unlikely through Frequent).
- Likewise, the Severity “box” contains damage levels (Negligible through Catastrophic).

As Risk is determined by a combination of Probability and Severity, the main area of the Matrix reveals the Risk
Levels. The levels are Low, Medium, High, and Extremely High.
To have a low level of risk, we must have a somewhat limited probability and level of severity. Notice that a Hazard with
Negligible Accident Severity is usually Low Risk, but it could become a Medium Risk if it occurs frequently. Likewise, a
Hazard with a Critical Accident Severity Level could be a Low Risk if it almost never happens. Extremely High Risk is the
smallest level, but it has the greatest potential for disaster as Critical/Catastrophic damages are Likely/Frequently going to
occur!

The Risk Assessment Codes (RACs) are simply Roman Numerals and Letters combined to easily label the Severity and
Probability Combinations that form the Levels of Risk. Notice that:
Catastrophic (I) and Likely (B) form RAC IB, which denotes an Extremely High Risk.
Moderate - Frequent (RAC IIIA) is a High Risk.
Critical - Seldom (RAC IID) is a Medium Risk, and
Negligible - Likely (RAC IVB) and Negligible – Unlikely (RAC IVE) are both Low Risks.

Let us now use the risk assessment process in a couple of case examples. (quickly go to next slide)

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 RAC Example

Inappropriate equipment was used to wash an aircraft.

Inadequate Brushes
Damage to aircraft/people from brushes would be Negligible (IV).
Accidents are Unlikely from using inappropriate brushes (E).

RAC Code is IVE…a Low Risk.

Let us assume we just discovered a potential Hazard in washing aircraft with inappropriate
equipment (inadequate brushes).

The damage (Severity) to the aircraft, or to personnel, by using a different kind of brush would be
Negligible (IV), limited to probably only minor scratches.

The probability of an accident at all, is Unlikely (E).

So, the RAC is IVE….a Low Risk.

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 RAC Example

What if goggles were not used during the aircraft wash?

Lack of Goggles
Damage to the aircraft is certainly Negligible, but eye
injuries could be Critical (II). Not using goggles on aircraft
washes may cause eye accidents (Seldom-D).
Critical II and Seldom D: RAC IID - A Medium Risk.

But what if we took this same scenario and changed the inappropriate equipment from brushes to
goggles?

The damage to aircraft would be non-existent or Negligible, however personal injury, in the form of
eye damage, could be Critical (II).

The probability of an accident from not using goggles is not an everyday occurrence, but it will
happen on seldom occasions (D). Note: Remember, even though they do not have goggles (100% of
the time for this hazard), it will only be an accident if fluid enters and damages the eyes (much less
than 100%, or more likely, on a seldom basis).

So, this aircraft washing scenario has a RAC of IID, a Medium Risk.

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 RAC Example

Task Change: Welding, without goggles!

Damage to the aircraft components could be Moderate, but
eye injuries could be Critical (II). Not using goggles during
welding will Frequently (A) cause accidents.
Critical (worst case) II and Frequent A: RAC IIA
An Extremely High Risk!

Finally, let us take the ‘lack of goggles” and apply it to a different task, one that obviously has more
potential to damage the eyes.

Welding aircraft components without goggles could potentially produce Moderate damage to the
components, but would cause Critical eye injury (II).

The probability of having accident level injuries to the eyes would be very high without welder’s
goggles (Frequent –A).

This RAC is IIA…an Extremely High Risk!

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 Risk Assessment Matrix

PROBABILITY

Frequent Likely Occasional Seldom Unlikely

A B C D E

Catastrophic I Extremely
S
High
E
V II Welding High Goggles
Critical
IIA IID
E
R
I Moderate III Medium Low
T
Y Brushes
Negligible IV IVE

Given our “inappropriate equipment” hazards, the risk levels changed dramatically based
upon severity of damage and the probability of accident level occurrence.

Inappropriate Brushes for Aircraft washes were a Low Risk. As you can see, the potential for
damage was low with brushes…no matter what the task. It was also an unlikely cause of any
accident.

Goggles, however, protect sensitive eyes from hazards. Damage to eyes could reach Critical
severity. As such, the only remaining determination for Risk is how often the potential exists for that
damage. Washing aircraft (without goggles) will cause damage to your eyes less often than welding
(without goggles) will. Risk goes from Medium to Extremely High because of this likelihood for
injury.

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 Case Study: HFACS-ME with RACs

An unsupervised electrician was told to conduct some

aircraft electrical repairs. A “seasoned pro”, he decided that
it wasn’t necessary to secure power or use tags for such a
small job. Unable to trace the wires adequately in the dark,
confined area with his flashlight, he decided to disconnect
the most likely of several wires. The electrical short
destroyed several pieces of equipment.

Facilitator: Please read this slide’s “Case Study” for students (it is not in the Student Guide). You
may also want to have students classify the causal factors using the HFACS-ME Framework prior to
advancing to the next slide for extra practice.

We will now merge our previous discussions of HFACS-ME with our new system to identify
RACs.

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 HFACS-ME Analysis
Error Categories of HFACS Framework
First Order Second Order Third Order
Management Organizational - Inadequate Processes - Inadequate Documentation - Inadequate Design
Conditions - Inadequate Resources

Supervisory - Inadequate Supervision - Inappropriate Operations - Uncorrected Problem

- Supervisory Misconduct
Maintainer Medical - Mental State - Physical State - Limitation
Conditions
Crew Coordination - Communication - Assertiveness - Adaptability/Flexibility

Readiness - Training/Preparation - Certification/Qualification - Infringement

Working Environment - Lighting/Light - Weather/Exposure - Environmental Hazards

Conditions
Equipment - Damaged/Unserviced - Unavailable/Inappropriate - Dated/Uncertified

Workspace - Confining - Obstructed - Inaccessible

Maintainer Acts Error - Attention/Memory - Judgment/Decision-Making - Knowledge/Rule Based

- Skill/Technique

Violation - Routine - Infraction - Exceptional

- Flagrant

Using the HFACS-ME Framework, an Accident Investigator would select the Error Categories shown:

Management Conditions
Supervisory - Inadequate Supervision. No supervision at all.

Maintainer Conditions
Medical – Mental State. Complacency and Over-Confidence affected his
decisions on securing power, tagout procedures, and, selection of the
“probable” wire without verification.

Working Conditions
Environment – Lighting/Light. Area was not adequately illuminated.
Equipment – Unavailable/Inappropriate. His flashlight was inadequate.
Workspace – Confining. With the poor lighting, it added some difficulty in tracing wires.

Maintainer Acts
Error – Judgment/Decision Making. Choosing to disconnect the likely wire without
adequate verification.
Violation – Infraction. Ignoring tagout and power securing requirements.

Facilitator: You may wish to have students assign RAC Codes to these HFACS-ME Factors before
advancing the slide.

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 RAC Codes
Maintainer Acts
Violation – Infraction. RAC-IA
Error – Judgment/Decision Making. RAC-IB

Maintainer Conditions - Medical – Mental State. RAC-IC

Management Condition-Supervisory-Inad. Supervision. RAC-IC

Working Conditions
Equipment – Unavailable/Inappropriate. RAC-ID
Environment – Lighting/Light. RAC-ID
Workspace – Confining. RAC-IID

IMPORTANT!! RACs are based on FUTURE accident potential. This exact accident may not happen again, but the
individual causal factors will remain unless corrected. So we must assign RACs (and corrective actions) to our cause
factors based upon their potential to cause NEW accidents.
Example: If we stopped a friend BEFORE he drove without a seat belt, there would be no accident. Because there was no
accident (this time), would you assign a RAC of IVE (Unlikely-Negligible) for not using seat belts while driving. No! Lack
of seat belts occasionally results in fatal accidents….so a RAC of IC would be more appropriate.

Note: Why are there no Severity III or IV levels? Because this accident reached a Critical Severity Level (in equipment
damage), proving our accepted causal factors have at least Critical (or worse) Severity potential.

Infraction. IA. Not securing power while working on electrical wires will frequently cause accidents, severe injuries, or
even fatalities. Our man was lucky!
Judgment/Decision Making. IB. “Guessing” the correct electrical wire is likely to result in catastrophic accidents, though
it has slightly less potential than deliberately working on a live wire as noted in the infraction above.
Mental State. IC. Complacency and overconfidence may cloud judgment, but professionalism should err on the side of
safety. This occasionally causes catastrophic electrical accidents.
Inadequate Supervision. IC. A “seasoned pro” electrician shouldn’t need much supervision. This case shows that a lack
of supervision can still be a catastrophic factor amongst “professionals” who violate safety rules.
Inappropriate Equipment. ID. The flashlight was not the best, but it didn’t force him to choose not to secure power or
guess the wrong wire. It simple made the intended task a bit more difficult. Weak flashlights, as seen here, occasionally may
contribute to potentially Catastrophic Accidents.
Lighting/Light. ID. In this case, same as Inappropriate Equipment (poor flashlight).
Confining. IID. The confining area was the least influential of the factors on his decision. He had enough light to
determine “likely wires” and chose to ignore the hazards of other wires. A similar situation would seldom involve even a
critical accident.

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 Risk Assessment Matrix

PROBABILITY

Frequent Likely Occasional Seldom Unlikely

A B C D E

Violation Judgment Mental State/ Equipment/

Catastrophic I IA IB Supervision Lighting
S Extremely IC ID
E High
V II High Confining
Critical
IID
E
R
I Moderate III Medium Low
T
Y
Negligible IV

The completed Matrix shows:

1. The Violation (IA) and Judgment Errors (IB) must be corrected first (Extremely High Risk).
2. The Supervisory, Mental State, and Lighting Issues are a close second (High Risk)
3. The Confining work area is the last priority (Medium Risk)

Although in hind sight, these RACs seem to be rational, we have often chosen the wrong
priorities in the past. For example, if we wanted newer aircraft (accident or not), would we spend all
of our time arguing about the lowest priority factor (confining spaces) while simply writing off the
others as “do more training”. Would lighting be considered at all? Would Supervision?

RACs identify accident risks, not political issues or pet projects.

RACs provide the ability to prioritize accident intervention strategies.

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 Summary
¾Risk Assessment helps organizations to
analyze individual hazards by their risk
potential.

¾RACs provide a simple means to classify

risks by their probability and severity.

¾Organizations can effectively use RACs to

select the appropriate intervention strategies
for prevention of future accidents.

Summary:

-Risk Assessment helps organizations to analyze individual hazards by their risk potential.

-Risk Assessment Codes (RACs) provide a simple means to classify risks by their probability and
severity.

-Organizations can effectively use RACs to select the appropriate intervention strategies for
prevention of future accidents.

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 Questions?

Questions?

NTSB Photo (http://www.ntsb.gov/events/2000/aa1420/default.htm):

American Airlines Flight 1420
Little Rock, Arkansas
June 1, 1999

The accident aircraft, a McDonnell Douglas MD-82 on a regularly scheduled passenger flight from
Dallas, TX, on June 1, 1999, overran the end of the runway, went down an embankment, and
impacted approach light structures after landing at Little Rock airport. Thunderstorms and heavy rain
were reported in the area at the time of the accident. There were 11 fatalities, including the aircraft
captain, and numerous injuries among the 145 passengers and crew aboard the flight.

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