Army risk management doctrine is second to
none in its depth, breadth, and clarity, yet many
leaders fail to take advantage of the power of
existing tools to accomplish missions safely. The most
serious accidents (classes A through C) still occur in
significant numbers despite the use of existing risk management
tools. Changes must be made if the Army is to
achieve breakthrough results in safety and entrench risk
management in its culture. The purpose of this article is
to demonstrate how current practices in the application
of risk management doctrine at the unit level prevent
the Army from reaching its safety goals and to propose
modifications to the risk management worksheet that
will correct those practices.
|A not-mission-capable piece of engineer equipment is loaded onto a trailer for transport
from Forward Operating Base Hammer to Victory Base Complex. Composite risk management requirements must be followed in this operation to ensure the safety of both personnel and equipment.
While deployed to Baghdad from November 2007
to January 2009, I served as the company commander
of the 57th Transportation Company and reviewed risk
assessments for more than 800 missions. I also observed
the battalion commander review more than 2,000 logistics
convoys. While in Baghdad, my unit served under
two Active Army support battalions
from two installations and received
convoy escorts from three different
Army Reserve Infantry companies.
I observed a number of ineffective
practices that were common among
multiple units throughout the deployment.
Many of these practices were the
same ones that I was guilty of practicing
as an airborne Infantry platoon
leader. These practices included—
• Allowing risk to compound.
• Using a previous risk assessment as a template without performing a mission-specific analysis.
• Completing the risk management worksheet (RMW) as an afterthought.
• Generating laundry lists of hazards and controls.
• Failing to enforce controls.
• Not reassessing risk as conditions changed.
During the deployment, the battalion commander was
constantly training senior noncommissioned officers and
junior officers to fix these practices.
Some will argue that these practices are isolated and
are not widespread in the Army. However, conversations
with peers, reviews of preliminary loss reports,
data from the Army Combat Readiness/Safety Center,
and personal experience all suggest that composite risk
management has not yet become the norm in the Army.
|An M1 Abrams tank is loaded
onto a flatbed trailer for retrograde
from a small base in Baghdad, Iraq,
back to Victory Base Complex.
Following composite risk
requirements for loading the tank
will help ensure that it arrives
at its final destination
without an accident.
The most detrimental practice affecting the successful
execution of missions is the failure to identify compounding
risks. In nearly every serious accident, multiple
factors combined to set the conditions for a mishap. In isolation, the contributing factors would not likely
have caused an accident; combined, the hazards resulted
The stories frequently told by Soldiers about catastrophic
events highlight inexperienced leaders in
unfamiliar environments with improperly trained and
supervised Soldiers using poorly maintained equipment.
This reality emphasizes one of the major shortfalls of
the RMW: Instructions for completing the worksheet
state that the overall risk for a mission is determined by
the hazard that has the highest residual risk. This would
place a mission with five hazards having a residual risk
of medium at the same risk level as a mission that has
only one hazard with a medium risk level. Clearly, these
two missions do not have the same risk level, yet there
are no concrete procedures for addressing the increased
risk of the first mission.
To address this shortfall, the instructions for the RMW
should include a requirement to upgrade mission risk to
the next level if the mission has four or more hazards at
medium or high levels. Missions with low residual risk
should be excluded because all of the hazards will have
a residual risk of low.
A mission with four medium-level risks should be
upgraded to high because of the effects of compounding
risk. This informs the next-level authority of the level of
difficulty of the mission with respect to the importance
of the mission. That authority then may choose to bring
more resources to bear, postpone the mission, or direct
execution because of the mission's importance. Determination
of hazard severity and probability is largely a
judgment call by experienced leaders using subjective
criteria. This method takes advantage of that experience
and improves leader visibility of elevated risk missions.
Laundry List of Hazards and Controls
The next negative practice is the inclusion of a laundry
list of hazards and controls. This often results in
a three- to five-page RMW. While long RMWs make leaders feel more comfortable about
all of the risks being addressed by
controls, they do not result in safer
I frequently found that critical hazard
controls were buried under trivial
ones. During my tour, a convoy commander
often read off a long list of hazards and controls
at the end of an already long convoy brief. Few Soldiers
listened to the litany of hazards and controls. Some of
this was due to the repetitive nature of the missions, but
some of it was also due to human limits for information
Within the safety brief, the list of controls included actions
such as rehearsals that were already complete and
the designation of the minimum rank of the leader of the
convoy. Rebriefing these controls provided information
that the Soldiers did not need and initiated the mental
trigger for them to stop paying attention. Also on the list
were many known standards and regulations. Reinforcing
the most relevant standards for a mission has significant
value, but an extensive list has the opposite effect
and negates any intended emphasis. As a result, Soldiers
may have successfully executed the controls that prevent
minor accidents but neglected the controls that prevent a
The Soldiers and leaders did not intend to execute
some of the controls. I believe the primary cause for
this trend was the dilution of emphasis and competition
among the laundry list of tasks on the RMW. It is
the approval authority's responsibility to provide clear,
prioritized instructions free of nuance. The current form
of the RMW does not set the conditions for this.
Foundation for Accident Prevention
Although long risk assessments address every conceivable
risk, they fail to provide a foundation for preventing
the most serious accidents. The solution to this
situation is twofold.
First, conduct a thorough risk assessment. Prioritize
the list of hazards based on residual risk. Controls
identified in the planning and preparation phase of the
mission should be executed. Selecting the right level of
leader for the mission, inspecting equipment, and conducting
rehearsals are all essential elements to successful
mission execution and should be part of companystandard operating procedures. Rehearsals in particular
aid in developing the subconscious execution that is so
critical to effective units. These controls, however, need
not be reinforced in the mission brief as they are already
completed. This leads to the second component of the
During the mission brief, the controls requiring specific
Soldier actions during execution, particularly those
that are not routine, are the most important elements
of the RMW. I call this component of the RMW "the
execution list." Soldiers and noncommissioned officers
already have a tremendous amount of information to
process, and it is critical that they do not receive any that
The number of hazards for a specific activity should
be limited to seven on the execution list. This facilitates
greater emphasis on the most salient hazards. It also
provides leaders with specific areas on which to focus.
Research shows that it takes many repetitions of a task
to make it part of the subconscious. Limiting the number
of hazards to seven improves the probability that Soldiers
will listen to, remember, and execute the controls
and that leaders will enforce them.
As specific controls are repeated and enforced over
multiple cycles, nonprogrammed behaviors become
programmed. Once a control becomes habitual, remove
it from the RMW and move the next hazard by priority
onto the execution list. This method results in a dependable
ratcheting down of risk over time.
The approval authority should approve missions based
on the full list of hazards and controls and validate the
top seven hazards on the execution list. This will allow
leaders to address lower risk hazards with specific controls
in the mission planning phase while preventing the
dilution of the most critical controls during execution.
A secondary effect of long RMWs is the copying
of risk assessments from previous missions without
performing mission-specific analysis. During my tour,
I required handwritten RMWs from leaders to combat
this trend. Convoy commanders frequently handed the
battalion commander risk assessments that contained
hazards irrelevant to the current mission. Most officers
have seen RMWs for winter operations that included
hot-weather injury risks. While limiting the number of
hazards for the execution list will not eliminate the tendency
to reuse RMWs, it causes leaders to think harder
about which hazards and controls are on that list.
The last habit to be addressed is the timing of the
completion and approval of the RMW. One of the key
characteristics of risk management is that it is a continuous
process. Unfortunately, the current Army culture
surrounding risk management involves a single evaluation
that is rarely modified or reevaluated as the mission progresses through planning and execution.
One of the lessons I learned as an approval authority
was that reviewing the RMW the day of the mission did
not provide the time needed to make adjustments. As
mission execution gets closer, fewer risk control options
are available. Identifying specific leaders for more
difficult missions, rehearsals, and equipment inspections
is a critical control that is not available as time runs out.
Mission changes in this timeframe result in greater risk
as leaders include unplanned activities in their timelines.
This stress before execution often leads to confusion
about priorities and results in the neglect of other controls.
A leader racing out to notify Soldiers of modified
timelines close to execution also causes subordinates to
lose confidence in him.
The corresponding problem with completing the
RMW too early is that conditions on the ground, such
as enemy and weather, can change significantly or new
hazards can emerge before execution, affecting mission
risk. The solution to this problem is to include boxes on
the right-hand side of the RMW for each hazard, where
leaders can input the residual risk for hazards during
planning, preexecution, and execution. The approval
authority signs the risk assessment in the planning
phase and may delegate the pre-execution and execution
reevaluations one level down. Delegation of the reevaluation
includes specific instructions about notification in
the event that the hazards of the mission are upgraded
because of changes in conditions. The approval authority
may choose to retain direct reevaluation responsibility
if he wishes.
Composite risk management doctrine is sound, but it
is not embedded in Army culture. The operational risk
management worksheet embeds this doctrine and will
help the Army reduce on-duty accidents in a dramatic
way over the long term. Operational risk management
will help the Army keep its promise of "Mission First,
Soldiers Always" by providing the right information at
the right time, resulting in improved decisionmaking,
resource allocation, Soldier survivability, and mission