Chapter 14 Annex F - Maintaining Risk Awareness

Two simple techniques designed to help people maintain risk awareness in dynamic operating environments are the Rule of Three and PEAR (People, Environment, Actions and Resources). Used in combination, these techniques enable the identification of emerging risks immediately before and during the execution phase of an activity. They complement deliberate risk management activities and directly support decisions relating to the adequacy of risk control measures. The use of the Rule of Three and PEAR ensures that the management of risk is not confined to the planning phase of a mission or activity. It enhances effective risk management in all activities and at all times.

Rule of Three

The Rule of Three provides a simple way of applying a level of immediate risk management. The basic premise is the traffic-light system outlined in Figure F–1. The activity, product or service is to be stopped if RED, but too many AMBER lights may be just as risky. Safety events all too often happen because of a combination of relatively minor events and situations.

Figure F-1: Rule of Three

PEAR

PEAR directly supports the application of the Rule of Three by helping to identify hazards and risks. The PEAR acronym stands for People, Environment, Actions and Resources.

People—who perform the task. People (the humans in the system) relates to the suitability (physical, cognitive and social) of the selected personnel for a particular task. Suitability not only covers knowledge and skills, but also human factors considerations such as fatigue, stress and motivations. It addresses an individual’s physical, physiological, psychological and psychosocial factors. It focuses on individuals, their physical capabilities and the factors that affect them. It also considers the mental state, cognitive capacity and conditions that may affect an individual’s interaction with others. Table F–1 below outlines examples associated with people.

Table F-1: People

Environment Physical and Organisational—in which they work. Environment is not just the physical environment (lighting, temperature, noise levels and time of day) but also the organisation itself (quality of supervision, amount of supervision and pressures to complete an activity, product or service). Both the physical workplace (eg flight line, hangar or workshop) and the organisational environment that exists within the organisation needs to be considered. The physical environment is clear; it includes the physical attributes of the environment such as temperature, humidity, lighting, noise, cleanliness and workplace design. Environment overlaps with the Resource component of PEAR when it comes to providing portable heaters, coolers, lighting, clothing, and workplace and task design. The second, less tangible aspect of environment is the organisational aspect which is typically related to cooperation, communication, shared values, mutual respect and the culture of the organisation. Table F–2 outlines examples associated with environment.

Table F-2: Environment

Actions—they perform. Actions identify the requirements of the task to help to identify any specific areas that might increase the risk of error, such as ambiguous information, or complex tasks that require specialist knowledge and skills. Successful HF programs analyse the actions people perform to complete a task safely and efficiently. It identifies the knowledge, skills, attributes, instructions, tools and additional resources required to conduct a task. Table F–3 outlines examples associated with actions.

Table F-3: Actions

Resources—necessary to complete the task. Resources can be defined as anything that is required to complete the tasks successfully (examples include personnel, procedures, tools, available time and personal protective equipment). It is sometimes difficult to separate resources from other PEAR elements. In general, the characteristics of People, Environment and Actions dictate necessary Resources. Many resources are tangible, such as lifts, tools, test equipment, computers, PPE, and manuals. Other resources are less tangible, for example the number of personnel to complete a task, the qualifications required to complete a task, and the amount of time allocated. Table F–4 outlines examples associated with resources.

Table F-4: Resources

Applying the Rule of Three and PEAR

Prior to commencing an action, product or service, use PEAR to identify conditions or circumstances that may become a concern to you and others. Speak up if you identify any AMBER or RED conditions or circumstances. Take time to think about the issues and discuss them with your team and supervisor. If AMBER or RED:

AMBER = Communicate and Consider:

Occurs where the condition or circumstance, while within limits, is nearing the boundary of being acceptable

Ensure you understand the issues and, if required, seek additional information

Discuss the issue with others in your team, or your immediate supervisor

Consider what can be done to eliminate or otherwise minimise an AMBER into a GREEN

Continue if you are satisfied that nothing further can be done but maintain vigilance in this area

Ensure all solutions are appropriate and authorised for use

Add up all the remaining issues classified as AMBER to see if you can proceed with the activity, product or service

Remember three or more AMBERs equal a RED.

RED = Stop:

Occurs where a condition or circumstance is out of limits or unacceptable

Always STOP if you have a RED

If activity, product or service is underway, current actions are to be immediately halted or the situation stabilised to a safe position to evaluate the concern

Discuss the issue with others in your team, or your immediate supervisor

Identify what you can and cannot do to eliminate or otherwise minimise the concern

Do not proceed until the RED is eliminated and returns to GREEN (or possibly minimised to AMBER).

Ensure all solutions are appropriate and authorised for use. In the event the condition or circumstance cannot be changed, address issue through CoC. Remember to address any remaining AMBERS. A RED does not necessarily mean you cannot do the activity – it means stop and reassess the situation and evaluate your options. Always apply the principles of risk management including:

try to eliminate all risks

if the risk can’t be eliminated, then minimise by applying all reasonable controls

ensure all controls are appropriate and authorised for use

ensure all risk-based decisions are made at the appropriate level.

Where and When to Apply

Using Rule of Three in combination with PEAR allows for a relatively simple methodology for identifying and responding to changes that can occur in the operating environment. Plan, Brief, Execute, Debrief (PBED) is useful for assessing risks and their controls then communicating and managing risks inherent to an activity, product or service. The techniques are suitable for incorporation into daily activities, including:

Plan. Preparation for a task or activity.

Brief. Briefing of the task or activity to personnel.

Execute. Execution phase of the task or activity.

Debrief. Debriefing of the task or activity with personnel, and manager.

It is essential that the outcomes of the Rule of Three are reviewed following the completion of an activity, product or service. Conducting a review is essential to identify what worked, what did not work, and to document any lessons learned. Where this process identifies limitations, these are to be fed back into the formal deliberate risk management process making it more robust for future operations.

Further actions

Discussions amongst personnel should include how risk awareness techniques like Rule of Three and PEAR can be used effectively. When working in a group environment, it is important for personnel to have a clear and common understanding of how the techniques will be used and, in particular, what will constitute an AMBER or RED. Terms like ‘counting your AMBERS’, ‘managing into the GREEN’ or ‘close to RED’ should be used.

Knock-it-off and Time-out

Integral to the effective use of risk awareness techniques like Rule of Three and PEAR are the concepts of ‘Knock-it-off’ and ‘Time-out’. These concepts are essential to ensuring everyone has a voice if they see an unsafe situation developing. Verbalising either of these terms sends a message to those involved in a specific action to stop, take a moment to reset and re-evaluate the current situation. Everyone (regardless of rank or position) is empowered to use these terms without any fear of repercussion. When either term is used, all current actions are to be halted immediately, the situation is to be stabilised to a safe position and the concern evaluated.