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- Implement ERM process early
- Create a culture of risk awareness/ERM
- Create risk management framework

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- It would have identified those responsible and what actions should have been taken
- Chain of custody
- They even said "if it wasn't for the bad weather" this would never have happened

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As mentioned in the ppt, ERM consider activities in strategic level, If ERM was introduced in the Comair, they could foresee the risks of the management system, also, Delta should run they activities from enterprise-level to subsidiary level. For a enterprise this size, the three lines of defense would prevent those problems from happening.

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- Control measures
- Monitoring & Evaluation plan

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Both Comair and Delta should be responsible for the problem. Both enterprise lack the culture of risk awareness, the action was not taken when the IT department detect the problem.

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- Why x 5 could lead to solutions and actionable items with priority assessments

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- Provides reason for urgency
- Assigns significance to risks

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One of the main ways that ERM has stopped issues from occurring is that by way of ERM, a system of terminology (lexicon). This helps  identify and classify particular issues, rather than being lost in translation regarding what the problem is. In short, ERM provides a system of language that can be used to classify issues.

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-lack of risk handlining procedure result delay in issue resolution
-ERM is a management system that can not be established over night, it take times.

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Governance: Ensure the replacement project is making progress according to plan.
Accountability: Unclear roles of pushing the replacement project
Issue Resolution: Too slow to act
Root Cause: Bad ERM

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- Overall the lack of the ERM or similar system
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- Review process not implemented into the project
- Government supervision is not in place

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Foster risk intelligence culture
Discuss risk with management team
Approve common risk

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- Reversing the perception of risk in the middle and senior levels
- Establish a sound risk discovery mechanism and encourage employees to discover enterprise risks on their own

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Management is chaotic after the merger. Comair does not approve the acquisition very much, so it maintains the original team, but at the same time the capital expenditure needs to be determined by delta.

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Comair was still using the nearly 20-year-old crew management system from SBS, though with a lot more care. SBS implemented a bridge solution, dividing the legacy system into two modules.
ERM can make risk avoidance strategies at an early stage to help Comair develop the new IT module or system to replace the old one.

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1. IT could disrupt that sense of complacency
2. At that time, the business units were expecting IT to push a project through. And IT was waiting for the business unit to push it through. They should take responsibility.
3. Comair IT executives could do the kind of thorough management analysis.

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root cause: and managers didn’t pay attention to the severity of problems identified

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Control risks at present
Evaluate and provide risk-related information
Integrate other risks into decision making to evolve and transform new organizational strategies

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1.The system was not replaced in time. The old system can hardly handle subsequent growth in business and unforeseen situations

2.What happened at Comair is hardly an isolated problem.

3.Operational risks are not introduced into day-to-day decision-making.

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Implement the ERM process and anticipate the risks of the management system.

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ERM is able to effectively deal with future events that may generate uncertainty in terms of management decisions. The specific process of team management is to cultivate the team's ability to identify risks and develop a risk response framework. Under the premise of ensuring the normal risk management. ERM respond in a manner that reduces the likelihood of downside outcomes and increases the upside.

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Using ERM, Comair should provide a comprehensive and systematic approach to more aggressive and comprehensive risk management; It also provides a common dictionary of risk terms and direction and guidance for the implementation of risk management. At the same time, should Comair management require the organization to examine its complete risk portfolio, consider how these risks relate to each other, and require managers to develop appropriate risk mitigation methods to address these risks in a manner consistent with the organization's strategy and risk appetite

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Comair's IT manager and Delta's finance manager went through multiple rotations, which led to systemic problems that were never resolved. ERM, on the other hand, makes it clear who is responsible when risks turn into problems and occur. ERM can also help managers to conduct risk management analysis and reduce the impact of personnel changes on risk management

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The two companies need to share responsibilities, especially Comair's IT manager and Delta's financial manager are particularly accountable. The IT manager was changed many times and even was absent, resulting in system problems not being followed up continuously. A continuous risk register can reduce the impact of personnel changes. But the funding approval was not passed, leading to the ultimate risk of outbreak.

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2nd line of defence
a step of management strategy to recognise, comparing and measure the risks.

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Establishe a Enterprise risk management framework
predic and make solutions for future risks in advance
Arrange managers to monitor and control these risks

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The most basic, Comair should foster a risk intelligent culture and discuss enterprise risks with executive management, which is a solution at the governance structure level. From the system and operation level, internal audits like provide timely risk-related information can help Comair identify corporate risks as soon as possible. There is a complete analysis and solution system to manage these risks.

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governance:
-develop and formulate mitigation plans
-discuss risk matrix as early as possible
accountability:
-system bias on the system used
-lack of risk mitigation plan on transferring the new system
Issue resolution:

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We found that the key value of ERM is a kind of guideline that teaches people what should they do when there is a risk or an issue. It could prevent people from getting panic and cut the loss. ERM could have good countermeasures about the black goose.

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There was a long time before Comair had to update its system. But Comair did not want to make the change. It could lead to a serious consequence but they kept rejecting updates until they had to or failure happens eventually. So we think it is a typical Gray rhino.

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1. Primary cause of the collapse: the undersized gusset plates (Design error)
2. Extraordinary weight: construction equipment and material resting on the bridge just above its weakest point at the time of the collapse
3. No regular safety check.

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-Professional indemnity issue related to consultants negligence.
-The building materials and specifications seriously do not meet the design requirements (the thickness of the main weighing part is only 1/2 of the specified thickness).
-Maintenance Expection.

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-No special sufficient funds for bridge repair and maintenance.

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-Government neglect of infrastructure
-Lack of supervision mechanism

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-The Delta only cares about whether the company is profitable and ignores the risks and problems within the company. In addition, The Delta could not amicably accept the acquired company, which also caused some problems.
-The Comair management did not realize the problems in IT, and still tried to use the previous way of working. At the same time, IT executives did not thoroughly analyze the potential risks of the work system, and missed the best time to resolve the risks.

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1. Ignorance of the bridge maintenance and quality
2. Bridge overload

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1.1 ignore the importance of a component of the bridge.
1.2 The department that was responsible for the bridge construction didn't check the quality of the component.

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-Design fail to match the actual car load during peek hours
-Material cracks should have been detected

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2.1 The bridge has gotten some attention for potential structural issues and design problems.

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Direct cause:
nearly 300 tons of construction equipment and materials stockpiled on the bridge deck for the ongoing repair work contributed to the collapse by further stressing the crucial gusset plate that failed

Root causes:
1. Material corrosion & lack of structural integrity(thin gusset plate etc) - reduced load-bearing capacity
2. no funding plan for bridge upgrading
3. Lack of strong supervision and inspection during construction period in the beginning

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2.2didn't take measures to limit the volume of the bridge

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Why it fail? - Lack of maintainance and upgrading on structure
Why no maintain in time？- low priority for this bridge (risks are not prioritised)
Why low priority? - Limited resource (i.e. money and man power)
Why limited resource? - Not enough money allocated for the maintainance
Why no money? - Risks are not addressed properly or not paid enough attention
Conclusion: They need a good ERM so that the risks can be detected in time and handled properly.

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Preliminary calculation & estimation led to the insufficient initial design.

The preliminary design gave out the insufficient load capacity of the gusset plates.

The fracture of the four critical gussets and lack of daily maintenance led to the final collapse of the main bridge span.

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The bridge was rated as structurally deficient that need to replace

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Why 1: Safety of the public
Why 2: Death of public (13)
Why 3: Bridge collapsed
Why 3.1: Poor management of bridge quality checks/low prioritisation/barriers to challenging the status quo/Poor Critical thinking
-> 3.1.1 Inadequate review procedures
-> 3.1.1.1 40yo bridge had poor engineering knowledge for the lifespan it has existed and therefore checks were not standard
-> 3.1.1.1.1: 1/2 inch gussets should be 1 inch
-> Solution add the gusset check to review process

3.1.2 Missed opportunities to resolve known issues/politics

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2.3 Not enough evaluation and analysis of materials choosing at the stage of bridge construction.

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-There is a problem with the building materials used in the bridge, and the load-bearing capacity of the materials is not paid attention to the support.
-There is not enough supervision on the purchase of materials, and the supplier hopes to obtain more profits.
-In the construction process, there is no set of standards to evaluate a series of behaviors of purchase and construction.

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1.1.1 Lack of training in gusset plates inspection

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1. Errors in bridge design
2. The increased dead load
3. Lack of training on gusset plate inspection
4. Lack of procedure for ensuring all calculations performed
5. No policy requiring permission to stage materials
6. No evaluation of gusset plate capacity
7. Lack of regular safety inspectation