1st Edition

Risk-Based Thinking Managing the Uncertainty of Human Error in Operations

By Tony Muschara Copyright 2018
    300 Pages 25 B/W Illustrations
    by Routledge

    300 Pages 25 B/W Illustrations
    by Routledge

    Society at large tends to misunderstand what safety is all about. It is not just the absence of harm. When nothing bad happens over a period of time, how do you know you are safe? In reality, safety is what you and your people do moment by moment, day by day to protect assets from harm and to control the hazards inherent in your operations. This is the purpose of risk-based thinking, the key element of the six building blocks of Human and Organizational Performance (H&OP).

    Generally, H&OP provides a risk-based approach to managing human performance in operations. But, specifically, risk-based thinking enables foresight and flexibility—even when surprised—to do what is necessary to protect assets from harm but also achieve mission success despite ongoing stresses or shocks to the operation. Although you cannot prepare for every adverse scenario, you can be ready for almost anything. When risk-based thinking is integrated into the DNA of an organization’s way of doing business, people will be ready for most unexpected situations. Eventually, safety becomes a core value, not a priority to be negotiated with others depending on circumstances.

    This book provides a coherent perspective on what executives and line managers within operational environments need to focus on to efficiently and effectively control, learn, and adapt.

    Contents

     

    List of Figures

    List of Tables

    List of Experiences

    Special Thanks

    Introduction

    What This Book Is About

    Hu and H&OP

    Principles – Core Beliefs Espoused in this Book

    Why Read This Book

    Who This Book Is Written For

    As You Read the Book

    Chapter 1 A Nuclear Professional

    Chapter 2 A Strategic Approach

    Work and the Workplace

    The Hu Risk

    Hu Risk Management Model

    The Building Blocks of H&OP

    Things You Can Do Tomorrow

    Chapter 3 Fundamentals of Human and Organizational Performance

    The Notion of Human Error

    The Basics About Behavior, Error, and Violations

    The Basics About Work Context – Local Factors

    The Basics About Organization and Management

    Defenses – Controls, Barriers, and Safeguards

    The Severity Pyramid – Misunderstood

    Resilience – Adaptive Capacity of Front-Line Workers

    Things You Can Do Tomorrow

    Chapter 4 Risk-Based Thinking and Chronic Uneasiness

    Nothing Is Always as it Seems

    Risk-Based Thinking – Four Cornerstone Habits of Thought

    Chronic Uneasiness

    The Front-Line Worker – Hazard or Hero?

    Technical Expertise – The Bedrock of Risk-Based Thinking

    Conservative Decision-Making

    Safety Is a Core Value

    Things You Can Do Tomorrow

    Chapter 5 Critical Steps

    A Risk-Based, Yet Efficient Approach

    Recognizing a Critical Step

    Origins of the Critical Step Concept

    Risk-Important Actions (RIAs)

    Managing Critical Steps

    Is 99 Percent Good Enough?

    Things You Can Do Tomorrow

    Chapter 6 Systems Thinking for H&OP

    System Basics

    Systems Thinking – Blunt End and Sharp End

    The Work Execution Process

    Systems Thinking – The Flow of Influence

    Things You Can Do Tomorrow

    Chapter 7 Systems Learning

    What is Systems Learning?

    Drift and Accumulation

    Learning Methods

    Event Analysis

    Corrective Action / Preventive Action Process

    Learn from Success as Well as Failure

    Things You Can Do Tomorrow

    Chapter 8 Managing Human Performance

    The Basic Management Cycle

    Plan – Form Expectations

    Do – Communicate and Train

    Check – Observe and Inspect

    Adjust – Give and Receive Feedback

    Human Performance Tools

    Accountability and Just Culture

    You Can Engineer Performance

    Things You Can Do Tomorrow

    Chapter 9 Integrating and Executing H&OP and Risk-Based Thinking

    Remember the Seven Principles of Managing H&OP

    Build a Business Case

    A Playbook

    Integration – Enabling Risk-Based Thinking

    Execution – Deploying H&OP

    Promoting Risk-Based Thinking and Chronic Uneasiness

    Things You Can Do Tomorrow

    Epilogue: Live Long and Prosper

    Appendix 1: Glossary of Terms

    Appendix 2: Generic Local Factors

    Appendix 3: Common Error Traps

    Appendix 4: Fundamental Human Performance Tools

    Appendix 5: Candidate Indicators for H&OP

    Appendix 6: The Building Blocks of H&OP – Self-Assessment Criteria

    Appendix 7: Suggested Reading

    Index

    Biography

    Tony Muschara is the Principal Consultant at Muschara Error Management Consulting, LLC, specializing in human error risk management in high-hazard, industrialized environments, and is a Certified Performance Technologist (CPT), awarded by the International Society for Performance Improvement (ISPI). Tony became a nuclear plant simulator instructor at Farley Nuclear Plant (1983–1985) and then joined the Institute of Nuclear Power Operations (1985–2007) where he authored several human performance guidelines for the nuclear industry. Many of his documents were adopted by the U.S. DOE and the World Association of Nuclear Operators. Tony received a BS degree in general (mechanical) engineering from the U.S. Naval Academy, served in the U.S. Submarine Service (1975–1982), Qualified in Submarines, qualified as Engineer of Naval Nuclear Propulsion Systems, retired as Captain, USNR. Tony also received an MBA from Kennesaw State University, USA.

    'This book provides sound principles for managing hazardous operations that would otherwise take years to understand through trial and error. The real-world application of Muschara’s material has produced immediate results.' — Lee Reynolds, SI Group, Inc.

    'The "Must-Read" book on reducing risks from human error; Tony' s passion is for people who do hazardous work, keeping them safe, helping them succeed. Tony is one of the best, an exemplar practitioner of resilient, reliable operations.' — W.E. Carnes, U.S. Department of Energy (ret.), former Senior Advisor for Human Performance & High Reliability

    Tony's book brings together much of the new thinking about Human Error and Safety in a practical guide to those who manage any organization, whether it be safety-critical or simply an economic enterprise. Very helpful and easy to follow.' — John Wreathall, Independent consultant in organizational safety for nuclear power, health care and transportation

    'Tony Muschara begins to build a much needed bridge from a traditional view of human performance to the "new view", moving toward increasing resilience and reliability with an understanding that work is variable thus adaptability is key to success.' — Elizabeth Lay, founder and principal, Applied Resilience, LLC, Houston Texas

    'Tony has managed to create a meaningful reference book for practitioners while laying out a guide to culture change for leaders!' — Mike Blevins, Luminant COO (retired)