CRITICAL STEPS
Managing What Must Go Right
in High-Risk Operations
A NEW BOOK FROM TONY MUSCHARA, RON FARRIS, AND JIM MARINUS
“What activities, if performed less than adequately, pose the greatest risks to the well-being of the systems?”
- DR. JAMES REASON, AUTHOR & PROFESSOR EMERITUS
A CRITICAL STEP is a human action that will trigger immediate, irreversible, and intolerable harm to an asset, if that action or a preceding action is performed improperly.
CRITICAL STEPS happen every day at work and at home, purposefully.
Work does not happen otherwise. Work is energy directed by people to create value.
If an operation has the capacity to do work, then it has the capacity to do harm.
But people are imperfect—we make mistakes, and
sometimes we lose control of the work.
Therefore, work is the use of force under conditions of uncertainty.
Why Read this Book?
The overarching goal of managing CRITICAL STEPS is to maximize the success
(safety, reliability, productivity, quality, profitability, etc.) of people’s performance
in the workplace, to create value for the organization without losing control
of built-in hazards necessary to create that value.
Whether a human action involves clicking on a link attached to an e-mail message, walking down a flight of stairs with a newborn baby in arms, engaging the clutch on a gasoline-driven chain saw, or administering a medication to a patient in a hospital,
these all satisfy the definition of what constitutes substantial risks in our daily lives, professionally or personally.
Human error in high-hazard operations cannot be left to chance—
the risk, their related hazards and assets’ exposures to those hazards,
must be managed, organizationally and in real time at the worksite.
The practice of managing CRITICAL STEPS changes the emphasis from simple error avoidance to ensuring success proactively and systemically.
An added benefit of this practice optimizes efficiencies and productivity as well as safety of operations that are indeed high risk. It provides a structure for everyone in the organization to have ongoing, robust, technical, interdisciplinary conversations about what must go right in the pursuit of business goals.
While the practice of managing CRITICAL STEPS focuses on what’s most important, it accordingly identifies low-risk work activities where the loss of control has little or no impact. There is no need to prevent all human error. One, it’s impossible; two, it’s expensive; and three, it distracts from your focus. To us it makes better sense to target high-risk activities, ensuring that they go right, and to avoid the truly high-risk errors. This has the effect of giving greater control of low-risk operations to the expert judgment of the workforce.
Table of Contents
The Book
Endorsements
About the Authors
Ron Farris
Ron has over 39 years of research and operational experience in the US Navy, Department of Energy, Nuclear Regulatory Commission, Electric Power Research Institute, electric utility industry, and petrochemical.
Tony Muschara
Tony has over 40 years of experience in consulting, training, and management positions in commercial and military nuclear power operations.
Jim C. Marinus, Jr.
Jim Marinus specializes in high-risk operations management, high reliability, and resilience. Consulting support includes oil, commercial airlines, and the US Department of Energy.
