Critical Steps
Managing What Must Go Right
in High-Risk Operations
A NEW BOOK FROM TONY MUSCHARA, RON FARRIS AND JIM MARINUS
Note: The illustration above is an
anticipated facsimile of the book’s cover
Managing What Must Go Right
“What activities, if performed less than adequately, pose the greatest risks to the well-being of the system?”
- 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
Chapter 1: What is a Critical Step
Chapter 2: Thinking About Human Performance Risk
Chapter 3: Work Execution Process
Chapter 4: Risk-Important Actions
Chapter 5: Performing Critical Steps
Chapter 6: Managing Critical Steps
Chapter 7: Critical Step Mapping
Chapter 8: Integrating and Implementing Critical Steps
The Book
Endorsements
“Finally, a book that can be used both as a scholarly reference and for the morning job safety brief. This book won’t be on my shelf, it will be on my desk dog-eared and highlighted for use! A great resource penned by professionals and practitioners.”
James Merlo, Ph.D.
Former Vice President, North American Electric Reliability Corporation (NERC)
“Critical Steps builds on Tony’s earlier work, Risk-Based Thinking, and others to bring practical hands-on guidance to those responsible for safe operations in high-hazard environments. It is based on recent developments in our understanding of how safe and highly reliable (and profitable!) performance is accomplished in everyday operations. If this is your area of responsibility, you should study this well.”
John Wreathall
Author and Researcher
"Critical Steps shines light on probably the least understood area of the safety profession—serious injury and fatality events. The book is written for us practitioners who influence organizations from midlevel. If you desire to improve your organizations safety & reliability performance then get your highlighter out, this is a must read."
Mike Donavan
Manager Safety, Liquids Pipelines
Enbridge Pipelines, Inc.“
“Critical Steps embraces human fallibility and equips leaders with tools to address that reality. The authors provide a practical framework to focus and prepare a team to execute high-risk evolutions.”
Luke Kelvington, CDR,
U.S. Navy
“Critical Steps provides great insight into managing the risk of human error where it is most important. The authors provide excellent examples and stories to anchor these concepts in real world situations. When you’re ready to get started, this book shows the way with pointers for managing change with step-by-step guidance for mapping and managing your critical steps.”
Amy D. Wilson, Ph.D.
Global Human Performance Director, BioPharmaceutical Operations
“This book was written for operators by operators. Each chapter provides practical summaries, relevant Q&A, and implementation ideas. As a former professional aviator, I would recommend this book to every aviation department with a Crew Resource Management training program.”
Thomas Swanson, CDR,
U.S. Navy (Ret.)
Nineteen years flying for the U.S. Navy and 23 years as a commercial pilot
About the Authors
Tony Muschara
Tony has over 40 years of experience in consulting, training, and management positions in commercial and military nuclear power operations.
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.
Jim Marinus
Jim Marinus specializes
in high-risk operations management, high reliability,
and resilience. Consulting support includes oil, commercial airlines, and the US Department of Energy.
