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
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 ReliabilityTony'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)
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