1st Edition

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

ISBN 9781138302495
Published November 10, 2017 by Routledge
300 Pages 25 B/W Illustrations

USD $54.95

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Book Description

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.

Table of Contents



List of Figures

List of Tables

List of Experiences

Special Thanks


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


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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)