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.

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