In Tony Muschara’s 2018 book Risk-Based Thinking, Managing the Uncertainty of Human Error in Operations he so eloquently lays out how “risk-based thinking” has to become a belief and value within senior leadership, such that they are guided by safety in their decisions, responses, and behavior choices. Muschara has his seven (7) principles of risk-based thinking that are a MUST for organizations to take that step to move beyond the traditional OSH measures that have gotten us this far.
- People have dignity and inherent value as human beings.
- People are fallible.
- People do not come to work to fail.
- Errors are predictable and manageable.
- Risk is an inherent, dynamic feature in the way an organization operates.
- Organizations are perfectly tuned to get the results they are getting.
- The causes of tomorrow’s events exist today.
People have dignity and inherent value as human beings
Everyone wants to be treated with respect, fairness, and honesty, characteristics that are important to building trust and credibility within any organization.
PEOPLE SHOULD NOT BE TREATED AS A LIABILITY—AS OBJECTS TO BE CONTROLLED, BUT AS KNOWLEDGEABLE AND RESPECTED AGENTS OF THE TECHNICAL SIDE OF THE ORGANIZATION who have its best interests at heart.
Relationships are integral to open communication, and there are no laws against treating people with dignity and respect.
People are fallible
To err is human—error is normal. Fallibility is a permanent, intrinsic feature of the human condition, and this trait poses a hazard when people do work. Human fallibility can be moderated, but it CANNOT BE ELIMINATED.
It introduces uncertainty into any human endeavor, especially in hands-on industrial work. However, people are also brilliant. They possess a wide range of capabilities and can adapt and improvise to accommodate inadequate resources, weak training, poor tools, schedule conflicts, and process shortfalls, among other workplace vulnerabilities. In order to protect assets, they can adjust what they do.
ASSUME PEOPLE WILL ERR AT THE MOST INOPPORTUNE TIME. THEN, MANAGE THE RISK.
People do not come to work to fail
Most people want to do a good job—to be winners, not losers. ERROR IS NOT A CHOICE—IT’S UNINTENTIONAL.
Nobody errs purposefully. ERROR IS NOT SIN—IT’S NOT IMMORAL. Error tends to break things. Sin, in contrast, is selfish in nature and tends to break relationships.
Reprimanding people for error serves no benefit.
People are goal-oriented, and they want to be effective. They adapt to situations to achieve their goals. This means well-meaning people will take shortcuts, now and then, if the perceived benefit outweighs the perceived cost and risk. This, too, is normal.
All people’s actions, good and bad, are positively reinforced, usually by their immediate supervisors and by personal experiences of success (as they perceive it), which sustains their beliefs about “what works” and what does not. Sometimes perceptions are wrong.
Errors are predictable and manageable
HUMAN ERROR IS NOT RANDOM—it is systematically connected to the work environment—the nature of the task, its immediate environment, and the factors governing the individual’s performance. Despite the certainty of human error over a long period for large populations,
A SPECIFIC ERROR FOR AN INDIVIDUAL PERFORMING A PARTICULAR TASK AT A PRECISE TIME AND PLACE UNDER CERTAIN CONDITIONS CAN BE ANTICIPATED AND AVOIDED. For example, what is the most likely error when writing a personal check on 2 January of every year? You know the answer. However, NOT ALL ERRORS CAN BE ANTICIPATED OR PREVENTED. This is why defenses are necessary.
As your organization matures in its application of RISK-BASED THINKING, there will be less dependence on predicting the occurrence of human error and more focus on protecting assets from harm.
Risk is an inherent, dynamic feature of the way an organization operates
When work is executed, various intrinsic energy sources, tools, and materials are used to accomplish the work.
Consequently, hazards exist (built-in) within an organization’s facilities because of its purposes. For larger, more complex organizations, the risk is dynamic.
RISK LURKS EVERYWHERE AND VARIES AS AN OUTCOME OF THE DIVERSE WAYS AN ORGANIZATION IS DESIGNED, CONSTRUCTED, OPERATED, MAINTAINED, AND MANAGED, AS WELL AS ITS TEMPO OF OPERATIONS.
Safe and resilient organizations are designed and built on the assumptions that people will err, things are not always as they seem, equipment will wear out or fail, and that not all scenarios of failure may be known before operations begin.
Organizations are perfectly tuned to get the results they are getting
PEOPLE CAN NEVER OUTPERFORM THE SYSTEM THAT BOUNDS AND CONSTRAINS THEM.
All organizations are aligned internally to influence the choices people make and the outcomes they experience—good and bad.
All work is done within the context of its management systems, technologies, and societal, corporate, and work-group cultures.
Organizations comprise multiple, complex interrelationships between people, machines, and various management systems, and managers go to great lengths to create systems for controlling the work. But we all know there is no such thing as a perfect human, system, process, or procedure. Once systems go into operation, they prove to be imperfect.
The causes of tomorrow’s events exist today
THE CONDITIONS NECESSARY FOR HARM TO OCCUR ALWAYS EXIST BEFORE REALIZING THE HARM. Some are transient, most are longstanding.
Most of the time, these conditions are hidden or latent. Latent conditions tend to accumulate everywhere within an organization and pose an ongoing threat to the safety of assets.
These conditions are shaped by WEAKNESSES AT THE ORGANIZATIONAL AND MANAGERIAL LEVEL, AND THEY MANIFEST THEMSELVES IN THE WORKPLACE AS FAULTY PROTECTIVE FEATURES, HIDDEN HAZARDS, AND ERROR TRAPS.
These system weaknesses and workplace vulnerabilities usually exist long before the unwanted consequences ever come to fruition. This means that events are organizational failures.
Risk-Based Thinking, Managing the Uncertainty of Human Error in Operations, Tony Muschara, 2018