Risk-Based Thinking
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Risk-Based Thinking

Managing the Uncertainty of Human Error in Operations

Tony Muschara

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eBook - ePub

Risk-Based Thinking

Managing the Uncertainty of Human Error in Operations

Tony Muschara

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About This Book

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.

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Publisher
Routledge
Year
2017
ISBN
9781351400169

1 A nuclear professional

The nuclear professional is thoroughly imbued with a great respect and sense of responsibility for the reactor core—for reactor safety—and all his decisions and actions take this unique and grave responsibility into account.
Foreword of Principles for Enhancing Professionalism of Nuclear Personnel, Institute of Nuclear Power Operations1
As a twenty-something submarine officer on the USS Andrew Jackson (SSBN619), a fleet ballistic missile submarine, I was awed daily by the inner workings of the boat. I graduated from the U.S. Naval Academy with a degree in engineering, but that was the last time I did any “engineering.” I was destined to become an operator (at least for a while). After seven years of active duty in the U.S. submarine force, I was truly an operator at heart. Eventually, I relished every aspect of “operating,” from starting up to shutting down, even the daily drills to practice responding to simulated casualties. At first, that was not the case.
I was slow on the uptake—I’m a slow learner, even today. If I don’t understand something, it is hard for me to function. Such was the case during my first couple of months during my skills training at a U.S. Navy Nuclear Prototype Training Unit (NPTU) near Hartford, CT. For six months, several of my classmates, enlisted personnel, and I applied the academic principles of reactor theory, thermodynamics and fluid flow, water chemistry, and health physics we had learned in a classroom at one of the Navy’s Nuclear Power Schools to the practical operation of an actual land-based submarine nuclear plant. I had never before operated a nuclear reactor or a steam plant and its associated equipment. Overnight, we were literally thrown into the hazardous domains of high-pressure steam, high-voltage electricity, nuclear radiation, rotating equipment, and myriads of twisting runs of electric cables, high-temperature steam piping, pumps, tanks, and valves. It seemed everything was hot. It was a dangerous place, which became most vivid one evening when one particular Navy operating expectation nearly got me killed.
During one late-night shift in the submarine prototype’s lower-level engine room, I was operating the steam plant’s main feedwater and condensate systems in a training role (under the instruction of a qualified instructor). During a steamplant startup, I was directed to start up the second of two main feed pumps right away. In compliance with expectations, I intended to verify that a pump would rotate before starting its motor—the operator had to physically grab the pump shaft with both hands to spin it to ensure it would rotate freely. (I’m sure there was a rational technical reason for this practice.) Still a novice, distracted by thinking about the next steps, I had unknowingly become disoriented as to the “port” (left) and “starboard” (right) sides of the submarine’s engine room. In my haste, I forgot to check the running indicator lights on the control board. At the time, the port-side pump was already running, while the second, starboard-side pump was idle. In the deafening noise of the engine room and through the earmuffs I wore for hearing protection, it wasn’t obvious from the sound which pump was running. What’s worse, the shaft of an operating pump looks idle even though it’s rotating at 3600 RPM. I went to the wrong pump. Operators faced aft, while standing in front of the Feed and Condensate System control panel—I turned and walked right instead of left. As I reached in to rotate the pump shaft, my trainer screamed at the top of his lungs, “Stop!” Fortunately, I heard him. I was mere inches from having my arms ripped off and likely being killed. Wow!
It was my first dramatic encounter with a serious system failure, though I didn’t know it at the time. I felt like a fool—I “should have” been paying attention. Looking back, I marvel at the foolishness of a policy that required a worker to handle a potentially deadly piece of equipment in order to discover whether or not it was operable. And the two checks to determine its safety—audible and visible—were nearly 100 percent unreliable given the conditions in the immediate work environment (what I call local factors).
I shudder to think what could have happened. It was an unsafe practice, but as a junior officer, I didn’t know what to do about it. I shook it off as experience. But, I realized then, even before reporting to the real Navy, that simply following procedures do not always protect you. I was more cautious from then on.
After completing my training and qualifications at the prototype and spending a few months at “Sub School” in Groton, Connecticut, I reported to the AJ (Andrew Jackson) for my first at sea duty assignment. I remember walking down the “gang plank” in the early morning fog in Holy Loch, Scotland. Within the first hour of my arrival, without unpacking my bags, I performed a reactor startup, taking it critical in preparation for getting underway on my first submarine patrol. I actually enjoyed it—I knew what I was doing. This was an important “practical factor” for my qualification as an Engineering Officer of the Watch (EOOW). My EOOW qualification card listed knowledge requirements and several practical factors (operational evolutions) that I had to perform satisfactorily prior to qualifying to stand the watch unsupervised. Reactor startups didn’t happen that often, and I had arrived just in time to take a seat at the controls of an operating nuclear reactor.
In the 1970s and 1980s, the Cold War was “raging” between the U.S. and the then Soviet Union. I had to learn not only how to operate the nuclear propulsion system, but also how to operate a submarine. My first six months or so on thesubmarine was devoted mostly to qualifying and developing proficiency in operating the submarine’s nuclear propulsion system. Soon thereafter, my focus shifted to the forward part of the submarine to qualify in submarine operations. To be “Qualified in Submarines” meant I was knowledgeable of virtually all of the submarine’s systems and technically proficient in submarine operations along with its missile and torpedo weapon systems. Within 18 months of reporting aboard, I was authorized to wear the gold dolphins submarine warfare specialty pin on the left breast of my uniform.
After qualifying in submarines, I had to become proficient in submarine warfare—this, too, fascinated me. While at sea, the officers and crew studied and practiced everything we could to reliably launch missiles, shoot torpedoes to survive attacks from the enemy, and stay afloat. We ran engineering casualty and tactics drills almost every day, except Sundays—we needed the rest. We relentlessly trained and practiced fighting, staying alive, keeping the submarine operational—ready to pull the trigger—if ordered. It never happened, thank God. The drills helped us learn what we didn’t know and where we lacked skills—believe it or not, mistakes were commonplace. Once, while moored alongside, I unintentionally depressurized a reactor coolant loop below the minimum pressure allowed for the operation of a reactor coolant pump. It was like popping the top off a can of soda. Without going into the technical details, I felt horrible and terribly embarrassed for committing such a bonehead mistake. At the time, I was the most experienced engineering department officer on board, and was “qualified” as an engineer of naval nuclear propulsion systems. I wasn’t supposed to make such a mistake. Several enlisted men and myself spent the next 12 hours during the night shift recovering from my mistake. They were not happy campers.
The Engineer qualification was awarded by Naval Reactors (NR) in Washington, the U.S. Navy’s engineering organization for development of shipboard nuclear propulsion applications.2 The months of in-depth study of naval nuclear propulsion systems preceding the engineer exam helped me recognize the limits and complexity of engineering design and the operation of its systems, structures, and components. After passing an eight-hour written examination and surviving several in-depth interviews by NR experts, I received a formal Navy letter that designated me as an “Engineer of Naval Nuclear Propulsion Systems.” I remain proud of that accomplishment to this day. This was a pre-requisite for a subsequent assignment to a nuclear submarine as its Engineering Officer.
My experiences with nuclear submarine operations at sea instilled in me a deep-rooted respect for the ocean, nuclear power, and the complexity of the technology associated with it, and the fragility of human life and human structures. As a product of Admiral Rickover’s nuclear Navy and the Cold War, I emerged from my naval career with a strong sense of what is required to operate safely and reliably—to fight and stay alive. A wary and disciplined approach to operations is forever instilled in my soul, in my subconscious mind—it has never left me, and I believe this mentality still has value today. Some call it the Old View. As a former nuclear navy-trained officer, I am imbued with aprofound understanding of the naval nuclear principles and practices that came from being immersed in nuclear submarine operations for several years. Below, I list Admiral Rickover’s time-tested industrial principles,3 described in my own words, that I believe still apply today:
• Respect the technology—hazards are intrinsic in all work. All technologies possess some dynamic residual risks that cannot be eliminated. Remain mindful of the technology’s potential for harm.
• Develop expertise—train front-line workers, including their managers, to understand the technology. The level of training and proficiency must be commensurate with the technology’s complexity and risk.
• Be conservative—allow margin for possible unknown and unforeseen effects. Things are not always as they seem. Mistakes will be made at all levels—by executives, managers, engineers, as well as operators.
• Know what is going on—work out some simple and direct ways to stay informed and to have the means for an independent review. Learn—know what has happened, what is happening, and what should be changed going forward.
• Get into the details—when ignored, an operation could slide through recurring at-risk practices (drift away from expectation) into failure so fast that no policy decisions, however wise, could resurrect it.
• Face the facts—resist the temptation to minimize the potential consequences of problems and to try to solve them with limited resources, hoping that somehow things will work out. Humble yourself—ask for and accept help. Force problems up to higher levels where more resources can be applied.
• Accept responsibility—take ownership of all aspects of your operation. Courageously, admit mistakes. Don’t pass the buck—admit personal responsibility when things go wrong.
After my first tour at sea, I went back to Sub School, not as a student, but as an instructor. I spent two years as a submarine tactics instructor, helping prepare the officers of other submarines get ready for their deployments. It was here I confirmed in my heart that I enjoyed instructing and helping people understand the what’s, the how’s, and the why’s of what they were learning. In light of my close call at the submarine prototype and my time at sea, I realized how important expertise was in operating hazardous plant systems and equipment safely and reliably. I remember during my last couple of years on the AJ, other enlisted sailors and officers working on their own qualifications, came to me for one-on-one “checkouts” (a dialogue aimed at validating the trainee’s system knowledge and understanding). To their chagrin, they sometimes found it frustrating to work with me. A signature from me on their qualification card indicated (to a third-party reviewer) that they possessed satisfactory knowledge and understanding of the system we were reviewing. However, I wasn’t one to give away my signature—being “graped off.”4 Since I knew what was at stake in submarine operations during the Cold War, I did not go easy on them, and invariably, our conversations revealed critical gaps in their understanding. Fartoo many individuals did not recognize how dangerous a job they had and what they had to know to not only operate according to procedures, but also to ensure our survival if things did not go as planned.
At the conclusion of my tour of duty at Sub School, I resigned my commission in the U.S. Navy to pursue a career in civilian life—my wife and I had two children by this time. To me, family is more important than career. Former submarine officers were in high demand in the commercial nuclear industry in the early 1980s. Pursuing my joy of training, I joined a technical training firm as a nuclear plant control room simulator instructor. Here, I realized that things could still go wrong, even when everything was in compliance with the plant’s technical specifications. You are not necessarily safe when you are “crossing a street in the crosswalk.” You’re still in the “line of fire”5 while in the crosswalk. In any industrial operation, you still have to be alert to equipment failures, unknown conditions, and human error.
After a couple of years training nuclear plant operators, I joined the Institute of Nuclear Power Operations (INPO) in the spring of 1985, as a training evaluator.6 Soon, I learned about INPO’s Human Performance Department (HPD). Although not assigned to work there, I was immediately intrigued by its purpose and the technology—the Human Performance Enhancement System (HPES). INPO had formed the department as part of the commercial nuclear ...

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