2. Man Says Hold the Cheese…*

A man in his early 20s orders two hamburgers without cheese at a drive through window of a local fast food restaurant. This young man has a life-threatening allergy to cheese. However, after receiving his order, he does not check that the hamburgers have no cheese. He assumes there is no cheese on his order since he had mentioned it five separate times in ordering as he stated afterwards to a news reporter. Later, after dimming the lights to watch a movie, he bites into one of the hamburgers and swallows the food. He does not taste the cheese. Immediately, he suffers a severe allergic reaction to the cheese. Fortunately, some family members are with him, and they rush him to a nearby hospital in time to save his life. Taking that first bite and swallowing the food was the point of no return, and it almost cost him his life.

* Adapted from Anderson, J. (August 10, 2007). “Man says hold the cheese, claims McDonald's didn't, sues for $10 million,” Charleston Daily Mail.

CRITICAL STEPSManaging Human Operations That Must Go Right Every TimeTony Muschara, CPTMuschara Error Management Consulting, LLC, 4724 Outlook Way NE, Marietta, Georgia 30066-1790 United States | tmuschara@muschara.com

1. What is a Critical Step?1, 2

Critical steps make safety boundaries of assets explicit in an operation, where they can experience harm due to work. Work requires human touchpoints to initiate transfers of energy, movements of mass, or transmissions of information. As points of no return, critical steps are tight coupling situations intolerant of error—single-error vulnerabilities. Words used to define a critical step (definition at right) are descried below:• Asset – things valued by an organization; important to

fulfillment of the organization’s mission and purposes• Inherent hazards – sources of energy, mass, and information

designed into a process with the intent to add value during production or services

• Human Action – physical movements initiated by people; an interaction with an asset or hazard that could trigger an unwanted outcome (harm), if control is lost (see touchpoint)

• Will – no uncertainty that harm will occur; no doubt• Immediate – harm ensues after loss of control; harm realized

within moments of action, whether recognized or not by the performer; consequences occur faster than people can humanly respond to avoid the onset of harm

• Irreversible – no undo; cannot return to original, previous, unharmed condition by simply reversing the initiating action; point of no return

• Intolerable Harm – worst case outcomes related to key assets involved with an operation; serious unwanted effects; not always self-revealing; reserved for actions that trigger serious harm

9. Risk-Based Thinking3

Risk-based thinking provides a logical approach to deciding what to do for safety, especially when one must adjust to local conditions inconsistent with procedures. Risk-based thinking is usually preceded with a sense of uneasiness about a specific operation. People with a chronic uneasinesse possess a deep-rooted respect for the technology, assets, and inherent hazards as well as a mindfulness of their own fallibility. Such feelings provoke a search for facts, which risk-based thinking facilitates through the following mental practices: Anticipate – know what to expect (accomplishments/assets) Monitor – know what to pay attention to (critical steps) Respond – know what to do (positive control*) Learn – know:

what has happened (past) what is happening (present) what to change (future)

* Positive Control – actions to ensure that “what is intendedto happen is what happens, and that is all that happens.”

Do you need a parachuteto skydive?

Source: United States Army

3. Examples of Critical Steps

• Breaching a pressure boundary (pipes and tanks)• Entering a confined space (atmosphere)• Taking a bite of a cheeseburger (for someone

allergic to cheese)• Opening or closing a circuit breaker (electricity)• Making an incision (surgery)• Clicking “Send,” “Open,” “Start,” “Go,” or “Enter”• Crane operator taking tension on a heavy lift• Opening the bottom valve on tank containing

cancer-treatment drug substance on a fill line• Leaping out of the door of an airborne aircraft

(skydiving)• Entering the line of fire (direct exposure to a hazard

you have little or no control over)• Pulling the trigger on a firearm

6. Examples of Risk-Important Actions (RIA)

• Donning personal protective equipment• Pressurizing a tank• Hovering cursor over “Send,” “Start,” or “Enter”• Checking a hamburger for the presence of cheese

(for someone allergic to cheese)• Climbing a ladder• Securing the drain plug during an oil change of an

automobile• Stopping at a Stop Sign• Verifying initial conditions specified in a chemical

process procedure• Taking the safety off on a handgun

7. Linkages Between Critical Steps and Risk-Important Actions (RIA)

1 Adapted from Center for Chemical Process Safety (1994). Guidelines for Preventing Human Error in Process Safety. New York: American Institute of Chemical Engineers. pp.209-211.2 The term “critical step” was adopted from Fischer, S., Konkel, H., Houghton, K., Wilson, M. (1998). Identification of Process Controls forNuclear Explosive Operations (Report LA-UR 98-2246). Los Alamos: Los Alamos National Laboratory, U.S. Department of Energy. Retrieved from http://www.osti.gov/scitech/servlets/purl/296659/.

3 Adapted from Hollnagel E. (2009). The Four Cornerstones of Resilience Engineering from Nemeth, C., Hollnagel, E., and Dekker, S. Resilience Engineering Perspectives, Volume 2, Preparation and Restoration. Farnham: Ashgate. pp.117-132.4 The human performance tools (non-technical skills) Self-Checking and Peer-Checking described on this panel were retrieved and adapted from the following U.S. Department of Energy (DOE) Website: http://energy.gov/sites/prod/files/2013/06/f1/doe-hdbk-1028-2009_volume2.pdf

Copyright © 2015 Muschara Error Management Consulting, LLC. All rights reserved.

4. TouchPoints (exposures: human couplings with assets)

10.Enhancing Positive Control of Critical Steps4

11.What are You Going to Do About Critical Steps?

Safety is not what you have, it is what you do, especially at critical steps. There is no margin for error at a critical step—performance must be perfect. Critical steps always involve substantial transfers of energy, movements of mass, or transmissions of information, which could trigger serious harm if control of such operations is lost. You can better protect assets from human failures by 1) pinpointing assets needing protection during an operation, 2) identifying touchpoints, 3) assessing the consequences of a loss of control at each touchpoint (Is the touchpoint a critical step?), and, then,4) introducing means to exercise positive control at critical steps and their related RIAs that precede them. Remember, critical steps are ALWAYS critical. Workers improve their chances of performing critical steps without error by engaging in a dialogue before beginning work (RU-SAFE). Systematically identifying and controlling critical steps is an important safety function to incorporate into daily work processes. Such previews of high-risk work improves a work team’s chances for success not only during expected circumstances but also during varying or unexpected situations by sensitizing them to the assets that need protection, their hazards, and their potential pathways.

Critical Step: A human action that will trigger immediate, irreversible, intolerable harm to an asset,

if that action or a preceding action is performed improperly.

5. What is a Risk-Important Action (RIA)?

8. Identifying Critical Steps and RIAs(Critical Step MappingSM, abbreviated)