The Hidden Power of Critical Steps

By better understanding human performance principles and implementing systems-based safety approaches, organizations can greatly reduce workplace errors that lead to disastrous consequences.

When considering safety in high-risk industries such as chemical plants, oil refineries, or nuclear facilities, we often imagine complex systems, high-tech equipment, and rigorous protocols. But what if the most powerful safety tool isn’t a machine or a manual, but rather a specific moment? Effectively managing a single step in a process that, if done wrong, is unrecoverable and could lead to disaster, is critical to maintaining safe industry practices. These moments are called critical steps, and understanding them could be the key to preventing catastrophic accidents.

Widely considered the father of process safety, Trevor Kletz once said, “There’s a belief by some that most accidents are caused by human error. It’s true in a sense, but it’s not very helpful. It’s a bit like saying falls are due to gravity.”

If we do not understand how humans succeed and fail, we cannot predictably and effectively manage tasks that could cause catastrophic harm. Process safety professionals have been trying to understand and manage human error for decades. However, they often lack the requisite background in the corresponding science and practical application of human and organizational performance. The fundamentals of human behavior are not often well-covered in undergraduate engineering curricula. Furthermore, in many engineers’ early careers, they are told that if things go wrong, it is their fault, and if they put the blame elsewhere, they are making excuses or justifications. It is time to take the next logical steps in understanding and managing human performance.

Human performance is a systems-based approach to understanding how and why people make errors and what can be done about them. Three things can be done with errors: prevent them, reduce their probability, and mitigate their consequences. Human performance embraces the inevitability of human fallibility in the performance of tasks and favors system designs that accommodate people’s needs, limitations, and capabilities. W. E. Deming, considered the father of quality, would say, “Fix the system, and you fix it for good. Fix the person, and you only fix it for now.”

This article presents the foundational elements of human performance, critical step technology, and essential leadership characteristics that enable sustainable change...