Two problems frequently afflict plant safety efforts. First, engineers repeat mistakes that caused serious accidents at other sites because they never learned or have forgotten the lessons the initial mishap taught, warned the late safety guru Trevor Kletz (see: “Bhopal Leaves a Lasting Legacy.”) Second, even when reviewing past incidents, staff may discount the chance of errors should a similar situation develop at their site. That’s because reviews typically start by presenting the outcome, which often makes the proper steps that should have been taken to prevent the event all too obvious. As the saying goes, hindsight is 20/20.
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“This hindsight bias makes it difficult to objectively review a case study or incident without second-guessing the actions taken by those involved,” notes Trish Kerin, director of the IChemE Safety Centre (ISC), Melbourne, Australia. “The fact is, we cannot ‘unknow’ information, so overcoming hindsight bias is perhaps more difficult than overcoming other types of bias,” she adds.
To tackle this problem and enhance learning, the ISC launched at the Hazards 26 Conference in late May in Edinburgh, Scotland, a series of interactive case studies that approach safety training in a nontraditional way. In the case studies, participants face an event as it occurs, make decisions and see the consequences of their actions, explains Kerin.
“This method of communicating a case study has never been done elsewhere in the world. The key difference in how these case studies are presented is in the sequence and context of the information presented. The case study commences with background information and places the audience in the position of making decisions at key points in the sequence. The consequence and actual incident the scenario is based on are not revealed until the end of the case study. This allows people to experience the context in which decisions are made, rather than focus on the actual decisions.”
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The launch includes three case studies: “A Tank Farm,” “A Gas Plant” and “A Coal Mine.” Each one costs £250 (about $365) and consists of a series of short videos totaling 35–40 minutes as well as facilitation notes, all on a USB memory stick. The ICS opted for videos to ensure consistent presentation of material and foster reuse of the training tool. The package is designed for companies to use internally without having to bring in outside specialists.
“Each case study has key learning points that are relevant regardless of the industry you work in. For example, ‘A Coal Mine’ focuses on engineering decision-making and risk assessment, whereas ‘A Gas Plant’ focuses on operational decision-making,” she notes. “The videos take the time to explain how the facilities work, so no pre-knowledge is necessary.”
“Each case study runs for about 90 minutes, including discussion time,” says Kerin.
“Once the context is set, the events that led up to the incident start to unfold. At suitable points in the story, the audience are given a chance to make a pivotal decision… the facilitator then discusses the audience decision before restarting the video to see what decision was made by the people involved in the real event. Each case study typically has three decisions to be made.”
“Interestingly, the participants often make the same decisions that were made in the real event. This can be a very eye-opening experience for the participants,” Kerin points out.
The ISC hopes that engaging the audience in the incident in this way will lead to better retention of the lessons learned.
Other case studies may be developed in the coming year, Kerin adds.
For more information on this intriguing and innovative training resource, go to www.ichemesafetycentre.org/Isc-case-studies. (For more on the center’s plans, see: “CP Talks to Head of New Safety Center.”)
I applaud the ISC for addressing hindsight bias. I hope we can look back on the launch as an important event in improving process safety training.
