441154 Improving Learning through Interactive Case Studies

Tuesday, April 12, 2016: 2:00 PM
360 (George R. Brown )
Trish Kerin, IChemE, Melbourne, Australia

Tragically, there is no shortage of case studies available to share learnings from catastrophic incidents across many industries, but we do not seem to be applying the learnings. We continue to see the same causal factors resulting in new incidents. It is possible that we fail to learn the lessons from case studies, because we are too caught up in trying to understand how the people in the incident failed to see all the warning signs that in hindsight are so obvious to us. The concept of hindsight bias started to be described in the 1970's, to explain the inclination after an event to believe you know the result all along, even when there was little or no evidence to predict it. Hindsight bias can play a part when we try and learn from incidents.  For example, following the Clapham Junction railway accident, the report (Hidden, 1989) stated "There is almost no human action or decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact." This paper will explore how hindsight bias occurs and techniques, such as interactive activities, to avoid or minimise it when attempting to learn from case studies.

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See more of this Session: Enhanced Application of Lessons Learned
See more of this Group/Topical: Global Congress on Process Safety