The EI Learning from Incidents webcast asked ‘How can we do this better?’ Lorraine Braben (LBC) reported from the EI’s Hearts & Minds program which found that incidents are often not shared outside of an organization. Matthew Laurie (CRA Ltd.) cited some major UK catastrophes (Alton Towers rollercoaster and the Grenfell Tower fire) to ask, ‘Why are we not using these incidents? Is it our cognitive biases, the not invented here syndrome?’ He cited Daniel Kahneman on the psychology of judgement and decision making and the fallibility of the human brain. Humans have three biases viz, attribution error, false unique bias and confirmation bias. Attribution error is what leads us to consider ourselves ‘safe’ drivers while considering other road users as ‘bad actors’. Likewise other companies may be considered as ‘bad, not like us’. False uniqueness is the tendency to see oneself (or one’s company) as ‘special’. ‘We all believe we are above average’ which is clearly impossible. Likewise, ‘that would never happen in oil and gas, we are better skilled, and don’t have much to learn from others’. Confirmation bias makes us ignore stuff that contradicts our existing beliefs.
Braben came back to enumerate the learning opportunities that incidents outside of one’s own industry can bring. These include safety KPIs, emergency preparedness and more. Incident accountability is key here. At Alton Towers, multiple stakeholders were involved in managing the facility with poor coordination, change management and a confused regulatory environment. In fact, the Alton Towers system detected another train on same track but the trip was reset even though a train with passengers was moving forward. Multiple people were involved in resetting the trip with no defined leader, no accountability and no authorization was given for the train to move forward.
At Grenfell, a bewilderingly complex regulatory structure led to multiple failures both before and during the fire. Residents safety concerns were ignored, safety equipment left unrepaired and, during the fire, there was continuing advice to residents to ‘stay put’.
Lawrie then addressed the confirmation bias phenomenon, qualifying the Internet as a ‘confirmation bias machine!’ Safety professionals need to ‘slow down’ their reasoning process and think of multiple explanations, challenging their own story and bring in views from outside their own industry. ‘Challenge your team to think of other explanations’.
The webinar concluded with the EI’s Stuart King who explained how the EI’s Toolbox helps with learning from other industries. Toolbox is a free to use web app that focuses on high incidence events and hazards to frontline workers. Supervisors visit the Toolbox to locate an incident relevant to a particular situation. Content from the Toolbox can then be leveraged in planning meetings to raise awareness of hazards and to effect additional safety measures. The toolbox is designed to make it easy to find relevant content, ‘cross fertilized’ from different industries. EI is also currently funding research into ‘reflective learning’. This derives from the fact that ‘reading is not learning’ and that true learning involves asking questions of oneself and one’s colleagues.
Other safety related resources cited in the Q&A included Lloyds List and the Federal Aviation Authority’s lessons learned website. There are also some free incident learning resources for the chemical/process industries from the Hazards Forum, EPSC, AICHE, CSB, EMARS and of course, IOGP.
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