An expert team is investigating a complex process incident that has had a considerable negative impact within the organisation. The team members share a similar background, and they spend a lot of time analysing and discussing what was happening in the plant as the incident unfolded. They are presented with a fascinating, but complicated picture and some of the information even seems to contradict what they expected to see. Based upon the groups’ experience, they focus on some of the indicators that were present in the previous incidents they investigated.
The team conduct a number of interviews with key personnel. One of the key operators, who was involved with the tasks in the area where the incident occurred, isn’t able to describe what happened in a very satisfactory way and appears to mix up the timing of certain events. The team also interview a highly experienced process technician who, despite not being present during the incident, is able to provide information in a much more fluent and cohesive manner. All the interviewees talk about a recent reorganisation, and some make statements about the competence and experience level on site.
The investigation team focus on the details of the incident and assess some of the decisions that were made in the period leading up to it. It seems clear that the incident could have been avoided under slightly different circumstances, and that many of the risks involved were foreseeable. As the investigation report is being finalised, the team is sent some copies of emails that provide more detailed information about the condition of a piece of equipment involved in the incident.
This example provides several examples of situations that could affect the judgement and actions of the investigation team through cognitive bias. Up until the point when the email came through about the equipment, the biases of those interviewed, as well as the investigators, were leading the investigation in a certain direction.
Although often described in a negative light, cognitive biases help the human brain to successfully negotiate normal life. They enable quick decision making, help to provide meaning and save our brains the time and energy. Crucially, cognitive bias affects all humans, though one of many acknowledged biases is the “bias blind spot” - a tendency for individuals to see themselves as less susceptible to bias than others. Some of these biases are better known than others, and the investigation example above provides examples of two of them, namely confirmation bias and hindsight bias.
At The Keil Centre, we maintain a directory and working knowledge of cognitive biases and are able to provide advice on where they pose a risk in areas like risk assessment, safety leadership or investigations. We know how biases interact with our models of human error, and we can provide solutions for managing this risk.