We recently completed a research task for a client about repeat incidents in a high-risk operating context across numerous global jurisdictions. There weren’t too many surprises in the main triggers to these events: shift structure-induced fatigue, PPE failures, plant and equipment integrity, weak inspections regime, and so on. The usual suspects.

But looking under the hood more carefully, we found a very interesting cocktail of cognitive hazards (ie expectations bias, fast-thinking habitual decision-making, urgency & stress, visual system failures) that played major roles in the slips and mental lapses at the heart of many of the incidents.

This insight has pointed to an opportunity to refocus the power of the “pre-start” to prime the work group for these hard-wired cognitive challenges that we all suffer from to a greater or lesser extent. This requires supervisors to have some basic understanding of cognitive hazards and how to identify which work exposures will see them rear their head, and later on, an education program focused on helping employees understand their own cognitive hazards and how to mitigate their effect when in the field.

Even more interesting, the analysis shed light on a few systemic factors that had little to do with the operator’s ability to do something ‘right’ every time. Requests for plant and equipment improvements had been delayed or de-prioritised; supervision was not as “present” as you would hope; breakdowns in critical controls were not getting the requisite attention; and a failure to see patterns of small errors and breakdowns had become more significant over time.

While we tend to focus analysis on “what the worker did”, you can see the same cognitive hazards at a leadership level:

• Expectations Bias, that another similar incident is unlikely, and we can get away with delaying our response
• Fast-Thinking decision-making that falls back on past experiences and habitual response to familiar problems
• Urgency & Stress that narrows the leader’s ability to properly account for broader risk/reward judgement
• Visual-System failures that show up in simply not noticing the weak signals of critical procedure breakdowns right in front of you

In the world of fatality prevention, we already know that what alleviates low consequence risk won’t work so well at the pointy end or build the necessary culture of weak signals attention. We also have to recognise and mitigate the cognitive hazards that act as natural human limitations to noticing, analysing, and responding to those weak signals in the first place.

Without high quality analysis of the integrity of critical controls, your organisation’s serious incident risk profile is pretty much held hostage to the cognitive hazards we all live with every day. If you want to gain real control of your potential for serious incident or fatality, you need analytics that have been proven to deliver the kind of business intelligence required to get in front of operation unreliability. Talk to us today about how Incident Analytics can help you get there.

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