2019 NSC Congress & Expo

109 - Seeing Past the Effects of Bias on Incident Investigation (Room 24A)

Incident and near-miss investigation is central to an effective safety program and to managing risk reduction. However, time and again we find that investigations are rushed, incomplete and inaccurate in their conclusions and recommendations. All of this can lead to the recurrence of an event that was ultimately avoidable. These challenges come from gaps in “visual literacy” and some associated biases that cause or allow errors to occur and undermine our safety programs. This session focuses on how the concept of visual literacy helps mitigate many of these common problems. We’ll discuss the skills needed to work around this inevitable bias and a process for enhancing the efficacy of your investigations.