2025 Spring Meeting and 21st Global Congress on Process Safety

(51b) Seeing the Invisible

Author

One of the key challenges with identifying and therefore being able to manage weak signals is that they are weak by nature. After the incident it is obvious that the signal was there. We are left thinking ‘if only people noticed it at the time and took action’. So how do we get better at identifying and then managing weak signals? How do we see the invisible?

Cognitive biases impact our ability to see weak signals. We can be struck by Confirmation Bias, where we seek information that confirms our already held belief – dismissing the weak signals, Anchoring, were we base decision on the first piece of information, even if proved to be subsequently wrong – dismissing the significance of a weak signal or the Curse of Knowledge, were we assume others would make similar decision because they must know what we know – assuming other can see the weak signal. These are just a few examples of common biases that inhibit our ability to fully see weak signals.

But there is a bias that can actually help us to identify weak signals, and we can train that to be more effective. This is the frequency illusion, where our subconscious brain is primed to notice things and patterns, no matter how weak.

This paper will discuss the challenges in seeing weak signals before an incident and then explore a technique to use priming to train our brains to look for likely weak signals. It will discuss a workshop methodology that combines an assessment of likely failure modes on bow ties with learnings from previous incidents.

Keywords: Weak Signals, Failure,