(188c) Unraveling Reactive Chemicals Mysteries: Cognitive Bias Effects on an Incident Investigation

How do you determine the root cause of an incident when the only witness of what happened was fatally injured? What do you do when all of the witnesses of an incident have unclear memories of what occurred, or if the accounts conflict with what science says is possible? There are many potential traps, pitfalls, red herrings, and wrong turns that can occur in challenging incident investigations and it is of critical importance that investigators tirelessly work toward identifying the true root cause. It can be argued that misidentification of a root cause can result in a more hazardous environment than never performing the investigation at all. In this presentation highly valuable learnings and examples from investigations are discussed, including: where a single piece of overlooked evidence unlocked a root cause, when a red herring led a team astray, when conflicting evidence threatened to make a conclusion impossible, and where confirmation bias drove an investigation far down the wrong path.