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CHEMICAL ENGINEERING TRANSACTIONS
VOL. 77, 2019
A publication of
The Italian Association
of Chemical Engineering
Online at www.cetjournal.it
Guest Editors: Genserik Reniers, Bruno Fabiano
Copyright © 2019, AIDIC Servizi S.r.l.
ISBN 978-88-95608-74-7; ISSN 2283-9216
Application of Case Study Material in Undergraduate
Learning
Trish C. Kerina,*, Michaela Pollockb
aInsitution of Chemical Engineers Safety Centre, Level 7, 455 Bourke St Melbourne VIC Australia, 3000
bDepartment of Chemical Engineering, University College London, Torrington Place, London, WC1E 7JE, United Kingdom
tkerin@icheme.org
When we review a case study it can be very tempting to judge the actions of the people involved with the
benefit of hindsight. Because we know the outcome, it seems obvious what decisions led there. This hindsight
inhibits our ability to learn from the event because we fall into the trap of justifying why we would not make the
same decision. To counter this, the IChemE Safety Centre started to develop some case studies that try to
minimise hindsight bias. These case studies were developed with a non-technical workforce audience in mind,
and have been successfully employed in a variety of industrial and commercial settings containing wide-
ranging audiences. Furthermore, this has enabled them to be utilised at universities to impart process safety
knowledge at an early stage in undergraduate studies and bring a realistic industrial setting into an academic
environment. University College London is one such university, where they have adapted the case studies to
gain other additional insights and support learning outcomes of introductory safety courses given to second
year undergraduates who are still developing their core chemical engineering knowledge and have had limited
exposure to industrial settings. This paper will explore the basis for the case study development and they key
requirements to reduce hindsight bias. It will then explain different options for how they can be used in an
educational setting to give students the experience of a process safety incident as well as an understanding of
the varying demands on a worker in an operational facility. Reflections upon how the case studies have
already been used in academia and some suggestions on further ways in which the case studies can be used
in an academic setting are made. Finally, some recommendations for additional support material that could be
developed by the IChemE Safety Center to further encourage the use of the case studies in academia are
made.
1. Introduction
Think about a movie you saw with a surprising twist in the plot. Did you identify the twist before it became
obvious? Or did you get a surprise with the twist but then said to yourself “I knew that was going to happen”.
Once we know the outcome, our perspective of the events changes. The next time you saw the movie, you
could pick out very early on what the different clues were that gave the plot away. This is because we can’t
“unknow” what we already know. This phenomena is called Hindsight Bias, and is one of the many cognitive
biases that impact how humans respond to events.
Now think about the last incident investigation report you read. It would have detailed the sequence of events
that took place leading up to the loss of control and flowing onto the consequences. Think about your
response when you read about a vessel with a faulty level indicator being overfilled and a loss of containment
occurring, which then ignited. Filling a vessel with a faulty level gauge seems like a silly thing to do, and an
overfill scenario seems to be very logical in hindsight. But in that situation there are many factors that may
have impeded the decision making of the individual who decided to fill the vessel in those conditions.
As defined by Blank, Nestler, von Collani and Fischer (2008), there are three levels of hindsight bias; Memory
Distortion, Inevitability and Foreseeability. Roese and Vohs (2015) go on to explain these. Memory Distortion
is where a judgement was made prior to an event but remembered differently after the event, to align with the
outcome. Inevitability suggests that the outcome was predetermined, or a belief that it just had to happen. This
is partly related to how hindsight bias impacts learning from incidents. Lastly Foreseeability is about believing
DOI: 10.3303/CET1977065
Paper Received: 22 December 2018; Revised: 26 April 2019; Accepted: 11 July 2019
Please cite this article as: Kerin T., Pollock M., 2019, Application of case study material in undergraduate learning, Chemical Engineering
Transactions, 77, 385-390 DOI:10.3303/CET1977065
385
that you would have predicted the outcome in the same circumstances. It involves making judgements about
our own capability and knowledge. It is this form of hindsight bias that largely impacts our ability to learn from
incidents, as we judge the actions of others while believing that we would have seen the incident outcome as
a real possibility and therefore prevented it occurring. This is because when we consider the incident report
we know the outcome that did occur. We then fall into the trap of thinking that we would never have made the
same obvious mistake that led to the incident occurring. This then becomes a blocker to learning from the
incident. We are subconsciously justifying that our behaviour would have been different rather than thinking
about what we need to do to prevent a similar incident. This leads to an over confidence in our own abilities.
2. Case studies to minimise hindsight bias
2.1 How the case studies were developed
The IChemE Safety Centre (ISC) set about developing some case studies to try and minimize the impact of
hindsight bias on the audience, in an effort to create better learning from incidents. A key step here was also
to involve the participant in the experience, so the learning was active.
Once an incident was selected for this treatment, research was conducted into the findings to dig deep into the
context of the sequence of events that took place. It was vital to understand the context as this provided
reasons why the decisions were made. It was also vital to tell the story without disclosing the actual incident
and hence consequence at the start, this allowed people to be immersed in the context without having the
foreseeability, and thus minimising the impact of hindsight bias.
The next step was to actively involve the participants in the decision making, giving them a chance to
contribute to critical events as they unfolded. This was done by establishing a consistent decision point, that
would be asked at three times throughout the development of the story to the eventual conclusion.
A significant challenge in developing the materials was to take a complex and nuanced incident that had
several technical aspects to it and present it in such a way that technical knowledge of the subject matter was
unnecessary to participate in the story and decision points. Engineering concepts needed to be simplified, and
the inherent technology explained.
Once the story had been established and simplified, the decisions were inserted at three points within the
case study to provide the interactive experience. This then allowed the participants to understand the context
and make the critical decisions. This led to participants having the experience of making the decisions which
led to the incident, without having to suffer the consequences personally. While this is not a replacement for
having the real experience, it does go some way to providing insight into their own thought and decision-
making processes as well as generating some of the emotional response you would see in the real incident.
For this reason, it is critical that the activity is facilitated, as like in any incident, people need to discuss their
feelings and debrief. The facilitation notes focus on the emotional response of the audience at the end of the
exercise and then bring it back to how you can take this experience back into your workplace to help you
make better decisions. There have been some instances where participants have complained that they were
led to making the decision that resulted in the incident, by the context development. This is usually a defensive
response to realizing they have caused the incident and a great example of how hindsight bias actually works.
When they only see the context and not the outcome they can easily make similar decisions. In this instance
the facilitator would discuss this as a key learning, if a person has been led to make a particular decision by
watching a short video, they have shown that they are capable of making a similar decision when surrounded
by work pressures and context.
There are two versions of each case study. The first containing the three decision points, where the
participants make a key decision at three points in the story line. The second version contains some additional
exercises, where the concepts of lead process safety metrics and process safety competencies across the
whole organisation are explored. These exercises allow the participants to consider what metrics may have
been the most useful in the developing incident, resulting in detailed consideration of metrics they may not
normally have been exposed to. It also allows them to consider specific process safety competencies and
think about who in the organisation should be involved at each level of the competency.
As at July 2018 there were six case studies available, covering a wide range of industries. Each case study
also has a specific story and theme. The theme of the case study can be more useful to understand than the
industry setting, as the learnings can be applied across multiple industries.
Table 1 details the Case Studies.
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Table 1 Case Study details
Title Story Theme
Gas Plant Set in a gas process plant, the
participant plays the role of a plant
operator responding to the events of
the day.
Management of Change.
Tank Farm Set in a tank farm, the participant
plays the role of a plant operator
responding to the events of the day.
Safe operation of tank farms and shift
handovers.
Coal Mine Set in a coal mine, the participant
plays the role of advisor to the mine
manager during the design and
construction of the mine.
Safety Governance and design and
construction decision making.
Offshore Platform Set on an offshore platform the
participant plays the role of an
incident investigator, investigating a
gas leak.
Permit to Work systems.
Lift Off Set in a space agency the participant
plays the role of an engineer in the
launch assessment team.
Organisational culture and ethical
decision making.
Tidal Wave Set in a power plant the participant
plays the role of the plant supervisor.
Natural hazard triggering technological
disaster (Natech) and emergency plan
resilience.
These case studies were designed for use in the workplace. So far they have been run in a variety of settings,
including large conferences, small work teams from one company and audiences made up of different
companies and or roles. They have worked for groups as senior at the company directors all the way to the
front line operations teams. Where they have been run in very large audiences, mobile phone polling
technology has been used to gather people’s decisions and guide the facilitator’s discussion with the group. In
smaller audiences, there are suitable handouts allowing people to mark their decision and then contribute to
the conversation led by the facilitator. The full case study experience takes between 90 and 120 minutes,
depending on which version is run. The 90 minute activity explores the decision points, while the 120 minute
exercise explores the decisions and the exercises around lead process safety metrics and process safety
competencies. As noted above, the case studies have their own facilitation notes, so they can be run internally
or with an external facilitator. The ISC runs several facilitated programs each year, and uses the case studies
within several of its public training offerings. Feedback from both facilitators and participants has been very
positive. The following quotes have been received in feedback forms:
“every person in an organisation needs to experience this to build their understanding of culture” – participant
“I knew I had them in the story when they all fell silent at one point, when they realized what was about to
happen next and that their decisions had led to it” – facilitator
Given the success of the case studies in the wide-ranging settings and formats described above, one of the
next aims of the ISC was to further extend the use of the case studies to an academic environment. It was felt
that the manner in which the engineering concepts were simplified for a non-technical audience made the
case studies easily accessible to an undergraduate academic setting where students are building up their core
chemical engineering knowledge. The application in academia is discussed below.
3. Applying the case study material in an academic setting
In an undergraduate academic setting there are a number of challenges and constraints faced by educators
with regards to how to effectively teach safety to large cohorts of students who are still developing their core
chemical engineering knowledge. Furthermore, many students, particularly at the undergraduate level, will
have limited, if any, site experience. As such, hindsight bias is not the main obstacle in a student’s analysis of
a past accident. Instead a lack of understanding of the context of a past accident, the decisions that led to the
accident and the key learnings from the accident is the challenge faced by educators. Moreover, in an
academic context educators are limited by the pre-defined learning outcomes of the course, the lecture theatre
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or classroom environment in which teaching takes place and the timeslot provided in which to teach safety,
potentially as little as 1 hour a week to cover a specified amount of material. However, as outlined by
Shallcross (2013) employing learnings from past accidents within an academic context are a valuable and
useful tool in teaching safety in an academic environment.
Within the context of the challenges and constraints of an academic environment the ISC case studies are a
valuable resource. Each of the ISC case studies not only highlight how hindsight bias can impact the learnings
from an accident, but also focus on different themes and industries as shown in Table 1. Furthermore, the
interactive nature and focus on accessibility of the ISC case study videos to a wide-ranging audience lends
well to engaging students and enhancing their understanding of often complex and unknown situations. It is by
utilising these variations in themes and industries that the ISC case studies can effectively be used in an
academic environment by providing well-researched, real-life examples of safety accidents that can support
students in the learning of particular safety concepts or technologies that are being examined within a lecture
context. In the next section of this paper the use and adaption of the ISC case studies to highlight certain
points within a series of lectures on introduction to safety as part of the lecture course entitled ‘Design and
Professional Skills II (DPS II)’ for second year undergraduate chemical engineering students on the Integrated
Engineering Programme (IEP) at UCL are exemplified. For further information and examples on how teaching
safety is embedded throughout the chemical engineering IEP teaching framework see Pollock and Sorensen
(2018).
3.1 Examples of specific adaptations of case studies for an academic environment
Risk evaluation and decision making
One of the learning outcomes of the second year Design and Professional Skills II course is to gain an
understanding of issues important to engineering designers including decision-making. This is framed within a
design context in 4 week-long mini design projects, called Scenarios, and also exemplified in a safety context
in the introduction to safety lectures, which is one of the topics included in the lecture course that forms part of
DPS II. Students are introduced to the definition of risk (AIChE CCPS, 2008) and the contribution to the
evaluation of risk firstly through the expected frequency of an incident and secondly through the impact or
severity of the incident. Risk matrices are introduced to students together with categories of different levels of
risk, frequency and severity and their respective descriptions similar to those shown in AIChE CCPS (2008).
The ISC coal mine case study whose theme is safety governance and design and construction decision
making is used to contextualise the learning objectives to a real-life industrial setting with a safety focus. A six
minute video extract from the ISC case study is played to students in the lecture theatre where different
methods by which to build a second ventilation shaft are examined and commented upon from the perspective
of different stakeholders. Following the video, students are asked to discuss and complete a decision point
worksheet developed by the ISC which asks students to decide if different stakeholders would recommend
each of the methods by which to build the second ventilation shaft. This exercise exemplifies decision-making
to students in a real-life safety context. In order to support the learnings on risk matrices which had just been
introduced in the lecture, the ISC decision point worksheet was further extended to ask students for their
evaluation of the risk matrix category for each ventilation shaft construction method.
In the same lecture hazard evaluation methods and how they can be used effectively at different stages within
the process design cycle are introduced. To conclude this part of the learning, students are once again
reminded of the ISC coal mine case study and are asked to discuss and recommend appropriate hazard
evaluation studies that should have been performed on the recommended method for building a second
ventilation shaft. During in-class discussions students are encouraged to identify in which part of the process
design cycle the ISC coal mine case study video is set and what would be appropriate hazard evaluation
methods and why.
Inherent safety
A further learning outcome from the Design and Professional Skills II course is an understanding of the
concepts of inherently safer design. The principals of inherent safety are initially introduced to students in the
first year Design and Professional Skills I course. These are further built upon in DPS II with a particular focus
on inherently safer design within the process industries. Approaches to design which are inherently safer and
contrasting approaches to design which are not inherently safer are discussed within the lecture.
These learnings on inherently safer design are then emphasised on a real-life example by examining the
design and operation of a tank farm as described in the ISC case study tank farm. Again an extract of the ISC
case study video is shown to the class, in this case up to 12 minutes of video, which describes the layout and
operation of the tank farm and the events leading up to the incident. In this case however, the decision point
worksheets and exercises developed by ISC are not given to the students. Instead, before watching the video
students are asked to observe and note down where principals of inherent safety could have been used to
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improve the design and operation of the tank farm. To aid students’ understanding of the tank farm described
in the video, the schematic overview of the tank farm developed by ISC can be handed out. Students then
discuss in small groups where inherent safety principals could have been used to improve the design and
operation of the tank farm and then with the class as a whole in a discussion led by the instructor.
There are many benefits to this exercise where students can consider inherent safety on a real-life industrial
problem. They can observe the impact of inherent safety not only on design but also on operation and how
this can contribute to a safety incident. Furthermore, for students in only the second year of their
undergraduate studies it is very valuable opportunity to bring a realistic, operational setting into the lecture
environment.
3.2 Reflections on how case studies can be applied in academic setting
From the two examples outlined it can be seen that the ISC case study videos have been effectively used and
adapted for an academic setting. One of the main benefits of the ISC case studies is that they enable well-
researched, real-life industrial examples to be brought into an academic lecture theatre environment through
well-made, clear and accessible videos of past incidents. The format of the ISC case study videos, decision
point worksheets and exercises are also very accessible to educators to adapt for their specific needs and can
deviate from the original intention of the ISC which was to remove hindsight bias. This is because of the
richness of content within the well-researched case studies where different industries and themes within safety
are examined. Educators teaching safety can easily adapt the ISC case studies to focus on specific themes
within safety or examine safety issues within specific industries. In advanced safety courses, the case studies
can be used to demonstrate the original intention of ISC developers, namely examining removing hindsight
bias. For example, final year or postgraduate students with a firm grasp of chemical engineering fundamentals
and introductory safety concepts, who may already have studied some past accidents and feel that they would
not make the same mistakes as have been made in the past, may enhance their learning of past accidents
through the removal of hindsight bias. Moreover, educators can even use the ISC case studies in fundamental
chemical engineering lectures, where safety is not the main focus of the entire lecture course, to highlight a
specific safety aspect of a given technology in just one lecture. Furthermore, the decision point worksheets
and other exercises that have been developed by the ISC can be used directly in an academic setting,
modified to highlight additional learnings or completely new exercises can be developed by educators to
emphasis other learnings that can be gained from the ISC case studies.
Reflecting back on how the case studies were incorporated into second year introduction to safety lectures at
UCL, it was found that incorporating the ISC case studies into an academic setting was easy and indeed very
relevant at highlighting specific concepts. However, this could only be achieved once the material within the
ISC case study had been studied in detail by educators in charge of the course. To further aid educators in
incorporating the ISC case studies into an academic setting the ISC could develop further support material in
the form of a brief synopsis of each case study. This could include information on the actual incident being
studied, the safety themes addressed within the case study and which video extracts within the full range of
case study videos developed exemplify the different safety themes.
4. Conclusions
The case studies were originally developed for use within companies and designed to be run as a complete
activity, focused on attempting to remove hindsight bias from the participants to generate a higher quality
experience. However given the approach that was taken, by simplifying complex process safety concepts so
all aspects of a business could participate, using short video segments, setting context and drawing out
specific themes, they have proved useful in other areas such as the academic environment, as exemplified by
their use in introductory safety courses at University College London.
The richness of the content within the ISC case studies, in terms of well-researched past accident material
and accessibility of the format of the ISC case studies videos to a wide-ranging audience lends itself very well
for use in a variety of academic settings from introductory to advanced safety courses as well as specific
technical lectures. As has been outlined in this paper, the focus of application within an academic setting can
deviate from the original intention of removing hindsight bias and can instead focus on particular safety
themes or specific technologies. The ISC decision point worksheets and exercises can be used as originally
developed, adapted or completely new exercises can be developed to further support learning. Overall, there
is a significant benefit to students to support their learning outcomes in an academic environment by bringing
well-researched, real-life situations, in an accessible and clear format into the lecture theatre.
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Acknowledgments
The case studies were created under the direction and at the request of the IChemE Safety Centre by Mr Brett
Mahar.
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