Process safety isn’t only about investigating major or near-miss incidents after they occur. The best process safety professionals develop a sharp “Sherlock Holmes” mindset that helps them investigate anything unusual in day-to-day operations — before small anomalies turn into big problems.
This expanded approach emphasizes sensitivity to operations, one of the key pillars of a strong process safety culture. It means staying curious, observant, and methodical when something doesn’t look quite right.
As Sherlock Holmes famously observed:
“When you have eliminated the impossible, whatever remains, however improbable, must be the truth.”
Becoming Sherlock Holmes in the Plant
Imagine you are Sherlock Holmes walking through your facility. You notice small clues that others might overlook:
- A weird operational result — a temperature, pressure, or flow reading that’s slightly off trend
- A bad process safety metric that suddenly worsens or behaves strangely
- An unexpected near-miss, low-level alarm spike, or equipment anomaly
- A strange lab result or product quality deviation
- An unusual maintenance finding during routine inspections
Instead of dismissing these as “normal variation” or jumping to quick explanations, treat them as mysteries worth solving.
As Sherlock Holmes warned:
“It is a capital mistake to theorize before one has data. Insensibly one begins to twist facts to suit theories, instead of theories to suit facts.”
The Sherlock Approach – Key Principles
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Observe Carefully and Gather Data First Walk the unit, review trends, talk to operators, and collect evidence while memories and data are fresh.
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Ask Better Questions Challenge assumptions: What exactly changed? When did it start? What else is connected? Use structured tools like 5-Whys, timelines, or causal factor charting — not just for incidents, but for any operational puzzle.
- Eliminate the Impossible (and Avoid Red Herrings) Look beyond the most obvious explanation. Watch for confirmation bias and multiple contributing factors. Systemic issues in procedures, training, equipment, or culture are often the real culprits. **Real Example** During an audit of a polymerization reactor, I noticed a higher-than-normal reflux temperature in the condensate stream. Instead of accepting it as normal variation, I requested an inspection of the condenser. The inspection revealed many plugged tubes that were significantly reducing cooling efficiency. Had this gone undetected, it could have led to a runaway polymerization reaction.
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Build the Case with Deductive Reasoning Connect the dots logically. Many “small mysteries” reveal weaknesses that could prevent future incidents if addressed early.
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Focus on Learning and Prevention Turn every investigation — big or small — into actionable improvements that strengthen safeguards and operational discipline.
Why This Mindset Matters
Developing sensitivity to operations through this Sherlock-style curiosity delivers powerful benefits:
- You catch and correct small deviations before they escalate into reportable incidents or loss of containment.
- You build a culture of continuous learning and proactive problem-solving.
- You improve overall process safety performance and operational excellence.
Many serious events begin with subtle anomalies that were overlooked or poorly investigated.
Practical Tips to Sharpen Your Sherlock Skills
- Train teams to treat every unusual metric or operational surprise as a learning opportunity.
- Hold short “mystery-solving” reviews for anomalies.
- Document and share lessons across sites and departments.
- Encourage a blame-free environment focused on facts and systemic fixes.
Final Thought Great process safety professionals are part engineer, part detective. By adopting the mindset of Sherlock Holmes — curious, observant, persistent, and committed to the truth — we move beyond reactive incident learning to true sensitivity to operations. We don’t just solve the mystery; we prevent the next one.
What operational “mysteries” have you investigated lately? Share your experiences or favorite Sherlock-style lessons in the comments below.
Want to go deeper?
In a follow-up post, I’ll explore how to turn this Sherlock Holmes mindset into a structured process safety feedback and learning system. Drawing from my 2022 paper in Process Safety Progress, we’ll look at how to design and use leading and lagging metrics effectively, avoid common pitfalls, and build a true learning organization that acts on small signals before they become big problems.
Reference Adapted and significantly expanded from: Klein, J.A., “The ChE as Sherlock Holmes: Investigating Process Incidents,” CEP, October 2016.