Mind the Risk
A portal for sharing information within the field of SHEQ through regular blogs and reflections, sharing information on relevant professional literature and sharing (own) publications. It was started by the author of 'Safety Myth 101' and 'The First Rule of Safety Culture'.
You Are Not So Smart
"Like lots of people, I used to forward sensational news stories without skepticism and think I was a smarty pants just because I did a little internet research. I didn’t know about confirmation bias and self-enhancing fallacies, and once I did, I felt very, very stupid. I still feel that way, but now I can make you feel that way too.
You Are Not So Smart is a fun exploration of the ways you and everyone else tends to develop an undeserved confidence in human perception, motivation, and behavior. I hope by reading it and listening to the podcast you’ll rediscover a humility and reconnect with the stumbling, fumbling community of man trying to make sense of things the best we can."
Rebels at Work
"This is a place of ideas, stories and resources for Rebels at Work, those of us trying to improve, change and innovate at work -- regardless of whether we have a formal position of authority.
In today's unpredictable world, expertise and "solutions" have a short shelf life. The cycle of learning, acting and adapting needs to be turned from low to high for our organizations to evolve and for us to grow as people. Crank it up, dear Rebels. The world needs us everywhere, now more than ever."
(in Dutch only)
"Stichting ZorgVeilig zet mensen en organisaties in beweging. Stap voor stap naar een veiliger organisatiecultuur. Zowel sociaal als fysiek en organisatorisch veilig. Want in een veilige omgeving is het aangenaam en goed werken voor werknemers.
In organisaties waar ruimte is voor het goede gesprek, is het goed toeven voor klanten en cliënten, bewoners en patiënten. We raken mensen met verrassende, ontroerende en onvergetelijke (ervarings)interventies in het hoofd én in het hart. Zo brengen we mensen en organisaties in beweging naar een cultuur waarin iedereen met een gerust hart klant, cliënt of patiënt zou willen zijn."
The Cynefin Framework
"The framework changes, because as we use it, it has an evolutionary journey towards “better” and more coherent.
During the pandemic, I’ve been using this version of it to help people think about what to do and this is how I propose to tour you around it as well. First, it’s helpful to orient people to the framework. To begin with, it has five domains: the one in the middle, plus four others."
We will contact you as soon
Speaking requests for Benno Baksteen
are coordinated by:
Assemblee Speakers Bureau
Under his pen name Max Drenth also has a personal website: maximfebruari.nl
About the links
Our main message is that the fysical world will only change when people actually do something. The virtual world of rules, procedures and protocols will help a lot to do the right things, but should support, not dominate.
For doing the right things the proper culture is also very helpful. The problem is that you can not make or create a culture. It has to grow. And it grows through doing things together. It also takes time, there is no quick fix. So it needs both vision and patience.
When we started this website -back in 2011- the world of systems seemed to be dominant in the SHEQ arena. Take the infamous safety ladder, which is not a ladder but a taxonomy. We had the impression we were pretty lonely when we followed trailblazers like Sidney Dekker and Erik Hollnagel with our emphasis on doing things and on supporting in stead of restricting front-line actors. And on the fact that the only way forward is by doing things and learning from them. Not by top-down implementation of ever more rules and procedures.
However this turned out not to be true. Several other people and groups, also in non-technical domains, came to similar conclusions. See the links on the left. All in all many insights and a lot of analysis tools were available. What was missing was an easy-to-use tool to implement the insights. Enter the DEGAS-circle: not an analysis tool, obviously, but a framework for direct action.
As almost everything the DEGAS-circle too is based on a lot of analysis and work by others. See for a summary of the literature the DEGAS library, which can be entered through the image on the Publications page. See the additional links below for a few on-line sources as well. An example of a five-step plan for implementation, based on the DEGAS-circle, can be found on the Publications page, 2018.
"A just culture protects people's honest mistakes from being seen as culpable. But what is an honest mistake, or rather, when is a mistake no longer honest? It is too simple to assert that there should be consequences for those who 'cross the line'. Lines don't just exist out there, ready to be crossed or obeyed. We -people- construct those lines; and we draw them differently all the time, depending on the language we use to describe the mistake, on hindsight, history, tradition, and a host of other factors. What matters is not where the line goes, but who gets to draw it. If we leave that to chance, or to prosecutors, or fail to tell operators honestly about who may end up drawing the line, then a just culture may be very difficult to achieve. The absence of a just culture in an organization, in a country, in an industry, hurts both justice and safety."
"My problem is that since I started to think about the efficiency–thoroughness trade-off (ETTO) principle as a way to make sense out of what people do, I seem to find examples of ETTO everywhere. This is not something that I do intentionally, but the efficiency–thoroughness trade-off principle is seemingly ubiquitous. Indeed, the obviousness of the phenomenon is so strong that reason seems to demand that it should be questioned. But try as I might to eradicate it, it still persists. Writing this book can therefore, in a sense, be seen as a way to get rid of the ETTO demon, or at least to pass it on to someone else, like the Monkey’s Paw."
"Recent analyses of major incidents, such as BP’s Texas City and Macondo disasters and the loss of the space shuttle Columbia, have moved from considering immediate factors and basic organizational failings to including cultural issues. Culture is, however, even more difficult to incorporate into incident investigations and analyses than are organizational factors. This chapter provides a structured approach to analyzing individual, organizational and cultural/regulatory factors based upon the bowtie methodology, using well-defined rules to distinguish three levels of causation."
"Foodstuffs play a prominent role in Professor James Reason’s thinking about safety. In an anecdote up there with Isaac Newton’s apple moment, Reason turned his professional attention to safety in the 1970s after a domestic ‘disaster’ where he absent-mindedly put cat food in his teapot. (The cat and the pot are given equal billing with an airliner and nuclear power station on the cover of Reason’s memoir, A Life in Error.) The model is a metaphor for the way circumstances arise and retreat like the holes in Swiss Emmentaler cheese. It springs from the understanding that there are at least four types of failure required to allow an accident to happen; failures of organisational influences, supervision, preconditions and specific acts."
"The First World War provided considerable stimulus to Human Factors activity as it became necessary to optimise factory production, much of which was being done by women totally new to this working environment. The Second World War again provided a stimulus to Human Factors progress as it became apparent that more sophisticated equipment was outstripping man's capability to operate it with maximum effectiveness. The Liveware is the hub of the SHEL model of Human Factors. The remaining components must be adapted and matched to this central component. The original SHEL concept, named after the initial letters of its components, Software, Hardware, Environment, Liveware, was first developed using a different model from the one used here."