A few years ago, I encountered the below sign before entering a construction site. For now, let’s not dwell on the text that appears to value administrative action above anything else (and probably will be incomprehensible to the often foreign, predominantly Eastern European, workers) and instead look at the pictograms on the bottom that inform us about some safety requirements on that location.

Taking the information on that sign literally, one was obliged to wear an impressive collection of gear: safety gloves, fall protection, a hard hat, safety boots, gas masks, safety goggles and hearing protection.

It looks like they wanted to make sure that they didn’t forget anything, covering their asses to the max. Interestingly they screwed up on that part, because it was work at the rail tracks where high-visibility reflective safety dress is prescribed per regulations. And of course, there was no working at height at that location.

In my book I call this safety-itis, a serious condition that seems to have befallen many a company. Just drown people in a huge number of obligations.

Safety Dancing

Things can also be done quite differently. The other day, a colleague of mine had a little excursion to the renowned Norwegian glass factory at Hadeland. Visitors to this facility can observe glassblowers performing their fascinating trade. Being a safety nerd, like many of us, my colleague noticed the sign below.

 While the first part is interesting, I’d like to concentrate on the second part of the text right now.

Glassblowers clearly deal with high risks and a lot of energy. Hazards include extremely high temperature and heavy and sharp objects. Still, many of these people perform their jobs in t-shirts and shorts (check for example this dude).

If you observe a glassblower at work, it looks at times as if they are dancing, moving in intricate patterns around their blowing tube with the hot piece of glass on its tip. And while I’m no dancer myself, I presume it’s not easy to do so in protective full body gear…

A True Story

This reminds me of an anecdote from my own professional past at the workshop in Haarlem. Most people never have the chance to look under train carriages. Hidden for most of us, you will find an impressive amount of wires, pipes, appendages and what not. Many uneven and sharp (or blunt) objects where you can bump and harm your head while you are working under the train, fixing stuff or just doing ordinary maintenance.

In my time, engineers would often wear just a cap (which would prevent grease, rust, dust and other stuff getting on their head and in their hair). Later we also had safety caps (like a baseball cap with a Kevlar inner) for those who wanted them. There were barely ever head injuries (I recall none in seven years time). Like the glassblowers, engineers performed kind of a ‘dance’ when they walked in the small space under the train. They knew exactly when to duck and when to bend to avoid bumping into appendages and pipes.

When I moved on to another job, my position was filled by a hold-the-railing type safety officer. One of his first actions was to bully the management in the departments about the ‘intolerable’ lack of head protection. After all there were sharp objects under the trains, and people could get cuts and infections from the dirt and rust under the trains. And so on. Within no time there were signs all over the place, pointing out the mandatory wearing of hard hats followed by some heavy enforcement.

The result: a spike in neck injuries. Because of the focus on enforcement people complied, wore hard hats and kept bumping into all kinds of stuff under the trains. After all, they moved like they always had done. The problem, however, was that they had “grown” by a few centimeters. While they did not get any cuts or infections, the energy was transferred to their necks leading to some injuries. Lost time injuries even, which hadn’t been there before.


Looking back at the construction site above, I clearly prefer the Hadeland solution. I do of course appreciate the difference between a construction site and a glassblowing workshop with highly skilled professionals in relatively stable environment and activities. Still, an overkill of useless mandatory gear is not helpful at all and rather creates cynicism and ridicule with regard to safety rules.

The message today: sometimes it should be obligatory to wear safety gear, without leaving a choice. I fully support mandatory wearing of PPE in cases where this makes sense. But just as often one should leave room to use your head and skills.

Do not interfere with skillful dancers, they may actually hurt themselves while you are trying to protect them!


Many thanks (once again) to my friend and colleague Beate Karlsen for spontaneously providing the inspiration for a little blog.


Also published on Linkedin

Feedback is a necessary element of learning. According to Wikipedia, Feedback occurs when outputs of a system are routed back as inputs as part of a chain of cause-and-effect that forms a circuit or loop. The form of this information fed back to the control mechanism or initiator often determines further action.

In most simple terms: if you get positive feedback (result as wanted) you will do more of what you did before, if you get negative feedback (result not as wanted) you will probably change what you did before in the hope to get a positive result, or you will stop what you did altogether.

Much of the work on behavioural change relies on feedback (whether this is the optimal way to go is a question not to be discussed here). Carrots and Sticks, and the C of ABC are very much about feedback. Also the Plan-Do-Check/Study-Act cycle and the scientific method are based on (among other things) feedback. 

Trial - error - learning

Feedback is also what trial and error is all about. Mommy says to toddler “Do not touch the stove. It is hot”. Toddler follows human nature and is going to explore for himself anyway. Toddler burns his fingers and learns the lesson through a harsh and direct form of feedback. Toddler might even have some second loop learning (“Must listen more often to mommy, she knows stuff”) although that may go overboard when the teenage years arrive. But I digress…

Feedback teaches us about our actions and the system we are in and this contributes to our learning. We have to realise, of course, that some things are complicated or complex and in some cases what we perceive as feedback of a cause-and-effect relationship is not necessarily that. We may get back to that another time, for now we stick to another thing related to feedback.

Feedback in practice: A silly example

Feedback must be specific and understandable to be useful.

The other week I accidentally ended up on the Amazon page of my book and I saw that some people had left a review. Until then I had not realised that this was a possibility, so this was nice surprise. I had gotten feedback on the book through various channels, and here was yet another one.

Obviously, I was very pleased to see some extremely positive reviews. The interesting thing is, however, that one often learns most (at least with regard to things that should be changed) from critical or even negative feedback. So far two of those.

One reviewer complained about the small print. Point taken. I had received similar feedback from two or three other readers previously, and while I still stand back the decision to keep the number of pages below 300 and not delay the publishing date by redoing the entire layout (ETTO!), I see that a larger font would have been better. This is good feedback. Lesson learned. For the next book, I will do the print differently. I will also be able to fill a book more quickly, so kind of a win-win situation.

The other reviewer, however, managed to leave the comment “Not what I expected”.

Okay… What to do with that kind of feedback? It could in fact have been useful if he had specified what these expectations were. Then I could have decided if his expectations matched with my objectives when I wrote the book. Did he expect something in full colour? A couple of how-to checklists? Long, thorough discussions of safety subjects? All valid expectations for him (or her), but none of these were included in my plans this time. I might consider them for another book, however, if I was convinced that they would fit the purpose.

Since the feedback says nothing about the book, but only something about the reviewer, there will alas be no learning from this kind of feedback. Well, apart from that it served as a learning example here. So at least we have that and it wasn’t all useless. And maybe I should work on my mind-reading powers...

Feedback? Yes, Please!

I am here to learn, to explore, to discuss and to improve. Professionally and personally. In that respect I think it is valuable and great to get (and give) feedback - positive AND negative, as long as it is constructive. So please keep it coming, to me and to others, so that we can improve. 


Also published on Linkedin.

At the moment, I am working through Todd Conklin’s books. A worthwhile exercise because they get me thinking about learning, how we involve people and how we do assessments and investigations.

I started with his latest book about asking better questions; a subject that very much appeals to me. One thing that stuck out right from the start, and also made me wonder, is that he favours asking “How” over asking “Why”. Going back, I noticed that he even dedicated his previous book “Pre-Accident Investigations” (that I have yet to read) to people who asked “How”.

Therefore, in line with the latest book, I wondered if “How” really is a better question than “Why”?


Before we continue with my musings, you might want to hear Todd himself on the subject in a rather short podcast. Here he argues that “How” is less inflammatory that “Why”. It is less blaming. It is a better way to start a conversation and avoid defensiveness than “Why”. The biggest pay-off for Todd is that it is much more operationally informative. “Why” ends usually up on some level with an incentive, which ends up with a choice (and had that choice not been made then the accident had not happened). According to Todd, “How” forces you to look at context and understand conditions. “How” takes you from the human element and puts you into the system/organisational activity. Complex systems do not have individual moments (causes). They have motions and conditions that should be understood.

Todd also says not to overthink it, just try it. Language changes and thinking changes and it may give you better opportunities for improvement.

Overthinking “How” and “Why”

I am sorry, because maybe I am going to overthink it. However, since Todd makes the point so forcefully, I just have to reflect a bit on it. I agree strongly that choice of language and the way you use it affect how you think and what you will find. The problem is that for me personally “How” does not add that special extra, or leads me more towards context than asking “Why”.

It may be a language thing (having other languages than English as my mother tongue), or my background (that includes both engineering and law school), but for me “How” asks for a mechanism. Granted, this may leave some room for context and conditions, but it mainly describes the event and not much of the surroundings and background. For me, “How”, is a rather technical question and often stops with direct cause(s). More or less. Feel free to disagree and experience this differently.

The driver for safety investigations should be curiosity, not accountability. I cannot see that “How” is a better expression for curiosity than “Why”. It is a different expression for curiosity for sure. Still, “Why” asks for (a) reason(s), and suggests clear-cut causal connection(s). By that, I do agree with Todd that “Why” may (mis)lead you to disregard complexity, while “How” leaves room for complexity even if it doesn’t ask for it explicitly. Still, both “How” and “Why” can do so if you ask it often enough in many different directions.

For me personally, “Why” would also be the better guide to develop ideas around local rationality. However, this also connects to the major drawback of the word. As Todd justly says: “Why” can easily lead you to decisions and choices that have been made and a major focus on the human element. The step towards judgement and blame is then quickly made. That may very well be the biggest issue with “Why”: the way “Why” has been practiced in the past, especially in the RCA-context of 5 Why linearity. “Why” is pretty much connected to the ‘old view’ of safety where errors are seen as causes and problems instead of as symptoms. Therefore, using “How” instead of “Why” can be very much of symbolic significance rather than that it really is superior.

Is “How” Really Better Than “Why”?

Trying to conclude: is “How” a better question? I do not know (yet). It is a different question, however, and that alone enrichens your view by using it.

A word of caution, however. I have not asked the man himself, but I am rather sure that Todd agrees: Asking “How” is not a silver bullet or magic wand. Asking “How” alone does not make you a better investigator. And the last thing we want or need is a ‘New View LEAN Consultant’ selling us a ‘5 How Model’. 

That is why I would like you to actually think about the question for yourself. A simple instruction like “Ask how, not why” without any deeper understanding will/may backfire. I am afraid that without proper mind-set and training any simple question (especially when asked repeatedly) can or even will lead you astray. It may even be more important what you want to achieve with a question than what question you actually ask (although some questions are very unwise).

Besides, why think binary anyway. We should not think “either/or”, but rather “both/and”. Maybe a good way would to be starting with “How” (I fully agree that it is a better opener for a discussion), and move to “Why” later on? Maybe it is even better to ask a longer question in the line of: “What conditions were present and may have contributed?”. It is not as short and snappy as “How” or “Why”, but then, should we not be reluctant to simplify?

Many thanks to Timothy van Goethem, Vincent Steinmetz and Beate Karlsen who helped to shape these reflections. Still, I have to stress that the above opinions and views are my responsibility and not necessarily the truth. I would love to hear yours, discuss, explore and learn!


Todd Conklin bibliography:

Simple Revolutionary Acts - Ideas To Revitalize Yourself And Your Workplace (2004, ISBN 978-0595320653)

Pre-Accident Investigations - An Introduction To Organizational Safety (2012, ISBN 978-1409447825)

Pre-Accident Investigations: Better Questions (2016, ISBN 978-1472486134)


Also published on Linkedin.

For many years, I have been working with and for safety on level crossings. The other week, however, I found myself in the local newspaper (front page and all…) arguing against a recently implemented safety measure. Paradoxical, or not? First, some necessary background information…

Level crossings

Level crossings are places on the railroads that generally have a rather high risk. Here is a possibility that common road users (cars, busses, cycles and pedestrians) meet a train. Trains contain a lot of energy (mass and speed!), cannot steer away (being ‘locked’ to the rails) and take a long distance to stop. In many cases, the meeting of train and common road users is fatal, or at least highly damaging, for the latter.

For this reason, often safety measures have been implemented, like automatic barriers, warning lights, signs and the like. Safety measures will vary, depending upon the situation. In Norway, for example, all level crossings with public roads have to be secured, while the smaller infrequently used level crossings in the woods or rural areas will have significantly less safety measures. Locations with the highest risk or locations that provide special problems are preferably removed, by building a fly-over or culvert and making it a crossing in different levels. Separating various modes of traffic in space is better (but more expensive) than building barriers.

The location

When you leave the station of my hometown and travel north, after about a mile you will meet four unprotected level crossings connected to some farms beside the train line. If you try Google Maps and put in the coordinates 59.565506, 11.297634 you get an idea of the situation.

The terrain is relatively flat, but slopes on one side and there are some curves. Vegetation can be another challenge that disturbs the line of sight. Most of these level crossings are used very infrequently and are even closed with a fence that the user can open if necessary (for example, when a farmer has to get to the fields on the other side of the tracks). One of the level crossings is clearly in daily use for farm traffic and people who live in the woods a few hundred meters from the tracks. All level crossings have “Stop, Look, and Listen” signs.

It is safe to say that the situation has been like this for many years, decades probably, and the people who live there and use the level crossings are very familiar with the situation (I actually spoke to one of the farmers). Save for the odd visitor, I dare say that only people with experience and knowledge of the situation use these level crossings. The chance for an unfamiliar random passer-by is remote because the roads are literally going nowhere.

Another safety measure

During a recent upgrade/maintenance on the line, someone noticed that none of the unprotected level crossings on the line had a sign that ordered the train driver to blow the horn to signalise “Train coming”. The infrastructure manager decided to correct this non-compliance. From that moment on, train drivers did as they were ordered and created a decent amount of noise in the wide area that previously had been quiet.

Blowing horns is a safety measure with a long historic tradition. From their early beginning, locomotives have been equipped with loud horns or bells to warn vehicles or pedestrians that they were coming. Steam locomotives had steam whistles, the later diesel and electrical locomotives got specifically designed train air horns. Train air horns are significantly louder than their counterparts in cars and trucks are.

To reduce the impact on people living nearby, train drivers have to blow the horn only between 06:00 and 22:00 - apart from emergencies (like people or animals on the tracks), of course. The problem is that even by restricting the honking to these hours, there still is noise at least 4 times per hour. There are people living within 100 metres of the place where the trains blow the horn - with NO sound-reducing barriers in-between. There is also a nursing home close by.

Additionally, even though rules try to stipulate how the horn signal is to be given (and I assume train drivers are trained about this), not all train drivers do it the same way. Some blow the horn significantly longer, earlier, or louder than others, creating more nuisance than others do.

Some critical questions

I have not been part of, or seen, the assessments that were part of the decision to putting up signs that are causing the noise. When I filed a complaint, the answer I received referred to compliance to some rule. And I presume (but again, I can be mistaken) that this is as simple how the process went: a non-compliance was identified and without much thought a process was started to fix the problem. Undoubtedly with the best of intentions and the assumption that it would improve things, but I doubt that real risk-based thinking was part of the process.

And while I wasn’t part of the process, I can ask a couple of critical questions:

1: Management of Change?

I wonder if someone has assessed the effects of the change. It looks so simple and straightforward, but is it really? One may think that the more safety measures the better, but believing that implementing safety measures is only positive or neutral is a fallacy. Neither do more safety measures automatically mean lower risk/safer.

Just some points for consideration:

  • More often than not, new measures create new problems. In this case among other things noise.
  • The frequent use of sound signals may cause desensitisation. After a while, people may get used to it and no longer react to it. The warning signal thereby loses its function because it is overused. Kind of the “Cry wolf” effect. Experience shows that people do not react (or only badly) when an alarm goes off in a shopping centre and offices (“Oh, it’s probably another false alarm”), and the “Don’t leave your luggage unattended” messages on airports have become part of the background noise, nothing more.
  • It can lead to changed behaviour, for example that people start trusting on the horn signals and stop looking out for themselves, leading to risky situations when a train driver forgets to give the signal, or outside the period of 06:00 - 22:00.

2: Suitable and effective measure?

While the measure has a long tradition and is implemented as a standard solution, I wonder if it is a solution that suits our modern time at all?

These days, people walk around with their iPods or mobile phones and headphones all the time, or have loud music in cars. On the locations we are talking about here, there are probably tractors that are pretty noisy themselves and some farmers use hearing protection while operating them. So it's doubtful that the warning signal reaches its intended 'audience'.

We should also consider how honking is perceived in normal life. While we cannot fully compare road and rail traffic (for example the meaning of a ‘red signal’ does not have the same impact), the function of using a horn is generally as a warning signal in extraordinary situations (although I know that drivers in some ‘southern’ or ‘eastern’ cities appear to use it as a means to signalize that they participate in traffic). So shouldn’t be using the train horn also be reserved for extraordinary situations, like when there are people on the rails when the train approaches, or possibly when there is fog and visibility is bad?

Using a danger/warning signal as a constant signal means that its effect wears off very quickly, leading to the above mentioned desensitisation.

3: Gain or pain?

One may wonder what the cost/benefit looks like in this case.

Typically these cost/benefit assessments only look at safety and money. I presume that the process (if there was any, because usually they are done very implicitly, especially when triggered by non-compliances) went somehow like this: There is an additional safety measure, so we assume safety improves. The expenses are relatively limited for the infrastructure manager who has to put up a couple of signs (although you may be surprised about the total costs if you factor in the design, planning, updating of maps, etc.) while the cost for the railway undertaking is nil (train drivers have to do their job, and that they do already).

However, this look at cost/benefit is too limited. Besides the elements safety and money, also other factors should be included in the assessment, like efficacy (the assumed safety gain may not be there at all) and the effect on other areas than safety (like environment and welfare in this case). One will also notice then that we are dealing with various, non-overlapping groups of stakeholders that all have different costs and benefits. Safety gain (or loss) concerns passengers and personnel in the train and road traffic using the level crossing (gains for these two groups are different, mind you!), cost and compliance concern the infrastructure manager and railway undertaking while environmental and welfare aspects concern the people living in the area.

Dealing with risk means making trade-offs between various aspects. Even if safety would improve thanks to the signalling with the horn, someone else pays the price. What is more important? Quite importantly also, who gets to decide? Were other stakeholders, like the neighbours or the municipality, even involved in the decision? Or, were they only confronted with the results? (As far as I know the answers the answers to the last two questions are No and Yes, respectively).

I am not necessarily a fanatic adept of utilitarianism, but I am rather sure that Bentham would not approve of this. To me it does not sound like the solution with the greatest gain for the greatest number.

What can we learn

Let me first say very clearly that I do not know if the implementation of this ‘safety measure’ was wise. Answering the questions raised above might help determining that. And there are surely other important factors not mentioned here that should be considered too. For now, I am very sceptical.

Some may wonder what the fuss is all about. Why make safety so complicated. Simple answer: because it already is. I do not make it so. In fact, I think that this case illustrates very well that safety is often way too complex to dumb it down into compliance with a rule and implementing a simplistic standard measure. Other lessons might be:

  • One size usually fits no one really well.
  • More is not always better. It is not always a matter of the old Dutch saying of “baat het niet dan schaadt het niet” (“if it doesn’t help, it doesn’t do harm”), because it just might do harm.
  • Implementing safety measures will change the system that can (will) lead to changed behaviour, which may actually lead to a reduced level of safety.
  • Compliance is not the same as safety.
  • Talking to various stakeholders will give you a richer picture of the problem, and lead to better (more robust) decisions.


Also published on Linkedin.

The Frequency Illusion bias can be a funny thing. And I’m not only saying this because for some strange reason it is also called the Baader-Meinhof Phenomenon. The Frequency Illusion is when people learn or notice something new they start seeing it everywhere. It is why pregnant women see pregnant women everywhere. Or take myself. Last winter we bought another car we are extremely satisfied with. Afterwards I started noticing the same model and make everywher. Same colour even. There appear to be zillions of them in our little part of the world.

It can also happen in a professional sense like when you learn something new and then recognise it in many events and situations that you come across. You actually you have to watch out for this so that you don’t over-do it and attribute every event and every situation to that new thing, be it culture, drift, complexity or whatever.

Still, once you start studying human factors you will recognise a lot of stuff therefrom in everyday life, and media. Sometimes you even come across some rather funny examples. Let’s look at one.

Art Destroyed

You may have heard about this case on the news a week or so ago. The headline that brought it to my attention said: “Old Lady Destroys Piece Of Art in German Museum”.

Upon reading that headline some thoughts popped in my head, immediately. Vandalism? Not likely (but not impossible), being an old lady. Dementia? That’s more of a possibility… But wait, we are so quick with our judgements and biases. Another thing to watch out for, even more maybe than seeing things we learned recently. Let’s first get some information.

What had happened was that the lady in question was on a day out to an art museum with the nursing home where she lives. One of the pieces of art, made by avant-garde artist Arthur Köpcke in 1965, looks like a giant unfinished crossword puzzle.

What the old lady (aged 90) did was finish some missing parts of the puzzle. Which gets me laughing aloud, but that is just my sense of humour.

How on Earth…

At first one may wonder “How could she do that?!”. She was in a museum after all, isn’t it ‘common sense’ that you cannot and shall not write on pieces of art in a museum? She must be dementing!

But, as the interviews in the media show, she may be living in a nursing home, this old lady had her senses very much together. And while the Mirror calls it an error, the lady even admits to that she did it on purpose! Vandalism after all then? 

No! A perfect example for local rationality. If you look at the context the actions of the old lady make perfect sense.

Local rationality

Perfect sense? Come on, some may say, as you mentioned above this was a museum! Right, but:

  • This museum (of modern art) contains a lot of interactive art where visitors are encouraged to interact with the pieces of art.
  • Not this one, but that was not made explicitly clear. Instead there was the clear instruction, or at least encouragement on the piece of art, saying "insert words".
  • The lady therefore believed that she would be acting in the artist’s interest and intention if she did insert words.
  • Because she was not carrying one herself, she went to borrow a pen from the museum staff making her intentions clear. Nobody stopped her.

Looking at this context the old lady’s actions make a lot of sense. People do things because it makes sense to them at that moment and place, given their current knowledge, resources and goals. That is what local rationality means in a nutshell: it makes sense for that person, at that moment, at that place.


Interestingly, the old lady may actually have done the artist and owner of the piece a favour. The piece was rather unknown before she ‘reworked’ it. After it was in the news all over the world the value has gone up significantly.

By the way, this was not the first time that people unknowingly destroy ‘art’ framing it in their context and local rationality, the most famous probably being Joseph Beuys’ Fettecke (‘grease corner’) being ‘cleaned up’. Maybe this should be a hint for some artists that they should make their art recognizable as such. Environment determines behaviour in a major way, after all.

p.s. The museum has now put up a sign telling visitors that the crossword is NOT one of their interactive pieces of art…


Also published on Linkedin.