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  • 7/31/2019 Risk Makes Sense Final Promo

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    Risk Makes SenseHuman Judgement and Risk

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    10 Jens Place

    Kambah AC 2902

    Copyright 2012 by Robert Long.

    All rights reserved including the right o reproduction in whole or in part in any orm.

    ISBN 978-0-646-57094-5

    Graphic design and layout by Justin Huehn.

    Scotoma Press

    Risk Makes SenseHuman Judgement and Risk

    Dr Robert Long and Joshua Long

    National Library of Australia Cataloguing-in-Publication entry

    Author: Long, Robert

    itle: Risk makes sense : human judgement and risk / Robert Long, Joshua Long.

    ISBN: 9780646570945 (pbk.)

    Subjects: Risk-taking (Psychology) Risk perception. Risk--Sociological aspects.

    Social choice.

    Other Authors/Contributors: Long, Joshua.

    Dewey Number: 302.12

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    iv Risk Makes Sense v

    Contents

    With Tanks............................................................................................................................................................................................................viii

    Glossary............................................................................................................................................................................................................................ix

    Book Logo .....................................................................................................................................................................................................................ix

    What Tis Book Is About ................................................................................................................................................................................x

    Structure and Use o the Book.................................................................................................................................................................xii

    SECTION ONE What We Know About Risk ..............................................................................................................................................1

    CHAPTER 1 Myths About Risk ...............................................................................................................................................................................3

    An Introduction to Myths About Risk: ed, the ractor and a Risk rade-o..........................................3

    Myth Busting ...............................................................................................................................................................................................................4

    Common Sense Created Not Assumed .............................................................................................................................................6

    Te Lord Young Report and unCommon Sense.......................................................................................................................8

    Tey are Just Idiots - Te Intelligence Myth.................................................................................................................................8

    Te Precaution Myth and a Wayside Story.................................................................................................................................10

    Perceptions and Scotoma...............................................................................................................................................................................13

    Te Engineer Out the Idiot Myth.......................................................................................................................................................14

    Te Follow Your Feelings Myth..............................................................................................................................................................15

    Te can do Myth .................................................................................................................................................................................................16

    Te Anxiety and Fear Myth........................................................................................................................................................................18

    Motivation and Learning as Myth Breakers ..............................................................................................................................19Workshop Questions.........................................................................................................................................................................................20

    ransition ......................................................................................................................................................................................................................21

    CHAPTER 2 Gambling and Risk ......................................................................................................................................................................23

    Why Gambling and Risk?............................................................................................................................................................................23

    Learning From Young People at-risk ..............................................................................................................................................27

    Risk and Youth Detention ............................................................................................................................................................................29

    Te Poker Machine Maze.............................................................................................................................................................................30

    Is Risk Neutral?.......................................................................................................................................................................................................31

    Risk Assessment by Weight?......................................................................................................................................................................34

    Counter-Intuitive Responses to Risk................................................................................................................................................36

    Responses to a Risk Averse Society.....................................................................................................................................................37

    Workshop Questions.........................................................................................................................................................................................39ransition ......................................................................................................................................................................................................................39

    CHAPTER 3Language, Culture and Discourse ...............................................................................................................................41

    Playing Sae ................................................................................................................................................................................................................41

    Te Fundamentalist Quest or Certainty.......................................................................................................................................43

    Language as a ool o rade .......................................................................................................................................................................46

    Its Important What is Not Said ............................................................................................................................................................47

    Culture: More Tan Just What We Do Around Here...................................................................................................49

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    vi Risk Makes Sense Chapter 1: Myths about Risk vii

    Cultural Dierence and Language .......................................................................................................................................................55

    Generative Culture Spin ................................................................................................................................................................................57

    Culture o Risk Scorecard.............................................................................................................................................................................58

    Te Power o the Negative and the Positive................................................................................................................................62

    Workshop Questions.........................................................................................................................................................................................64

    ransition ......................................................................................................................................................................................................................64

    SECTION TWO What We Know About Human Sensemaking .........................................................................................65

    CHAPTER 4 Learning, Motivation and Risk ........................................................................................................................................67

    An Apprenticeship in Learning..............................................................................................................................................................67

    Learning About Learning ............................................................................................................................................................................70

    ypes o Learning.................................................................................................................................................................................................73

    Te Essentials in Learning...........................................................................................................................................................................77

    Learning and an Induction Scorecard...............................................................................................................................................78

    Results..............................................................................................................................................................................................................................80

    How We Learn is What We Learn .....................................................................................................................................................80

    Motivation and Learning ..............................................................................................................................................................................81

    Creativity, Learning, Doubt and Risk ..............................................................................................................................................81

    Entertaining Doubt, the Key to Learning....................................................................................................................................82

    Motivation, Design and Attraction .....................................................................................................................................................84

    Workshop Questions.........................................................................................................................................................................................85

    ransition ......................................................................................................................................................................................................................85

    CHAPTER 5 The Unconscious and Risk .................................................................................................................................................87

    Perception Blindness and Observation Capability...............................................................................................................87

    Te Reliability o Our Perception.........................................................................................................................................................90

    Te Wise Delinquency o Decision Makers...............................................................................................................................91

    Bias, Balance and Rational Systems ....................................................................................................................................................92

    Intuitive, Counterintuitive and Nonintuitive Tinking ....................................................................................................94

    Cognitive Dissonance and Why Some Decisions About Risk Dont Seem to Make Sense .......96

    A Beaconseld Story about Dissonance......................................................................................................................................102

    One Brain, Tree Minds..............................................................................................................................................................................103

    Te Unconscious and Risk........................................................................................................................................................................104

    Te Unconscious and Priming ..............................................................................................................................................................105

    Workshop Questions......................................................................................................................................................................................107ransition ...................................................................................................................................................................................................................107

    CHAPTER 6 SenseMaking, Mindfulness and Risk..................................................................................................................109

    How do we Make Sense? ...........................................................................................................................................................................109

    Mindulness and High Reliability Organisations...............................................................................................................111

    Cultural Change..................................................................................................................................................................................................116

    Mapping Organisational Sensemaking.........................................................................................................................................118

    MiProle Structure...........................................................................................................................................................................................122

    MiProle Survey Summary......................................................................................................................................................................128

    Workshop Questions......................................................................................................................................................................................129

    ransition ...................................................................................................................................................................................................................129

    SECTION THREE What We can do to Make Better Sense of Risk ......................................................................131

    CHAPTER 7 Framing and the Language of Zero .......................................................................................................................133

    Since When Did Intolerance Become a Virtue? .................................................................................................................133

    Te Zero Harm Discourse ........................................................................................................................................................................135

    Its Zero Degrees in Canberra oday and Tey Say It Will Be wice as Cold omorrow ........136

    What is the Risk Discourse at your Work?...............................................................................................................................138

    Please Explain? Questions about Zero .........................................................................................................................................139

    What is an Aspiration? A Tought rom Teology..........................................................................................................139

    Are We Priming Workers to Fail? .....................................................................................................................................................140

    Sense Pathways.....................................................................................................................................................................................................141

    Risk Makes Sense ..............................................................................................................................................................................................143

    Good Goal Setting ...........................................................................................................................................................................................144

    Workshop Questions......................................................................................................................................................................................145

    ransition ...................................................................................................................................................................................................................145

    CHAPTER 8 Leadership and Conversations in Risk..............................................................................................................147

    Where o From Here?..................................................................................................................................................................................147

    Te Miracle o Dialogue .............................................................................................................................................................................149

    Leadership in Risk - Te Essential Capabilities ..................................................................................................................150

    Responding to Conrmation Bias .....................................................................................................................................................152

    Creativity and Improvisation, Leadership Excellence ....................................................................................................153

    Sam is the Man ....................................................................................................................................................................................................154

    Your alk Matters - Skilled Conversations...............................................................................................................................156

    Te Compliance Mentality Compared to Excellence in Risk Leadership.................................................158

    Systems Fatigue, Human Nature and Flooding ...................................................................................................................159

    Entertaining Doubt, the Key to Managing Risk.................................................................................................................160

    Tinking and Acting Outside Te Box in Leadership ................................................................................................161

    Challenging Punitive Culture with an Innovative Approach to Lead Indicators...............................163

    Challenging Dumb Down Tinking About Risk...............................................................................................................164

    Conclusion................................................................................................................................................................................................................166

    Bamboozled.............................................................................................................................................................................................................167Workshop Questions......................................................................................................................................................................................168

    Further Directions .............................................................................................................................................................................................169

    raining.......................................................................................................................................................................................................................169

    CHAPTER 9 A Reading List ................................................................................................................................................................................171

    About the Authors............................................................................................................................................................................................178

    Notes...............................................................................................................................................................................................................................179

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    Foreward

    I knew something was missing, but I could not put my nger on it. What I was doing lacked

    completeness, logic, a recognition o reality. Tings just did not seem to make complete sense. Here I

    was, a mining engineer in charge o building an underground gold mine, recruiting experienced people,

    developing and rolling out our saety management system, and guided by OHS legislation, Australian

    Standards, Codes o Practice, guidelines, current industry standards, and a plethora o published and

    borrowed material. Yet, something was still not quite right.

    Risk management is a cornerstone o saety management, and legislation enshrines ones obligations toidentiy hazards, reduce the risks, implement actions and monitor the outcomes. No-one should argue

    with the moral, social and legal obligation to provide a sae work place, but what is sae? Can a work

    place be without risks? Can all risks be identied and controlled to an acceptable level, whatever that

    might mean?

    As I set about building the underground mine and the team that would operate it, where people would

    go to work up to a kilometre underground, or i they were in the gold processing plant, be operating

    around vats o sulphuric acid at 40 degrees Celsius, or cyanide (one o the most deadly chemicals known

    to man), or pouring gold bullion that when molten was over 800 degrees, it became clear to me that

    simply ollowing the prescriptive risk management process o hazard identication, risk assessment, risk

    mitigation actions and monitoring would not o itsel result in the elimination o accidents. Te notion

    that we could be the conqueror o all risks by this simple method o using a likelihood / consequence

    matrix, coming up with a ranking and believing we had actions that could control the risks pigeon-holing them and allowing us to move on to the next challenge, seemed awed. Why? Because people

    were involved!

    I was chair o the states minerals industry OHS Committee and early on organised and attended a

    presentation on BBS Behavioural Based Saety. Te classic examples o the Piper Alpha oil rig re

    and the space shuttle Columbia disaster were given that described the excellent saety systems and

    procedures in place at the time, and the one common wild card people! Tis resonated with that which

    I had been struggling to identiy as missing how to manage risk and peoples interaction with that.

    Ten I met Rob Long. Robs wide ranging proessional and academic experiences, his own quest to learn

    more and contribute, and his engaging and inquisitive mind has made him a consultant, mentor and

    riend o mine.

    I have now worked with Rob or almost a decade, and at two mine sites, on a journey that has

    involved the meshing together o risk management with people management in order to improve

    saety perormance at the workplace. It has involved the oten conronting sel assessment o my own

    emotional intelligence, what is required in saety leadership, communication and listening, observing

    and understanding. It has involved trying to understand peoples own risk taking behaviours, their

    perceptions and risk tolerance, how the very blokey world o mining inuences behaviour, what is said

    and not said, what is done and not done, what culture is and isnt.

    Rob has helped me to understand that human behaviour, belies, attitudes and perceptions are variable,

    volatile, inconsistent and personal. Risk management must deal with these human traits and emotions

    a simple risk matrix solution wont. More paperwork is not the answer, and I hope that the legislators

    recognise this in reading this book. Being mature enough to have adult conversations about the sot

    side to saety management peoples perceptions, behaviours, attitudes human actors is essential.

    Rob has helped me to understand the people side o risk, and this has helped me to make sense o risk

    management. I hope this book does that or you also.

    Matthew Gill

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    With Thanks

    Helen, Rick, Josh, Kerrie and Jenni: every risk has a consequence, every adventure an unknown path,

    every blind corner a new lesson. How did I know at the age o 20 that this journey with you would be

    what it has become? Sometimes the best way to learn is to take the rst step and with some hope, aith

    and love, then turn those risks into blessings. You are the blessings o that journey.

    Ava and Layla: whilst I would want you to be wrapped in cotton wool, I know that learning doesnt

    come easily, without some hurt and pain. Every day I see you, I re-live the journey o love all over again.

    Tanks Mitch or being so understanding, patient and generous.

    Mates: Keith, Errol and Dave, thanks or your support and understanding.

    Mentors: Graham, Robert, Clive, Daryll, Bill, Craig, Stuarte and Jim, thanks or your inspiration,

    patience and passion.

    Kathy, Chris, Brenda and Judy: Tanks or listening, challenging and caring.

    A special thanks to Christine Wilde and Marg or proo reading and corrections.

    About the Book Logo

    Te three symbols on the cover and in the ooter o this book serve to highlight the three key elements

    required to make sense o risk. Te rst is the symbol or psychology, the Greek letter Psi. Whilst

    this symbol is located in the head, making sense o risk is also about social psychology, the way we

    think together and how we are aected by groups. Te arational in sensemaking is critical i one is

    to make sense o risk. Making sense o risk is much more than a rational logical exercise. Te second

    symbol o the dice represents uncertainty and chance, i we are going to make sense o risk, we need

    to better understand how humans make decisions in states o uncertainty. Te third symbol representsthe mechanics o the brain, the neuroscience o the brain and mind are critical i n understanding how

    humans make sense o risk.

    Glossary

    aRational: not based or governed by reason. Neither rational nor irrational but non-rational.

    Cognitive Dissonance: developed by Leon Festinger. Reers to the mental gymnastics required to

    maintain consistency in the light o contradicting evidence.

    Discourse: developed by Michael Foucault. Te transmission o power in systems o thoughts

    composed o ideas, attitudes, courses o action, belies and practices that systematically construct the

    subjects and the worlds o which they speak.

    Flooding: reers to when human senses are ooded beyond the capacity to cope.

    Fundamentalism: originally coined in reerence to a rigid theological movement in the USA in 1905

    upholding the literal interpretation o the Bible. More generally, undamentalism reers to rigid aith

    like black and white thinking and actions on issues.

    Heuristics: reer to experience-based techniques or problem solving, learning, and discovery.

    Heuristics are like mental short cuts used to speed up the process o nding a satisactory solution,

    where an exhaustive search is impractical. Heuristics tend to become internal micro-rules.

    Hubris: indicates a loss o contact with reality which results in extreme overcondence and

    complacency.

    Mentalities: comes rom the French Annales School o History and reers to the history o attitudes,

    mindsets and dispositions. It denotes the psychosocial and cultural nature o history.

    Mindfulness: developed by Karl E. Weick and indicates: the preoccupation with ailure; reluctance to

    simpliy interpretations; sensitivity to operations; commitment to resilience, and deerence to expertise.

    A ull denition o mindulness is in Chapter 6 SenseMaking, Mindulness and Risk.

    Priming: is an implicit memory eect which inuences response. Priming is received in the

    subconscious and transers to enactment in the conscious.

    Risk Homeostasis: developed by Gerald Wilde. Te hypothesis o risk homeostasis holds that

    everyone has his or her own xed level o acceptable risk.

    Scotoma: a scotoma is an area o loss or impairment o visual ability surrounded by a eld o normal,

    well-preserved vision. A blind spot can be physical, psychological and cultural.

    Sensemaking: is about paying attention to ambiguity and uncertainty. Developed by Karl E. Weick

    to represent the seven ways we make sense o uncertainty and contradiction. A ull denition o

    sensemaking is in Chapter 6 SenseMaking, Mindulness and Risk.

    Unconscious: processes o the mind which are not immediately known or made aware to the conscious

    mind. Te term subconscious is also used interchangeably and denotes a s tate below the conscious

    state. Te subconscious is more associated with psychoanalytics.

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    What This Book Is About

    A Newsletter in 2011 by the Health and Saety Executive (HSE) in the UK lists a number

    o things that have been banned. Dodgem cars, school sack races and kite ying, amongst the

    activities which have been banned. Some schools have banned kids playing on monkey bars

    and others have banned leather ootballs. A local council has instituted a $1000 penalty or kite

    ying on council ovals in case somebody might get hit. Even the Royal British Legion had to

    stop selling poppies with pins on Remembrance Day in case people might prick themselves.

    (Safety SnippetsEdition 22, September 2011)

    Eective thinking and acting about risk is not only about the preservation o lie but, the living o lie.

    Tis book is about the sense o learning, adventure and creativity in the interpretation o risk. Te risk

    management industry is about decisions and attempts to render the unpredictable consequences o

    decisions, predictable and controllable. Such an endeavour is problematic urthermore, trends which

    advocate the total elimination o risk, are even more problematic. Te trajectory and language o the

    anti-risk endeavour is lie destroying and anti-learning. You cant live lie without a trade-o or risk.

    You cant learn without risk. Te report above demonstrates just how absurd things have developed

    in our risk adverse society. We seem more than ever preoccupied with law suits than learning, more

    anxious about injury than adventure and, earul o harm rather than welcoming creativity. Te quest

    or certainty, absolute control and the elimination o doubt is a undamentalist pursuit.

    Tis book is about how human judgement and decision making aect the way we make sense o risk.

    Te idea o making sense which is pivotal to this book, is about much more than an exercise in rationallogic. Te idea o sensemaking and mindulness come rom Pro. K. E. Weick and the title o this book

    Risk Makes Senseneeds to be understood in light o the specic denition o these terms. Tis is a book

    about the psychology o risk, learning, motivation, perception and possibilities. Learning should be the

    lens through which we view risk. Risk is not bad.

    Learning is how we should make sense o risk. In a growing risk averse society one could be orgiven

    or thinking that risk doesnt make sense. Te approach which seeks to manage what is uncertain with

    rationalist-only approaches tend to make poor sense o risk. When so much o human decision making

    is arational (non-rational) how does it make sense to respond with rationalist methods? Te rationalist

    approach to making sense o risk seeks sense in checklists, systems and regulation. When humans

    respond to lie arationally, the rationalist approach determines that risk doesnt make sense. Tis is

    evident in the continued banning o activities, over regulation o actions and the expanding industry in

    risk bureaucracy. When risk makes sense, rationalist approaches should decrease, not increase. Arationalhuman action requires arational human responses.

    One rationale or writing this book is to dispel simplistic understandings o human management o

    risk, what you might call, risk myths. What I term in the nal chapter o the book risk quackery. Te

    trouble with risk myths is that they are believed, made unquestionable but dont work. Tis book seeks

    to question these risk myths, open up debate and make the complexity o risk decision making more

    sensible and understandable.

    So how do people make sense o risk? Do people who take risks leading to accidents, lack common

    sense? Is it all just a matter o human error? What part does context play in how people take risks?

    Are humans hard wired in ways that trigger risk taking? Does risk taking change just because o the

    way we talk about it? Tese are some o the questions which are addressed in this book.

    Te book is structured in three parts. Te rst part is: What we Know about Risk, the second is: What

    we Know about Human Sensemaking and the third is, What we can do to Make Better Sense o Risk.

    We know a lot about the psychology o risk and human decision making, we have learned this rom

    understanding what happens to people with addictions. People who are attracted to cults, gambling and

    substance abuse tell us a great deal about human j udgment and risk. Some o the things we learn aboutrisk taking and uncertainty rom these activities, inorm the discussion in the book.

    Unortunately, whole industries have now built up around risk management, where even the slightest

    risk is now turned into a negative, with many organisations choosing the slogan o zero harm as their

    mantra. In some organisations it seems that the word risk has become associated and equated with the

    word evil. Te motto and language o zero is everywhere, sometimes spoken o in organisations like a

    religious undamentalist belie. Te cult o zero is so pervasive that to question it incurs the wrath o an

    inquisition. Te language o zero has become threaded into popular saety culture and industry without

    question. Te language and trajectory o zero doesnt make sense under the lens o learning, motivation

    and imagination. It is as i the very taking o a risk in some industries is equated with stupidity. It is as

    i risk doesnt make sense.

    Rather than resist risk or extinguish risk, we need to embrace it and better understand it rom a

    psychological and cultural perspective. Tis is a purpose o the book.

    I we learn something rom the discussion o this book it should be o practical value. Its not good

    enough just to learn about how people make risk trade os, how blindsidedness occurs or how

    complexity oods the senses, we must know what to do about these things. Whilst it is helpul to have

    tools or thinking about risk at work, when those thinking tools ood a persons capacity to think and,

    clutter their sensemaking, people retreat back to assumptions and guesswork. Whatever we do to make

    sense o risk, we must not urther ood people.

    When I was a boy the message at Sunday School was delivered like an insurance policy against

    the greatest risk or humans, damnation and hell. Te church tradition I was raised in could not

    understand why people would not take up this insurance policy. Indeed, other religions competed

    in variations to this story o risk and made dierent sense o it. How did this make sense?

    We can learn a lot about how people make sense o risk rom a study o undamentalisms. Ater all,

    how we make sense o risk is all about what we do with uncertainty.

    Te view o this book is not the view that comes rom legislators and regulators who invest so much

    in their work as guardians o the law. Te discussion o this book has its ocus on learning, psychology,

    culture, and how making sense o risk makes us truly human. Te discussion o the book should not be

    interpreted as a direct attack on regulators and legislators but rather an approach to get some balance

    into the debate o how people make sense o risk.

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    Chapter 9: A Reading List xvxiv Risk Makes Sense

    Te afrmation o one view, does not necessarily mean a total rejection o another. Te discussion

    o this book seeks to complement the regulatory-only view o risk. It is important to realise that

    sensemaking about risk extends beyond the bounds o regulation and legislation. Te realm o the

    unconscious and arational are also critical in making sense o risk. Te book argues that a regulation-

    only approach ails to ully make sense o risk. It is only when one includes and embraces the

    psychology and culture o risk in understanding, that risk can truly make sense.

    So, what is the response o this book to this malaise o banning, over regulation, ooding the

    sensibilities o people, risk elimination and the nonsense o zero? Te answer is not more paperwork

    but more eective conversations and dialogue that is tuned into the psychology and culture o risk.Tis is the direction o Chapter 8 Leadership and Conversations in Risk.

    Risk Makes Sense is a disposition that understands the psychology and culture o risk, and the

    counterintuitive nature o human decision making. As you read the book, the lter and ocus o

    learning should be applied to every topic; learning is the lens through which we can best make sense o

    risk.

    Rob Long

    Structure and Use of the Book

    Tis book is best thought o as a collection o short ideas ollowing chapter themes. Te rst three

    chapters (section one), deal with what we know about risk. Chapters our to six (section two) deal with

    what we know about humans and sensemaking. Chapters seven and eight (third section) deal with

    solutions and responses to issues discussed in the rst six chapters.

    Te book is not intended to ow in a cumulative argument like an academic piece but is rather

    intended or readers to sur like the Internet, jumping in and out o topics as required.

    Some sources and books are reerred to throughout the book more as a pointer or urther interest, than

    or academic validation. A complete reading list is at the end o the book or those who wish to delve

    urther into the topic.

    Te book can also be used as a workshop and training manual or programs in leadership and

    management in risk. Each chapter end has a section o suggested workshop questions which can be

    used by saety or security proessionals or as a ramework or a saety culture or security culture training

    programs with Dr Long and his team.

    For those who wish to read the book rom cover to cover, there are transitions at the conclusion o each

    chapter to help direct ow between chapters.

    Josh and I share the writing o this book which is most apparent in story reerences.

    In a world o growing risk aversion, one could be orgiven or thinking that risk doesnt make sense.

    Risk elimination thinking and behaviour sets a trajectory or a dumb down workplace culture.

    Te more eorts are made to engineer out the idiot, the more the system creates an unthinking

    workorce.

    A Newsletter in 2011 by the Health and Saety Executive (HSE) in the UK lists a number

    o things that have been banned. Dodgem cars, school sack races and kite ying, amongst the

    activities which have been banned. Some schools have banned kids playing on monkey bars

    and others have banned leather ootballs. A local council has instituted a $1000 penalty or kite

    ying on council ovals in case somebody might get hit. Even the Royal British Legion had to

    stop selling poppies with pins on Remembrance Day in case people might prick themselves.

    (Safety SnippetsEdition 22, September 2011)

    Te report above demonstrates just how absurd things have developed in our risk adverse society. Te

    reality is, there is no learning without risk. Risk is not bad. You cant live lie without a trade-o or

    risk. You cant learn without risk. We seem more than ever preoccupied with law suits than learning,

    more anxious about injury than adventure and, earul o harm rather than welcoming creativity. Te

    quest or certainty, absolute control and the elimination o doubt is a undamentalist pursuit.

    Te evolving language o risk elimination and cult-like xation with everything zero is a language

    which osters the development o an unthinking workorce. As risk aversion increases, so do the

    resulting management systems which accompany it. Tis results in ooding the worker so that they

    deault to gut instincts, personal micro-rules and risk quackery. Tis increases risk. Rather than resist

    risk or extinguish risk, we need to embrace it and better understand it rom a psychological and cultural

    perspective. Tis is a purpose o the book.

    Te answer to the challenges o risk is not more paperwork but more eective conversations and

    dialogue that is tuned into the psychology and culture o risk. When learning is the lens through which

    we view risk, risk makes sense.