Article Summary – Causes of Disaster at Chernobyl: The Absence of Psychological Safety

(See below for the complete article)

In 1986, the nuclear power plant at Chernobyl in the Ukrainian SSR (the territory of modern Ukraine) suffered a catastrophic failure that directly killed 31 people and is estimated to have indirectly killed tens of thousands more. Whilst the plant itself possessed an inherently unsafe design, the wider culture in the Soviet Union at the time discouraged raising concerns or speaking up about mistakes. A fear of authority and the need to please political masters resulted in a fear- and compliance-driven culture. During a planned power shutdown, operators who were concerned about the safety of the process, including shutting off or ignoring safety systems, were not able to raise concerns. The test was executed and resulted in a steam explosion, followed by a nuclear meltdown. Combined with a lack of safety features such as concrete containment and water moderators, this resulted in a cloud of radiation that spread across Ukraine and Europe.

Organisational issues, including poorly designed equipment, flawed operating procedures and a systemic lack of a safety culture, were endemic to RBMK nuclear plants across the Soviet Union, not just Chernobyl. The hierarchical decision-making process further complicated the disaster response, delaying critical evacuation decisions due to fear of potential repercussions for decision-makers. The Soviet healthcare system, despite its egalitarian goals, was underprepared for a disaster of such magnitude, lacking both the expertise and the equipment to handle a public health crisis on this scale. Among the response crews, the hierarchical decision-making process stifled initiative, and suppressed information about the dangers of the degree of radiation emanating form the reactor. At the government level, a pervasive culture of secrecy and denial bred in part by a desire to preserve national pride obstructed the acceptance of external help, stalling recovery efforts and exacerbating the disaster’s effects.

Viktor Bryukhanov, Nikolai Fomin, and Anatoly Dyatlov ended up in jail for years after the event, despite doing their best in difficult technical, social, and political contexts, and suffering radiation poisoning as a result. This punishment only served to suppress further concerns and prolong the problem.

The Chernobyl Sarcophagus now. Photo by Mick De Paola on Unsplash

A lack of psychological safety, resulting in operators not speaking up about their concerns, was fundamental to the causal chain of events that led to the disaster. Had operators, decision-makers, and politicians felt safe and able to raise concerns and make decisions, the disaster may not have occurred, or had it occurred, the impact could have been mitigated. Of course, there is no root cause, but the official findings state that the RBMK-1000 reactor could *only* have been operated in an environment where there was no safety culture. The Chernobyl disaster underscores the importance of transparency and an open culture in both disaster response and prevention. It serves as a poignant reminder that a culture that values secrecy and punishment over learning from mistakes is more likely to experience catastrophic failures. 

The Chernobyl Disaster: how a lack of transparency and a culture of authority caused a disaster and inhibited learning.

The Chernobyl disaster occurred on April 26, 1986, at the No. 4 reactor of the Chernobyl Nuclear Power Plant, near Pripyat in the Ukrainian SSR. The plant operators wished to run a test to see whether, if the reactor was shut down in an emergency, the still-spinning turbines of the reactor would provide power to the operations of the plant itself whilst diesel generators powered up. The test had been conducted three times previously, but not successfully, and involved shutting down critical safety systems to simulate the conditions properly (IAEA, 1992). This time, the test was executed, but operators lost control of the reactor, which exploded and threw a cloud of radiation into the atmosphere that spread across Northern Europe.

Normal Accidents

Only two years before the Chernobyl disaster, Charles Perrow raised concerns that the world would suffer a significant nuclear power catastrophe due to the high complexity and tight coupling (dependencies) between components in nuclear reactors, which, when they fail, interact in unexpected ways and cause failure cascades that are hard for us to understand, especially under time pressure (Dekker, 2006). Perrow noted in his 1984 book “Normal Accidents: Living with High-Risk Technologies“: “unless we are very lucky, one or more [serious nuclear accidents] will appear within the next decade and breach containment” (Perrow, 1984). Perrow only needed to wait two years before his prediction came true. Subsequent disasters such as Fukushima also followed the Perrowian script of unpredictable complexity combined with tight coupling of systems.

Unsafe Design

The RBMK-1000 reactor at Chernobyl was inherently unsafe and lacked crucial safety features (Medvedev, 1990). The Soviet Union began their nuclear power programme in the 1970s, behind other developed nations, and were less concerned about significant accidents. They often did not build containment structures for reactors and rarely required emergency cooling systems (Perrow, 1984), and a “lack of human factors considerations at the design stage was one of the primary causes of the Chernobyl accident” (Meshkati, 1991). The RBMK reactors use graphite as a moderator instead of water: graphite allows for a much higher energy output and facilitates a less costly design, however, it is more likely to result in a runaway chain reaction: in water-moderated reactors, as water boils, it becomes less effective in facilitating the reaction, resulting in a feedback loop that keeps the reactor in check. Graphite will continue to facilitate the reaction even as temperatures increase out of control. To stop the reaction in case of emergency, control rods made of boron carbide could be lowered into the reactor. Boron carbide absorbs neutrons, slowing the reaction. The more control rods that are lowered, the greater the effect. However, the control rods in the RBMK reactor at Chernobyl also possessed graphite tips, and when they were lowered into the reactor to slow it down, they jammed, which not only prevented the boron from slowing the reaction, but actually increased the energy of the reactor further due to the extra graphite present (World Nuclear Association, 2009). The operators then activated the cooling system which added water into the reactor. An explosion resulted from the water instantly evaporating in the heat of the reactor, which lifted the concrete roof and exposed the reactor core, as well as hurling pieces of super-heated and highly radioactive material around the area.

Authoritarianism and a Lack of Transparency 

The Soviet authorities initially hid the disaster. It was indicated only after radiation levels were detected at Forsmark, Sweden’s second largest nuclear power plant, when a worker passed through a radiation check that showed high radiation levels on their shoes. There was initial concern that an accident had taken place at Fosmark, but further investigation showed the source was within the Soviet Union. (Hohenemser, 1986). The secrecy surrounding the disaster and the initial attempts to downplay its severity further hindered response and disaster mitigation efforts.

Human Error and Blame

The political climate in the Soviet Union played a significant role in the ill-preparedness for the Chernobyl disaster. The authoritarian structure of the Soviet government and communist party hierarchy fostered a culture of fear, compliance, and punishment for mistakes that ranged from being expelled from the (communist) party to being imprisoned. This environment discouraged open discussion of problems and hindered the development of a robust safety culture (Josephson, 1991). The disaster was later blamed on human error, with the government focusing on the power plant operators’ violations of procedures and regulations, rather than acknowledging underlying systemic issues. This root cause of “human error” was shown to be due to poor knowledge of nuclear reactor physics and engineering, as well as lack of experience and training. The hunt for the single root cause was complete – as far as Soviet authorities were concerned, individuals were to blame and the case could be closed. Rather than human error being the start of investigations, in the Soviet Union, it was often the end of investigations (​​Reilly, 2019). Particularly in cultures of blame, but in reality all environments to greater or lesser degrees, people will hedge, qualify, weaken or soften their language about concerns and mistakes, for fear of punishment, embarrassment or humiliation (Dekker, 2011). “Being blamed in the context of a safety investigation is contrary to the purpose of a safety investigation, partly because it is deathly for an occurrence reporting system, and for any subsequent investigations and learning” (Shorrock, 2016). In this way, we can see that rather than achieving justice and reducing mistakes, blame cultures actually increase the likelihood of mistakes and further, even worse, disasters in the future. 

Political and Financial Pressure

The Soviet Union was under a great deal of economic pressure. Sanctions by the West and chronic under-production meant that the economy was faltering. Cheap energy from nuclear power was seen to be one of the drivers of a successful Soviet economy, but scarce resources and corruption at levels of government put pressure on the builders of nuclear power stations to cut corners in order to achieve deadlines and make do with substandard building materials (Plokhy, 2018). The Soviet Union’s economic plans prioritised the rapid expansion of nuclear power to meet energy demands, often at the expense of safety. This myopic short-termism was characteristic of a preference for short-term benefits over long-term risks, leading people to prioritise immediate needs and ignore potential future disasters (Meyer & Kunreuther, 2017). 

Failure to Learn

The Chernobyl disaster wasn’t even the first serious nuclear power disaster in the Soviet Union. The Soviet authorities covered up the Kyshtym disaster which occurred on September 29, 1957, at the Mayak nuclear fuel reprocessing plant, near the city of Chelyabinsk. It’s considered one of the worst nuclear accidents in history, ranking as a Level 6 event on the International Nuclear Event Scale (INES) (Akleyev et al, 2017). More than 10,000 square kilometres of land, affecting tens of thousands of people, were contaminated, and resulted in many radiation-related illnesses and cancers in people nearby. The secrecy surrounding the Kyshtym disaster and other incidents prevented open discussion, analysis, and learning from past mistakes (Brown, 2013), which contributed to the failure to adequately prepare for the Chernobyl disaster. Indeed, the 1986 Chernobyl disaster wasn’t even the first serious incident at the Chernobyl plant. On September 9, 1982, during preparations for a scheduled reactor shutdown, one of the channels ruptured and released radiation into the reactor compartment. The KGB chief of Kyiv city and region, N. K.Vakulenko, reported no cause for concern and stated the repairs would take five days (Povidomlennya, 1982). A month later, a secret report noted that vegetation and topsoil in an area up to 14 kilometres around the station had been contaminated, polluting rivers and lakes that were used for fishing by the locals (Marples, 2004). Past incidents provide one of the best, if not the best, way to prepare for subsequent disasters, but only if we can be honest and transparent about what happened, what we did and why we did it.

Saving Face

Culturally, the Soviet authorities were keen to avoid any implication that Soviet engineering was of a lower standard than in the West. A great deal of national and party pride was at stake, and Soviet press at times suggested that agents of the West had intentionally caused the disaster itself through sabotage (Plokhy, 2018). This animosity and fear of the West not only fostered further secrecy but caused reluctance to accept external assistance, fearing that accepting help would be perceived as a sign of weakness, which further exacerbated the situation, prolonging the disaster’s effects and hindering the disaster recovery process. 

Organisational Culture

Organisationally, problems with equipment, operating procedures, and the safety regime at Chernobyl were far from isolated occurrences, but rather were endemic (Marples, 2004). Cultures of production, where problem solving and heroics are valued, structural secrecy where information does not cross boundaries and silos, and a gradually increasing acceptance of risk contributed significantly to disasters such as the Challenger shuttle of the same year, and Chernobyl itself (Vaughan, 1996). These organisational factors not only made a disaster more likely, and the operators of the plant less able to prepare for such an incident, but meant that the response and recovery operations were hampered and made less safe for personnel. The 1992 IAEA report of the findings into the disaster referred to poor practices and procedures, communication, levels of trust, and lack of regulatory enforcement at nuclear plants across the Soviet Union, not just Chernobyl (INSAG, 1991). INSAG coined the term’ safety culture’ to refer to the safety regime that should prevail at every nuclear plant, not just Chernobyl (Dieterich et al, 2016). The lack of disaster preparation, technical expertise and understanding of radiation incidents within the organisation also contributed to ineffective and sometimes counterproductive response strategies such as dropping 5,000 tonnes of sand, lead, boron and dolomite onto the reactor in an effort to mitigate the radioactive fallout, but in fact resulted in a serious concern that it could cause a greater explosion as well as cause the floor of the reactor to fail, and allow the reactor contents to contaminate groundwater (Potter and Kerner, 1991).

Hierarchy and Disaster Response 

When it came to disaster response, bureaucratic processes and the hierarchical nature of decision-making within the Soviet system hampered the response efforts. Bosses, instead of making decisions to evacuate local towns and villages, delegated the decision up the chain of command, for fear of making the wrong decision and being punished for it (Plokhy, 2018). Tests within hours of the incident showed that at the current level of radioactivity, the intake for citizens of Prypiat might be around 4.5 roentgens per day. Yevgenii Vorobev, a senior medical officer, was reluctant to order an evacuation, preferring to delay the decision, and it was only on April 27, at 1pm (more than 34 hours after the explosion) that the evacuation of Prypiat was ordered (Plokhy, 2018b). Residents were given less than 90 minutes to pack belongings, and radiation levels were reaching 600 milliroentgens per hour – equivalent to a full body CT scan every hour (US EPA, 2019). This slow response resulted in higher than necessary exposure to radiation, which for some groups of people, and especially children, was high enough to cause both short term functional thyroid changes and thyroid cancer in some individuals (IAEA, 2006).

Disaster Preparedness

The Soviet healthcare system was also unprepared for such an incident. Whilst the Soviet Union prided itself on its success in making health care available for all as a free public

Service (Tulchinsky and Varavikova, 1996), hospitals across most of the country lacked both the expertise and equipment to treat acute radiation sickness, and neither were there effective protocols in place to deal with a nuclear power public health incident (WHO, 2005).

Chernobyl director Viktor Bryukhanov, chief engineer Nikolai Fomin and his deputy, Anatoly Dyatlov were sentenced to 10 years in Soviet jail, after being imprisoned just six weeks after the incident (Bohlen, 1987). In fact, all three acted reasonably given the pressures they were under, their knowledge, understanding of the situation and available focus of attention, particularly given the Soviet culture (Verplanken, 1991). If we punish making mistakes, such as jailing the operators of a nuclear plant that was inherently unsafe, we don’t end up with fewer mistakes: we simply end up not hearing about them until they’re too big to hide. Just as increasing aircraft technical reliability did not lead to a decline in the number of accidents (Hagen 2013), relying solely on technical solutions to preparedness only increases the complexity threat humans must deal with, and increases the risk of failure through complexity and coupling (Perrow, 1984). In reality, we must address the human factor. It is only humans that can adequately prepare and respond to disasters. 

The International Community

Fortunately, lessons were learned from Chernobyl: the Chernobyl accident stimulated national authorities and experts to a radical review of their understanding of, and attitude to radiation protection and nuclear emergency issues (NEA, 2020). It also catalysed the acknowledgement of the international community that nuclear power concerns cannot be delegated away to the country where the plant resides. A nuclear power disaster anywhere in the world could affect everyone in the world.

A direct institutional response to this recognition was the formation of the World Association of Nuclear Operators (WANO) in 1989, three years after Chernobyl. Founded at an inaugural meeting in Moscow, jointly hosted by the UK’s Central Electricity Generating Board and the USSR’s Minister of Atomic Energy, WANO brought together around 140 delegates from 29 countries. Its mission is to maximise the safety and reliability of nuclear power plants worldwide through mutual support, the exchange of operating experience, and the sharing of best practices. Critically, this includes a Performance Analysis programme whose success depends on members’ willingness to share data and experience openly: precisely the kind of transparency that was so catastrophically absent in the Soviet system. Peer Reviews became a member obligation in 2006, with every commercial nuclear power plant in the world having received at least one by 2010 (International Atomic Energy Agency, 2017). WANO represents a structural attempt to institutionalise what no individual organisation can manufacture alone: a culture of openness across an entire industry.

Learning from other domains

In order to prepare, prevent, and respond to similar nuclear power risks in the future, nuclear power could learn a lot from the aviation industry, who, in response to many high-profile disasters in the 1970s and 1980s, jointly and globally adopted practices under the umbrella term Crew Resource Management (CRM) (Geraghty, 2023). CRM encourages crew to speak up and foster environments where speaking up, even questioning orders in the military (Hagen, 2013) is rewarded, not punished. Part of the CRM approach includes blameless and anonymous incident reporting systems such as ASRS in the US and CHIRP in the UK, which are not used to punish or reprimand people but to improve training, documentation, processes and technology. Currently, the nuclear power equivalent, the International Reporting System for Operating Experience (IRS) (an international system jointly managed by the IAEA and the Nuclear Energy Agency of the OECD) only allows “authorised” users to submit reports – unlike ASRS or CHIRP which allow anyone to report issues. 

Incident reporting and learning is only part of the solution, however. Given that nuclear power plants are driven and influenced by political, economic, environmental and organisational forces, we should endeavour to reduce the influence of those outside forces when they can impact on safety, through organisational and pan-industry culture and practice. Given that we cannot completely isolate ourselves from those broader political and sociocultural forces, we should remember that where there are cultures of secrecy, punishment for mistakes, and fear of speaking up, we will never be able to fully prepare, or effectively respond, to disasters.

Conclusion

Secrecy inhibits disaster preparedness, response and recovery. Through being honest and transparent, we can respond rapidly and appropriately to the disaster occurring and better prevent and prepare for similar disasters happening in the future. Covering disasters in a shroud of secrecy and punishment for mistakes robs us of both these opportunities to mitigate the impact of a disaster and prevention of future disasters. It’s no surprise that two of the world’s worst nuclear power disasters occurred in cultures of secrecy and punishment for mistakes. 

Note: throughout this article the Ukrainian city of Chornobyl is referred to using the Russian spelling of Chernobyl, as it was known at the time. 

References:

Akleyev, A., Krestinina, L., Degteva, M., & Tolstykh, E. (2017). Consequences of the radiation accident at the Mayak production association in 1957 (the’ Kyshtym Accident’). Journal Of Radiological Protection, 37(3), R19-R42. doi: 10.1088/1361-6498/aa7f8d

Brown, K. 2013. Plutopia. Nuclear Families, Atomic Cities, and the Great Soviet and American Plutonium Disasters. Oxford: Oxford University Press

Dekker, S. 2006. The Field Guide to Understanding Human Error. Ashgate Publishing Company, USA.

Dekker, S. 2011. Drift into Failure. Farnham, Surrey: Ashgate.

Dieterich, S., Ford, E., Pavord, D. and Zeng, J., 2016. Quality and safety improvement in radiation oncology. Practical Radiation Oncology Physics, pp.165-178.

Geraghty, T, 2023. Psychological Safety in Aviation. Psychsafety.co.uk. Available at https://psychsafety.com/psychological-safety-aviation/ Accessed April 7 2023.

Hagen, Jan U. 2013 “Confronting Mistakes”.. Palgrave Macmillan UK, doi:10.1057/9781137276186. 

Hohenemser, C., Deicher, M., Ernst, A., Hofsäss, H., Lindner, G. and Recknagel, E., 1986. Chernobyl: an early report. Environment: Science and Policy for Sustainable Development, 28(5), pp.6-43.

IAEA. 1992. “INSAG-7: The Chernobyl Accident: Updating of INSAG-1” (PDF). Archived (PDF) from the original on October 20 2018. Retrieved November 8 2018.

INTERNATIONAL ATOMIC ENERGY AGENCY (2006) , Environmental Consequences of the Chernobyl Accident and their Remediation: Twenty Years of Experience, Radiological Assessment Reports Series No. 8, IAEA, Vienna 

International Atomic Energy Agency (2017) IAEA and WANO strengthen cooperation to increase nuclear safety, IAEA. Available at: https://www.iaea.org/newscenter/news/iaea-and-wano-strengthen-cooperation-to-increase-nuclear-safety

INTERNATIONAL NUCLEAR SAFETY ADVISORY GROUP, 1991, Safety Culture, Safety Series No. 75-INSAG-4, IAEA, Vienna.

Josephson, P. (1991) “Atomic Culture in the USSR: Before and After Chernobyl”, Soviet Social Problems, pp. 57-77. doi: 10.4324/9780429307140-5.

Marples, D.R., 2004. Chernobyl: a reassessment. Eurasian Geography and Economics, 45(8), pp.588-607.

Medvedev, Z A. 1990. “The legacy of Chernobyl”. United States.

Meshkati, N. (1991). Human factors in large-scale technological systems’ accidents: Three Mile Island, Bhopal, Chernobyl. Industrial Crisis Quarterly, 5(2), 133-154.

Meyer, R., & Kunreuther, H. (2017). The Ostrich Paradox: Why We Underprepare for Disasters. Wharton School Press. https://doi.org/10.2307/j.ctv2hdrfz6

NEA, 2020. Chernobyl: Chapter IX. Lessons learnt. Available at: https://www.oecd-nea.org/jcms/pl_28391/chernobyl-chapter-ix-lessons-learnt (Accessed: April 7 2023).

PERROW, C. (1984). Normal Accidents: Living with High Risk Technologies 

Shorrock, S. (2016) Just Culture: Who Are We Really Afraid Of?, Humanistic Systems. Available at: https://humanisticsystems.com/2016/11/24/just-culture-who-are-we-really-afraid-of/ (Accessed: March 28 2023).

Plokhy, S. (2018). Chernobyl: The History of a Nuclear Catastrophe. Basic Books.

Plokhy, S. (2018b): The Chernobyl Cover-Up: How Officials Botched Evacuating an Irradiated City. History Reads. Available at: https://www.history.com/news/chernobyl-disaster-coverup (Accessed April 3, 2023)

Povidomlennya UKDB URSR po m. Kyievu ta Kyivs’kii oblasti do Druhoho Holovnoho upravlinnyaKDB SRSR ta 2-ho Upravlinnya KDB URSR pro avariinu zupynku 9 veresnya 1982 r. ener-gobloka No. 1 Chornobyl’s’koi AES (Information of the Ukrainian KGB for the city of Kyiv andKyiv Oblast to the Second Chief Department of the KGB USSR about the Accident Hold-Up of9 September 1982 at the First Reactor Unit of the Chornobyl Nuclear Power Station),” September 10, 1982, DA SBU, F.65, Spr. 1, T.5, Ark. 164.

Reilly, B. (2019) Failure—Is It A Matter Of When? – Barry O’Reilly Chernobyl Case Study, Barry O’Reilly. Available at: https://barryoreilly.com/explore/blog/failure-is-it-a-matter-of-when/ (Accessed: March 27 2023).

Tulchinsky, T.H. and Varavikova, E.A., 1996. Addressing the epidemiologic transition in the former Soviet Union: strategies for health system and public health reform in Russia. American Journal of Public Health, 86(3), pp.313-320.

US EPA, 2019, “How Much Radiation Am I Exposed To When I Get A Medical X-Ray Procedure? | US EPA: https://www.epa.gov/radiation/how-much-radiation-am-i-exposed-when-i-get-medical-x-ray-procedure. Accessed April 3 2023.

Vaughan, D., 1996. The Challenger launch decision: Risky technology, culture, and deviance at NASA. University of Chicago press.

Verplanken, B., 1991. Public reactions to the Chernobyl accident: a case of rationality?. Industrial crisis quarterly, 5(4), pp.253-269.

William Potter & Lucy Kerner, 1991. “The Soviet military’s performance at Chernobyl,” Europe-Asia Studies, Taylor & Francis Journals, vol. 43(6), pages 1027-1047.

World Health Organization, 2005. Chernobyl: The true scale of the accident. 20 years later a UN report provides definitive answers and ways to repair lives. Available at: https://www.who.int/news/item/05-09-2005-chernobyl-the-true-scale-of-the-accident. Accessed April 7 2023.

World Association of Nuclear Operators (WANO) (no date) Leading Nuclear Excellence. Available at: https://www.wano.info

World Nuclear Association, 2009. Sequence of Events: Chernobyl Accident Appendix 1. Retrieved May, 10, p.2012.

Psychological Safety at Work

This week, I’ve been reading the UK Civil Aviation Authority’s Flight-crew human factors handbook, because that’s the sort of thing I like to read 😀 There’s so much great stuff in there, largely applicable, of course, to aviation, but generalisable across many contexts. One part that jumped out was this table of the relative impact of various life events on stress. Interestingly, a vacation scores higher than a minor law violation!

Here’s a great little article by Tim McMahon about a Ted Talk video by Astro Teller, of X (used to be Google X), the “moonshot factory” inside Alphabet. Featured in Amy Edmondson’s “The Fearless Organisation”, Teller describes how in order to succeed at something big, you conversely have to make it very safe to (intelligently) fail. I like Tim’s breakdown of Astro’s key points:

• Run at the most challenging parts of the problem at hand first. Failures will often lead you to the path of success.
• Shift your perspective. Sometimes shifting your perspective is more powerful than being smart or right.
• Encourage the path of least resistance. Make it a safe space to fail and reward and celebrate failures. This can come in the form of hugs, high-fives, applause, promotions, or even bonuses.

Thanks to Tony Joyce for the tip.

This is also relevant to making failing safe: Tolerated failure implants learning better than success, by Chris Bolton, talking about “tolerated failure”, a term he first heard from Dave Snowden. Chris summarises his points:

1. Tolerated failure is an important part of what we do to learn as we grow up. However, within the world of work it is less common and failure (in whatever disguise) is something to be avoided.
2. Training activities that deliberately design in, failure ‘opportunities’, can help to develop the recognition and acceptance of tolerated failure.
3. Likewise business case options appraisals. Options appraisals should include details of the prototypes or tests that were tried and failed, and what was learned. This should give the end product a chance of surviving in the wild.

I love this piece by Gail Markin, “Create Safer Spaces instead of Brave Spaces”, about collective action to foster psychological safety over individual responsibility to speak up. “It will never be equally safe for all, but it can and should be a safer space.  A brave space, yes, but that puts the responsibility on the individual and it is also a collective and systemic responsibility.  It is actually more the latter two, or there is damage done to the brave.  Courage is noble but equal courage does not produce equal results and therefore was never equal to begin with.”

And this is a fab piece by Rita McGrath that dives into how to manage in uncertain and complex contexts, intelligent failures and experimentation: “Stop the blame game. Design experiments that reflect real life. Stop imposing the expectation of meeting plans on people doing things in unpredictable environments. Recognize that failure maybe needs to be re-defined.“

This week’s poem:

The Sea, by Pablo Neruda

I need the sea because it teaches me.
I don’t know if I learn music or awareness,
if it’s a single wave or its vast existence,
or only its harsh voice or its shining
suggestion of fishes and ships.
The fact is that until I fall asleep,
in some magnetic way I move in
the university of the waves.

It’s not simply the shells crunched
as if some shivering planet
were giving signs of its gradual death;
no, I reconstruct the day out of a fragment,
the stalactite from the sliver of salt,
and the great god out of a spoonful.

What it taught me before, I keep. It’s air
ceaseless wind, water and sand.

It seems a small thing for a young person,
to have come here to live with his own fire;
nevertheless, the pulse that rose
and fell in its abyss,
the crackling of the blue cold,
the gradual wearing away of the star,
the soft unfolding of the wave
squandering snow with its foam,
the quiet power out there, sure
as a stone shrine in the depths,
replaced my world in which were growing
stubborn sorrow, gathering oblivion,
and my life changed suddenly:
as I became part of its pure movement.