In the afternoon session, last Wednesday, at Plant Success' Inaugural PlantManagement Forum, AMEC Paragon's Risk Engineering Manager, Ian Sutton, gave an overview of PSM, and the things that PSM cannot deal with. He discussed what he called "the limits of safety improvements" and what to do about Black Swans. Black Swans are low probability but very high impact events. Sutton pointed out that Black Swan events all have three basic characteristics: they are a surprise, they do real damage and their causes aren't determined until afterward with 20-20 hindsight, after which the causes and solutions appear obvious. Sutton talked about what leadership means in the aftermath of such a worst case event. Good leadership gives us the ability to recover faster, better and implement new risk management strategies so that such an event will be planned for, and no longer be a Black Swan.