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“How organizations deal with failures or accidents is particularly instructive. Pathological organizations look for a “throat to choke”: Investigations aim to find the person or persons “responsible” for the problem, and then punish or blame them. But in complex adaptive systems, accidents are almost never the fault of a single person who saw clearly what was going to happen and then ran toward it or failed to act to prevent it. Rather, accidents typically emerge from a complex interplay of contributing factors. [...] Thus, accident investigations that stop at “human error” are not just bad but dangerous. Human error should, instead, be the start of the investigation. Our goal should be to discover how we could improve information flow so that people have better or more timely information, or to find better tools to help prevent catastrophic failures following apparently mundane operations.” — Nicole Forsgren