Traditional accident models assume every failure traces back to a broken part. STAMP treats safety as a control problem instead, which explains disasters where every component worked as designed.

Distributed causation means complex failures have many causes spread across time, systems, and organizational boundaries. Fixing just one leaves the rest in place.

Resilience Engineering is the framework for building systems that hold up when the unexpected is inevitable. Redundancy and rigorous testing still leave room for your system to fail anyway.

A just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees.