There’s an implicit assumption behind these questions that because there was a bad outcome, that there must have been a bad action (or an absence of a good action) that led to that outcome. Instead, the idea that systems fail because somebody did something wrong (or didn’t do something right) is more like a lens or a frame, it’s a perspective, a way of making sense of the incident. An alternative lens for making sense of an incident is to ask the question “how did this incident happen, assuming that everybody did everything right?”