“We make our system of work safer by creating fast, frequent, high quality information flow throughout our value stream and our organization, which includes feedback and feedforward loops. This allows us to detect and remediate problems while they are smaller, cheaper, and easier to fix; avert problems before they cause catastrophe; and create organizational learning that we integrate into future work. When failures and accidents occur, we treat them as opportunities for learning, as opposed to a cause for punishment and blame.”