Very good piece. Explains why postmortems are important. It also explains how to prepare your organization to conduct them and how to do them properly. This is important since a lot of pressure will happen in case of a failure.

A bit heavy handed in the way it tries to paint Root Cause Analysis as evil. Still it has good points about its shortcomings. In particular I appreciate the emphasis on complexity which indeed points to have contributing factors and unexpected outcomes. Definitely things to keep in mind for any postmortem efforts.

If you want to get to the bottom of a problem and of why an accident happen, people need psychological safety. This is indeed necessary if you want them to share truthfully why the accident happened in the first place. Otherwise fear will drive the conversation and hide important facts.