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.

A good reminder about the impacts of Goodhart's law, or even simply of measuring the wrong thing. I like the conclusion overall: it's fine to measure things but that shouldn't be the center of the decision taking and conversations need to take a larger role into it.

Definitely a good list of places I'd love to visit and get lost into.

In our industry, we obsess too much over individual performance. In turn it means that the systems we put in place within or around our teams get neglected... this is a problem because it is what has the biggest impact on quality and performance.

Good points to keep in mind regarding team size. It's a delicate balance to strike in an organization.