Lots of good insight into systems thinking in this short paper, but I think the best part is this:
There are multiple contributors to accidents. Each of these is necessary insufficient in itself to create an accident. Only jointly are these causes sufficient to create an accident. [...] Thus, no isolation of the 'root cause' of an accident is possible. The evaluations based on such reasoning as 'root cause' do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.