Lots of folks are commenting on the internal dynamics, but the other part that didn't resonate with me was actually the what happens next part. This may be an overreaction on my part, stemming from watching lots of engineers suggest expensive solutions to relatively minor issues. And it's a mistake I've made myself before as well, I started in telecom with very strict standards for availability, so it's hard to beat out of me the desire to look through the most minor alarm for a potential problem brewing or get to a root cause of the most minor incidents.

And maybe this is just a part that the article dodges, but for something described as non-catastrophic, I would suggest that there shouldn't be a presumption of changes. In my view there should be an assessment of the risk of re-occurrence, and if it was a near miss, what is the risk had it not been a near miss. And then even should changes be part of the outcomes, how expensive are those to implement compared to whatever the issue was, and if they're too expensive compared to the risk, don't put resources into it.