Indeed, a good paper. Some aspect of points 7 and 11 were relavent in several unfortunate incidents I’ve been involved with.
Point 7 - ascribing a single root cause in some incidents is an impossibility. Too many variables, ie. several, and in some instances a dozen or more human elements over a protracted period of time are often contributory to an incident.
Point 11 - speaks to the control of costs involved in work and getting work done. After an incident occurs in the marine world, the practictioner (mariner in the hot seat after an incident) either truly made a mistake, or took a risk doing something with unintended consequences, or was the at the receiving end of pressure from someone to get something accomplished, also with unintended consequences. In any case, it’s the practitioner who’s usually held responsible for the incident.
I imagine every person with seagoing experience and reading this thread has witnessed the result of points 7 and 11 especially, and perhaps one or more of the other 16 points itemized in Dr. Cook’s paper.