The linked article in the OP is very short, an example might have been helpful.
My take on the article is it’s intended to create a shift in perceptive. The way it’s framed is not on that first link in the error chain but how to manage emerging risk.
From the article:
The most dangerous situations onboard are not always those where nobody sees the risk. They are often the situations where several people see it — yet no one fully assumes authority to decisively act on it.
It’s often the case framing incidents or events in more than one way can be useful.
Edit: The grounding of the Algoma Verity in the Delaware river is probably a good example where this framing would be useful. Both the captain and the pilot recognized the risk, the pilot said he was “running out of room” and the captain pointed out the ship was outside the channel but neither one of them took any action to rectify the situation.