"Armchair quarterbacking" is spot on.

The author asks for a deep, system-theoretic analysis... immediately after the incident. That's just not how reality works.

When the house is on fire, you put it out and write a quick "the wiring was bad" report so everyone calms down. You don't write a PhD thesis on electrical engineering standards within 24 hours. The deep feedback-loop analysis happens weeks later, usually internally.