A picture is worth a thousand words:
https://upload.wikimedia.org/wikipedia/commons/8/8f/Systems_...
The institutional response to managing the risk of complex systems is often to introduce layers of approval and process that appear to be dealing with a problem ("this system can't fail, therefore please check with everyone involved in the system before making a change") but really have little real world value except driving everyone crazy and incurring enormous cost. They also shield individuals from real responsibility (how carefully do you review something you are the only approver on? What if there are 5 approves? What about 15?).
A better answer is to find ways to conduct real world tests with subsets of your system where you can roll back bad consequences. As far as I can tell This is the approach of google/Facebook and other newer tech companies with pushing small changes to subsets of customers for testing.
Legacy enterprise companies are woefully inequipped to do this for the most part, both technically and culturally.
Some industries have regulations that make this approach difficult (financial services) or human consequences to failure that make the cost of experimentation too high (medicine, airlines, etc)
Having worked in heavily bureaucratic organisations, I was reading the pdf as an allegory of the blame game and safety first heavily bureaucratic, process driven culture big orgs have, which do nothing to do actually reduce risk - rather it stifles people actually being able to, and wanting to, change anything.
Basically I came away with the opposite to what you said.