I've skimmed it, looks like a guide on leading a blameless postmortem of an event (ie. an accident). That is, a postmortem where the goal is to figure out how the systems in place allowed people to make the mistakes that caused the problem, instead of placing blame on people who (may or may not have) made the mistakes that led to the problem.
I also basically skimmed it, agree they don't focus on finding fault/placing blame. Also there was emphasis on understanding why people did what they did -- not why they didn't do something they didn't do.
It's policy document regarding the company's Standard Operating Procedures for conducting post-mortems on "incidents," which is technical parlance for investigating SNAFU's, major and minor, and assigning blame if appropriate or necessary.
Involving hundreds of employees in the handling of millions of credit card transactions, regardless of however trivial the goods may seem, requires caution.
