[OnlyOneCannolo]

I'm re-reading what I wrote, but I still can't see how you inferred that implication.

I agree that a hazard analysis should have identified it. But whether it did or didn't, there are still many possible reasons why it wasn't addressed effectively. Hence, a systemic failure.

I have no idea if it's legal, but any punishment would probably be on the company rather than the individuals.

[DoingIsLearning]

I read it as if you were implying that identifying this was only attainable with very senior staff, which I disagree. But indeed perhaps I read too much into your comment.

[OnlyOneCannolo]

If anything, it's the opposite. Even if engineering advocates for doing more about the problem, it only takes one manager screw it up. Either everyone has to want an ethical product, or there have to be formal processes to make everyone do the right thing whether they want to or not. Ideally both.