These kinds of reviews can be helpful, but complex systems will tend to break in unexpected ways, even when all recommendations are followed. Didn't this organization experience a similar incident several years later, with some similar characteristics? At some point, you have to look at leadership and question what the common denominator might be.

Thankfully, in both cases, affected individuals were able to react to effect positive outcomes and mitigate potential disasters.

This reminded me about the actual house used in the movie. There is a decent article on it:

https://www.fancypantshomes.com/movie-homes/the-real-life-ho...