According to an internal investigation this problem was an accident waiting to happen (forgive the pun) and completely avoidable. Bureaucratic inertia and territory protection (i.e. CYA) seem to have been at the forefront.
In her message to employees (FOUND HERE) about the results of an internal report she said the following:
"So if you are aware of a potential problem affecting safety or quality and you don't speak up, you are a part of the problem. And that is not acceptable. If you see a problem that you don't believe is being handled properly, bring it to the attention of your supervisor. If you still don't believe it's being handled properly, contact me directly."Odd a CEO telling rank and file employees to contact them directly with an issue. Unprecedented, right?
No. In a terrific book I read a year or two ago "The Power of Habit: Why We Do What We Do in Life and Business" by Charles Durhigg tells the story of former US Treasury Security Paul O'neil who became an unlikely CEO of the steel conglomerate ALCOA.