Yeah it probably could've been caught. Major disasters are always this way, someone does something they shouldn't have, two people that should've checked were o

Yeah it probably could've been caught. Major disasters are always this way, someone does something they shouldn't have, two people that should've checked were on vacation and the third one was asleep, and a manager saying let's goooo because we're in a hurry and way behind! Come on, just skip the checklist this once, it'll be fine. It's always a perfect storm and it will always happen, we can just reduce the frequency with more and more safeguards. If something is so critical that people will die if it doesn't work, it needs backups and probably secondary backups, end of story. Hospitals that were brought down with this have no excuse.