So the reporting of the incident is here:
And the actual prevention of future deaths report is here:
I’m a little surprised this isn’t more well known about, as it’s a good case study as to why we have the systems we do.
So the reporting of the incident is here:
And the actual prevention of future deaths report is here:
I’m a little surprised this isn’t more well known about, as it’s a good case study as to why we have the systems we do.