Similar kind of thing has happened to the rail industry. Back in 1986 a train driver made a very serious error at Colwich in Staffordshire which resulted in two trains colliding and the driver of the other train being killed (these days he would have been lawyered up facing a manslaughter charge). back in 1986 he was not long afterwards at an inquiry explaining what had happened and why he made the fatal error. British Rail admitted responsibility within 24 hours .. within a few weeks a amendments had been made to the rulebook and changes in signalling introduced. Back in those days the emphasis was to find out what had happened as quickly as possible and to find a way to try to prevent it happening again. Leap forward to the late 1990s onwards and it would take months or even years to do what the old system had done within weeks.