The hours of often conflicting testimony and remorseless cross-examination had dispelled any lingering notion that the accident had been caused by an inexplicable technical failure—revealing instead a pattern of mismanagement and miscommunication at the highest levels of the agency. An organization that had, since its inception, boasted of its ability to manage extraordinary risk on the frontiers of technology and learn from its mistakes had instead overlooked a litany of clear warnings; the signals lost in the noise of a complacent can-do culture bred by repeatedly achieving the apparently
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