I see so many parallels to bad devops patterns I’ve seen. You build your incident response protocols around a metric alarm (bouy being released). However the alarm is noisy so people either ignore the alarm or suppress it (welding the bouy in place). And then when an actual accident occurs your response is ineffective.
Nothing can be actual human care and attention. Everything can break and no automated system made by careful people is exempt from needing that.
I'm reminded that late into development of a Pixar movie servers crashed, work was lost, and the automated back up system failed. The only thing which saved it was that an artist took a copy of the project home to work on it.