The failures were identified after many people got sick and there was no choice but to start an "RCA."

I would remind you that these "failures" were not some black swan level of event that we can't foresee, it was plain and direct negligence.

The rotten mean was literally, and I mean quite literally, piling up.

You are being EXTREMELY outright dishonest in your perspectives here. I don't say this lightly, there is no possibility of reconciling your statements and the facts of the case.