How can this happen over a thousand times without raising eyebrows? I can just imagine top managers noticing this and looking the other way to save their asses. Nobody wants to be the one who gets associated with such a scandal and ostracized for it. The fact that a documentation is often the only way to get heard is alarming.
It's enough to notice shortcomings and just not investigating further due to being perceived as complicated.
How can we build companies that incentivizes whistle-blowing the right(morally/legally correct?) way?