All good points - I was working from the assumption that, since something like this happened in the first place, the odds are much, much higher that there’s less of an official framework around things and more of the “old boys club” like you mentioned, with oversight failures and spotty or nonexistent auditing.
Now, everything could be linked back to some bizarre special case scenario that nobody knew to look out for… But 99.999% of the time, it’s something predictable and preventable, so someone screwed up. Especially in something like this where a screwup is both massively expensive to fix and incredibly dangerous.