> Kitchensoap rightly observes that "this event was very harmful" does not imply "this event was caused by extreme negligence".
What makes negligence extreme? Doing things you have specifically been warned against would be one thing, but there are others, including being oblivious to the magnitude of the risk when, with a little thought, it should have been clear.
The inverse of the above quote is equally valid: not-very-harmful outcomes do not imply that the negligence is not extreme, and it was all the days of operating without big problems that allowed the organization to be blind to the risk it was running, day in, day out.
OP wrote:
>> Clearly Knight thought [its controls] appropriate or they would have fixed it.
But the problem is that it did not think about it, in a meaningful way: it did not have an informed opinion. Every day in which nothing very bad happened contributed to the normalization of deviance. I am sure there were other days when things went wrong, but without the worst possible outcome, and they became just part of the way things are, instead of a wakeup call.
What makes negligence extreme? Doing things you have specifically been warned against would be one thing, but there are others, including being oblivious to the magnitude of the risk when, with a little thought, it should have been clear.
The inverse of the above quote is equally valid: not-very-harmful outcomes do not imply that the negligence is not extreme, and it was all the days of operating without big problems that allowed the organization to be blind to the risk it was running, day in, day out.
OP wrote: >> Clearly Knight thought [its controls] appropriate or they would have fixed it.
But the problem is that it did not think about it, in a meaningful way: it did not have an informed opinion. Every day in which nothing very bad happened contributed to the normalization of deviance. I am sure there were other days when things went wrong, but without the worst possible outcome, and they became just part of the way things are, instead of a wakeup call.