That is one clusterfuck of mistakes listed in the article. I watched the video back then and wondered how that could happen, turns out it happened almost by design.
Almost reminds me of the Boeing crashes...too many engineering departments not talking to each other, no one really in charge of the overall. And generally no one sitting and thinking through what could go wrong.
I'm just a mechanic myself, but that kind of thing baffles me. Every job I do I always think through what could go wrong or how I could be wrong all along the way; with the equipment, with the diagnosis, with the procedure, with managing lifts and so forth - the whole thing.