> That means that somewhere there's a written policy defining where they should and shouldn't be doing these things, and that the policy wasn't strictly observed this time. They weren't just doing this randomly; they had procedures designed, ostensibly, to protect public safety, and the procedures weren't followed. A failure of leadership occurred at multiple levels, but, as is so common these days, nobody will be held accountable. It'll be given lip service and hand wringing, but ultimately nothing will be done.

Procedures are there to look nice in the book, what matters is culture of use. Because culture always wins with procedures.