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No team is going to prevent issues like this 100% of the time. That's a wildly unrealistic expectation.

Wherever the bar is, it won't be 100%. That's why good leadership invests in the ability to respond well to mistakes that will inevitably be made.

Still. These incidents should be so rare, that when they occur, it is more likely to be leadership failure than a series of unfortunate events.

This replacing the leadership is always the right response.