An apparent screw up that would fall into the 'there, but for the grace of god...'
However, if my memory serves me correctly, it was a guy by the name of Max Surplice (not kidding) in charge of cost cutting that first came up with the great scheme of reducing manuals on aircraft to save money.
Bet he got a bonus for compromising an hitherto foolproof and successful system that had stood the test of time.