in general you don't know there is a problem until after the accident.
True statement when One does not look for a problem and ignores any report of a problem and relies upon established procedures and policies to be totally effective and compliant with all Rules and Regulations.
The reality is only through continuous examination and consideration of the way we do business can we be assured what we do and how we do it....is not subject to unrecognized potential failures.
Waiting for the Autopsy results is just waiting for proof positive we failed on the front end of the process and any changes we make after the fact ignores they should have been seen much earlier and acted upon.