have prevented the deaths. This is the real problem. Someone knew and tried to warn through the proper channels that there was a real risk. Yet nothing was done and people died as a result.

In any organization communication has to be clear, be heard, be acknowledged, and acted upon. Training and procedures must be set up so that every member of the group know how and when to act if a major threat is discovered.

These may be rare instances and governments may have done great in hundreds of others. But still these deaths will haunt them.