This article offers more clarity on the CNSC role in the isotope fiasco. It shows that the CNSC had instilled a 'high friction' upward communication culture. That means 'everybody' knew about the bad pumps, but that it was difficult to bang on the closed doors of upper management. In other words, they couldn't have just communicated it, they would have needed to raise an alarm, and send all the headless chickens flying. No bureaucrat ever wants to do that! It was probably justified to fire Keen, as head bureaucrat.
We always had the same problem in the old company. Everybody would know about a problem, or an issue, but you couldn't get it up, and there were a lot of 'potential' issues! Every once in a while something would blow up and break down the doors of upper management. Then they always got mad that nobody told them about it in advance! They were still struggling with this when I left, mainly by trying to create a weighted 'threat' list. They also had a system where anybody could jot down issues, but this became quite mucky with ridiculousness.
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