The Commission concluded that this crisis was avoidable—the result of human actions, inactions, and misjudgments. Warnings were ignored. “The greatest tragedy would be to accept the refrain that no one could have seen this coming and thus nothing could have been done. If we accept this notion, it will happen again.”

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Documents and emails, audio recordings and transcripts of interviews, reports and fact sheets developed by the staff, and graphic illustrations created by the Commission throughout its investigation.

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