This was not an edge case, it was a swiss cheese failure that was just waiting to happen.

In a tech company this would correctly be thought of as a systemic failure as opposed to a personal one.

There are so many questionable design choices here for a system that is supposed to be used in high-stress situations. A lot of it reads as someone thinking "ooh yeah it would be cool if it did X" instead of "what's the simplest and dumbest possible way to do this".