The take-home message from them:
Overall, he said, the safety measures that were in place did what they were designed to do.
"The cabinet did its job," he said. "It's proof that those safety measures work."
I would like to seen their after action investigation report.
Their engineering controls did appear to work. But-
"An ounce of prevention is worth a pound of cure."
I wonder about their administrative controls in place - especially their chemical storage and inventory program.
I might speculate a chemical storage issue: incompatibility and/or chemical expiration issue.
If this was the root cause, it would have been preventable.
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