It's actually pretty astounding how many people this must have gone through before being rolled out to customers. I can only imagine the size of the departments at Boeing dealing with SQA, risk-management, engineering review, readiness reviews, compliance etc etc etc. It's not believable that no one in this chain of groups raised a red flag of concern re lack of redundancy and poor documentation/training (etc etc ad nauseum); the CEO is a figurehead compared to the myriad decision makers below him entrusted to do **** right.
This is probably going to result in indictments of engineers and managers and even developers deep into Boeing, not unlike engineers being arrested in the wake of VW's diesel affair. With hundreds of dead people Boeing's fuckup is unimaginably worse than that; heads will roll.
It's just really, really hard to understand how a company that has been doing aircraft for the better part of a century and big liners since the 1940s or 1950s could have screwed this up so badly. Although I happen to think that engineers these days are simply not as good as they were when Boeing drew up the 747 on paper drafting boards, there's a lot of "safety nets" (reviews, SQA, qualification, compliance etc) that had giant holes in them; apparently managers aren't as good as the "good old days" either.