As I explained earlier, you can go through all the different decision points in the steps, and it is comprehensible to understand those decision points and when different decisions should have been made to correct the problem.
What's incomprehensible, as you said, is how nobody said that this was not going to work. How did nobody say that this needs to be delayed, that it needs to be stopped? Why was it that all of the checks and balances that had built up over the years, many probably coming out of Auditor General report recommendations to put more checks and balances in place, were not sufficient to be able to stop Phoenix?
To me, that is what is incomprehensible.