General Motors’ report on its ignition switch recall is an extensive and disturbing document on a corporate and engineering culture that failed. It’s also a chronicle of a management structure gone terribly wrong, which allowed the errors of a few people to have massive repercussions.

Though many are at fault, the original defective part, as well as perhaps the biggest contributing factor to delaying the problems discovery, came down to one former GM engineer, Raymond DeGiorgio.

DeGiorgio was originally in charge of the faulty ignition switch, according to the report. When he received switches that were well below the company’s specifications for the torque it took to shift the ignition key—meaning the key could be turned too easily, by jostling, for example—he asked the supplier to improve them. After hearing that this might cause more issues with already faulty electronics, he told the supplier not to make changes, and then approved a part he knew wasn’t up to snuff.

The problem was that he was able to approve this in 2002 without anyone signing off or showing a single other person the test results, according to the report. He was repeatedly asked about the performance of the switch after reports of cars stalling out, but never revealed it didn’t meet specifications, a fact that would have significantly helped the investigation.

In late 2005, DeGiorgio started working with the ignition switch supplier (Delphi Automotive) to put a stronger spring in the part, a change he had dismissed as impractical years earlier. On his own, he was able to order the part, which resolved the problem in subsequent models, without documenting the mechanical change or changing the part number. This confused investigators for years to come, because they couldn’t figure out why the airbags deployed in some cases, but not in others, with what appeared to be the same part.

“DeGiorgio states that he does not remember any of these events, including the discussions with Delphi about increasing torque, the use of a Catera spring he had previously worked on, or the authorization of the change,” according to the report.

But the rogue employee narrative doesn’t let GM off the hook. Over nearly a decade, the company didn’t investigate the problem urgently enough, and the probes missed easily available information. The years-long assumption that cars stalling when moving at high speed was a convenience issue, instead of a safety issue, allowed the problem to remain unresolved.

While safety was always emphasized as critical, these errors took place at a time when cost control was a constant mantra at GM. An engineer said cost control “permeates the fabric of the whole culture.”

There was an intense focus on avoiding delays and delivering on time. If a person responsible for a vehicle made a change that affected others, they were seen as responsible for the costs incurred on every other vehicle. And staff reductions put more pressure on engineers, including those in the position DeGiorgio held.

While there wasn’t an explicit tradeoff, it’s easy to see how such an environment might discourage someone from stepping up, admitting fault, and starting a costly recall process.

Employees interviewed for the report cited a resistance to speaking up out of fear of push-back. The culture emphasized deferring responsibility, instead of taking it on. A witness described a phenomenon called the “GM salute,” where one points outward towards others, indicating that the next person is at fault.

In an interview with investigators, CEO Mary Barra described the “GM nod” where everyone would agree on a plan of action, but never follow through. The result was that nothing moved quickly. In a speech to employees yesterday, Barra encouraged them to rapidly approach managers—or even her personally—with any issues they see going forward.

There were also clear problems with oversight. The report suggests that the company needs to change the fact that so many engineering decisions were poorly tracked, and that individual engineers could make decisions and changes that cost lives and caused injury without leaving evidence of the change.

Many of the best companies give employees significant autonomy. But autonomy only works when there’s accountability and transparency. It fails if there’s a culture of fear and of deflecting blame.