Let's say Amazon leadership is appalled at these conditions. Management by metric is working insofar as it goes, but you really didn't know how bad it was sever

Let's say Amazon leadership is appalled at these conditions. Management by metric is working insofar as it goes, but you really didn't know how bad it was several layers down. How would an organization identify something systemic like this? E.g., identifying that unexpected consequences had popped up and you'd created an environment where people were afraid even to speak up?