Airsound et al,
If you want to read more about this kind of thing, may I also commend Nancy Leveson's book "SAFEWARE: SYSTEM SAFETY AND COMPUTERS" or look at her website
http://sunnyday.mit.edu/
and from the papers section
http://sunnyday.mit.edu/papers.html#org:
Technical and Managerial Factors in the NASA Challenger and Columbia Losses: Looking Forward to the Future by Nancy Leveson, in Handelsman and Kleinman (editors), Controveries in Science and Technology (to appear) , University of Wisconsin Press, 2007. (DOC )
This essay examines the technical and organizational factors leading to the Challenger and Columbia accidents and what we can learn from them. While accidents are often described in terms of a chain of directly related events leading to a loss, examining this event chain does not explain why the events themselves occurred. In fact, accidents are better conceived as complex processes involving indirect and non-linear interactions among people, societal and organizational structures, engineering activities, and physical system components. They are rarely the result of a chance occurrence of random events, but usually result from the migration of a system (organization) toward a state of high risk where almost any deviation will result in a loss. Understanding enough about the Challenger and Columbia accidents to prevent future ones, therefore, requires not only determining what was wrong at the time of the losses, but also why the high standards of the Apollo program deteriorated over time and allowed the conditions cited by the Rogers Commission as the root causes of the Challenger loss and why the fixes instituted after Challenger became ineffective over time, i.e., why the manned space program has a tendency to migrate to states of such high risk and poor decision-making processes that an accident becomes almost inevitable.
NEW:
What System Safety Engineering can Learn from the Columbia Accident by Nancy Leveson and Joel Cutcher-Gershenfeld, Int. Conference of the System Safety Society, Providence Rhode Island, August 2004. (PDF )
Many of the dysfunctionalities in the system safety program at NASA contributing to the Columbia accident can be seen in other groups and industries. This paper summarizes some of the lessons we can all learn from this tragedy. While there were many factors involved in the loss of the Columbia Space Shuttle, this paper concentrates on the role of system safety engineering and what can be learned about effective (and ineffective) safety efforts.
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