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Kinda low-hanging fruit, but someone's gotta pick it.
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Pretty much when an engineering thing goes wrong. It was because of managers and bureaucracy. It happened with NASA's Challenger mission and this one is probably another incident like it. The engineers are the most technical, precise, accurate people ever. It is very rare that something catastrophic will go buy unnoticed.
https://www.spacesafetymagazine.com/space-disasters/challenger-disaster/challenger-management-failure/