It seems like a none of the above situation because each of those should have really minimized the chances of something like this happening. But this is pure sp

It seems like a none of the above situation because each of those should have really minimized the chances of something like this happening. But this is pure speculation. Even the most perfect organization engineering culture can still have one thing get through... (Wasn't there some Linux incident a little back though?) Quality starts with good design, good people, etc. the process parts come much after that. I'd like to think that if you do this "right" then this sort of stuff simply can't happen. If we have organization/culture/engineering/process issues then we're likely not going to get an in-depth public most-mortem. I'd love to get one just for all of us to learn from it. Let's see. Given the cost/impact having something like the Challenger investigation with some smart uninvolved people would be good.