Seconded. People burned alive until we learned. Surely there is a middle ground that will let us speed up while staying fairly safe, but it's important to remember that outside of software, many rules are written in blood.
I don’t hold a strong opinion either way - in terms of process and documentation versus freestyling it - but that fire was predicted, and I think the concerns were documented.
It can and did happen again, twice, on the shuttle project. Both the O rings and the ice damage were documented.
Ultimately, any process (or lack of process) can be subverted by a bad culture. And unreasonably excessive process - as perceived by the participants - can damage culture as much as not enough.
The problem is that culture is ineffable, so we try to nail it to the ground with whatever we can think of.
