I wonder what the person or persons involved in making or forcing decisions such as this, where the ultimate "unintended consequence" is so catastrophic, think and or feel when death is the result.
Yeah, That is an issue engineers at all levels need to deal with. The decision to go totally ozone friendly was made at a very high level with the expectation that lower level materials and process people would check and verify that all the changed issues were OK. The problem is that the lower level engineers were resigned to the change, knowing that high management had endorsed it and so the tendency was to bulk copy a new spec in place of an old one. I.E. where it used to say clean with MEK it now reads clean with ethanol. This was done with manhy processess, in fact there were lists where you could look up the substitute process that was intended to replace the other process. So no one really had the responsibility at any level. I was not on the shuttle program to know whether additional critical tests were performed, I suspect they were because of the man rating, but the obvious result was that they moved to allow more debris rather than rethink the foam process.
On the program that I was on, a resin error was cleaned up with alcohol and the clean up was good to the naked eye but not good at a microscopic level. This problem cost us a test missile flight, because of the thin layer of goo on electric contacts.