I think it&#x27;s extremely misguided to assume that the problem here was a matter of writing style.  I think it&#x27;s naive to assume that the people who received this memo weren&#x27;t aware that it was bringing attention to an engineering issue that could lead to loss of human life.  I think it&#x27;s misguided and not supported by the evidence to assume that was the gap in understanding that lead to the problem.  They&#x27;re working on rockets.  People working on rockets know what the stakes are.  These are the risks engineering projects like this are structured around dealing with.<p>And I think it&#x27;s pretty disrespectful to the engineer who is still haunted by this to say that what he really should have done was switch some sentences around and that would have totally solved the problem.<p>This is a strongly worded document.<p>Making safety a priority doesn&#x27;t mean starting every engineering document with the words &quot;loss of life&quot; which is a really common outcome of engineering failures on programs like this.  Making safety a priority means putting the risk of an engineering failure up front and knowing that an engineering failure in a life-critical system is critical.  Making safety a priority means people don&#x27;t have to tell you what the stakes are every single sentence, because everyone already knows and so what you really communicate is how much risk there is, not the fact that risk exists.  Making safety a priority means even if you&#x27;re working on an engineering problem that wouldn&#x27;t lead to loss of life, you fix the thing because you might be wrong and it might be part of a correlated failure one day that does lead to loss of life.  Making safety a priority doesn&#x27;t involve writing engineering documents in a way that makes them more amenable to skimming.<p>It&#x27;s a rocket.  Engineering doesn&#x27;t have to go that far wrong on rockets for people to die.  When someone sends a letter to a VP of engineering which begins with &quot;This letter is written to insure that management is fully aware of the seriousness&quot; then everyone who receives that memo is paying attention and if they aren&#x27;t then it&#x27;s not the writing skills of the people involved that are at fault.<p>I don&#x27;t think a single person who was aware of the O-ring issue was unaware of the stakes.  That didn&#x27;t show up in any reports on the panel.  What did show up was they estimated the risk of the problem wrong.  The first sentence of this engineer&#x27;s letter went towards establishing the seriousness of the engineering failure.  Because that was the part that needed to be communicated most clearly.