Apparently, the Defense Contract Management Agency didn’t get to do their inspection job:

We found that the Defense Contract Management Agency (DCMA) did not perform mandatory hardware inspections on bolt catchers used in Space Shuttle operations. Specifically, we found that DCMA Quality Assurance Representatives (QAR) either (a) removed the requirement for mandatory inspections without obtaining NASA’s authorization or approval, or (b) gave final approval for manufactured bolt catchers although not all inspections required throughout the bolt catcher manufacturing process were performed. When inspections were performed, however, we found that DCMA QARs were not always adequately trained to perform the types of inspections delegated. We also found that NASA relied entirely on DCMA to provide surveillance of bolt catcher manufacturing without the oversight that NASA regulations required.

I just threw up in my mouth.