During a missile decommissioning procedure on Aug. 29-30, 2007, airmen at Minot Air Force Base, North Dakota, mistakenly loaded six nuclear warheads onto a B-52 bomber destined for Barksdale Air Force Base, Louisiana. Airmen failed to handle the warheads in accordance with U.S. Air Force nuclear weapons regulations, allowing the warheads to bypass five safety nets and resulting in the unauthorized transfer. This event is considered one of the most serious breaches in the Air Force's positive control of nuclear weapons. After studying this incident, we find that a slow evolution of expedient processes eroded firmly established safety protocols over time. This study reminds us that in applying NASA's broad range of procedures and processes to high-energy systems, it is not enough to comprehend procedural steps — operators and managers alike must understand the rationales behind the procedures to avoid losing sight of safety goals and of the consequences of mission failure.