Know the business
Comments above are valid and highlight what can be missed, however if we go beyond the technical causes, the one part missing is an appreciation of the business and the under pinning technology that will deliver these key outcomes. If there had been an appreciation of this, and you can use Config to deliver this as well as other options, then not only would there have been a chance of greater appreciation of the risk but steps could have been made to mitigate this scenario. Mapping end to end the key business processes with key outcomes and then adding in the technology footprint supporting these. This can be used in a number of areas - risk, SLA management, Change Management, ROI, to name a few.
In relation to the 'railway network' example I am a supporter of taking the human chance for failure out where we can, so could there have been something as simple as labelling or schematic or such, given the scenario happens on occasion. I have seen these examples in the past and unfortunately it feels we have to learn the hard way, but it would be more remiss if we did not apply the learning across the estate. So in this example was there a solution and did the organisation look at where they had a similar set up and apply that learning ? Then did they take it up a level and identify similar situations based on people plugging a cable into the wrong hole.
Both are easy to write about and harder to get after but can be done.
Biting the hand that feeds IT
