This is one of the best incident reports I think I&#x27;ve ever read, detailed, honest and without recrimination.<p>I&#x27;m reminded of something I read in a book a while back about aviation disasters &quot;It&#x27;s not the first problem that kills you, it&#x27;s the second&quot;.<p>In this post the described system for change management is at least as good as any I&#x27;ve seen in production and yet a series of small problems got out of hand quickly.