This must never happen again
Why is it that so many IT managers and governors expect zero incidents? It happens. But when it does, they introduce more controls to stop a recurrence. Wrong attitude and wrong response.
After a while, such organisations are so constipated by controls that nothing gets done. Controls are not the correct response to mistakes. Don't bring in a control: fix the quality, through learning and improvement.
If we ran motorways by the same principle that any accident must never happen again, the speed limit would be 3kph, and all cars would have a man walking in front ringing a bell and swinging a lantern.
Don't stop people doing things that cause mistakes. If it hurts do it more. If we suck, do it until we suck less. Learn. Kata.
Something will happen again. All complex systems are always broken. The system eventually fails. Be fast, competent, and relaxed about fixing it.
Made in New Zealand 
