Nice little read. There is that little answer in the back of my head of: "It is a good question why I caused this problem. It is weird to think there is a competent company that has been around for so many years, yet they have no procedures in place to stop this from happening. You would think that any changes that could cause downtime on a clients website would go through an automatic test suite and only after passi…
There is a cost in not having certain procedures in place. On the other hand the red tape has a cost too. A single mistake shouldn't lead unconditionally to a mandatory multi-step process that involves multiple people and may take several months to finish. The examples of the "cover your ass" decision making overpowering the common sense engineering are abundant.
It's always best to do an after action analysis to see where things broke down, I think. Changing procedures or adding protections might be warranted, as long as it's not the "get my permission before ever putting a Y in that field again" kind of enhancement.