CHANGE APPROVAL PROCESSES i. Knight Capital - $440M trading loss ii. Counterfactual Narratives 1. Accident due to change control failure – seems valid since we can imagine better control practices could the risk earlier prevent the issue or could have taken steps to detect and recover faster 2. Accident due to testing failure – seems valid since better testing practices could have mitigated iii.

judgment of those decisions lies in hindsight 5. Propose countermeasures to prevent a similar accident from happening in the future and ensure these countermeasures are recorded with ta target date