Computerworld has an amazingly detailed description of the VA’s August IT breakdown.

On the morning of Aug. 31, the Friday before Labor Day weekend, the Region 1 data center was packed with people. According to Director Eric Raffin, members of the technical team were at the site with staffers from Hewlett-Packard Co.conducting a review of the center’s HP AlphaServer system running on Virtual Memory System and testing its performance.

About the same time, staffers in medical centers around Northern California starting their workday quickly discovered that they couldn’t log onto their patient systems, according to congressional testimony by Dr. Bryan D. Volpp, the associate chief of staff and clinical informatics at the VA’s Northern California Healthcare System. Starting at about 7:30 a.m., the primary patient applications, Vista and CPRS, had suddenly become unavailable.

What follows is a step-by-step analysis of how not to solve a systems problem.