What can we learn from the "human error" during the Oscars?

posted Mar 5, 2017, 6:21 AM by Niels Jensen   [ updated Mar 22, 2017, 3:43 AM ]
At the Oscars 2017 the wrong movie was at first declared a winner of the best movie award. That turned out to be a mistake. Others would properly call it a human error, because the wrong envelope was handed to one to the two host on the stage in Hollywood. If you are in the latter group, then I suggest using a few minutes to watch a video from Lund University's Human Factors and System Safety department here.

First learning from the Oscars is that, what happened at the Oscars was NOT a human error. I would classify it as an envelope design error. However, one could also argue, that it was a envelope circulation control error. Maybe it was actually the circulation system, which did not work this time around.

In his blog Steven Shorrock points out, that what happened at The Oscars was essentially the start of the discipline human factors and ergonomics during WWII. More relevant however, is that the design of the envelopes, were such, that it is a surprise, that this has not happened before in the history of The Oscars. On the outside all the envelopes at the Oscars were completely identical. This means if was completely up to the assistancts from PriceWaterhouseCooper to ensure that the correct envelope was handed to the host on the stage. Given the number of envelopes and the fact, that duplicates of each were available the likelihood of a wrong envelope being handed to a host can easily be calculated.

Second learning from the Oscars is that, handing information from one person to another should be analyzed as a transportation system, where items can e.g. be wrongly delivered. Although the Oscars considered something could happen to the host on stage, their risk assessment did not consider the transportation risk involved in handling the envelopes. 

As Steven writes: "Experience of human factors suggests a number of coding methods, e.g. shape, colour, size, that used appropriately, can help to make vital distinctions.", and points out that within the pharma industry both the European Medicines and the UK's National Health Service have developed guidelines for design for patient safety of medication packaging, attached below. 

From the outside it appears, the stage host at the Oscars did in some way realize, that he did not have the correct envelope. Since this situation was properly not covered in the rehearsal for the Oscars, the host became uncertain about what to do. 

Third learning from the Oscars is that, you should train people on abnormal situation handling. 

Steven finnish by writing that, for the post part the human in the system is less like a golden Oscar, and more like someone using the abilities of mind and body to connect parts of a system that only work because people make them work. This aspect of human performance in the wild is usually taken for granted. But in the real world, peopel create safety. And for that, they deserve an Oscar.
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