Cautionary Tales

Roman Mars:
This is 99% Invisible. I’m Roman Mars.

Roman Mars:
There are lessons to be learned in our failures. Touching a hot stove once will teach you to never touch a hot stove again, but when it comes to the failures of complex systems, it’s sometimes hard to know what went wrong and when. This is where Tim Harford also known as the undercover economist, in his brand new show, ‘Cautionary Tales’, comes in. It’s a podcast that brings you stories of awful human error, tragic catastrophes, daring heists and hilarious fiascos. His stories will delight you, and if you’re smart, they will scare the bejesus out of you, but they’ll also make you wiser.

Roman Mars:
The episode we’re hearing today is about a fiasco that is often blamed on bad typography, hence my specific interest in it, but the full explanation turned out to be much weirder and more surprising. Here’s Tim Harford with ‘Cautionary Tales’.

Tim Harford:
You’ve heard this story before. You might even have watched it happening live. 33 million people did. There they stand together on stage. Faye Dunaway and Warren Beatty, Bonnie and Clyde, together again after 50 years. Even for a pair of veteran Hollywood stars, it must’ve been a nerve-wracking moment. Yet their task seemed simple, open a red envelope, take out a card and read out the title of the film that’s won the Academy Award for Best Picture.

Tim Harford:
Beatty opens the envelope, so far so good. Then he looks at the card in his hand, he hesitates, then he looks inside the envelope again as though checking just here if there was a cover note, he looks over at Dunaway, then raises both eyebrows. She reaches over and touches his arm affectionately.

Warren Beatty:
“And the Academy Award.”

Tim Harford:
Beatty begins. He pauses again. He looks at the card again. He slips his hand inside the envelope one more time. The audience laughs at the moment of maximum tension that old rogue is playing with everyone’s emotions. He continues.

Warren Beatty:
“For Best Picture.”

Tim Harford:
He stops again. Faye Dunaway thinks he’s goofing around too. “You’re impossible,” she says. “Come on.” He shows her the card. She doesn’t hesitate for a moment.

Faye Dunaway:
“La La Land.”

Tim Harford:
The audience erupts in applause and the producers of ‘La La Land’ take to the stage to give their acceptance speeches. Meanwhile, off in the wings, an accountant named Brian Cullinan knows that the biggest screw up in the history of the Academy Awards is in full flow. The 2016 winner of Best Picture isn’t ‘La La Land’, it’s ‘Moonlight’. So, yes, you’ve heard this story, but have you understood what it really means? You’re listening to another cautionary tale.

Tim Harford:
There’s a simple way to tell the story of this fiasco. As Warren Beatty walked on stage, Brian Cullinan’s job was to hand him the envelope for Best Picture. Instead, Cullinan handed over the envelope for Best Actress. A few moments earlier, that award had been worn by Emma Stone for her performance in ‘La La Land’, and so when Beatty opened the envelope, he saw ‘Emma Stone, La La Land’. Jimmy Kimmel, the host of the Oscars that evening, jokingly blamed it all on Beatty.

Jimmy Kimmel:
“Warren, what did you do?”

Warren Beatty:
“I want to tell you what happened.”

Tim Harford:
But it really wasn’t Beatty’s fault. He didn’t understand what he was looking at and rather than say the wrong thing, he hesitated, then he turned to Faye Dunaway. She was the person who actually uttered the title of the wrong film, but it wasn’t her fault either. Imagine her situation. She’s on stage in front of the most star-studded audience imaginable, plus tens of millions watching live on television. Beatty seems to be messing around and she doesn’t know why. The first thing she sees on the card is ‘La La Land’, and straight away, that’s what she says.

Tim Harford:
Some people blame Beatty. Some people blame Dunaway. Most people blame Brian Cullinan, the accountant who handed over the wrong envelope, but all of those people, I think are making a mistake.

Tim Harford:
Almost a decade ago, years before this fiasco, I interviewed one of the world’s most important thinkers on how accidents happen. He’s a sociologist named Charles Perrow, and he told me something that stuck in my mind, that we always blame the operator. It’s always he says, ‘a case of pilot error’. Charles Perrow is a wise old man. He’s older than the Academy Awards themselves. He was four back in 1929 when they were first presented, and Perrow is absolutely right. We inevitably look for someone to blame and that inclination leads us astray.

Tim Harford:
Our instinct is to blame the accountant, Brian Cullinan, he did give Beatty the wrong envelope. He was distracted. He tweeted a photograph of Emma Stone holding her Oscar statuette. At a time he should have been focusing on giving Beatty the right envelope, he was on his phone, enjoying being close to one of the world’s most beautiful people at her moment of triumph.

Tim Harford:
We can all learn a lesson from that. Get off your phone. Get off your phone when you’re supposed to be having dinner with your family. Get off your phone when you’re supposed to be driving, and get off your phone when you’re supposed to be giving the envelope containing the Best Picture card to Warren Beatty.

Tim Harford:
But the reason that it’s a mistake to simply blame Cullinan, is because Cullinan was just being human. Humans are always getting distracted. Humans are always making mistakes. If our systems can’t cope with those mistakes, then it’s hopeless to demand better humans, we need better systems. When ‘La La Land’ fleetingly won ‘Moonlight”s Oscar, some rich and successful people suffered some embarrassment and some heartache, but nobody died. Yet the lesson of the fiasco is far from trivial. The same kind of mistake in different situations can be catastrophic. Such mistakes can lead to nuclear accidents and financial meltdowns. And when I say can lead, I mean have led. Such disasters have already occurred. So, let’s try to understand what really happened that strange night at the Oscars. Perhaps we can use that insight to prevent far more serious calamities.

Tim Harford:
Let’s talk about problem number one, bad typography. I know it sounds strange, but it’s true. The card that Beatty took out of the envelope had nine words on it, and the largest word is, Oscars. Really? Is that really the most important piece of information? Are we worried that without it, Warren Beatty’s going to think he’s at the Iowa State Fair handing out a medallion for the best hog? The words ‘La La Land’ and ‘Emma Stone’ are printed with equal weight. Even though the winner is Emma Stone, the rest is detail.

Tim Harford:
Meanwhile, the important words, Best Actress, are tucked away at the bottom of the card and they’re tiny. If Best Actress, had been prominent, Warren Beatty wouldn’t have been confused, he would have known that he had the wrong card in his hand. And if Emma Stone had been in larger type than La La Land, Faye Dunaway wouldn’t have blurted out the name of the wrong film. It would’ve been awkward for Beatty and Dunaway to walk off stage to get the right envelope, but not nearly as awkward as not walking off stage to get the right envelope. So, the Academy should hire a designer, but they’re not the only ones.

Tim Harford:
Imagine that you’re the night shift supervisor at a nuclear power plant. It’s 4 o’clock in the morning and you don’t know it yet, but the turbine system that draws away the heat from the reactor core has just shut down. You’re going to have to make some quick decisions, assuming you can figure out what’s going wrong and why.

Supervisor:
(alarms blaring)
“What’s that?”

Operator 1:
“Ah, let’s see.”

Operator 2:
“Ah, I think it’s … Ah, geez, the noise. Can we shut it down?”

Supervisor:
“I think… No, can you?”

Tim Harford:
During the first few minutes of the accident, more than a hundred alarms went off and there was no system for suppressing the unimportant signals so that operators could concentrate on the significant alarms. Information was not presented in a clear and sufficiently understandable form. That’s from the overview of the official inquiry into what was then arguably the world’s most serious nuclear accident at Three Mile Island in 1979. It destroyed the reactor, came close to a serious release of radioactive material on the Eastern seaboard and shattered the reputation of the American nuclear industry. It’s striking how quickly the inquiry focused in on the question of design, but to anyone who studies how accidents happen. It’s not surprising at all.

Don Norman:
The plant’s control rooms were so poorly designed that error was inevitable.

Tim Harford:
Don Norman, the Director of the Design Lab at UC San Diego, was asked to help analyze the problems at Three Mile Island.

Don Norman:
Design was at fault, not the operators.

Tim Harford:
The control panels were baffling. They displayed almost 750 lights, some next to the relevant switches or above them or below them, sometimes nowhere near the relevant switch at all. Red lights indicated open valves or active equipment. Green indicated closed valves or inactive equipment, but since some of the lights were typically red and others were normally green, the overall effect was dizzying. So, yes, the operators made mistakes at Three Mile Island, but with better design, they might not have.

Tim Harford:
Warren Beatty and Faye Dunaway would sympathize, but something else went wrong that night at the Oscars, something deeper and more surprising. It’s a strange effect and it was first observed by a man less famous for looking at why things go wrong and more famous for looking at the stars. Galileo Galilei is known for his astronomy and because his work was consigned to the church’s ‘Index Librorum Prohibitorum’, the list of forbidden books, but the great man’s final work opens with a less provocative topic, the correct method of storing a stone column on a building site. Bear with me, this book from 1638 is going to explain the Oscar fiasco and much more.

Galileo Galilei:
“I must relate a circumstance which is worthy of your attention as indeed are all events, which happen contrary to expectation, especially when a precautionary measure turns out to be a cause of disaster.”

Tim Harford:
A precautionary measure turns out to be a cause of disaster. That’s very interesting, Galileo, please go on.

Galileo Galilei:
“A large marble column was laid out so that it’s two ends rested each upon the piece of beam.”

Tim Harford:
I can picture that in my mind, support the column while it’s being stored horizontally ready for use. If you lay it on the ground it may get stained and you’ll probably break it when you try to get ropes underneath it to pull it upright. So yes, store it flat but propped up by a support at one end and a support at the other. But what if the column can’t support its own weight like that and simply snaps in half? Galileo has thought of that.

Galileo Galilei:
“A little later it occurred to a mechanic that in order to be doubly sure it’s not breaking in the middle, it would be wise to lay a third support midway. This seemed too all an excellent idea.”

Tim Harford:
Yes. If two supports are good, surely three supports are better.

Galileo Galilei:
“It was quite the opposite, for not many months passed before the column was found cracked and broken exactly above the new middle support.”

Tim Harford:
How did that happen?

Galileo Galilei:
“One of the end supports had after a long while become decayed and sunken, but the middle one remained hard and strong, thus causing one half of the column to project in the air without any support.”

Tim Harford:
The central support didn’t make the column safer. It pressed into it like the central pivot of a seesaw snapping it in half. Galileo’s tale isn’t really about storing columns and neither is mine. It’s about what I’m going to call Galileo’s principle, the steps we take to make ourselves safe sometimes lead us into danger.

Tim Harford:
But the problem Galileo described is well known to safety engineers. There’s an article in the fine scholarly journal ‘Process Safety Progress’ titled ‘No Good Deed Goes Unpunished: Case Studies of Incidents and Potential Incidents Caused by Protective Systems’. These case studies are magnificent. There’s a chemical plant where two pressure relief systems interact in a way that means neither of them work. There’s a flair designed to destroy pollutants, which ends up causing the release of toxic gases. There’s an explosion suppression device that causes an explosion.

Tim Harford:
This kind of thing happens more than you might think. An example is one of the earliest nuclear accidents at Fermi 1, an experimental reactor in Michigan. It’s barely remembered now except in Gil Scott-Heron’s song ‘We Almost Lost Detroit This Time’. The operators at Fermi 1 lost control of the nuclear reaction for reasons that were baffling to them. Some of the reactor fuel melted. It was all touch and go. Eventually, they got the reactor under control, shut it all down and waited until it was safe to take it all apart. It was almost a year before the reactor had cooled enough to identify the culprit. A piece of metal the size of a crushed beer can had blocked the circulation of the coolant in the reactor core. It was a filter that had been installed at the last moment for safety reasons at the express request of the Nuclear Regulatory Commission. It had come loose and caused the entire problem.

Tim Harford:
Galileo’s principle strikes again. Why do safety systems sometimes backfire? The wise old sociologist, Charles Perrow’s most famous book is called ‘Normal Accidents’. It’s about how certain kinds of system are vulnerable to catastrophic failure, so vulnerable in fact that we should view accidents in those systems as inevitable. The vulnerable systems have two features. The first is that they’re what Perrow called tightly coupled. In a tightly coupled system, one thing leads to another and another and another. It’s like domino toppling, which is actually a great example of a tightly coupled system. Once you start, it’s hard to hit the pause button. A second feature is complexity. A complex system has elements that interact in unexpected ways. A rainforest is a complex system, so is Harvard University, but Harvard University usually isn’t tightly coupled, if there’s a problem, there’s also time to find a solution.

Tim Harford:
A system that’s both complex and tightly coupled is dangerous. The complexity means there will occasionally be surprises. The tight coupling means that there will be no time to deal with the surprises. Charles Perrow’s theory explains Galileo’s principle. Every time you add a feature that’s designed to prevent a problem, you’re adding complexity. The middle support for the column added complexity, so did the safety filter that damaged the Fermi 1 reactor. Safety systems don’t always make us safe.

[BREAK]

Tim Harford:
Here’s the question we should be asking about that bizarre evening at the Oscars. How was it even possible for the distracted accountant, Brian Cullinan, to give Warren Beatty the wrong envelope. A few minutes earlier the envelope for best actress, the envelope containing the card that read ‘Emma Stone, La La Land’, that envelope had been in the hands of Leonardo DiCaprio as he stood on stage announcing her win. How could that envelope have made its way into the hands of Warren Beatty? The answer, it didn’t.

Tim Harford:
There were two envelopes. Every envelope for every category had a duplicate version waiting in the wings. These duplicate envelopes were there as a safety measure and that safety measure is what made the fiasco possible. Galileo’s principle had bitten hard.

Tim Harford:
Charles Perrow’s argument is that when systems are both complex and tightly coupled, we should expect catastrophic accidents. Does the Academy Award ceremony fit that description? It certainly tightly coupled. You can’t easily interrupt a live TV spectacular in front of millions of people to ask for advice. The show must go on, yet the ceremony doesn’t have to be complex. Giving an envelope to Warren Beatty doesn’t have to be complex, but you can make it complex if you try.

Tim Harford:
Brian Cullinan’s partner in crime that evening was Martha Ruiz. Like Cullinan, she was a senior accountant. The pair of them carried identical briefcases with an identical set of envelopes.

Martha Ruiz:
“On the day of the show. We’ll get the ballots and Brian and I will go to the theater on two separate roads. He’ll go one route and I’ll go another route.”

Tim Harford:
That’s how Martha Ruiz helpfully explained things to journalists. Just before Oscar night, both she and Cullinan had been proudly giving interviews about the foolproof system.

Martha Ruiz:
“We do that to ensure that in case anything happens to one, the other will be there on time and delivering what’s needed with the full set. We do have security measures up until we’re at the theater and delivering that envelope to the presenter just seconds before they walk on stage. We’ll be in two different locations. Brian will be on stage right and I’ll be on stage left.”

Tim Harford:
It all sounds sensible and in many ways it is sensible. It’s also complicated. The system of twin envelopes meant that every time an envelope was opened on stage, it’s duplicates in the wings had to be set aside. Martha Ruiz, stage left, handed the envelope for best actress to Leonardo DiCaprio leaving Brian Cullinan stage right with a job of discarding the duplicate, the job he failed to do. If there hadn’t been that set of twin envelopes, Warren Beatty could never have been given the wrong one.

Tim Harford:
So bad design helped cause the Oscar fiasco. It also helped cause the accident at Three Mile Island and a complicated safety system was that the root of the Oscar farce. It was also at the root of the Fermi 1 accident, but it’s not just Oscars and nuclear power. I promised you a financial catastrophe too and in this one, both safety systems and bad typography, are to blame. You might even start to see the banking crisis in a very different light.

Tim Harford:
In September 2008, at the height of the financial crisis, an insurance executive named Robert Willemstad requested a meeting with Tim Geithner. Geithner would later be the treasury secretary. At the time, he was the president of the New York Federal Reserve. That meant he was responsible for supervising Wall Street’s banks, including Lehman Brothers, which was on the brink of collapse. Robert Willemstad was the boss of an insurance company called AIG, and since AIG wasn’t a bank, it was far from obvious why Willemstad was Geithner’s problem. In his book ‘Too Big to Fail’, the journalist Andrew Ross Sorkin reports the intimate details of this ill-fated meeting.

Assistant:
“I’m really sorry Mr. Willemstad, Mr. Geithner is going to be a few minutes.”

Robert Willemstad:
“No problem. I have time.”

Assistant:
“I’m sorry. I know you’ve been waiting a long time. Mr. Geithner’s on the phone to the boss of Lehmann Brothers. He’s up to his eyeballs in Lehmann.”

Tim Harford:
Tim Geithner was also exhausted. He’d been on an overnight flight from a banking conference in Switzerland. He must’ve felt completely overwhelmed. Who wouldn’t have?

Tim Geithner:
“Bob, is it? Sorry to keep you waiting. Come in.”

Tim Harford:
Willemstad got his moment. He badly needed to be able to borrow from the Fed. Not normally something AIG would be allowed to do, but he also didn’t want to panic Geithner. He needed to walk a tightrope. To suggest that AIG could use some help, but wasn’t actually bankrupt.

Tim Geithner:
“Is this a critical or emergency situation, Bob?”

Robert Willemstad:
“Well, let me just say that it would be very beneficial to AIG, Mr. Geithner. Perhaps I can leave this with you.”

Tim Harford:
Willemstad handed Geithner a briefing note buried deep within it was a fast-ticking time bomb. The largest firms on Wall Street were relying on AIG to pay out on insurance against financial trouble. The total sum insured was a truly ludicrous $2,700,000,000. AIG couldn’t possibly pay if all the claims came in and it was starting to look as though they might. But that meant that the big Wall Street banks wouldn’t get the insurance payments they were relying on. AIG was both a bigger threat to the financial system than Lehman Brothers and a far more surprising one. If AIG was a safety net, it was one that wasn’t going to break anyone’s fall. But to realize that, Tim Geithner would actually have to read and absorb the information in the note and he was busy, really busy. So instead, he filed it away and turned back to the Lehman Brothers problem. AIG would meltdown a few days later.

Tim Harford:
The parallels with Oscar night are uncanny. For one thing, Geithner who’s no fool, had no idea how to interpret what he was looking at. It was unexpected and the key information was buried in the small print. Faye Dunaway and Warren Beatty know the feeling. Then there’s Galileo’s principle. Safety systems don’t always make us safe. Those insurance contracts were supposed to offset risk, not create it, right? But by now, we know that safety systems also introduce new ways for things to go wrong. The insurance contracts that we’re about to destroy AIG were called credit default swaps. They had become popular as a way to offset risk with the blessing of regulators. They seemed a smart idea, just as the third support for the columns seems like a smart idea and the metal filters at the Fermi reactor and the duplicate set of award envelopes, but they backfired. Wall Street banks were relying on these credit default swaps to keep them safe if there was trouble. When it became clear that insurance companies such as AIG couldn’t possibly payout, the banks all scramble to sell off their risky investments at the exact same time, for the exact same reason.

Tim Harford:
A few days after Willemstad had met Geithner, officials and bankers worked through the weekend on the Lehman Brothers problem. Only on Sunday evening did one of those bankers receive a request from a treasury official to ask if she could drop everything and work on rescuing AIG instead. The surprising phone call was greeted with a response that was unsurprisingly unsuitable for family ears.

Investment Banker:
“Hold on, hold on. You’re calling me on a Sunday night saying that we just spent the entire weekend on Lehman and now we have this. How the (beep) did we spend the past 48 hours on the wrong thing?”

Tim Harford:
How indeed. For the same reason, they gave the Oscar to the wrong movie. Confusing communication and above all a safety system that created a brand new way to fail. The banking crisis of 2008 shook the world financial system and destroyed millions of jobs. More than a decade later, we’re still living with the consequences. It was, in its way, a more serious crisis than any nuclear accident. It was certainly far graver than a bungle at the Oscars, yet the same problems were the roots of all these accidents. After the ‘La La Land’ shambles, Vanity Fair reported.

Vanity Fair:
“The Oscars have an intense six-step plan to avoid another envelope disaster.”

Tim Harford:
The six steps include getting rid of the two accounting partners, Brian Cullinan and Martha Ruiz, and the twin sets of envelopes. Instead, says Vanity Fair, “There will be three partners.”

Vanity Fair:
“A third partner will sit in the show’s control room with the producers. All three partners will have a complete set of envelopes.”

Tim Harford:
If having two sets cause the problem, having three sets is better, right? I’m not sure Galileo would agree.

Tim Harford:
You’ve been listening to ‘Cautionary Tales’. I expand on some of the ideas in this episode in my book, ‘Adapt’. You might like it. ‘Cautionary Tales’ is written and presented by me, Tim Harford. Our producers are Ryan Dilley and Marilyn Rust. The sound designer and mixer was Pascal Wyse, who also composed the amazing music.

Roman Mars:
In the time since this story was produced, Charles Perrow, the brilliant sociologist and author of ‘Normal Accidents’, who was mentioned in the episode, passed away. ‘Cautionary Tales’ is a production of Pushkin Industries, including the talented Julia Barton, Heather Faine, Mielo Bell, Carley Migliore, Jacob Weisberg, and Malcolm Gladwell.

Roman Mars:
I don’t know how you could have listened to more than three minutes of this episode and not subscribe to ‘Cautionary Tales’, but maybe you were driving or you were doing the dishes and your hands were wet. If so, you can remedy that right now by opening up the podcast app you’re listening to and subscribe to ‘Cautionary Tales’

Credits

Production

Cautionary Tales is hosted by Tim Harford from Pushkin Industries. Featuring original music and an award-winning cast including Alan Cumming and Archie Panjabi (The Good Wife), Toby Stephens (Die Another Day), Russell Tovey (Quantico) – and Malcolm Gladwell.

  1. Mickey Johnson

    Excellent episode. The BBC podcast “more of less” which Tim hosts is also fantastic. I would highly recommend it.

    I nearly lost it at the end with the academy’s solution to the La La Land Debacle. Its comically fitting.

    Its 2019. Why use envelopes at all? why not just code the names of the winners into the teleprompter the presenters read off of. The could just pretend to read it off of blank envelopes for nostalgia’s sake . They are actors after all…
    For a fail-safe they could give someone in the control booth a hardcopy of the full list.

  2. Jen

    I’m an engineer that works in a high risk industry. Quite frequently, the lack of complexity causes catastrophic, single mode failures (the filter taking down a nuclear plant is a good example of a simple, single mode failure in a complex system). What happens when you kick out one of those two columns? Still broke. For every one major failure regarding over complexity I can think of several more that that simple design resulted in failure. You need layers of designed controls so that one thing can’t take you down. Human factored design is hard, and humans are the least reliable control there is.

    The 3rd column support was unnecessary and destabilized the system – but a 4th would have eliminated single point failure. Any one of 4 supports, when correctly spaced, could be removed without catastrophic failure, leaving at least 3 completely adequate supports. Three columns is incomplete risk assessment and control. A simple system is more stable (ok with some movement, but will break the column if a support fully fails), but still accepts catastrophic failure as an option.

    Catastrophic accidents are unacceptable. Period. “Ooops, didn’t think of that” is not an excuse when human life is on the line.

    For the Oscars – I’d have a single set of envelopes and a auditor with a list. Worst come to worst, keep a few envelopes and cards ready so a new one can be assembled based on the list in moments. Keep the back up an obvious Plan B, preventing any situational confusion.

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