1 00:00:15,370 --> 00:00:22,570 Speaker 1: Pushkin. The ninety fifth Academy Awards are just around the corner, 2 00:00:23,050 --> 00:00:26,370 Speaker 1: and loyal Cautionary Tales listeners will know that the Academy 3 00:00:26,370 --> 00:00:30,210 Speaker 1: Awards ceremony was not so long ago the stage for 4 00:00:30,290 --> 00:00:34,970 Speaker 1: one of the most bizarre, fascinating, and instructive errors in 5 00:00:35,330 --> 00:00:39,250 Speaker 1: entertainment history. We explored that mistake in one of the 6 00:00:39,410 --> 00:00:43,250 Speaker 1: very first episodes of Cautionary Tales, and it remains one 7 00:00:43,290 --> 00:00:46,010 Speaker 1: of our best loved stories. If you want to know 8 00:00:46,090 --> 00:00:48,730 Speaker 1: more about the ideas in this episode, check out our 9 00:00:48,730 --> 00:00:52,170 Speaker 1: show notes, and in particular the wonderful book melt Down 10 00:00:52,490 --> 00:00:57,610 Speaker 1: by Chris Clearfield and Andrashtilchik. But first, another chance to 11 00:00:57,690 --> 00:01:06,690 Speaker 1: hear La La Land Galileo's warning. You've heard this story before. 12 00:01:07,410 --> 00:01:10,850 Speaker 1: You might even have watched it happening live. Thirty three 13 00:01:10,890 --> 00:01:17,130 Speaker 1: million people did. There they stand together on stage, Fade 14 00:01:17,250 --> 00:01:21,570 Speaker 1: Unaway and Warren, Beatty, Bonnie and Clyde together again after 15 00:01:21,690 --> 00:01:26,130 Speaker 1: fifty years. Even for a pair of veteran Hollywood stars, 16 00:01:26,490 --> 00:01:29,250 Speaker 1: it must have been a nerve racking moment. Yet their 17 00:01:29,330 --> 00:01:34,050 Speaker 1: task seemed simple. Open a red envelope, take out a card, 18 00:01:34,690 --> 00:01:36,890 Speaker 1: and read out the title of the film that had 19 00:01:36,890 --> 00:01:42,290 Speaker 1: won the Academy Award for Best Picture. Betty opens the envelope. 20 00:01:42,970 --> 00:01:46,170 Speaker 1: So far, so good. Then he looks at the card 21 00:01:46,210 --> 00:01:50,650 Speaker 1: in his hand. He hesitates. Then he looks inside the 22 00:01:50,770 --> 00:01:53,130 Speaker 1: envelope again, as though checking to see if there was 23 00:01:53,130 --> 00:01:56,890 Speaker 1: a cover note. He looks over at Dunaway, then raises 24 00:01:56,930 --> 00:02:01,210 Speaker 1: both eyebrows. She reaches over and touches his arm affectionately. 25 00:02:01,570 --> 00:02:06,650 Speaker 1: The Academy Award Betty begins. He pauses again, He looks 26 00:02:06,650 --> 00:02:09,490 Speaker 1: at the card again. He slips his hand inside the 27 00:02:09,570 --> 00:02:13,410 Speaker 1: envelope one more time. The audience laugh look at the 28 00:02:13,450 --> 00:02:16,890 Speaker 1: moment of maximum tension. That old rogue is playing with 29 00:02:16,930 --> 00:02:22,050 Speaker 1: everyone's emotions. He continues for a Best Picture. He stops again. 30 00:02:22,890 --> 00:02:26,410 Speaker 1: Faye Dunaway thinks he's goofing around too. You're impossible, she says, 31 00:02:26,410 --> 00:02:31,010 Speaker 1: come on, He shows her the card. She doesn't hesitate 32 00:02:31,290 --> 00:02:40,810 Speaker 1: for a moment. La La La. The audience erupts and applause, 33 00:02:40,930 --> 00:02:43,210 Speaker 1: and the producers of La La Lands take to the 34 00:02:43,290 --> 00:02:48,050 Speaker 1: stage to give their acceptance speeches. Meanwhile, off in the wings, 35 00:02:48,530 --> 00:02:53,050 Speaker 1: an accountant named Brian Cullenan knows that the biggest screw 36 00:02:53,130 --> 00:02:56,050 Speaker 1: up in the history of the Academy Awards is in 37 00:02:56,170 --> 00:03:01,090 Speaker 1: full flow. The twenty sixteen winner of Best Picture isn't 38 00:03:01,370 --> 00:03:07,490 Speaker 1: La La Land, It's Moonlight. So yes, you've heard this story, 39 00:03:08,530 --> 00:03:12,450 Speaker 1: have you on stood what it really means? You're listening 40 00:03:12,730 --> 00:03:39,290 Speaker 1: to another cautionary tale. There's a simple way to tell 41 00:03:39,330 --> 00:03:42,970 Speaker 1: the story of this fiasco. As Warren Beatty walked on stage, 42 00:03:43,450 --> 00:03:46,770 Speaker 1: Brian Cullenan's job was to hand him the envelope for 43 00:03:46,850 --> 00:03:52,250 Speaker 1: Best Picture. Instead, Cullenan handed over the envelope for Best Actress. 44 00:03:53,050 --> 00:03:56,290 Speaker 1: A few moments earlier, that award had been won by 45 00:03:56,370 --> 00:03:59,970 Speaker 1: Emma Stone for her performance in La La Land, and 46 00:04:00,050 --> 00:04:04,050 Speaker 1: so when Beatty opened the envelope, he saw Emma Stone 47 00:04:04,730 --> 00:04:08,810 Speaker 1: La La Land. Jimmy Kimmel, the host of the Oscars 48 00:04:08,810 --> 00:04:12,530 Speaker 1: that evening, jokingly blamed it all on Beati Larren, What 49 00:04:12,650 --> 00:04:16,610 Speaker 1: did you do? I wanted to tell you what happened, 50 00:04:17,330 --> 00:04:20,730 Speaker 1: but it really wasn't Beata's fault. He didn't understand what 51 00:04:20,770 --> 00:04:23,730 Speaker 1: he was looking at, and rather than say the wrong thing, 52 00:04:24,210 --> 00:04:28,450 Speaker 1: he hesitated. Then he turned to Faye Dunaway. She was 53 00:04:28,490 --> 00:04:31,490 Speaker 1: the person who actually uttered the title of the wrong film, 54 00:04:31,930 --> 00:04:35,530 Speaker 1: but it wasn't her fault either. Imagine her situation She's 55 00:04:35,650 --> 00:04:39,050 Speaker 1: on stage in front of the most star studded audience imaginable, 56 00:04:39,090 --> 00:04:42,850 Speaker 1: plus tens of millions watching live on television. Betty seems 57 00:04:42,890 --> 00:04:45,250 Speaker 1: to be messing around and she doesn't know why. The 58 00:04:45,290 --> 00:04:47,930 Speaker 1: first thing she sees on the card is La La Land, 59 00:04:48,210 --> 00:04:52,250 Speaker 1: and straightaway that's what she says. Some people blame Beattie, 60 00:04:52,770 --> 00:04:57,410 Speaker 1: some people blamed Dunaway, most people blame Brian cullenan, the 61 00:04:57,450 --> 00:05:01,250 Speaker 1: accountant who handed over the wrong envelope. But all of 62 00:05:01,290 --> 00:05:06,890 Speaker 1: those people I think are making a mistake. Almost a 63 00:05:06,930 --> 00:05:11,210 Speaker 1: decade ago, years before this fear asco I interviewed one 64 00:05:11,210 --> 00:05:15,130 Speaker 1: of the world's most important thinkers on how accidents happen. 65 00:05:15,890 --> 00:05:20,170 Speaker 1: He's a sociologist named Charles Perrault, and he told me 66 00:05:20,250 --> 00:05:23,850 Speaker 1: something that stuck in my mind that we always blame 67 00:05:23,970 --> 00:05:29,130 Speaker 1: the operator. It's always, he says, a case of pilot error. 68 00:05:30,370 --> 00:05:33,570 Speaker 1: Charles Perrault is a wise old man. He's older than 69 00:05:33,610 --> 00:05:37,010 Speaker 1: the Academy Awards themselves. He was four back in nineteen 70 00:05:37,050 --> 00:05:41,410 Speaker 1: twenty nine when they were first presented. And Perrault is 71 00:05:41,450 --> 00:05:45,770 Speaker 1: absolutely right. We inevitably look for someone to blame, and 72 00:05:45,890 --> 00:05:50,770 Speaker 1: that inclination leads us astray. Our instinct is to blame 73 00:05:50,810 --> 00:05:54,810 Speaker 1: the accountant, Brian Cullenan. He did give Beattie the wrong envelope. 74 00:05:54,890 --> 00:05:58,690 Speaker 1: He was distracted. He tweeted a photograph of Emma Stone 75 00:05:58,690 --> 00:06:01,810 Speaker 1: holding her Oscar statuette at a time he should have 76 00:06:01,810 --> 00:06:04,890 Speaker 1: been focusing on giving Beattie the right envelope. He was 77 00:06:05,010 --> 00:06:08,210 Speaker 1: on his phone, enjoying being close to one of the 78 00:06:08,250 --> 00:06:12,610 Speaker 1: world's most beautiful people at her moment of triumph. We 79 00:06:12,650 --> 00:06:15,690 Speaker 1: can all learn a lesson from that. Get off your phone, 80 00:06:16,010 --> 00:06:17,810 Speaker 1: get off your phone when you're supposed to be having 81 00:06:17,850 --> 00:06:19,930 Speaker 1: dinner with your family, get off your phone when you're 82 00:06:19,930 --> 00:06:22,210 Speaker 1: supposed to be driving, and get off your phone when 83 00:06:22,210 --> 00:06:24,930 Speaker 1: you're supposed to be giving the envelope containing the best 84 00:06:24,970 --> 00:06:28,690 Speaker 1: picture card to Warren Beatty. But the reason that it's 85 00:06:28,690 --> 00:06:32,370 Speaker 1: a mistake to simply blame Culonan is because Cullinan was 86 00:06:32,450 --> 00:06:36,850 Speaker 1: just being human. Humans are always getting distracted, humans are 87 00:06:36,890 --> 00:06:41,090 Speaker 1: always making mistakes. If our systems can't cope with those mistakes, 88 00:06:41,370 --> 00:06:45,410 Speaker 1: then it's hopeless to demand better humans. We need better systems. 89 00:06:47,410 --> 00:06:51,330 Speaker 1: When La La land fleetingly won Moonlight's Oscar, some rich 90 00:06:51,370 --> 00:06:55,570 Speaker 1: and successful people suffered some embarrassment, and some heartache, but 91 00:06:55,730 --> 00:06:59,930 Speaker 1: nobody died. Yet the lesson of the fiasco is far 92 00:07:00,010 --> 00:07:04,570 Speaker 1: from trivial. The same kind of mistake in different situations 93 00:07:04,850 --> 00:07:09,090 Speaker 1: can be catastrophic. Such mistakes can lead to nuclear accident 94 00:07:09,090 --> 00:07:14,090 Speaker 1: and financial meltdowns. And when I say can lead, I 95 00:07:14,130 --> 00:07:20,010 Speaker 1: mean have led. Such disasters have already occurred. So let's 96 00:07:20,090 --> 00:07:23,570 Speaker 1: try to understand what really happened that strange night at 97 00:07:23,570 --> 00:07:27,170 Speaker 1: the oscars. Perhaps we can use that insight to prevent 98 00:07:27,450 --> 00:07:43,130 Speaker 1: far more serious calamities. Let's talk about problem number one, 99 00:07:44,210 --> 00:07:48,370 Speaker 1: bad typography. I know it sounds strange, but it's true. 100 00:07:48,810 --> 00:07:51,490 Speaker 1: The card that Beatty took out of the envelope had 101 00:07:51,610 --> 00:07:55,410 Speaker 1: nine words on it, and the largest word is Oscars. 102 00:07:56,530 --> 00:08:00,690 Speaker 1: Really is that really the most important piece of information? 103 00:08:01,130 --> 00:08:03,810 Speaker 1: Are we worried that? Without it, Warren Beatty's going to 104 00:08:03,890 --> 00:08:06,650 Speaker 1: think he's at the Iowa State Fair handing out a 105 00:08:06,730 --> 00:08:11,290 Speaker 1: medallion for the best hog. The words La, La Land 106 00:08:11,410 --> 00:08:15,930 Speaker 1: and Emma Stone are printed with equal weight, even though 107 00:08:15,930 --> 00:08:20,450 Speaker 1: the winner is Emma Stone. The rest is detail. Meanwhile, 108 00:08:20,650 --> 00:08:25,090 Speaker 1: the important words best Actress are tucked away at the 109 00:08:25,130 --> 00:08:30,210 Speaker 1: bottom of the card, and they're tiny. If best Actress 110 00:08:30,370 --> 00:08:34,010 Speaker 1: had been prominent, Warren Baity wouldn't have been confused. He 111 00:08:34,050 --> 00:08:37,370 Speaker 1: would have known that he had the wrong card in 112 00:08:37,450 --> 00:08:42,090 Speaker 1: his hand. And if Emma Stone had been in larger 113 00:08:42,090 --> 00:08:45,970 Speaker 1: type than La La land Faye, Dunaway wouldn't have blurted 114 00:08:45,970 --> 00:08:48,530 Speaker 1: out the name of the wrong film. It would have 115 00:08:48,570 --> 00:08:51,090 Speaker 1: been awkward for Baiting and done Away to walk off 116 00:08:51,130 --> 00:08:54,330 Speaker 1: stage to get the right envelope, but not nearly as 117 00:08:54,330 --> 00:08:58,930 Speaker 1: awkward as not walking off stage to get the right envelope. 118 00:08:59,650 --> 00:09:03,890 Speaker 1: So the Academy should have hired a designer, but they're 119 00:09:03,890 --> 00:09:08,730 Speaker 1: not the only ones. Imagine that you're the night shifts 120 00:09:08,770 --> 00:09:12,970 Speaker 1: super advisor at a nuclear power plant. It's four o'clock 121 00:09:12,970 --> 00:09:15,690 Speaker 1: in the morning and you don't know it yet, but 122 00:09:15,810 --> 00:09:18,730 Speaker 1: the turbine system that draws away the heat from the 123 00:09:18,770 --> 00:09:22,290 Speaker 1: reactor core has just shut down. You're going to have 124 00:09:22,330 --> 00:09:25,770 Speaker 1: to make some quick decisions, assuming you can figure out 125 00:09:25,890 --> 00:09:34,050 Speaker 1: what's going wrong and why. What's that? Let's see, I 126 00:09:34,210 --> 00:09:41,610 Speaker 1: think it's Can we shut it down? I do no? 127 00:09:43,250 --> 00:09:48,370 Speaker 1: Can you? During the first few minutes of the accident, 128 00:09:48,930 --> 00:09:51,810 Speaker 1: more than one hundred alarms went off, and there was 129 00:09:51,810 --> 00:09:55,570 Speaker 1: no system for suppressing the unimportant signals so that operators 130 00:09:55,570 --> 00:09:59,930 Speaker 1: could concentrate on the significant alarms information was not presented 131 00:09:59,970 --> 00:10:03,850 Speaker 1: in a clear and sufficiently understandable form. That's from the 132 00:10:03,970 --> 00:10:08,370 Speaker 1: overview of the official inquiry into what was then arguably 133 00:10:08,410 --> 00:10:12,770 Speaker 1: the world's most serious nuclear accident at Three Mile Island 134 00:10:13,090 --> 00:10:17,370 Speaker 1: in nineteen seventy nine. It destroyed the reactor, came close 135 00:10:17,410 --> 00:10:21,090 Speaker 1: to a serious release of radioactive material on the Eastern Seaboard, 136 00:10:21,490 --> 00:10:25,770 Speaker 1: and shattered the reputation of the American nuclear industry. It's 137 00:10:25,850 --> 00:10:29,970 Speaker 1: striking how quickly the inquiry focused in on the question 138 00:10:30,010 --> 00:10:33,890 Speaker 1: of design, But to anyone who studies how accidents happen, 139 00:10:34,490 --> 00:10:37,850 Speaker 1: it's not surprising at all. The plan's control rooms were 140 00:10:37,890 --> 00:10:43,090 Speaker 1: so poorly designed that error was inevitable. Don Norman, the 141 00:10:43,130 --> 00:10:46,490 Speaker 1: director of the Design Lab at UC San Diego, was 142 00:10:46,570 --> 00:10:49,650 Speaker 1: asked to help analyze the problems at Three Mile Island. 143 00:10:50,250 --> 00:10:55,170 Speaker 1: Design was at fault that the operators the control panels 144 00:10:55,170 --> 00:10:59,490 Speaker 1: were baffling. They displayed almost seven hundred and fifty lights, 145 00:10:59,530 --> 00:11:03,010 Speaker 1: some next to the relevant switches, or above them, or 146 00:11:03,130 --> 00:11:06,450 Speaker 1: below them, sometimes nowhere near the relevant switch at all. 147 00:11:07,050 --> 00:11:12,290 Speaker 1: Red lights indicated open valves or active equipment. Green indicated 148 00:11:12,530 --> 00:11:16,610 Speaker 1: closed valves or inactive equipment. But since some of the 149 00:11:16,690 --> 00:11:20,090 Speaker 1: lights were typically read and others were normally green. The 150 00:11:20,250 --> 00:11:26,610 Speaker 1: overall effect was dizzying. So yes, the operators made mistakes 151 00:11:26,650 --> 00:11:30,370 Speaker 1: at Three Mile Island, but with better design they might 152 00:11:30,410 --> 00:11:37,730 Speaker 1: not have. Warren Beatty and Fade Unaway would sympathize. But 153 00:11:37,930 --> 00:11:40,850 Speaker 1: something else went wrong that night at the oscars, something 154 00:11:41,250 --> 00:11:45,810 Speaker 1: deeper and more surprising. It's a strange effect, and it 155 00:11:45,890 --> 00:11:48,850 Speaker 1: was first observed by a man less famous for looking 156 00:11:48,850 --> 00:11:52,490 Speaker 1: at why things go wrong and more famous for looking 157 00:11:52,490 --> 00:11:57,410 Speaker 1: at the stars. Galileo Galilei is known for his astronomy 158 00:11:57,850 --> 00:12:01,930 Speaker 1: and because his work was consigned to the Church's Index 159 00:12:02,050 --> 00:12:07,610 Speaker 1: Liborum Prohibitorum, the list of forbidden books. But the great 160 00:12:07,650 --> 00:12:11,930 Speaker 1: Man's final work opens with a less provocative topic, the 161 00:12:12,010 --> 00:12:16,290 Speaker 1: correct method of storing a stone column on a building site. 162 00:12:16,850 --> 00:12:20,610 Speaker 1: Bear with me, this book from sixteen thirty eight is 163 00:12:20,650 --> 00:12:24,770 Speaker 1: going to explain the Oscar fiasco and much more, a 164 00:12:24,890 --> 00:12:29,010 Speaker 1: master related circumstance which is worthy of your attention, as 165 00:12:29,050 --> 00:12:34,130 Speaker 1: indeed are ol events which happen contrary to expectation, especially 166 00:12:34,290 --> 00:12:37,210 Speaker 1: when a precautionary measure turns out to be a cause 167 00:12:37,490 --> 00:12:41,450 Speaker 1: of disaster. A precautionary measure turns out to be a 168 00:12:41,450 --> 00:12:45,170 Speaker 1: cause of disaster. That's very interesting, Galileo, please go on. 169 00:12:46,010 --> 00:12:49,890 Speaker 1: A large marble column was laid out so that its 170 00:12:49,930 --> 00:12:53,610 Speaker 1: two ends rested each upon a piece of beam. I 171 00:12:53,650 --> 00:12:56,650 Speaker 1: can picture that in my mind. Support the column while 172 00:12:56,650 --> 00:12:59,930 Speaker 1: it's being stored horizontally ready for use. If you lay 173 00:12:59,970 --> 00:13:02,330 Speaker 1: it on the ground, it may get stained and you'll 174 00:13:02,330 --> 00:13:04,850 Speaker 1: probably break it when you try to get ropes underneath 175 00:13:04,890 --> 00:13:08,410 Speaker 1: it to pull it upright. So yes, store it flat, 176 00:13:09,130 --> 00:13:11,610 Speaker 1: but propped up by a support at one end and 177 00:13:11,650 --> 00:13:15,050 Speaker 1: a support at the other. But what if the column 178 00:13:15,170 --> 00:13:18,450 Speaker 1: can't support its own weight like that and simply snaps 179 00:13:18,490 --> 00:13:23,170 Speaker 1: in half? Galileo has thought of that. A little later, 180 00:13:23,850 --> 00:13:26,890 Speaker 1: it occurred to a mechanic that in order to be 181 00:13:26,970 --> 00:13:30,050 Speaker 1: doubly sure of it's not breaking in the middle, it 182 00:13:30,090 --> 00:13:34,090 Speaker 1: would be wise to lay a third support midway. This 183 00:13:34,330 --> 00:13:39,610 Speaker 1: seemed to all an excellent idea. Yes, if two supports 184 00:13:39,610 --> 00:13:43,210 Speaker 1: are good, surely three supports are better. It was quite 185 00:13:43,250 --> 00:13:46,970 Speaker 1: the opposite, for not many months past before the column 186 00:13:47,010 --> 00:13:52,090 Speaker 1: was found cracked and broken exactly above the new middle support. 187 00:13:53,530 --> 00:13:56,370 Speaker 1: How did that happen? One of the end supports had, 188 00:13:56,490 --> 00:14:00,930 Speaker 1: after a long while, become decayed and sunken, but the 189 00:14:01,130 --> 00:14:05,610 Speaker 1: middle one remained hard and strong, thus causing one half 190 00:14:05,650 --> 00:14:08,770 Speaker 1: of the column to project in the air without any 191 00:14:08,770 --> 00:14:14,850 Speaker 1: sup The central support didn't make the column safer. It 192 00:14:15,170 --> 00:14:18,290 Speaker 1: pressed into it, like the central pivot of a seesaw, 193 00:14:18,610 --> 00:14:24,210 Speaker 1: snapping it in half. Galileo's tail isn't really about storing columns, 194 00:14:24,210 --> 00:14:27,290 Speaker 1: and neither is mine. It's about what I'm going to 195 00:14:27,370 --> 00:14:32,290 Speaker 1: call Galileo's principle. The steps we take to make ourselves 196 00:14:32,290 --> 00:14:38,610 Speaker 1: safe sometimes lead us into danger. The problem Galileo described 197 00:14:38,930 --> 00:14:42,530 Speaker 1: is well known to safety engineers. There's an article in 198 00:14:42,570 --> 00:14:48,570 Speaker 1: the fine scholarly journal Process Safety Progress titled no good 199 00:14:48,610 --> 00:14:53,770 Speaker 1: deed Goes unpunished. Case studies of incidence and potential incidence 200 00:14:54,290 --> 00:15:01,050 Speaker 1: caused by protective systems. These case studies are magnificent. There's 201 00:15:01,130 --> 00:15:05,170 Speaker 1: a chemical plant where two pressure relief systems interact in 202 00:15:05,210 --> 00:15:09,490 Speaker 1: a way that means neither of them work. There's a 203 00:15:09,530 --> 00:15:13,930 Speaker 1: flare designed to destroy pollutants which ends up causing the 204 00:15:14,010 --> 00:15:19,490 Speaker 1: release of toxic gases. There's an explosion suppression device that 205 00:15:19,610 --> 00:15:24,010 Speaker 1: causes an explosion. This kind of thing happens more than 206 00:15:24,050 --> 00:15:28,610 Speaker 1: you might think. An example is one of the earliest 207 00:15:28,850 --> 00:15:34,170 Speaker 1: nuclear accidents at Fermi One, an experimental reactor in Michigan. 208 00:15:34,770 --> 00:15:38,370 Speaker 1: It's barely remembered now except in Gil Scott Heron's song 209 00:15:38,930 --> 00:15:42,970 Speaker 1: We Almost Lost Detroit. This time, the operators at Fermi 210 00:15:43,010 --> 00:15:46,730 Speaker 1: one lost control of the nuclear reaction for reasons that 211 00:15:46,810 --> 00:15:50,010 Speaker 1: were baffling to them. Some of the reactor fuel melted. 212 00:15:50,130 --> 00:15:53,490 Speaker 1: It was all touch and go. Eventually they got the 213 00:15:53,530 --> 00:15:57,570 Speaker 1: reactor under control, shut it all down, and waited until 214 00:15:57,570 --> 00:16:00,250 Speaker 1: it was safe to take it all apart. It was 215 00:16:00,330 --> 00:16:03,570 Speaker 1: almost a year before the reactor had cooled enough to 216 00:16:03,650 --> 00:16:07,890 Speaker 1: identify the culprit. A piece of metal the size of 217 00:16:07,930 --> 00:16:12,050 Speaker 1: a crushed beer had blocked the circulation of the coolant 218 00:16:12,410 --> 00:16:16,170 Speaker 1: in the reactor core. It was a filter that had 219 00:16:16,170 --> 00:16:19,730 Speaker 1: been installed at the last moment for safety reasons, at 220 00:16:19,770 --> 00:16:24,330 Speaker 1: the express request of the Nuclear Regulatory Commission. It had 221 00:16:24,330 --> 00:16:31,050 Speaker 1: come loose and caused the entire problem. Galileo's principle strikes again. 222 00:16:33,210 --> 00:16:38,610 Speaker 1: Why do safety systems sometimes backfire? The wise old sociologist 223 00:16:38,770 --> 00:16:43,690 Speaker 1: Charles Perot's most famous book is called Normal Accidents. It's 224 00:16:43,690 --> 00:16:48,690 Speaker 1: about how certain kinds of system are vulnerable to catastrophic failure, 225 00:16:49,370 --> 00:16:52,810 Speaker 1: so vulnerable, in fact, that we should view accidents in 226 00:16:52,850 --> 00:16:58,050 Speaker 1: those systems as inevitable. The vulnerable systems have two features. 227 00:16:58,650 --> 00:17:02,210 Speaker 1: The first is that they're what Pero calls tightly coupled. 228 00:17:02,770 --> 00:17:05,730 Speaker 1: In a tightly coupled system, one thing leads to another, 229 00:17:05,890 --> 00:17:09,770 Speaker 1: and another and another. It's like domino toppling, which is 230 00:17:09,890 --> 00:17:12,970 Speaker 1: actually a great example of a tightly coupled system. Once 231 00:17:13,010 --> 00:17:16,410 Speaker 1: you start, it's hard to hit the pores button. A 232 00:17:16,570 --> 00:17:21,730 Speaker 1: second feature is complexity. A complex system has elements that 233 00:17:21,890 --> 00:17:26,650 Speaker 1: interact in unexpected ways. A rainforest is a complex system. 234 00:17:26,930 --> 00:17:32,330 Speaker 1: So is Harvard University. But Harvard University usually isn't tightly coupled. 235 00:17:32,610 --> 00:17:35,690 Speaker 1: If there's a problem, there's also time to find a solution. 236 00:17:37,010 --> 00:17:42,570 Speaker 1: A system that's both complex and tightly coupled is dangerous. 237 00:17:43,210 --> 00:17:47,650 Speaker 1: The complexity means there will occasionally be surprises. The tight 238 00:17:47,730 --> 00:17:50,610 Speaker 1: coupling means that there will be no time to deal 239 00:17:50,690 --> 00:17:58,850 Speaker 1: with the surprises. Charles Perot's theory explains Galileo's principle. Every 240 00:17:58,890 --> 00:18:01,690 Speaker 1: time you add a feature that's designed to prevent a problem, 241 00:18:02,210 --> 00:18:06,770 Speaker 1: you're adding complexity. The middle support for the column added complexity, 242 00:18:07,370 --> 00:18:10,610 Speaker 1: so did the safety filter that image the Fermi one reactor. 243 00:18:11,450 --> 00:18:22,210 Speaker 1: Safety systems don't always make us safe. Here's the question 244 00:18:22,250 --> 00:18:25,490 Speaker 1: we should be asking about that bizarre evening at the Oscars. 245 00:18:26,290 --> 00:18:30,810 Speaker 1: How was it even possible for the distracted accountant Brian 246 00:18:30,890 --> 00:18:35,610 Speaker 1: Cullenan to give Warren Beatty the wrong envelope a few 247 00:18:35,610 --> 00:18:40,010 Speaker 1: minutes earlier, the envelope for Best Actress, the envelope containing 248 00:18:40,010 --> 00:18:43,690 Speaker 1: the card that read Emma Stone La La Land. That 249 00:18:44,090 --> 00:18:47,890 Speaker 1: envelope had been in the hands of Leonardo DiCaprio as 250 00:18:47,970 --> 00:18:52,010 Speaker 1: he stood on stage announcing her win. How could that 251 00:18:52,490 --> 00:18:55,530 Speaker 1: envelope have made its way into the hands of Warren Beatty. 252 00:18:56,410 --> 00:19:03,970 Speaker 1: The answer it didn't. There were two envelopes. Every envelope 253 00:19:04,450 --> 00:19:08,410 Speaker 1: for every category had a duplicate version waiting in the wings. 254 00:19:08,850 --> 00:19:12,770 Speaker 1: These duplicate envelopes were there as a safety measure, and 255 00:19:12,970 --> 00:19:18,770 Speaker 1: that safety measure is what made the fiasco possible. Galileo's 256 00:19:18,810 --> 00:19:24,810 Speaker 1: principle had bitten hard. Charles Perrot's argument is that when 257 00:19:24,970 --> 00:19:29,690 Speaker 1: systems are both complex and tightly coupled, we should expect 258 00:19:30,050 --> 00:19:35,010 Speaker 1: catastrophic accidents. Does the Academy Award ceremony fit that description. 259 00:19:36,050 --> 00:19:39,890 Speaker 1: It's certainly tightly coupled. You can't easily interrupt a live 260 00:19:40,090 --> 00:19:43,810 Speaker 1: TV spectacular in front of millions of people to ask 261 00:19:43,850 --> 00:19:48,690 Speaker 1: for advice. The show must go on. Yet the ceremony 262 00:19:48,730 --> 00:19:52,410 Speaker 1: doesn't have to be complex. Giving an envelope to Warren 263 00:19:52,450 --> 00:19:56,450 Speaker 1: Beatty doesn't have to be complex, but you can make 264 00:19:56,490 --> 00:20:01,250 Speaker 1: it complex if you try. Brian Cullenan's partner in crime 265 00:20:01,330 --> 00:20:05,210 Speaker 1: that evening was Martha Ruise. Like Cullenan, she was a 266 00:20:05,290 --> 00:20:09,690 Speaker 1: senior accountant. The pair of them carried identical brief cases 267 00:20:09,970 --> 00:20:13,610 Speaker 1: with an identical set of envelopes. On the day of 268 00:20:13,610 --> 00:20:16,210 Speaker 1: the show, we'll get the ballots and Brian and I 269 00:20:16,250 --> 00:20:19,170 Speaker 1: will go to the theater on two separate roads. He'll 270 00:20:19,210 --> 00:20:23,130 Speaker 1: go one route and I'll go another route. That's how 271 00:20:23,210 --> 00:20:27,650 Speaker 1: Martha Louise helpfully explain things to journalists. Just before Oscar night, 272 00:20:28,130 --> 00:20:32,090 Speaker 1: both she and Cullenan had been proudly giving interviews about 273 00:20:32,130 --> 00:20:35,810 Speaker 1: the full proof system. We do that to ensure that 274 00:20:35,890 --> 00:20:39,450 Speaker 1: in kiss anything happens to one, the other will be 275 00:20:39,490 --> 00:20:43,410 Speaker 1: there on time and delivering what's needed with the full set. 276 00:20:44,090 --> 00:20:47,130 Speaker 1: We do have security measures up until we're at the 277 00:20:47,130 --> 00:20:51,610 Speaker 1: theater and delivering that envelope to the presenter just seconds 278 00:20:51,690 --> 00:20:55,530 Speaker 1: before they walk on stage. We'll be in two different locations. 279 00:20:55,650 --> 00:20:59,650 Speaker 1: Brian will be on stage right and I'll be on 280 00:20:59,690 --> 00:21:03,970 Speaker 1: stage left. It all sounds sensible, and in many ways 281 00:21:04,330 --> 00:21:10,330 Speaker 1: it is sensible. It's also complicated. The system of twin 282 00:21:10,490 --> 00:21:14,610 Speaker 1: envelopes meant that every time an envelope was opened on stage, 283 00:21:15,050 --> 00:21:18,210 Speaker 1: its duplicates in the wings had to be set aside. 284 00:21:18,970 --> 00:21:23,330 Speaker 1: Martha Ruiz stage left handed the envelope for Best Actress 285 00:21:23,370 --> 00:21:28,370 Speaker 1: to Leonardo DiCaprio, leaving Brian cullenan stage right with a 286 00:21:28,490 --> 00:21:32,490 Speaker 1: job of discarding the duplicate, the job he failed to do. 287 00:21:33,170 --> 00:21:36,770 Speaker 1: If there hadn't been that set of twin envelopes, Warren 288 00:21:36,810 --> 00:21:41,050 Speaker 1: Beatty could never have been given the wrong one. So 289 00:21:41,610 --> 00:21:47,010 Speaker 1: bad design helped cause the Oscar fiasco. It also helped 290 00:21:47,090 --> 00:21:51,770 Speaker 1: cause the accident at three Mile Island, and a complicated 291 00:21:51,850 --> 00:21:55,250 Speaker 1: safety system was at the root of the Oscar fast 292 00:21:55,290 --> 00:21:58,490 Speaker 1: It was also at the root of the Fermi one accident. 293 00:21:59,410 --> 00:22:03,450 Speaker 1: But it's not just Oscar's and nuclear power. I promised 294 00:22:03,450 --> 00:22:07,690 Speaker 1: you a financial catastrophe two and in this one, both 295 00:22:07,850 --> 00:22:12,370 Speaker 1: safety systems and bad typography at a blame. He might 296 00:22:12,410 --> 00:22:15,570 Speaker 1: even start to see the banking crisis in a very 297 00:22:15,570 --> 00:22:23,290 Speaker 1: different light. In September two thousand and eight, at the 298 00:22:23,290 --> 00:22:28,130 Speaker 1: height of the financial crisis, an insurance executive named Robert 299 00:22:28,210 --> 00:22:33,370 Speaker 1: Willemstat requested a meeting with Tim Geitner. Geitner would later 300 00:22:33,410 --> 00:22:36,410 Speaker 1: be the Treasury Secretary. At the time, he was the 301 00:22:36,450 --> 00:22:40,490 Speaker 1: President of the New York Federal Reserve. That meant he 302 00:22:40,650 --> 00:22:45,570 Speaker 1: was responsible for supervising Wall Streets banks, including Lehman Brothers, 303 00:22:45,930 --> 00:22:50,370 Speaker 1: which was on the brink of collapse. Robert Willemstadt was 304 00:22:50,410 --> 00:22:54,330 Speaker 1: the boss of an insurance company called AIG, and since 305 00:22:54,490 --> 00:22:58,490 Speaker 1: AIG wasn't a bank, it was far from obvious why 306 00:22:58,650 --> 00:23:04,050 Speaker 1: Willemstadt was Geitner's problem. In his book Too Big to Fail, 307 00:23:04,370 --> 00:23:09,210 Speaker 1: the journalist Andrew Ross Sorkin reports the intimate details of 308 00:23:09,330 --> 00:23:13,450 Speaker 1: this ill fated meeting. I'm really sorry, mister Willem's dead. 309 00:23:13,610 --> 00:23:16,610 Speaker 1: Mister Gattner's going to be a few minutes, no problem, 310 00:23:17,290 --> 00:23:20,450 Speaker 1: I have time. I'm sorry. I know you've been waiting 311 00:23:20,490 --> 00:23:23,690 Speaker 1: a long time. Mister Gattner's on the phone to the 312 00:23:23,850 --> 00:23:27,730 Speaker 1: boss of Layman Brothers. He's up to his arboles and Layman. 313 00:23:28,730 --> 00:23:32,690 Speaker 1: Tim Geitner was also exhausted. He'd been on an overnight 314 00:23:32,770 --> 00:23:35,610 Speaker 1: flight from a banking conference in Switzerland. He must have 315 00:23:35,690 --> 00:23:40,930 Speaker 1: felt completely overwhelmed. Who wouldn't have, Bob, is it sorry 316 00:23:40,930 --> 00:23:44,650 Speaker 1: to keep you waiting coming? Willemstad got his moment. He 317 00:23:44,890 --> 00:23:47,570 Speaker 1: badly needed to be able to borrow from the FED, 318 00:23:48,170 --> 00:23:51,930 Speaker 1: not normally something AIG would be allowed to do, But 319 00:23:52,010 --> 00:23:55,410 Speaker 1: he also didn't want to panic Geitner. He needed to 320 00:23:55,450 --> 00:23:59,370 Speaker 1: walk a tight rope to suggest that AIG could use 321 00:23:59,410 --> 00:24:03,650 Speaker 1: some help that wasn't actually bankrupt. Is this a critical 322 00:24:03,770 --> 00:24:08,130 Speaker 1: or emergency situation, Bob? Well, you know, let me just 323 00:24:08,170 --> 00:24:12,370 Speaker 1: say that it would be very beneficial to AIG. Mister Gaigner. 324 00:24:13,290 --> 00:24:16,530 Speaker 1: Perhaps I can leave us with you. William Stat handed 325 00:24:16,570 --> 00:24:21,170 Speaker 1: Gaigner a briefing note. Buried deep within it was a 326 00:24:21,170 --> 00:24:25,890 Speaker 1: fast ticking time bomb. The largest firms on Wall Street 327 00:24:26,210 --> 00:24:31,130 Speaker 1: were relying on AIG to pay out on insurance against 328 00:24:31,170 --> 00:24:36,450 Speaker 1: financial trouble. The total sum insured was a truly ludicrous 329 00:24:36,890 --> 00:24:43,970 Speaker 1: two thousand, seven hundred billion dollars. AIG couldn't possibly pay 330 00:24:44,050 --> 00:24:47,010 Speaker 1: if all the claims came in, and it was starting 331 00:24:47,050 --> 00:24:51,250 Speaker 1: to look as though they might. But that meant that 332 00:24:51,290 --> 00:24:54,810 Speaker 1: the big Wall Street banks wouldn't get the insurance payments 333 00:24:54,810 --> 00:24:58,610 Speaker 1: they were relying on. AIG was both a bigger threat 334 00:24:58,650 --> 00:25:01,730 Speaker 1: to the financial system than Lehman Brothers and a far 335 00:25:01,810 --> 00:25:06,290 Speaker 1: more surprising one. If AIG was a safety net, it 336 00:25:06,450 --> 00:25:10,010 Speaker 1: was one that wasn't going to break anyone's fall. But 337 00:25:10,330 --> 00:25:14,410 Speaker 1: to realize that, Tim Geitner would actually have to read 338 00:25:14,570 --> 00:25:18,610 Speaker 1: and absorb the information in the note, and he was busy, 339 00:25:19,530 --> 00:25:24,530 Speaker 1: really busy, so instead he filed it away and turned 340 00:25:24,570 --> 00:25:28,690 Speaker 1: back to the Lehman Brothers problem. AIG would melt down 341 00:25:28,810 --> 00:25:33,890 Speaker 1: a few days later. The parallels with oscarnite are uncanny. 342 00:25:34,770 --> 00:25:38,650 Speaker 1: For one thing, Geitner, who's no fool, had no idea 343 00:25:38,810 --> 00:25:42,250 Speaker 1: how to interpret what he was looking at. It was unexpected, 344 00:25:42,370 --> 00:25:45,290 Speaker 1: and the key information was buried in the small print. 345 00:25:45,970 --> 00:25:50,330 Speaker 1: Fade unaway and Warren Beatty know the feeling. Then there's 346 00:25:50,370 --> 00:25:55,970 Speaker 1: Galileo's principle. Safety systems don't always make us safe. Those 347 00:25:56,090 --> 00:26:00,810 Speaker 1: insurance contracts were supposed to offset risk, not create it, right, 348 00:26:01,610 --> 00:26:05,050 Speaker 1: But by now we know that safety systems also introduce 349 00:26:05,330 --> 00:26:09,730 Speaker 1: new ways for things to go wrong. The insurance contracts 350 00:26:09,890 --> 00:26:14,690 Speaker 1: that were about to destroy AIG were called credit default swaps. 351 00:26:15,490 --> 00:26:18,730 Speaker 1: They'd become popular as a way to offset risk with 352 00:26:18,850 --> 00:26:22,890 Speaker 1: the blessing of regulators. They seemed a smart idea, just 353 00:26:22,970 --> 00:26:25,890 Speaker 1: as the third support for the columns seems like a 354 00:26:25,930 --> 00:26:29,210 Speaker 1: smart idea, and the metal filters at the Fermi reactor 355 00:26:29,530 --> 00:26:34,090 Speaker 1: and the duplicate set of award envelopes, but they backfired. 356 00:26:35,090 --> 00:26:38,530 Speaker 1: Wall Street banks were relying on these credit default swaps 357 00:26:38,610 --> 00:26:41,850 Speaker 1: to keep them safe if there was trouble. When it 358 00:26:41,890 --> 00:26:46,610 Speaker 1: became clear that insurance companies such as AIG couldn't possibly 359 00:26:46,650 --> 00:26:50,090 Speaker 1: pay out, the banks all scrambled to sell off their 360 00:26:50,210 --> 00:26:54,170 Speaker 1: risky investments. At the exact same time for the exact 361 00:26:54,290 --> 00:26:58,930 Speaker 1: same reason. A few days after Willemstadt had met Geitner, 362 00:26:59,490 --> 00:27:02,730 Speaker 1: officials and bankers worked through the weekend on the Lehman 363 00:27:02,770 --> 00:27:07,250 Speaker 1: Brothers problem. Only on Sunday evening did one of those 364 00:27:07,290 --> 00:27:11,610 Speaker 1: bankers receive a request a Treasury official to ask if 365 00:27:11,650 --> 00:27:16,890 Speaker 1: she could drop everything and work on rescuing AIG instead. 366 00:27:18,010 --> 00:27:21,290 Speaker 1: The surprising phone call was greeted with a response that 367 00:27:21,450 --> 00:27:27,090 Speaker 1: was unsurprisingly unsuitable for family ears. Hold on, hold on, 368 00:27:27,570 --> 00:27:30,250 Speaker 1: you're calling me on a Sunday night, saying that we 369 00:27:30,370 --> 00:27:33,090 Speaker 1: just spent the entire weekend on laymen and now we 370 00:27:33,170 --> 00:27:35,850 Speaker 1: have this. How the fuck did we spend the past 371 00:27:35,930 --> 00:27:40,450 Speaker 1: forty eight hours on the wrong thing? How indeed, for 372 00:27:40,490 --> 00:27:43,650 Speaker 1: the same reason, they gave the oscar to the wrong movie, 373 00:27:44,210 --> 00:27:49,210 Speaker 1: confusing communication, and above all, a safety system that created 374 00:27:49,330 --> 00:27:54,890 Speaker 1: a brand new way to fail. The banking crisis of 375 00:27:55,010 --> 00:27:58,730 Speaker 1: two thousand and eight shook the world financial system and 376 00:27:58,810 --> 00:28:02,850 Speaker 1: destroyed millions of jobs. More than a decade later, we're 377 00:28:02,930 --> 00:28:06,850 Speaker 1: still living with the consequences. It was, in its way, 378 00:28:07,330 --> 00:28:11,530 Speaker 1: a more serious crisis than any nuclear accident. It was 379 00:28:11,570 --> 00:28:15,290 Speaker 1: certainly far graver than a bungle at the Oscars. Yet 380 00:28:15,410 --> 00:28:19,050 Speaker 1: the same problems were at the roots of all these accidents. 381 00:28:20,490 --> 00:28:24,890 Speaker 1: After the La La Land shambles, Vanity Fair reported the 382 00:28:25,050 --> 00:28:30,410 Speaker 1: Oscars have an intense six step plan to avoid another 383 00:28:30,730 --> 00:28:35,690 Speaker 1: envelope disaster. The six steps include getting rid of the 384 00:28:35,770 --> 00:28:40,610 Speaker 1: two accounting partners, Brian Cullenan and Martha Ruise, and the 385 00:28:40,690 --> 00:28:46,170 Speaker 1: twin sets of envelopes. Instead, says Vanity Fair, there will 386 00:28:46,210 --> 00:28:50,370 Speaker 1: be three partners. A third partner will sit in the 387 00:28:50,370 --> 00:28:54,050 Speaker 1: show's control room with the producers. All three partners will 388 00:28:54,090 --> 00:28:59,090 Speaker 1: have a complete set of envelopes. If having two sets 389 00:28:59,290 --> 00:29:04,250 Speaker 1: caused the problem, having three sets is better, right. I'm 390 00:29:04,250 --> 00:29:15,530 Speaker 1: not sure Galileo would agree. You've been listening to cautionary tales. 391 00:29:16,090 --> 00:29:18,330 Speaker 1: I expand on some of the ideas in this episode 392 00:29:18,410 --> 00:29:23,050 Speaker 1: in my book adapt You might like It. Cautionary Tales 393 00:29:23,170 --> 00:29:27,370 Speaker 1: is written and presented by me Tim Harford. Our producers 394 00:29:27,410 --> 00:29:31,050 Speaker 1: are Ryan Dilley and Marilyn Rust. The sound designer and 395 00:29:31,130 --> 00:29:35,490 Speaker 1: mixer was Pascal Wise, who also composed the amazing music. 396 00:29:36,770 --> 00:29:41,650 Speaker 1: This season stars Alan Cumming, Archie Panjabi, Toby Stephens and 397 00:29:41,850 --> 00:29:47,370 Speaker 1: Russell Tovey, with enso Celenti, Ed Gochen, Melanie Gutteridge, Mercia Munroe, 398 00:29:47,770 --> 00:29:53,410 Speaker 1: Rufus Wright and introducing Malcolm Gladwell. Thanks to the team 399 00:29:53,450 --> 00:29:59,010 Speaker 1: at Pushkin Industries, Julia Barton, Heather Fane, Mia LaBelle, Carlie Milliori, 400 00:29:59,370 --> 00:30:03,450 Speaker 1: Jacob Weisberg and of course the mighty Malcolm Gladwell. And 401 00:30:03,570 --> 00:30:34,330 Speaker 1: thanks to my colleagues at The Financial Times,