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