Alternative headline: “Poorly Designed Card Trips Up Beatty and Dunaway at The Oscars.” Or “A Bad Process Beats Warren Beatty Every Time.”
I'm in the Los Angeles area for some consulting work the next few days. I was happy that traffic from LAX seemed light because everybody in this area was home watching the Academy Awards on TV, or so it seemed.
I was with a colleague in the hotel bar when the chaos surrounding the Best Picture announcement took place:
Ah, that headline illustrates the tendency to ask “who?” instead of “why?”
In the “Lean management” approach, with roots in Toyota, the thought process is to look at systems and processes, rather than jumping to blame individuals (see this post, for example, or these others). The late quality guru W. Edwards Deming taught this as, well.
I'm sure you can find video of this on YouTube.
Note: I wrote and updated this post about a dozen times over an hour as new facts and insights came to light. That's not unusual when doing “root cause analysis” or “process improvement.”
This Variety article has video embedded, including the moment when the error was detected:
As this article says:
“There's commotion among the people standing behind him as a man wearing headphones appears and checks red envelopes being held by producers.”
Host Jimmy Kimmel asked, I think half jokingly, “Warren, what did you do????”
Ugh, more blame!
Somebody else is heard saying, during the confusion: “They read the wrong thing.” That's a factual statement. But, if the emphasis is on THEY, it's a blame statement. The real question is why the “wrong thing” was in their hands. Don't blame Beatty and Dunaway…. blame the process. Who designed this process? PWC? The Academy?
PricewaterhouseCoopers has apologized, by the way. PWC says they will investigate. I hope they ask “why?” and “how?” more than “who?” The Academy did not issue a statement.
Beatty explains what happened:
In the hour since this happened, it seems clear that Beatty and Dunaway didn't misread the card… it seems like they had the wrong envelope.
I see two different red envelopes/cards on stage during the chaos that occurred when they discovered the wrong winner had been read:
This tweet suggests that Emma Stone's winner card wasn't handed to her (is that the normal process?):
But Emma Stone said she was holding her winner's card… so was there NOT a card on stage that said “Emma Stone” when Beatty and Dunaway read it? Or there was a duplicate? How confusing.
Perez Hilton tweeted that the accountants, PWC, always have two sets of cards. I wonder why?
Having to “make sure” you're giving the right card to a presenter is also an accident waiting to happen, just as if a hospital tells nurses to “make sure” they are giving the right medication to a patient. Proper error proofing makes it difficult or impossible to do the wrong thing. That's a matter of system design, not “being more careful.”
This same thing about the dual cards was confirmed by a Facebook friend from LA who works in the entertainment industry:
Problem Solving and Prevention
When a mishap occurs, the key in a Lean mindset is to figure out why and how the problem occurred and then put “corrective action” in place to prevent future occurrences. Healthcare is still learning how to get good at this process, so they don't repeat the same mistakes over and over.
When the actor Dennis Quaid's twins were harmed by medical error, it was the exact same problem that occurred at other hospitals before, but healthcare (as a whole) didn't do enough to prevent future occurrences. They eventually did change the medication packaging, which is a good example of systemic improvement.
In a Lean culture, we make it hard for people to do the wrong thing… it's called “mistake proofing” or “error proofing” (read more about this).
In the problem solving process, we might ask “who, what, when, where, why, and how” — but the “who?” is more about “who was involved?” or “who discovered the problem?” not “who screwed up?”
In some of the initial local news reports, I give them credit for thinking about preventing future mishaps like this:
Good problem solving would ask how this happened. Was the Best Actress card with Emma Stone's name really left up on the podium?
If Beatty and Dunaway were confused because they saw “Emma Stone” and “La La Land” instead of just a movie's name, I wonder why didn't “pull the andon cord” (as we'd say in the Lean approach) and ask if something didn't seem right… they were only on TV in front of a global audience, so I understand the hesitance to say, “Hey, something is confusing here.”
Another Lean guy asked the same thing:
A “Lean culture” makes it safe for people to speak up without fear of being blamed or embarrassed. But again, most of us don't have the pressure of working on live TV.
Beatty did explain that he was a bit confused when he looked at the envelope… “that's why I looked at Faye,” but he didn't directly ask the producers something for help.
Somebody on ABC later said, “He was intentionally delaying and hoping somebody off stage would come in and help.” Good theory. But, the help came too late (in a Lean culture, the help comes immediately when you have a concern).
This tweet says Beatty whispered “it says Emma Stone”:
When I rewatched it, Beatty pulls out a card, looks at it (realizing it's wrong?), and then looks in the envelope as if there was going to be another card in there… the right one?
Apparently, it was the “Best Actress” envelope that he was holding… oops, that's a process problem. How was that card even up there? Was it on the podium? Handed incorrectly to Beatty as they walked out?
Here is the card that was supposed to have been read:
As I tweeted, “Best Picture” is in very small text at the bottom of the card… not the best possible design. That's like putting a medication name in really small letters on a bottle… a bad idea that's prone to error.
I'm jumping to solutions without fully understanding the current state process. but I think there's less risk of somebody accidentally reading “The Emmy goes to…” on this night. It should say “BEST PICTURE” in really big letters on the top of the card perhaps.
If Beatty and Dunaway had opened an envelope with a card that said “BEST ACTRESS” on top, would it have been much more clear that it was the wrong card? I think so.
I saw a good question about why this process isn't more electronic? Would that make it easier to “error proof” the process, or would that be prone to hacking?
What do you think? I won't be able to update this post during the day Monday as more details come out, so feel free to post comments.
I wish I could be there at “the gemba” to help do proper root cause analysis and process improvement. I'd be happy to have The Academy hire me to help them with processes for 2018… :-)
Watching again, I see the confusion on Beatty's face that was hard to pick up on real time (and I was only half watching). It was a but unfair to make Dunaway read the card, eh?
Are you able to use this mishap as a way of talking about errors, process, problem solving, root cause analysis, and problem prevention?
Scroll down to read updates and more thoughts in the comments section.
Related reading: Here is a post from a year later about their attempts to fix the process:What do you think? Scroll down to comment or share your thoughts and the post on social media. Don't want to miss a post or podcast? Subscribe to get notified about posts via email daily or weekly.