THE OSCARS MIXUP–IT’S THE SYSTEM, NOT THE PEOPLE. There was a lot of excitement last night at the Oscars. La La Land was announced as the winner for best movie, but after some of the acceptance speeches had been given, it was announced that the presenters had been given the wrong envelope and that the correct winner was Moonlight. Here is a Daily Mail article that explains what happened and shows some of the A listers in the audience reacting to the events.

I did not see any of this nor have I read much in the extensive post mortems about why the event happened and who was at fault. But I think this is another example supporting a rule proposed by W. Deming Edwards, the guru for the quality movement of the 1980’s. Edwards preached that errors were the result of the system rather than the workers. I posted on the rule here.

I also posted here about what cardiac surgeons had learned from studying Formula 1 pit crew procedures.The surgeons concluded that the Formula 1 crew had done more anticipation of things that could go wrong and had done more choreographing and rehearsal of coordinated responses when things did go wrong

The Oscars have some of the same problems that pit crews have—tight time frames and little rehearsal.

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