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Safeguard Magazine

The blame game

Remember how Warren Beatty read out the wrong winner at the Oscars? STEVEN SHORROCK says the incident and the response to it provide valuable lessons in building a just culture.

When the wrong Best Picture winner was read out live on air at the Oscars earlier this year, someone had to take the blame. Attention first turned to Warren Beatty and Faye Dunaway. They, after all, “touched it last”. But they had mitigating circumstances; they were given the wrong envelope. In any case, and perhaps more to the point, they are unsackable.

And so we go back a step, and ask: who gave the wrong envelope? Now we find our answer: the PricewaterhouseCoopers auditors Brian Cullinan and Martha Ruiz. Both were sacked from the role of overseer shortly after the mistake.

Three key charges are levelled against Cullinan. First, he gave the wrong envelope, confusing the right envelope and the spare envelope for an award just given. Second, Cullinan posted a photo of Emma Stone to his Twitter account just before his big mistake. Third, when the wrong Best Picture winner was read out, he didn’t immediately jump into action. And neither did Ruiz.

They had one job! And they messed up.

So what should be the response? The relevant concept here is “just culture”. In his book of that name Sidney Dekker says that “A just culture is a culture of trust, learning and accountability”. He outlines two kinds of just culture, retributive and restorative.


The first kind of just culture is retributive. According to Dekker, this asks:

  • • 
    Which rule is broken?
  • • 
    Who did it?
  • • 
    How bad was the breach, and what should the consequences be?
  • • 
    Who gets to decide this?

This is the typical form of just culture found for thousands of years in societies around the world. Most of us are familiar with this from being small children.

Dekker explains that with retributive just culture, we have three scenarios:

  • • 
    Honest mistake, you can stay.
  • • 
    Risk-taking, you get a warning.
  • • 
    Negligence, you are let go.

There are even commercialised algorithms to help organisations with this distinction and the appropriate response. David Marx’s Just Culture Algorithm advises to console true human errors, coach against risky behaviors, and ultimately discipline reckless behaviour.


If we look at the Oscars scenario, we can address the three charges made against Cullinan and Ruiz.

On the first charge – giving the wrong envelope – we can conclude that this is an example of an “honest mistake”. This honest mistake was influenced by a confusable spare set of envelopes. In human factors and psychology, we have researched and catalogued such actions-not-as-planned for decades through diary studies, experiments, report analysis, interviews and naturalistic observation. We have many terms for such an error, including “slip” and “skill-based error”.

In doctoral research that I began 20 years ago in the context of air traffic control, I developed a technique called “technique for the retrospective and predictive analysis of cognitive error” ( “TRACEr”). With TRACEr, we would probably classify this kind of error as Right action on wrong object associated with Selection error involving Perpetual confusion and Spatial confusion, which would be associated with a variety of performance shaping factors – aspects of the context at the time such as design, procedure, pressure and distraction.

We’ve all done it, like when you pick up the wrong set of near identical keys from the kitchen drawer, or the wrong identical suitcase from the airport luggage carousel. In stressful, loud, distracting environments and with confusable artefacts, the chances of such simple actions-not-as-planned increase dramatically.


On the second charge, some might argue that posing for a photograph and sending tweets just prior to handing out the Best Picture envelope counts as risk-taking, or even negligence. The TMZ gossip site wrote: “Brian was tweeting like crazy during the ceremony, posting photos … so he may have been distracted. Brian has since deleted the tweets.”

Meanwhile, People reported an anonymous source who claimed that “Brian was asked not to tweet or use social media during the show. He was fine to tweet before he arrived at the red carpet but once he was under the auspices of the Oscar night job, that was to be his only focus.” The source reportedly continued, “Tweeting right before the Best Picture category was announced was not something that should have happened.”

We can’t verify this but it is certainly sensible advice, bearing in mind what we know about distraction in safety critical industries and its role in accidents such as the 2013 train crash at Santiago de Compostela in which 79 people died.

But perhaps the acid test for this assertion is whether people would have said anything about that photograph or tweet had everything gone according to plan. Just culture requires that we isolate the outcome from the behaviour. Applying the definition and principles of retributive just culture, what we are interested in is the behaviour. If the right envelope had been given, then the photo on Twitter would likely have been retweeted hundreds or thousands of times, and reported on various gossip websites and magazines, with no judgement from the press and public about the wisdom of such an activity. Instead, the photo would have been celebrated, and any deviation from alleged instructions “not to tweet or use social media during the show” would have been laughed away.


The third charge, levelled at both accountants, was that they failed to respond in a timely manner on hearing La La Land read out instead of Moonlight. The prospect of an erroneous announcement was clearly imaginable to Cullinan and Ruiz, who spoke to the Huffington Post about this scenario just a week or so before that fateful night: “We would make sure that the correct person was known very quickly,” Cullinan said. “Whether that entails stopping the show, us walking onstage, us signalling to the stage manager – that’s really a game-time decision, if something like that were to happen. Again, it’s so unlikely.”

But could it be that, live on the night of the biggest show on earth, with the eyes of tens of millions upon them, they froze? Again, TRACEr might classify this as Omission – No decision – Decision freeze, with a variety of performance shaping factors such as stress and perhaps a lack of training (eg simulation or practice).

The “freeze” response is the neglected sibling of “flight” and “fight”, and occurs in traumatic situations. It’s the rabbit-inthe-headlights response. Many people involved in accidents and traumatic events have been known to freeze, including in aircraft accidents. It is a psycho-physiological response and few of us can claim immunity. If we take this as an example of freeze, associated with confusion, shock and fear, then can we say this is an “honest mistake”? Even this seems not to fit well, but for the sake of a retributive just culture process, let’s classify this omission as such (since it would seem hideously harsh to judge a psycho-physiological response as “risk taking” or “gross negligence”).


Now we have two counts of “honest mistake” for Cullinan and one for Ruiz, and one count for Cullinan where we are unsure of its classification. But if the tweet would not have been seen as a problem had the error not occurred, then no harsh personal responses are justified.

But they had one job! And, by Hollywood standards, such an important job! And it’s not like they are losing their actual jobs or their liberty. It’s hard to feel sorry for two well paid accountants, mingling with Hollywood celebs during one of the biggest shows on earth. And remember that the consequences for PwC are not insignificant. An unnamed source told People that “The Academy has launched a full-scale review of its relationship with PwC but it is very complicated.” So surely cancelling the involvement of the pair is justified, along with a few stories in the media?

Put aside for one moment that the duo are celeb-mingling accountants, and think of them as Brian and Martha – two human beings with families and feelings and ordinary lives outside of this extraordinary day. Most of us have experienced some kind of humiliation in life. It is deeply unpleasant and the memory can resonate for months, years, or a lifetime. Most of us, though, have not felt this humiliation in front of tens of millions of people on live TV, played back by hundreds of millions afterwards. Most of us have not been the subject of thousands of global news stories with front-page stories labelling us a “loser” and a “twit” and a “bungling bean counter”, with press hounding us and our families. Most of us have not been subject to hundreds of thousands of comments and memes on social media, nor have we needed bodyguards due to death threats. This is the reality for Brian Cullinan and Martha Ruiz.


There is another way, and according to Dekker this kind of just culture is restorative. Dekker says that a restorative just culture asks:

  • • 
    Who is hurt?
  • • 
    What do they need?
  • • 
    Whose obligation is it to meet that need?
  • • 
    How do you involve the community in this conversation?

Here we might say that those hurt might include the producers of La La Land and Moonlight, though neither have given that impression since the event. We might also list The Academy and PwC, in terms of reputational damage.

But the individuals most hurt are surely Brian and Martha. What do they need? We don’t know, but it is certain that their needs are not met by the response so far. Whose obligation is it to meet that need? Here one might say it is the obligation of The Academy and PwC, but we all have an obligation at least not to cause further harm.

The event may live on as an example to individuals and organisations in safety-critical, security-critical and business-critical industries when ordinary front-line workers get caught up in accidents that they never wanted to happen. Should we scapegoat pilots and air traffic controllers, or doctors and nurses, for actions and decisions taken with goodwill but with unintended consequences? Or should we seek to understand and redesign the system to increase the chances of success in the future? The choice will influence whether front-line workers disclose their “honest mistakes”, or cover them up.


In his book Black Box Thinking, Matthew Syed explains that “Failure is rich in learning opportunities for a simple reason: in many of its guises, it represents a violation of expectation. It is showing us that the world is in some sense different from the way we imagined it to be.”

The event is also a challenge to us, to society. Syed notes that “Society, as a whole, has a deeply contradictory attitude to failure. Even as we find excuses for our own failings, we are quick to blame others who mess up.” He continues, “We have a deep instinct to find scapegoats.” We are deeply hypocritical in our response to failure. He describes examples from healthcare and aviation, where, on reading or hearing about an accident, we feel “a spike of indignation”, “fury”, and a desire to stigmatise.

Paradoxically, the families of victims of accidents often have empathy for the front-line workers involved, and have a far more systemic view of the events than the general public, politicians, or – in many cases – official accident reports. This can be seen in the case of Martin Bromiley, whose wife died in a routine hospital accident in 2005. He went on to set up the Clinical Human Factors Group, and campaigns for just culture. It can also be seen in the families of those who died in the train crash at Santiago de Compostela in 2013, which was blamed on “human error” both in the press and in the official accident report. Following a review of the official accident report by the European Railways Agency, Jesús Domínguez, chairman of the Alvia victims’ association, told The Spain Report that “it confirms that the sole cause is not human error and that the root causes of the accident still need to be investigated”. On 28 July 2013, train driver Garzón Amo was charged with 79 counts of homicide by professional recklessness and an undetermined number of counts of causing injury by professional recklessness. The charges still stand today.

Of course, we cannot compare the outcome of The Oscars with any event involving loss of life. But the point is that our corporate and societal responses are similar, and have recursive effects, as Syed explains:

“It is partly because we are so willing to blame others for their mistakes that we are so keen to conceal our own. We anticipate, with remarkable clarity, how people will react, how they will point the finger, how little time they will take to put themselves in the tough, high-pressure situation in which the error occurred. The net effect is simple: it obliterates openness and spawns cover-ups. It destroys the vital information we need in order to learn.”


So we have two options available to us. According to Dekker, retributive justice asks who was responsible, and sets an example where those responsible have crossed the line. Restorative justice asks what is responsible, then changes what led up to the incident, and meets the needs of those involved. Both options can work and result in fair outcomes for individuals, but – especially outside of the judiciary – the latter is more effective and humane. If we want to learn and improve outcomes in organisations and society, the choice is clear: focus on human needs and on improving the system.

At the Oscars, the retributive route was chosen and got it badly wrong. In messy environments, blaming individuals for their actions-not-as-planned has destructive and long-lasting effects on individuals, families, professions, organisations, industries and society as a whole.

In the end, we all have one job. Our job is to learn.

Steven Shorrock is a human factors and system safety specialist with Eurocontrol, Belgium, and Adjunct Associate Professor at University of the Sunshine Coast, Australia. He is the co-editor of Human Factors and Ergonomics in Practice (CRC Press) and editor in chief of Eurocontrol’s HindSight aviation safety magazine. This is a slightly edited version of an article first published in his blog at in March 2017 and is reproduced with kind permission.

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