My fellow human factors specialist Steven Shorrock wrote an excellent blog about the incident at The Oscars where the wrong movie was initially awarded. Herein he describes what happened, and above all how it could happen. Basically the problem was in the design of the envelopes: the design of the envelopes for the various Oscar awards is identical. The only difference between the envelopes is the text that indicates the category. There is no other means of coding (e.g., colour, pattern) to indicate any difference. Although I am not aware of who was responsible for the design of the envelopes, the only barriers left to prevent handing the wrong envelope are thus the accountant (who was distracted), and in this case Warren Beatty. Warren seemed to have his doubts, but did get enough clues to stop the ceremony.

But….. it was just an award show, wasn’t it? Nobody got hurt, although the accountants of PWC were  threatened to death on social media. Now imagine the situation in a pharmacy. Numerous incidents are known where people died of getting the wrong medication or the wrong dose. We performed some (award nominated ;-)) research and redesign for medicine labels. Or imagine a control room where chemicals or inflammable fluids are blended. Drawing the wrong conclusion from information that is not well coded could result in disaster. Or the German train dispatcher who was distracted by a phone game and allowed two trains to access a single-track line, resulting in 12 deaths.

I rest my case: human centred design is essential (even in a game show).

[Photo: Craig Piersma CC BY-NC-ND 2.0 https://flic.kr/p/8NyHL6]