This year’s Oscars and the Best Picture mix-up gave me the perfect excuse to explore one of my favourite topics – how humans make mistakes and why we so often, fail to prevent them.

As everyone not currently living in a jungle without access to electronic media knows, the wrong movie was announced for best picture because the wrong envelope was given to presenter Warren Beatty.

It seems so simple – a distracted PwC representative (and who wouldn’t be in that environment) hands the wrong envelope to Warren Beatty. Simple human error, right? Shoot the perpetrator and move on… Yes and no.

When something like this happens, the media (and many of us) howl for someone’s head because – we collectively wonder – “How could they stuff up so badly?”

The more spectacular the mistake, the more vengeance that is demanded and despite living in the Internet age and considering ourselves socially evolved, many still want blood in some form when someone makes a mistake, commits a crime or causes an accident. (Just listen to the fans at a sports event when the umpire gets a decision wrong!)

The urge to punish, harks back to the beginning of human history and is demonstrated by the masses that until relatively recently in our history, would come out to witness witch burnings, beheadings or hangings, regardless of whether the ‘guilty’ person was in fact guilty.

The problem is that while vengeance or punishment might be satisfying and can have a damping effect on the intentional violation of rules, (although if it was really effective we would have no-one in prison) it is entirely ineffective in preventing mistakes.

Mistakes are a normal result of the limitations of human cognition. We all make mistakes. Mistakes come in many forms but essentially, are an unintended outcome from a specific action.

So can we prevent mistakes? No – and anyone who tells you otherwise, does not understand human cognitive limits and the behaviour that can follow.

It is quite simply impossible to create a mistake-free world, but we can do a pretty good job of preventing mistakes from having a negative outcome, by creating systems and processes that trap them. It is in this that PwC seems to have failed spectacularly. How?

For convenience, they had a system of duplicate envelopes with the details of the winners in each category and this allowed presenters to enter from different sides of the stage, presumably to make the flow on and off stage, more efficient.

However, this was such an obvious opportunity for error to creep in, it should have been held in check by a protective system – perhaps something as simple as disposal of the spare envelopes, following the announcement of each category. Had this happened, no amount of distraction would have caused the eventual chaos and embarrassment that occurred, and the PwC representatives would not have to be in hiding…

So, as we slowly put down the flaming torches and pitchforks, it might be helpful to work out where the human error sequence actually began. After all, this is the only way to prevent the same thing from happening again.

In reality there were numerous places where this error might have been trapped and embarrassment avoided – beginning with the design of the process for handing out the envelopes, the lack of a 2-person verification system as each category approached and finally the lack of an envelope disposal system, as each category was announced.

The person handing the envelopes to the presenter, was simply the last domino to fall. Laying all the blame at the feet of the PwC person handing out the cards may be convenient but will not solve the problem of a re-occurrence. The system needs to be changed.

This is where cries of derision usually erupt, objecting to ‘blaming the system’ for our own faults and yet this is an approach that can dramatically reduce mistakes which create negative outcomes and in fact, has transformed safety in many industries, beginning with aviation, which has become the safest form of transportation ever devised.

In aviation safety, the concept of ‘pilot error’ was retired long ago (although the media doggedly hangs onto it for effect) and instead, the entire environment in which mistakes occur is scrutinised, sometimes beginning as far back as the design of the aircraft. Aviation leads the world in the understanding of what we call Human Factors – the cognitive and behavioural weaknesses in humans, that lead to mistakes and in creating systems that trap errors before they cause harm. We proceed with the absolute certainty that humans are incredibly creative and will, inadvertently, find a way around whatever error prevention process we put in place, so we diligently work to create layered defences of processes, actions, double checks and warnings that keep us all safe in the air. Importantly, pilots and engineers are usually not punished for mistakes (as distinct from intentional violations) and are encouraged to self-report errors so that lessons can be learned.

How effective is this approach to preventing negative outcomes from mistakes?

In 2015 3.2 Billion people flew on the world’s airlines yet there was not a single loss of a jet airliner and no resulting deaths. In the same period 1.2 million people died on the world’s roads. That’s quite a contrast…

So next time you are tempted to unload on your favourite error-prone employee, ask yourself, “How much of this do I (or the organisation) own?” Then set about examining the whole picture, not just the hapless individual in your cross-hairs.