Typical Accident Causation Factors Seen in the Kohaku Kendama Failure Scene

Just as the New Year began, we had an earthquake, followed by an aircraft collision at Haneda Airport, causing a major stir. It is a double punch of truly painful events. I imagine many people are feeling the same heartache at this series of tragedies that have instantly blown away the New Year's celebratory mood.

Regarding the Haneda Airport accident, I believe a detailed investigation will be conducted from here on, but it seems that everyone's interest in the mechanisms of the accident and measures for accident prevention is rising, with people asking, 'What exactly was the cause of the accident?'

At a time when attention is focused on 'why accidents happen,' it just so happens that at the end of last year, an accident that can be called a typical example of accident mechanisms unfolded right before many people's eyes.

That is, the Kohaku kendama failure scene.

Of course, I am not saying this is the cause of the Haneda Airport accident. However, since a typical example of general accident factors occurred just recently, I thought it might be worth sharing now that interest in accident prevention is high, so I am taking up this topic today.

To tell the truth, I did not watch Kohaku live. I didn't watch it, but my wife told me, 'The kendama failure scene is surreal, so you should definitely watch it,' so I watched it on recording. (Also, as I will mention later, it is an important point that at this stage, I was watching it with the information that 'the kendama failed'.)

So, what happened with the kendama at the 2023 Kohaku?

As many of you probably already know, I will explain it roughly.

First, this is a regular Kohaku project to achieve a new Guinness World Record for consecutive successful kendama catches.

While the song is being sung, this time 128 participants were to perform kendama one after another in succession. And if everyone succeeded safely, it would be a new Guinness record.

In the first try, the person around the third one failed immediately, but it seems that a failure before the 10th person can be retried once, so they immediately started over from the first person.

However, as early as the 16th person, a mistake occurred. The scene where the ball was dropped and they went to grab it with their hand was clearly shown on the broadcast.

Since I knew the information that 'the 16th person failed,' I intuitively felt, 'Wow, they definitely failed,' and that there was no way to make excuses for this.

However, in the program, from the 17th person onwards, as if nothing had happened, the kendama relay continued one after another. The 16th person who failed also immediately went out of frame and never appeared again. They just continued with successful kendama catches one after another without any special mention of the 16th person.

At this point, it is possible to interpret it as a policy of 'even if someone fails, let's keep going until the end'.

And then, they succeeded up to the last person (the singer). Here, surprisingly, a victory pose was made.

Well, but maybe the singer just didn't notice the failure either—.

However, the Guinness adjudicator's verdict was—surprisingly—"Great success, a new Guinness record!".

The venue was filled with a celebratory mood.

It seems that from the time of the broadcast, there were voices on social media saying things like, "Wait, didn't they fail?" but the on-site judgment was that it was a "great success."

And so, the program continued as if everything was fine.

However, about an hour later, the record was revoked after it was confirmed via video that it was indeed a failure.

Now, I think this was quite an instructive accident case. Moreover, the fact that this entire sequence of events took place in front of a crowd the size of a nation's population makes it an extremely rare accident.

What is interesting about this kendama accident is that with so many people watching, no one was able to stop it (at the time) and say, "They failed.".

In general, there is of course the possibility that a failure might go unnoticed, such as in competitions where judging is difficult or if one happens to look away at the moment of failure.

However, the subject this time was kendama, a simple competition, and since the failure was relatively obvious, it cannot be said that the judgment itself was particularly difficult.

Yet, there were a large number of people at the venue, including a Guinness adjudicator, and even so, it proceeded as if nothing had happened until the end, and to top it off, a successful verdict was issued.

It is impossible that no one was watching or that no one noticed. But it was declared a great success.

Isn't this quite terrifying?

For example, imagine if this wasn't kendama.

Imagine if everyone vaguely noticed that a part was missing but no one said anything and it was shipped as "ready," or if everyone noticed that a person's surgical site was wrong but no one said anything and the surgery went ahead anyway.

It could lead to a very serious accident, right?

But in reality, these kinds of accident sequences happen quite often.

It is the typical accident mechanism of "I felt something was wrong, but I couldn't speak up." This is exactly the phenomenon that occurred with the kendama incident.

Now, I am by no means making fun of the people who were on site. I am fully aware that I, Egusa, am only able to say this because I am looking at things calmly "after hearing the results."

In the medical field, they might say "looking at it retrospectively," but this simply means that a third party is looking at it after the fact from an advantageous position, like a bystander seeing more than the players. It is not that the people on site were foolish and the outsiders were smart.

In fact, if I had been there in real-time at that moment, I, Egusa, might have easily judged it a success as well.

Seeing the vivid form of that "accident demon" at the Kohaku site is the lesson we should learn from this incident.

For example, imagine you were the Guinness adjudicator at the Kohaku site at that time.

You are in the middle of the overwhelmingly glamorous Kohaku stage. It is an extraordinary scene that most people would never stand in.

And then, the challenge begins.

Wait, it looked like the 16th person might have failed, but the 17th person and beyond start immediately, so you cannot take your eyes off it, and your thoughts are not settled.

And every player continues to succeed one after another as if nothing happened.

Moreover, the final singer is also pumping their fist and looking smug.

The audience in the venue is not booing, saying "You failed!", but is watching with bated breath.

"So, what is your verdict!?"

In a long-running, live, nationwide broadcast with massive viewership, the camera and microphone are immediately pointed at you. The announcer and everyone else are smiling.

Now, can you say "It was a failure!" here?

It happened in an instant, and you might have misjudged it. Above all, no one else in the venue is giving off a "feeling of failure."

Given the rhythm of the program, you are not given time to deliberate. You are required to answer immediately.

Since it is a live broadcast, there is no room for correction, and the moment you open your mouth, the entire nation will immediately know every word you say.

Of course, one could say that a professional would be someone who gives a failure verdict regardless of all this.

However, even for a professional, when placed under this much pressure and caught in such massive cognitive dissonance, it is extremely difficult to decide whether you can still trust your own judgment.

You don't have to be a Guinness adjudicator to imagine the situation from their perspective.

Try imagining that you were the person who failed at number 16.

Your mind goes blank, thinking, 'I failed, this is bad.'

Just when you think it's all over, the next person, number 17 and onwards,continues as if nothing happened.

Perhaps you really should declare that you failed. But if things are just proceeding as normal, you might think it's not good to break that atmosphere.

Besides, since there is a Guinness adjudicator there, they will surely make an official failure judgment without me having to say anything.

So, I'll just quietly wait for the judgment.

You could even be the person around number 100.

I thought maybe the person near the beginning failed, but they were in a distant position, and everyone else is continuing as if nothing happened, so I guess I just have to do my job when my turn comes.

If it was a failure, someone else will surely say something.

You could even be someone in the audience.

I feel like the person at number 16 made a mistake, but they were far from the stage, so maybe I misread it.

Besides, the players seem to be continuing as usual, and the people in other areas aren't making a fuss, so I guess it's fine...

Of course, these are all psychological states imagined by Egusa, but I think it's a very plausible story. In fact, there was a failure, yet a success judgment was rendered.

In other words, it can be considered that for everyone involved, the conditions were set where they couldn't speak up even if they noticed a failure, due to the immense pressure of the extraordinary stage of Kohaku, the flow of the live broadcast which left no time for deliberation and forced decisions based on split-second intuition, and above all, the consideration not to break the atmosphere of the venue where 'nothing happened.' They thought, 'If it really was a failure, someone else would point it out.' Many people likely even corrected their own perception, thinking, 'Since no one else is pointing it out, I must have misread it.'

However, as I mentioned earlier, the fact that 'no one reports that something felt off' is a very dangerous and typical factor in accidents. Even if there is a lack of preparation or a mistake or error, the go-ahead is given based on the assumption that 'it will probably be fine'.

This can be said to be a problem with the magic of the setting rather than the individual abilities or attitudes of the people involved.

Regarding this Kohaku incident, I think that forcing an immediate judgment on that big stage is an excessively harsh condition.

No matter how well-trained the Guinness adjudicator may be, they are not usually judging in a situation where they are being filmed in extreme close-up for a live broadcast with such high ratings. Rather, it must be said that this was a unique situation where professionals could not fully utilize their professional skills.

The danger of forcing immediate judgments in rapid succession like this is known in the medical field, which is why a step called a 'time-out' has been introduced. It is a step where everyone stops what they are doing once before starting surgery to confirm important matters. It is wisdom born from knowing how starting surgery while in a rush can induce medical accidents. Even for professionals, a moment of calm silence is necessary for accurate judgment.

Although there was a momentary pause during the Kohaku kendama segment, the final judgment was demanded suddenly amidst the commotion following the victory pose, so it cannot be said that an environment of calm silence comparable to a time-out was achieved.

I think this year's Kohaku vividly demonstrated how such pressure for immediate decision-making can distort the accuracy of professional judgment.

So, that concludes my explanation of typical accident factors as seen through the Kohaku kendama incident.

The Haneda Airport accident might also reveal some kind of typical accident factor like this. Something along the lines of 'it will probably be fine'.

I hope that the structural problems will be brought to light here as well, rather than pushing the cause onto human error or the level of individual ability.

Because failing to learn from failure is a greater failure than the failure itself.

References

To learn about the importance of learning from such accidents and failures, I recommend 'Black Box Thinking'.

It explains the mechanisms of failure and accidents more carefully and in more detail than my rough explanation.

Also, to learn about the terror of shared illusions (collective illusions) like 'they probably didn't fail,' I recommend 'Collective Illusions: Conformity, Complicity, and the Science of Why We Make Bad Decisions.' (I like the original title 'Collective Illusions' better than the Japanese title.)

I have also written a review article.

In terms of medical safety classics, I suppose it would be 'To err is human'.

It is a famous book that widely disseminated the lesson that since human error is bound to happen, blaming it solely on individual carelessness or ability will not prevent future accidents.

However, it might be out of print, so it may no longer be in general circulation.

I mentioned it just in case, as it is a book that left an impression on me based on my past learning.

Afterword (Added on January 30, 2024)

Regarding this matter, a follow-up report has been released where you can read the comments from the 16th person who failed the Kohaku kendama challenge.

According to this, the 'movements when failing' and 'movements when a success judgment was given' were apparently decided in advance, and it seems the sequence of events was that this person followed those instructions by staying still when they failed, and then made a victory pose when the success judgment was given.

In other words, it was arranged so that he could not express his own personal will during the program in the first place. While this seems like an unavoidable arrangement considering it was a live broadcast, it also serves as a backstory that illustrates how significantly a situation where members cannot voice their opinions can lead things astray.