Your delivery lead at a 200-person Melbourne transport operator needs a one-line change to a carrier contract by close of business. The RACI matrix names the commercial director, but that director is already offline for a family commitment and the backup is in another time zone.
The team defaults to the next person who replies in the group channel. That person has no budget delegation and no view of the downstream pricing impact, so they approve the variation to keep the trucks moving.
Three weeks later finance discovers the rate shift and the same delivery lead is asked why the model broke. The original decision log shows only a thumbs-up emoji from someone outside the formal chain.
Escalation rules were written for steady-state weeks. They assume the named owner will be reachable within the same working day and that every change arrives before lunch.
In practice the largest volume of urgent calls hits between 3:30 and 5:30 on Thursdays and Fridays when leave balances are being protected and calendars are already cleared.
The operating model therefore rewards the person who stays logged in rather than the person who carries the consequence. Over time that selects for availability theatre instead of accountable judgement.
Fixing it requires mapping authority to time-of-day and day-of-week, not just to role titles. Until that happens every Friday 4pm fire drill will still be signed off by whoever happened to be watching their notifications.