I doubt that very much design thinking went into that card at all, to be honest. I’m not really that interested in assigning blame as I am in asking “How could this have been prevented?” Clearly, there are a multitude of answers there, as with any large scale team effort. But if desiging a better cue card could have prevented it (a possibility, in my opinion), it’s a valuable conversation to have.
And that’s as it should be. People don’t really think about the value of good design until they’ve experienced a real consequence of bad design.