ကူးယူချက် 🔗
00:00:15
Speaker 1: Pushkin. This thing still on. Michael Lewis here. Guess what. I'm working on a second season of Against the Rules. I had so much fun doing season one that I decided to keep going. I'm back in the field with my producers, talking to people and poking around. The next season is going to be about coaches and why the role of coach has expanded so far beyond sports in American life. If everybody hates the ref, everyone seems to love the coach these days. In season two, I'm going to explore why it's out next spring. Meanwhile, I have something else for you to listen to. It's a new show from Pushkin Industries by a British writer I really admire. His name is Tim Harford. He's a familiar voice on the BBC. Whereas most recent series was about the modern inventions we might not have noticed but would shape our lives, this new show from Tim is called Cautionary Tales, and it's full of spectacular stories about other people's mistakes, my favorite kind of mistakes. Tim and his team of actors re enact airship disasters and great frauds and safety systems gone awry, and then he tells us what we can learn from it all. We've got one of the first episodes right here. This one is an unbelievable story about an enormous tanker about to crash into the coast of England. Give it a listen, then go subscribe to Cautionary Tales wherever you listen to your podcasts to hear more from Tim. And I promise I'll be back in this feed before you know it. Here's Tim Harford. I opened the wrapping paper hurriedly with nervous hands, excited to get at the gift inside. Little did I know, disaster was about to enter my previously happy childhood. It wasn't a disaster visited on mean or my family. It was a catalog of disasters for everyone else. For the gift was a book, and it was titled, in bold letters on a blood red background, the World's Greatest Mistakes. The stories were set out like a trashy and exciting tabloid newspaper. Some were absurd, like the bride who accidentally married the best man. Some of them were famous tragedies, the Titanic slipping beneath the icy sea, funny or sad. All of them fascinated me, and I realized something that has guided me throughout my life. Learning from other people's mistakes is a lot less painful than learning from your own. My name is Tim Harford. Some people call me the undercover Economist. I use scientific ideas to help people think more clearly about the world in my books, my ted Talks, my BBC shows, and my column for the Financial Times. That may sound all very grown up, but part of me is that little boy who loved stories of catastrophe, mistake and mayhem. So I still seek out and collect such stories, but now I probe the details. I challenge the orthodox view and look for the root causes and ponder how disaster could have been prevented. In short, I look for the painless lessons they can teach me. And now I want to share some of these cautionary tales with you too. Each story has a moral, each story is true, and each story, if you're not careful, could happen to you. So gather closer and I'll begin. We pray thee Lord, not that rex should happen, but that if any Rex do happen, thou wilt guide them to the silly isles for the benefit of the poor. Inhabitants. That's an old prayer from the Isles of Scilly. The isles are just off the coast of Cornwall, the southwest tip of Great Britain, and that prayer has been answered many times. The rocks around the islands have a fearsome reputation and it's well earned. One autumn night in seventeen oh seven, the Royal Navy lost its way in a storm. The flagship HMS Association struck a rock and went down in minutes. Eight hundred men drowned behind it. HMS Saint George hit the rocks and became stuck. So did HMS Phoenix, did HS Firebrow. HMS Romney lost her entire crew. HMS Eagle was shattered on the cruel stone. Hundreds more sailors died. That dreadful night was one of the worst disasters in the history of the British Navy. Local legend has it that there was one notable survivor, that the Commander in Chief of the British Fleets, Sir Cloudsley Shovel, was washed up on the beaches of the Aisles of Scilly, but was strangled by a local woman who fancied wearing his Emerald ring herself if she had been praying the old prayer God or the devil had been listening. It is a dark tale, but the story I shall tell you today is a far stranger one. It was some time after dawn on Saturday March the eighteenth, nineteen sixty seven. Martyr Christie was a langoustier, a French lobster boat, fishing for crayfish and crab between the mainland and the Isles of Scilly. Twenty one miles further west on deck was Captain Gui Folich, another langoustier, was near by, both of them enjoying rich pickings. A few hundred yards north of the Seven Stones. The Seven Stones make up a vicious reef about one third of the way between the Isles of Scilly and the mainland. At low tide, the unyielding rocks are visible, but even at high tide there marked by a lighthouse vessel warning ships to stay away. Gui Folich looked up from his lobster lions to see an unexpected sight, a vast black hull coming over the horizon from an unusual direction. He was surprised. A major vessel in that position would usually have passed outside of the aisles of Scilly rather than squeezing between them and the mainland. True, a big ship could come between the aisles of Scilly and the mainland, passing on either side of the seven Stones, but it would be a little on the tight side. And this ship, a supertanker, was very big. Indeed, in fact, it was the thirteenth biggest ship in the world. On the lighthouse vessel, the two seamen on watch saw the tanker approaching too. Have you seen this? Have you? Yeah? Look at that big bastro coming up. Gifolich could see the huge ship coming straight towards him as he fished kayak, but he wasn't worried. In between him and the oncoming juggernaut were the seven Stones. He later said, I was sure that before ever eating us, you would go on to
Load full transcript
the rugs. He yelled to his men, stop work, you're going to see something extraordinary. All seven of them lined up on the rail of Marta Christie to watch the oil tanker bear closer and closer, four miles, three miles. Folich was sure it was doomed. It just wasn't possible to turn a supertanker that quickly. Was it? Actually? Folich wasn't quite right. The tanker, whose name was Torry Canyon did still have room to turn. This wasn't a storm tossed fleet of sailing ships fumbling through the darkness. The weather was good, the visibility was good. Torry Canyon was a superb ship, in fine working order and armed with radar. The seven Stones were clearly marked on every chart, as well as being identified by the position of the lighthouse vessel. But Tory Canyon still wasn't turning. Gather close and listen to my cautionary tail. Nobody knew it at the time, but the trouble all started with a radio message from milford Haven, the harbor towards which Torry Canyon was sailing. Milford Haven is a major UK port, and the thing you need to know about ports in the UK is that the difference between high tide and low tide can be enormous. What's more, there are high tides and high tides, some are higher than others. The message from Milford Haven was simple enough. Torry Canyon needed to hurry. If the ship didn't arrive by eleven pm on Saturday evening, March the eighteenth, nineteen sixty seven, it would miss the extra high tide wouldn't be able to slip into the harbor and dock. It would then have to wait another six days before the tide would once more be high enough. Missing the eleven pm deadline would mean a very expensive delay. That news put Captain Pastrengo Rugiati under pressure. He had no more than one or two hours margin, not a lot, but Rujiahti had coped with worse. He'd been a navigator on an Italian submarine during the war, had survived a German prison camp, and had been commanding oil tankers for twenty years. Captain Rujati was in many ways a genial fellow, chatty and hospitable. He liked to eat good food, but insisted he shouldn't be served anything that wasn't available to his crew. As a result, the men on Torry Canyon ate very well. But Rujiahti was also a detailsman who kept a close eye on his officers. Rugiasty was extremely conscientious. He was a man who wanted to know absolute, loutely everything. Perhaps because of that, Ruggiati stayed up late on the Friday night before landfall preparing the paperwork for when they docked. It was only at half past three in the morning that he went to bed, leaving instructions that he was to be awakened first thing when the Aisles of Silly were sighted. It was half past six in the morning when the Aisles of Scilly appeared on the radar, about thirty five miles away. First Officer Silvano Bonfilio was on duty, and the position of the ship relative to the Isles of Scilly was an unpleasant surprise. Torry Canyon, plowing through the night across the ocean had been pushed off its intended course by the current and the winds. It was now headed between the islands and the mainland. Bonfilio immediately changed course, steering away from the channel, figuring that Captain Rugiati had intended to pass outside of the islands, but he hedged his beds. Rather than out to sea or closer to the mainland, he was bearing straight towards the Isles of Scilly. He then woke up Captain Ruggiati. Rugiati was angry. Was it because Bonfilio had changed course without checking, Was it because the new course was neither one thing nor another? Or was he just sleep deprived will our original heaving of eighteen degrees be free of the Sillies? Yes, then continue on course eighteen degrees. I intend to pass to the starboard of the Silly Isles. When Filio was so surprised he had to check that it understood the order, which irritated Ruggiati. Still further Still, a maneuver shouldn't be too perilous. It was perfectly possible to get even a large ship through. The standard manual for navigating the waters around the coast of the British Isles is called the Channel Pilot. If Captain Ruggiati had consulted a copy, here's what it would have said. The actual width of the channel between the nearest of the Silly Islands and Land's End is twenty one miles, but as the route taken by all large vessels should be eastward of seven stones light vessel, the navigable channel can only be considered as twelve miles wide. The lights render the passage perfectly simple at night as well as by day in ordinarily clear weather. But as there is no part of the coast of England more subject to sudden changes of weather, the greatest vigilance is necessary and a vessel's position, even in the clearest weather, should be checked by cross bearings at short intervals. But Captain Rugiati Alas did not have a copy of the channel pilot on board, and so he missed two important pieces of wisdom. First, if you want to go between the Isles of Scilly and the mainland, be careful. Second, pass between the mainland and the seven Stones. There is an alternative route between the seven Stones and the Aisles of Silly themselves, but the channel pilot doesn't mention it because it's narrower, six and a half miles wide rather than twelve. Why take the narrower channel when you could take the broader one. Of course, you could still fit an oil tanker through the narrower gap, even an oil tanker that's nearly as big as the Chrysler building, but you'd be cutting it close. You'd be better and nothing went wrong. Inertia is a powerful thing. That's true for an oil tanker the size of Torry Canyon, which needed nearly five minutes to make a ninety degree turn, during which time it would travel a mile and a half at cruising speed. But inertia is a powerful thing for humans. Too. We also sometimes struggle to change course. Psychologists have identified a strong bias towards the status quo. For example, whether we sign up for a workplace pension plan or not seems to depend on whatever the status quo is. If the default
option is to sign up, we sign up. If the default is to stay out, we stay out. As I say, inertia is powerful. Psychologists who study accidents have a name for a particular form of inertia. They call it plan continuation bias. It's best known in aviation. Pilots form a plan and then are reluctant to change it, even if the circumstances suggest they should. The pilots themselves have another name for it, get their itis. The classic form of get their itis is an approach to an airfield with a storm coming in. If you and well before the storm arrives, no problem. If the storm arrives before you land, that's not a crisis either. It's a hassle. You have to divert to another airfield, with all the delay, expense and annoyance that implies. But you do it because you don't want to fly into a dangerous storm. The risk comes, and the storm is closing in, but there's still a window of opportunity to land. The landing strip is so close, just minutes away. Tunnel vision sets in, people start to hurry, Margins for error are stripped away. Usually there's no harm done. The pilot lands just as the storm rips across, and congratulates himself or herself for keeping cool and showing skill under pressure. But sometimes the consequences are more serious. One study of get their Itis looked at twenty occasions when thunderstorms had closed in at Hartsfield Jackson, Atlanta's major international airport. Again and again, pilots decided to chant a risky landing, risky in the sense that the Federal Aviation Administration's official guidelines would have advised against it. One plane after another would land under ever more perilous conditions, until eventually one flight crew would resist the inertia and decide to divert elsewhere. At that point, every subsequent plane would also decide to divert. The madness only ended when someone set an example and changed the plan. I'm no airline pilots, but I sometimes suffer from get their itis in my own life. Perhaps you do too. For me, it tends to emerge when dealing with family logistics. I've got three children at two different schools, and they all have their hobbies and sports and all usual things. I'm sure many parents will be familiar with the play spinning that this sometimes involves. But then something goes wrong. The cars in the shop to be repaired, No problem, we can bike instead. Then someone needs to be at home to meet the plumber. We make contingency plans and they seem like they'll be fine, but then a fresh errand appears, or a babysitter calls to cancel. As complications mount, the plan starts to resemble an increasingly precarious assembly of stages and steps, lift, swaps and rendezvous. It's a Rube Goldberg fever dream of an itinerary. And then, if I'm lucky, either I or my wife will find enough headspace to say this is crazy. Someone's going to have to skip dance class tonight. We'll call the plumber to see if tomorrow's okay. Instead, we'll replace the entire time and motion nightmare with something radically simpler. But that's hard to do because of the inertia, because of the plan continuation by us, and the more the pressure mounts, the harder it is to see clearly just how precarious everything has become. I become so fixated on executing the plan that I don't have a moment to realize that it's now a stupid plan. Captain Rugiati was under pressure to reach the harbor at Milford Haven in time, and had been woken with the unwelcome news that the ship was off course too far towards the mainland. If he'd stopped to think or to talk to his officers, he would have realized that he still had time to turn and go the long way round outside the Aisles of Scilly. He only had an hour or two to spare, but a brief calculation would have revealed that the detour would have cost just twenty nine minutes. Yet he didn't pause to reflect. He snapped at Bonfilio and ordered him to stick to the course that would now cut inside the Isles of Scilly. Nor did he reflect that, since his ship had already been deflected by the current and the wind, those forces might well continue to work upon the ship, moving it out of its intended position. Under time pressure, he began to suffer get their itis. His plan was risky, and his plan was not about to change. At eight eighteen am, a junior officer calculated their position, this being the days before GPS. He did it with the ship's charts, a compass bearing, and a radar reading old school, but the inexperienced officer was anxious. He wasn't convinced he'd got the ship's position exactly right, but he didn't speak up. After all, there'd be another chance to take a fix in ten minutes or so. Captain Rugiati wasn't speaking up either, as the ship steamed north at sixteen knots nearly twenty miles an hour. He had already decided which course he would take, but he hadn't told his crew, which meant that they hadn't had a chance to comment, and they didn't feel entitled to ask. Captain Rugatti had actually decided to pass through the narrow channel, which involved bending the ship's course in a long, slow curve to the left. Why Perhaps because it was the most direct route, but mostly because well why not? To me? It was, they say, But should he not have taken just a few more minutes to avoid the narrow route? That was never in my mind. That's a revealing turn of phrase. Never, in my mind, Pastrenger Rugiati didn't even consider the possibility of going through the wider channel. And while that might seem strange to you or me, it's a natural feature of planned continuation by us. As the tunnel vision develops. We don't even think about alternatives to our ishor plan. We don't have the bandwidth. We continue to plow on. In two thousand and five, a young boy was rushed into a hospital emergency room. He suffered from asthma, and he was in distress. He was finding it harder to breathe and harder and harder, and then his breathing stopped. The medical team quickly strapped an oxygen mask on to the boy. That should have helped, but instead his
heart stopped beating two. There were eight trained medical professionals in the room, taking it in turns to perform CPR on the boy. Still no pulse, Still no breathing. The minutes ticked by a doctor slid a breathing tube down the boy's throat. No thing's happening. Is the tube in position? The tube's fine? I checked, Is there any pulse? Still nothing? Let's take the breathing tube out and try the airbag again. It's not helping. No, it wasn't helping. And the reason it wasn't helping was because the breathing apparatus was broken. It would have taken a few seconds to check if any of the five nurses or three doctors had thought to check, but they didn't think, not until the boy had been deprived of oxygen for ten minutes. Thankfully, this wasn't a tragedy. It was a training exercise. Instead of a real boy, it was a medical dummy that was lying on the bed failing to produce a simulated pulse or simulated respiration because the medical team didn't step back and think. This training scenario was conducted nineteen times, and videos of the exercise were studded by Marlist Christiansen, a professor of organizational behavior and previously the doctor Professor. Christiansen found that some medical teams took just seconds to identify the problem with a breathing equipment. This isn't working, it's broken. That's impressive, But perhaps more impressive were the teams who started with the wrong theory about the problem, but didn't get stuck on that idea. They didn't fixate on one possibility, or keep repeating the same approach over and over again. They would talk through what they were thinking and challenge themselves and each other. They could change course, but not every team did that. Many teams would hammer away at the same plan, regardless of the signs that it wasn't going to work. They didn't step back and think, They didn't talk things through, They just kept going. Could Captain Rugiati avoid the same fate. Captain Rugatti is now trying to curve his ship through the narrower channel. He doesn't even have the full six and a half miles to aim at because he's approaching at an angle. He's left himself precious little margin for error. As it is, Torry Canyon is heading straight for the submerged rocks at half past eight. As the slow, slow turn begins, two fishing boats appear on the radar, the two French langoustiers that are watching the oncoming supertanker with astonishment. Rugiati had planned to keep turning, but now he has to ensure he doesn't hit the boats. Suddenly, floats come into view. There are a sign of fishing nets beneath the surface. Tory Canyon can't possibly avoid them all and slices through one set of nets. Captain Rugiati pauses his turn in order not to shred thet He's now heading very close to where he thinks the stones are, but he still hopes to be able to resume his turn after passing the nets. But meanwhile, all the while, the current has been gently, insistently pushing Torry Canyon closer and closer to the seven Stones. At
this point, Rugiati seems to have woken up to the danger. He has precious little room for maneuver. Rather than curving out of danger, he's heading directly towards the seven Stones. He was later asked whether he would have been heading that way if not for the fishing boats and their nets. No, only a madman would have followed. In northern course, Rugiati now knows his heading is dangerous. His plan to go through the narrow channel is being frustrated, but as the pressure rises, he can't step back and form a better plan. Why doesn't he slow down? Why doesn't he abandon his plan to turn left into the channel and instead turned sharply right into deep water. That was never in my mind. Never. When get their itis takes hold there are a lot of things that should be in our minds but aren't. At eight thirty eight am, Captain Ruggiati takes a look at the charts. His junior officer has just taken another bearing. Ruggiati is an old hand. He can see at once that it can't be right. The crosses marking the ship's position should be at regular intervals, but they're not. One of the bearings is wrong. He doesn't know which. Maybe they're both wrong. Captain Ruggiati doesn't know where he is. The junior officer takes another bearing with the Captain's help. The new fix shows that the ship is closer to the seven Stones than they're realized, less than three miles. Remember, Torry Canyon takes a mile and a half to make a ninety degree turn on his trawler. Watching with horror guy Foliage has already concluded that it's all over. Torry Canyon can't possibly avoid the rocks, but he's wrong. There is still time. There's still time to turn into deep water. There's even still time to turn into the channel, which is what Pastrengo Rugiati has been trying to do for the last four miles and so, even though it doesn't really make sense anymore, that's what he continues to try to do. Helmsman can't do their wheel, Yes, Captain hard to part. Go to three fifty, Take her to three, take her to three twenty. Rugiati is ordering an ever tighter turn into the channel. Captain. Captain, the ship's are turning even now there's still time. She's not turning. Captain Rugiati needs to think, why isn't the ship turning? Perhaps the fuel pumps controlling the rudder have broken. Rajati has seen that happen before. He tries to dial the engine room, but instead he makes the kind of mistake you make when you've had three hours sleep and you only have seconds to solve a problem. He calls the officers dining room. Ah, captain, are you ready for breakfast? Well? God deal, God is a pig. That's some serious blasphemy from a good Italian Catholic. It's the blasphemy of a man who knows time has just run out. There's a photograph of Pastrenga Rugiati. I can't get out of my head. He's scrunched up in a confined space, his knees tucked into his chest as if to protect himself. His eyes rolled sharply to one side, his face ghoulishly lit from below. He's wearing a hospital gown and he's hiding under a
hospital bed. That's where he was when the paparazzi found him. He looks terrified. He's broken. His ship was gone, impaling itself onto the Seven Stones at full speed with a noise. One crewman said, look a slab of lead being ripped by spikes. Watching from his trawler, Gefolich turned to his men, that's the end of her. She'll never get off. He was right. The crew escaped safely, but during an attempt to re float the ship, there was a huge explosion. One of the salvage team was killed. By then, Torry Canyon's back was already broken and her underbelly sliced open by the teeth of the reef. She was bleeding one hundred and nineteen thousand tons of crude oil into coastal waters. It was an environmental catastrophe. The oil spill was unprecedented. Even today, there are places where you can still see the dark stain on the coast. Torry Canyon was, at the time the largest shipwreck in history and the largest maritime insurance claim. Rugiati took responsibility. He was the captain, and he was, he said, in charge of the best ship in their world for a ship's captain. His ship is all and I have lost mine. I'm terrified by the dimensions which the accident has assumed. The inquiry was conducted in private. Journalists weren't allowed in, but the manager of the hotel where the proceedings were being held told one of them that he had seen Captain Rugiati. I had a glimpse of this man. I had the impression of a man finished. He very seldom have so strong an impression from so short of seeing a man. I must answer for everything, for everyone. I must carry the cross alone. I wish I could tell the people of Cornwall how sorry I am, And he really was sorry. It was very bad. The disaster broke Rugiati. He spent months in hospital recovering from the strain and the anxiety and the heartbreak, which is where the eager photographers found him. A transcript of the inquiry was leaked to the journalist Richard Petro. The tanker owners were keen to downplay any fault on their part, including the fact that the steering had broken in the past, confusing Captain Ruggiati when the ship had failed to turn. But why had the ship failed to turn in those last moments? It was a small thing. After Ruggiahti had accidentally called the officer's dining room and slammed down the receiver, he looked across the bridge. From his position by the telephone, he could see that someone had inadvertently knocked the steering control lever. The ship's steering had simply been disconnected. All Ruggiati needed to do was switched the lever back and dragged Torry Canyon over to port. But he had lost time. With thirty seconds more to maneuver, I could have avoided the rocks. Ruggiati had made a plan, and as one small problem after another made the plan riskier and risk here he hadn't been able to adjust. Many leader things added up to one big disaster. That's true. The deadline, the currents, the fishing boats, the error from his junior officer, the steering control. It's bad luck thirty seconds before the sheep she was saved. But the missing thirty seconds aren't what interests me. What interests me are the two hours that Ruggiati had to save his Torry Canyon, the best ship in the world. He had two hours to reroot outside the aisles of Scilly, two hours to slow the ship down, two hours to ask for advice or to turn towards the wider channel, but he didn't do any of those things. After the exploitative photograph was released, there was a surge of sympathy for Ruggiati from around the world. People wrote letters of consolation. One that caught my eye was from a thirteen year old boy from County Cork in Ireland. I see beautiful tankers, but I'm sure I've never seen one as beautiful as yours. I thought and prayed for you. I am sure you will sail the seas again. Pastrengo Rougiati never did. His mistake was just too grave, But at the same time, it was also all too human. After all, it's our nature to be slow to change course. You've been listening to Cautionary Tales. If you'd like to find out more about the ideas in this episode, including links to our sources, the show notes are on my website, Tim Harford dot com. Cautionary Tales is written and presented by me Tim Harford. Our producers are Ryan Dilley and Marilyn Rust. The sound designer and mixer was Pascal Wise, who also composed the amazing music. This season stars Alan Cumming, Archie Panchabi, Toby Stevens and Russell Tovey, with enso Celenti, Ed Gochen, Melanie Gutteridge, Mercia Munroe, Rufus Wright and introducing Malcolm Gladwell. Thanks to the team at Pushkin Industries, Julia Barton, Heather Faine, mil LaBelle, Carlie Milliori, Jacob Weisberg and of course the mighty Malcolm Gladwell. And thanks to my colleagues at The Financial Times