November 15, 2019 • 35 mins
Torrey Canyon was one of the biggest and best ships in the world - but its captain and crew still needlessly steered it towards a deadly reef known as The Seven Stones. This course seemed like utter madness, but the thinking that resulted in such a risky manoeuvre is something we are all prone to do when we fixate on a goal and a plan to get us there.
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Episode Transcript
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Speaker 1 (00:15):
Pushkin. 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
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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.
(01:03):
All of them fascinated me, and I realized something that
has guided me throughout my life. 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,
(01:27):
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
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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
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each story, if you're not careful, could happen to you.
So gather closer and I'll begin. We pray thee Lord,
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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,
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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 flag ship HMS
Association struck a rock and went down. In minutes, eight
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hundred men drowned behind it. HMS Saint George hit the
rocks and became stuck. So did HMS Phoenix, so did
HMS 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
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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
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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
to day is a far stranger one. It was some
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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 guy Folich, another langoustier, was near by, both of
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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. Guifolich
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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 Silly,
rather than squeezing between them and the mainland. True, a
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big ship could come between the Aisles of Silly 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
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the lighthouse vessel, the two seamen on watch saw the
tanker approaching too. Have you seen this? Have you? Yeah?
Look at that big baster coming up. Guifolich could see
the huge ship coming straight towards him as he fished kayak,
but he wasn't worried. In between him and the oncoming
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juggernaut were the seven Stones. He later said, I was
sure that before ever eating us, you would go onto
the rucks. 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.
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Folich was sure it was doomed. It just wasn't possible
to turn a super tanker 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
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weather was good, the visibility was good. Tory or 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 Torry Canyon still wasn't turning. Gather close
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and listened 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
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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 Avon was simple enough. Torry Canyon needed to hurry.
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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 and 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
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a very expensive delay. That news put Captain Pastrengo Rujati
under pressure. He had no more than one or two
hours margin, not a lot, but Rujahti had coped with
worse He'd been a navigator on an Italian submarine during
the war, had survived a German prison camp, and had
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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 Rugiahty
was also a detailsman who kept a close eye on
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his officers. Ruggiastie was extremely conscientious. He was a man
who wanted to know absolutely everything. Perhaps because of that,
Ruggierhty 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
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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 Bonfiglio 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
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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 Ruggiati had intended
to pass outside of the islands, but he hedged his bets.
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Rather than heading out to sea or closer to the mainland,
he was bearing straight towards the aisles 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
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eighteen degrees be free of the cities? 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.
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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 Rugiati had consulted a copy, here's what it would
have said. The actual width of the channel between the
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nearest of the Scilly 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
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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
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of wisdom. First, if you want to go between the
aisles 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
Scilly themselves. But the channel pilot doesn't mention it because
it's narrower, six and a half miles wide rather than twelve.
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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.
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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
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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
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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
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form of get their itis is an approach to an
airfield with a storm coming in. If you land 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
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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.
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Usually there's no harm done. The pilot lands just as
the storm rips across. The congratulates himself or herself for
keeping cool and showing gill 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
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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
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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
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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 plate
spinning that this sometimes involves. But then something goes wrong.
The cars in the shop to be repaired, No problem,
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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
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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
to morrows okay. Instead, will replace the entire time and
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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
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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
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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 brief calculation
would have revealed that the detour would have cost just
twenty nine minutes. Yet he didn't pause to reflect. He
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snapped at Bonfilio and ordered him to stick to the
course that would now cut inside the Aisles 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
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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
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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 Ruggiaty 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,
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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 ruggati 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,
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well why not? To me? It was the same. 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 Ruggiati didn't even consider the possibility of going through
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the wider channel. And while that might seem strange to
you or me, it's a natural feature of plan continuation
by us. As the tunnel vision develops, we don't even
think about alternatives to our initial plan. We don't have
the bandwidth. We continue to plow on. In two thousand
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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
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trained medical called 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. 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
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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
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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 simulated respiration because the
medical team didn't step back and think. This training scenario
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was conducted nineteen times and videos of the exercise were
studded by Marliss Christiansen, a professor of organizational behavior and
previously a 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
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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.
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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.
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Captain Rugiati 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
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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 and floats come
into view. There are a sign of fishing nets beneath
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the surface. Torry Canyon can't possibly avoid them all and
slices through one set of nets. Captain Rugiati pauses his
turn in order not to shred the rest. 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,
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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
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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. 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
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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.
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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
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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
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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 Ujati has been trying to do for
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the last four miles, and so, even though it doesn't
really make sense anymore, that's what he continues to try
to do. Houndsman can't do their wheel, Yes, Captain hard
to part god to three fifty, take her to three ft,
take her to three twenty. Ujiati is ordering an ever
tighter turn into the channel. Captain, Captain, the ship's off
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turning even now, there's still time. If she's not turning,
Captain Rugiati needs to think, why isn't the ship turning.
Perhaps the fuel pumps controlling the rudder have broken. Rugiati
has seen that happen before. He tries to dial the
engine room, but instead he makes the kind of mistake
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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
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man who knows time has just run out. There's a
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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
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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, Gifolich turned to his men,
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that's the end of her. She'll never get off. He
was right. The crew escaped safely, but during an attempt
to refloat 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
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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
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the time the largest shipwreck in history, as the largest
maritime insurance claim. Rugiati took responsibility. He was the captain,
and he was, he said, in charge of the best
ship in the world for a ship's captain. His ship
is all and I have lost mine. I am terrified
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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 Ruggiati.
I had a glimpse of this man. I had the
impression of a man finished. He very seldom have so
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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 Ruggiati. He spent
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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
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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.
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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 Ruggiaste needed to do
was switched the lever back and dragged Torry Canyon over
to port. But he'd lost time. With thirty seconds more
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to maneuver, I could have avoided the rocks. Ruggierte had
made a plan, and as one small problem after another
made the plan riskier and riskier, he hadn't been able
to adjust. Many little things added up to one big disaster.
That's true. The deadline, the currants, the fishing boats, the
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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 Ruggierte had to save his
Torry Canyon, the best ship in the world. He had
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two hours to re root outside the isles 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
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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 Rugiati never did. His
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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
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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
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amazing music. This season stars Alan Cumming, Archie Panchabi, Toby Stephens,
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 Fame, Mia LaBelle,
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Carlie Milliori, Jacob Weisberg and of course the mighty Malcolm Gladwell.
And thanks to my colleagues at the Financial Times four
Pushkin. 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
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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.
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All of them fascinated me, and I realized something that
has guided me throughout my life. 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,
(01:27):
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
(01:48):
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
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each story, if you're not careful, could happen to you.
So gather closer and I'll begin. We pray thee Lord,
(02:32):
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,
(02:53):
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 flag ship HMS
Association struck a rock and went down. In minutes, eight
(03:15):
hundred men drowned behind it. HMS Saint George hit the
rocks and became stuck. So did HMS Phoenix, so did
HMS 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
(03:38):
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
(03:58):
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
to day is a far stranger one. It was some
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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 guy Folich, another langoustier, was near by, both of
(04:47):
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. Guifolich
(05:11):
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 Silly,
rather than squeezing between them and the mainland. True, a
(05:33):
big ship could come between the Aisles of Silly 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
(05:53):
the lighthouse vessel, the two seamen on watch saw the
tanker approaching too. Have you seen this? Have you? Yeah?
Look at that big baster coming up. Guifolich could see
the huge ship coming straight towards him as he fished kayak,
but he wasn't worried. In between him and the oncoming
(06:14):
juggernaut were the seven Stones. He later said, I was
sure that before ever eating us, you would go onto
the rucks. 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.
(06:43):
Folich was sure it was doomed. It just wasn't possible
to turn a super tanker 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
(07:05):
weather was good, the visibility was good. Tory or 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 Torry Canyon still wasn't turning. Gather close
(07:29):
and listened 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
(07:50):
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 Avon was simple enough. Torry Canyon needed to hurry.
(08:13):
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 and 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
(08:35):
a very expensive delay. That news put Captain Pastrengo Rujati
under pressure. He had no more than one or two
hours margin, not a lot, but Rujahti had coped with
worse He'd been a navigator on an Italian submarine during
the war, had survived a German prison camp, and had
(08:55):
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 Rugiahty
was also a detailsman who kept a close eye on
(09:17):
his officers. Ruggiastie was extremely conscientious. He was a man
who wanted to know absolutely everything. Perhaps because of that,
Ruggierhty 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
(09:38):
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 Bonfiglio 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
(10:01):
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 Ruggiati had intended
to pass outside of the islands, but he hedged his bets.
(10:22):
Rather than heading out to sea or closer to the mainland,
he was bearing straight towards the aisles 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
(10:45):
eighteen degrees be free of the cities? 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.
(11:06):
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 Rugiati had consulted a copy, here's what it would
have said. The actual width of the channel between the
(11:27):
nearest of the Scilly 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
(11:47):
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
(12:09):
of wisdom. First, if you want to go between the
aisles 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
Scilly themselves. But the channel pilot doesn't mention it because
it's narrower, six and a half miles wide rather than twelve.
(12:32):
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.
(13:06):
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
(13:30):
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
(13:53):
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
(14:17):
form of get their itis is an approach to an
airfield with a storm coming in. If you land 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
(14:37):
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.
(14:59):
Usually there's no harm done. The pilot lands just as
the storm rips across. The congratulates himself or herself for
keeping cool and showing gill 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
(15:20):
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
(15:45):
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
(16:08):
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 plate
spinning that this sometimes involves. But then something goes wrong.
The cars in the shop to be repaired, No problem,
(16:30):
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
(16:50):
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
to morrows okay. Instead, will replace the entire time and
(17:13):
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
(17:35):
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
(17:56):
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 brief calculation
would have revealed that the detour would have cost just
twenty nine minutes. Yet he didn't pause to reflect. He
(18:18):
snapped at Bonfilio and ordered him to stick to the
course that would now cut inside the Aisles 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
(18:38):
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
(19:01):
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 Ruggiaty 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,
(19:25):
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 ruggati 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,
(19:49):
well why not? To me? It was the same. 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 Ruggiati didn't even consider the possibility of going through
(20:10):
the wider channel. And while that might seem strange to
you or me, it's a natural feature of plan continuation
by us. As the tunnel vision develops, we don't even
think about alternatives to our initial plan. We don't have
the bandwidth. We continue to plow on. In two thousand
(20:43):
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
(21:08):
trained medical called 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. 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
(21:30):
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
(21:53):
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 simulated respiration because the
medical team didn't step back and think. This training scenario
(22:19):
was conducted nineteen times and videos of the exercise were
studded by Marliss Christiansen, a professor of organizational behavior and
previously a 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
(22:43):
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.
(23:06):
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.
(23:29):
Captain Rugiati 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
(23:52):
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 and floats come
into view. There are a sign of fishing nets beneath
(24:12):
the surface. Torry Canyon can't possibly avoid them all and
slices through one set of nets. Captain Rugiati pauses his
turn in order not to shred the rest. 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,
(24:36):
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
(24:57):
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. 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
(25:18):
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.
(25:39):
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
(26:02):
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
(26:26):
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 Ujati has been trying to do for
(26:47):
the last four miles, and so, even though it doesn't
really make sense anymore, that's what he continues to try
to do. Houndsman can't do their wheel, Yes, Captain hard
to part god to three fifty, take her to three ft,
take her to three twenty. Ujiati is ordering an ever
tighter turn into the channel. Captain, Captain, the ship's off
(27:11):
turning even now, there's still time. If she's not turning,
Captain Rugiati needs to think, why isn't the ship turning.
Perhaps the fuel pumps controlling the rudder have broken. Rugiati
has seen that happen before. He tries to dial the
engine room, but instead he makes the kind of mistake
(27:34):
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
(27:55):
man who knows time has just run out. There's a
(28:24):
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
(28:45):
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, Gifolich turned to his men,
(29:13):
that's the end of her. She'll never get off. He
was right. The crew escaped safely, but during an attempt
to refloat 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
(29:35):
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
(29:55):
the time the largest shipwreck in history, as the largest
maritime insurance claim. Rugiati took responsibility. He was the captain,
and he was, he said, in charge of the best
ship in the world for a ship's captain. His ship
is all and I have lost mine. I am terrified
(30:17):
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 Ruggiati.
I had a glimpse of this man. I had the
impression of a man finished. He very seldom have so
(30:41):
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 Ruggiati. He spent
(31:09):
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
(31:29):
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.
(31:50):
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 Ruggiaste needed to do
was switched the lever back and dragged Torry Canyon over
to port. But he'd lost time. With thirty seconds more
(32:12):
to maneuver, I could have avoided the rocks. Ruggierte had
made a plan, and as one small problem after another
made the plan riskier and riskier, he hadn't been able
to adjust. Many little things added up to one big disaster.
That's true. The deadline, the currants, the fishing boats, the
(32:36):
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 Ruggierte had to save his
Torry Canyon, the best ship in the world. He had
(33:01):
two hours to re root outside the isles 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
(33:21):
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 Rugiati never did. His
(33:46):
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
(34:08):
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
(34:32):
amazing music. This season stars Alan Cumming, Archie Panchabi, Toby Stephens,
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 Fame, Mia LaBelle,
(34:55):
Carlie Milliori, Jacob Weisberg and of course the mighty Malcolm Gladwell.
And thanks to my colleagues at the Financial Times four
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