WEBVTT - Against the Rules Presents: Cautionary Tales 0:00:15.276 --> 0:00:23.876 Pushkin. This thing still on. Michael Lewis here. Guess what. 0:00:24.636 --> 0:00:26.996 I'm working on a second season of Against the Rules. 0:00:27.476 --> 0:00:29.356 I had so much fun doing season one that I 0:00:29.396 --> 0:00:32.236 decided to keep going. I'm back in the field with 0:00:32.276 --> 0:00:35.836 my producers, talking to people and poking around. The next 0:00:35.876 --> 0:00:38.316 season is going to be about coaches and why the 0:00:38.396 --> 0:00:41.236 role of coach has expanded so far beyond sports in 0:00:41.276 --> 0:00:46.436 American life. If everybody hates the ref, everyone seems to 0:00:46.556 --> 0:00:50.676 love the coach these days. In season two, I'm going 0:00:50.716 --> 0:00:56.836 to explore why it's out next spring. Meanwhile, I have 0:00:56.916 --> 0:00:58.956 something else for you to listen to. It's a new 0:00:58.996 --> 0:01:03.196 show from Pushkin Industries by a British writer I really admire. 0:01:03.876 --> 0:01:07.276 His name is Tim Harford. He's a familiar voice on 0:01:07.276 --> 0:01:10.836 the BBC. Whereas most recent series was about the modern 0:01:10.836 --> 0:01:14.556 inventions we might not have noticed but would shape our lives, 0:01:16.156 --> 0:01:20.516 this new show from Tim is called Cautionary Tales, and 0:01:20.596 --> 0:01:25.796 it's full of spectacular stories about other people's mistakes, my 0:01:25.876 --> 0:01:29.836 favorite kind of mistakes. Tim and his team of actors 0:01:29.956 --> 0:01:35.396 re enact airship disasters and great frauds and safety systems 0:01:35.436 --> 0:01:38.036 gone awry, and then he tells us what we can 0:01:38.116 --> 0:01:41.516 learn from it all. We've got one of the first 0:01:41.556 --> 0:01:46.276 episodes right here. This one is an unbelievable story about 0:01:46.276 --> 0:01:50.796 an enormous tanker about to crash into the coast of England. 0:01:51.796 --> 0:01:55.556 Give it a listen, then go subscribe to Cautionary Tales 0:01:55.636 --> 0:01:58.916 wherever you listen to your podcasts to hear more from Tim. 0:01:59.676 --> 0:02:02.036 And I promise I'll be back in this feed before 0:02:02.076 --> 0:02:07.276 you know it. Here's Tim Harford. I opened the wrapping 0:02:07.316 --> 0:02:10.316 paper hurriedly with nervous hands, excited to get at the 0:02:10.356 --> 0:02:14.756 gift inside. Little did I know, disaster was about to 0:02:14.956 --> 0:02:19.356 enter my previously happy childhood. It wasn't a disaster visited 0:02:19.436 --> 0:02:22.156 on mean or my family. It was a catalog of 0:02:22.236 --> 0:02:25.756 disasters for everyone else. For the gift was a book, 0:02:26.836 --> 0:02:29.276 and it was titled, in bold letters on a blood 0:02:29.276 --> 0:02:34.636 red background, the World's Greatest Mistakes. The stories were set 0:02:34.676 --> 0:02:39.276 out like a trashy and exciting tabloid newspaper. Some were absurd, 0:02:39.276 --> 0:02:42.636 like the bride who accidentally married the best man. Some 0:02:42.716 --> 0:02:46.516 of them were famous tragedies, the Titanic slipping beneath the 0:02:46.716 --> 0:02:50.596 icy sea, funny or sad. All of them fascinated me, 0:02:50.996 --> 0:02:54.236 and I realized something that has guided me throughout my life. 0:02:54.876 --> 0:02:58.676 Learning from other people's mistakes is a lot less painful 0:02:58.876 --> 0:03:02.796 than learning from your own. My name is Tim Harford. 0:03:03.156 --> 0:03:07.396 Some people call me the undercover Economist. I use scientific 0:03:07.476 --> 0:03:10.876 ideas to help people think more clearly about the world 0:03:11.276 --> 0:03:14.516 in my books, my ted Talks, my BBC shows, and 0:03:14.676 --> 0:03:18.636 my column for the Financial Times. That may sound all 0:03:18.756 --> 0:03:21.476 very grown up, but part of me is that little 0:03:21.516 --> 0:03:28.076 boy who loved stories of catastrophe, mistake and mayhem. So 0:03:28.156 --> 0:03:31.436 I still seek out and collect such stories, but now 0:03:31.556 --> 0:03:34.956 I probe the details. I challenge the orthodox view and 0:03:35.156 --> 0:03:38.596 look for the root causes and ponder how disaster could 0:03:38.636 --> 0:03:42.556 have been prevented. In short, I look for the painless 0:03:42.636 --> 0:03:45.796 lessons they can teach me. And now I want to 0:03:45.796 --> 0:03:52.516 share some of these cautionary tales with you too. Each 0:03:52.676 --> 0:03:57.556 story has a moral, each story is true, and each story, 0:03:58.116 --> 0:04:02.556 if you're not careful, could happen to you. So gather 0:04:02.676 --> 0:04:19.076 closer and I'll begin. We pray thee Lord, not that 0:04:19.156 --> 0:04:23.396 rex should happen, but that if any Rex do happen, 0:04:24.156 --> 0:04:26.676 thou wilt guide them to the silly isles for the 0:04:26.756 --> 0:04:32.876 benefit of the poor. Inhabitants. That's an old prayer from 0:04:32.916 --> 0:04:36.116 the Isles of Scilly. The isles are just off the 0:04:36.156 --> 0:04:40.036 coast of Cornwall, the southwest tip of Great Britain, and 0:04:40.196 --> 0:04:44.356 that prayer has been answered many times. The rocks around 0:04:44.396 --> 0:04:48.156 the islands have a fearsome reputation and it's well earned. 0:04:49.076 --> 0:04:52.756 One autumn night in seventeen oh seven, the Royal Navy 0:04:52.836 --> 0:04:57.116 lost its way in a storm. The flagship HMS Association 0:04:57.636 --> 0:05:01.676 struck a rock and went down in minutes. Eight hundred 0:05:01.676 --> 0:05:06.036 men drowned behind it. HMS Saint George hit the rocks 0:05:06.036 --> 0:05:10.516 and became stuck. So did HMS Phoenix, did HS Firebrow. 0:05:11.276 --> 0:05:16.356 HMS Romney lost her entire crew. HMS Eagle was shattered 0:05:16.356 --> 0:05:21.276 on the cruel stone. Hundreds more sailors died. That dreadful 0:05:21.396 --> 0:05:24.676 night was one of the worst disasters in the history 0:05:24.756 --> 0:05:33.996 of the British Navy. Local legend has it that there 0:05:34.196 --> 0:05:38.276 was one notable survivor, that the Commander in Chief of 0:05:38.316 --> 0:05:42.116 the British Fleets, Sir Cloudsley Shovel, was washed up on 0:05:42.156 --> 0:05:45.596 the beaches of the Aisles of Scilly, but was strangled 0:05:46.076 --> 0:05:49.996 by a local woman who fancied wearing his Emerald ring 0:05:50.156 --> 0:05:54.636 herself if she had been praying the old prayer God 0:05:55.436 --> 0:06:01.156 or the devil had been listening. It is a dark tale, 0:06:01.916 --> 0:06:04.716 but the story I shall tell you today is a 0:06:04.756 --> 0:06:11.956 far stranger one. It was some time after dawn on 0:06:12.036 --> 0:06:18.716 Saturday March the eighteenth, nineteen sixty seven. Martyr Christie was 0:06:18.756 --> 0:06:22.836 a langoustier, a French lobster boat, fishing for crayfish and 0:06:22.996 --> 0:06:26.236 crab between the mainland and the Isles of Scilly. Twenty 0:06:26.236 --> 0:06:30.676 one miles further west on deck was Captain Gui Folich, 0:06:31.356 --> 0:06:35.516 another langoustier, was near by, both of them enjoying rich pickings. 0:06:35.556 --> 0:06:39.356 A few hundred yards north of the Seven Stones. The 0:06:39.396 --> 0:06:42.556 Seven Stones make up a vicious reef about one third 0:06:42.636 --> 0:06:45.356 of the way between the Isles of Scilly and the mainland. 0:06:46.236 --> 0:06:50.356 At low tide, the unyielding rocks are visible, but even 0:06:50.396 --> 0:06:53.596 at high tide there marked by a lighthouse vessel warning 0:06:53.636 --> 0:06:57.796 ships to stay away. Gui Folich looked up from his 0:06:57.836 --> 0:07:02.516 lobster lions to see an unexpected sight, a vast black 0:07:02.636 --> 0:07:07.156 hull coming over the horizon from an unusual direction. He 0:07:07.276 --> 0:07:11.156 was surprised. A major vessel in that position would usually 0:07:11.196 --> 0:07:14.716 have passed outside of the aisles of Scilly rather than 0:07:14.876 --> 0:07:19.516 squeezing between them and the mainland. True, a big ship 0:07:19.756 --> 0:07:22.236 could come between the aisles of Scilly and the mainland, 0:07:22.436 --> 0:07:25.636 passing on either side of the seven Stones, but it 0:07:25.716 --> 0:07:29.156 would be a little on the tight side. And this ship, 0:07:29.756 --> 0:07:34.396 a supertanker, was very big. Indeed, in fact, it was 0:07:34.436 --> 0:07:40.836 the thirteenth biggest ship in the world. On the lighthouse vessel, 0:07:41.036 --> 0:07:44.156 the two seamen on watch saw the tanker approaching too. 0:07:44.476 --> 0:07:47.036 Have you seen this? Have you? Yeah? Look at that 0:07:47.156 --> 0:07:51.916 big bastro coming up. Gifolich could see the huge ship 0:07:52.236 --> 0:07:57.476 coming straight towards him as he fished kayak, but he 0:07:57.556 --> 0:08:01.996 wasn't worried. In between him and the oncoming juggernaut were 0:08:01.996 --> 0:08:05.756 the seven Stones. He later said, I was sure that 0:08:05.956 --> 0:08:08.996 before ever eating us, you would go on to the rugs. 0:08:09.316 --> 0:08:13.636 He yelled to his men, stop work, you're going to 0:08:13.716 --> 0:08:18.196 see something extraordinary. All seven of them lined up on 0:08:18.236 --> 0:08:21.436 the rail of Marta Christie to watch the oil tanker 0:08:21.556 --> 0:08:29.716 bear closer and closer, four miles, three miles. Folich was 0:08:29.796 --> 0:08:32.796 sure it was doomed. It just wasn't possible to turn 0:08:32.836 --> 0:08:38.476 a supertanker that quickly. Was it? Actually? Folich wasn't quite right. 0:08:39.596 --> 0:08:44.196 The tanker, whose name was Torry Canyon did still have 0:08:44.356 --> 0:08:48.076 room to turn. This wasn't a storm tossed fleet of 0:08:48.156 --> 0:08:52.196 sailing ships fumbling through the darkness. The weather was good, 0:08:52.716 --> 0:08:56.836 the visibility was good. Torry Canyon was a superb ship, 0:08:56.876 --> 0:09:01.036 in fine working order and armed with radar. The seven 0:09:01.076 --> 0:09:04.276 Stones were clearly marked on every chart, as well as 0:09:04.276 --> 0:09:08.396 being identified by the position of the lighthouse vessel. But 0:09:08.756 --> 0:09:16.236 Tory Canyon still wasn't turning. Gather close and listen to 0:09:16.356 --> 0:09:30.636 my cautionary tail. Nobody knew it at the time, but 0:09:30.716 --> 0:09:34.196 the trouble all started with a radio message from milford Haven, 0:09:34.476 --> 0:09:38.916 the harbor towards which Torry Canyon was sailing. Milford Haven 0:09:38.996 --> 0:09:41.596 is a major UK port, and the thing you need 0:09:41.636 --> 0:09:44.036 to know about ports in the UK is that the 0:09:44.116 --> 0:09:47.716 difference between high tide and low tide can be enormous. 0:09:48.236 --> 0:09:51.436 What's more, there are high tides and high tides, some 0:09:51.676 --> 0:09:55.596 are higher than others. The message from Milford Haven was 0:09:55.676 --> 0:10:00.276 simple enough. Torry Canyon needed to hurry. If the ship 0:10:00.396 --> 0:10:04.516 didn't arrive by eleven pm on Saturday evening, March the eighteenth, 0:10:04.716 --> 0:10:09.076 nineteen sixty seven, it would miss the extra high tide 0:10:09.116 --> 0:10:11.316 wouldn't be able to slip into the harbor and dock. 0:10:12.116 --> 0:10:15.916 It would then have to wait another six days before 0:10:15.916 --> 0:10:19.276 the tide would once more be high enough. Missing the 0:10:19.356 --> 0:10:24.996 eleven pm deadline would mean a very expensive delay. That 0:10:25.156 --> 0:10:29.756 news put Captain Pastrengo Rugiati under pressure. He had no 0:10:29.836 --> 0:10:32.876 more than one or two hours margin, not a lot, 0:10:33.356 --> 0:10:36.756 but Rujiahti had coped with worse. He'd been a navigator 0:10:36.796 --> 0:10:39.796 on an Italian submarine during the war, had survived a 0:10:39.916 --> 0:10:43.076 German prison camp, and had been commanding oil tankers for 0:10:43.116 --> 0:10:47.876 twenty years. Captain Rujati was in many ways a genial fellow, 0:10:48.076 --> 0:10:51.196 chatty and hospitable. He liked to eat good food, but 0:10:51.316 --> 0:10:54.436 insisted he shouldn't be served anything that wasn't available to 0:10:54.476 --> 0:10:57.836 his crew. As a result, the men on Torry Canyon 0:10:58.116 --> 0:11:02.116 ate very well. But Rujiahti was also a detailsman who 0:11:02.196 --> 0:11:06.596 kept a close eye on his officers. Rugiasty was extremely conscientious. 0:11:06.836 --> 0:11:10.556 He was a man who wanted to know absolute, loutely everything. 0:11:10.916 --> 0:11:14.036 Perhaps because of that, Ruggiati stayed up late on the 0:11:14.076 --> 0:11:17.916 Friday night before landfall preparing the paperwork for when they docked. 0:11:18.436 --> 0:11:20.876 It was only at half past three in the morning 0:11:21.036 --> 0:11:23.756 that he went to bed, leaving instructions that he was 0:11:23.796 --> 0:11:26.476 to be awakened first thing when the Aisles of Silly 0:11:26.516 --> 0:11:30.476 were sighted. It was half past six in the morning 0:11:30.756 --> 0:11:33.316 when the Aisles of Scilly appeared on the radar, about 0:11:33.396 --> 0:11:38.436 thirty five miles away. First Officer Silvano Bonfilio was on duty, 0:11:38.836 --> 0:11:41.156 and the position of the ship relative to the Isles 0:11:41.156 --> 0:11:46.196 of Scilly was an unpleasant surprise. Torry Canyon, plowing through 0:11:46.236 --> 0:11:49.356 the night across the ocean had been pushed off its 0:11:49.396 --> 0:11:53.036 intended course by the current and the winds. It was 0:11:53.116 --> 0:11:58.556 now headed between the islands and the mainland. Bonfilio immediately 0:11:58.636 --> 0:12:02.476 changed course, steering away from the channel, figuring that Captain 0:12:02.556 --> 0:12:06.476 Rugiati had intended to pass outside of the islands, but 0:12:06.556 --> 0:12:10.436 he hedged his beds. Rather than out to sea or 0:12:10.476 --> 0:12:13.956 closer to the mainland, he was bearing straight towards the 0:12:14.036 --> 0:12:19.236 Isles of Scilly. He then woke up Captain Ruggiati. Rugiati 0:12:19.356 --> 0:12:23.156 was angry. Was it because Bonfilio had changed course without checking, 0:12:23.636 --> 0:12:25.836 Was it because the new course was neither one thing 0:12:25.876 --> 0:12:30.036 nor another? Or was he just sleep deprived will our 0:12:30.076 --> 0:12:33.716 original heaving of eighteen degrees be free of the Sillies? Yes, 0:12:34.036 --> 0:12:37.596 then continue on course eighteen degrees. I intend to pass 0:12:37.636 --> 0:12:41.716 to the starboard of the Silly Isles. When Filio was 0:12:41.836 --> 0:12:45.076 so surprised he had to check that it understood the order, 0:12:45.236 --> 0:12:50.236 which irritated Ruggiati. Still further Still, a maneuver shouldn't be 0:12:50.236 --> 0:12:54.316 too perilous. It was perfectly possible to get even a 0:12:54.396 --> 0:13:02.516 large ship through. The standard manual for navigating the waters 0:13:02.556 --> 0:13:05.356 around the coast of the British Isles is called the 0:13:05.476 --> 0:13:09.756 Channel Pilot. If Captain Ruggiati had consulted a copy, here's 0:13:09.756 --> 0:13:12.316 what it would have said. The actual width of the 0:13:12.396 --> 0:13:15.076 channel between the nearest of the Silly Islands and Land's 0:13:15.196 --> 0:13:18.276 End is twenty one miles, but as the route taken 0:13:18.316 --> 0:13:21.116 by all large vessels should be eastward of seven stones 0:13:21.276 --> 0:13:24.956 light vessel, the navigable channel can only be considered as 0:13:25.076 --> 0:13:29.036 twelve miles wide. The lights render the passage perfectly simple 0:13:29.036 --> 0:13:32.436 at night as well as by day in ordinarily clear weather. 0:13:32.916 --> 0:13:34.876 But as there is no part of the coast of 0:13:34.876 --> 0:13:38.636 England more subject to sudden changes of weather, the greatest 0:13:38.716 --> 0:13:41.916 vigilance is necessary and a vessel's position, even in the 0:13:41.996 --> 0:13:45.676 clearest weather, should be checked by cross bearings at short intervals. 0:13:46.996 --> 0:13:50.236 But Captain Rugiati Alas did not have a copy of 0:13:50.276 --> 0:13:54.156 the channel pilot on board, and so he missed two 0:13:54.476 --> 0:13:58.716 important pieces of wisdom. First, if you want to go 0:13:58.796 --> 0:14:04.116 between the Isles of Scilly and the mainland, be careful. Second, 0:14:04.636 --> 0:14:08.236 pass between the mainland and the seven Stones. There is 0:14:08.276 --> 0:14:10.756 an alternative route between the seven Stones and the Aisles 0:14:10.756 --> 0:14:14.036 of Silly themselves, but the channel pilot doesn't mention it 0:14:14.076 --> 0:14:17.396 because it's narrower, six and a half miles wide rather 0:14:17.476 --> 0:14:20.716 than twelve. Why take the narrower channel when you could 0:14:20.716 --> 0:14:24.156 take the broader one. Of course, you could still fit 0:14:24.196 --> 0:14:27.316 an oil tanker through the narrower gap, even an oil 0:14:27.356 --> 0:14:30.556 tanker that's nearly as big as the Chrysler building, but 0:14:30.676 --> 0:14:34.836 you'd be cutting it close. You'd be better and nothing 0:14:34.876 --> 0:14:56.276 went wrong. Inertia is a powerful thing. That's true for 0:14:56.356 --> 0:14:59.356 an oil tanker the size of Torry Canyon, which needed 0:14:59.516 --> 0:15:02.676 nearly five minutes to make a ninety degree turn, during 0:15:02.676 --> 0:15:05.276 which time it would travel a mile and a half 0:15:05.316 --> 0:15:10.196 at cruising speed. But inertia is a powerful thing for humans. Too. 0:15:10.996 --> 0:15:16.036 We also sometimes struggle to change course. Psychologists have identified 0:15:16.036 --> 0:15:20.676 a strong bias towards the status quo. For example, whether 0:15:20.716 --> 0:15:23.116 we sign up for a workplace pension plan or not 0:15:23.516 --> 0:15:26.996 seems to depend on whatever the status quo is. If 0:15:26.996 --> 0:15:29.796 the default option is to sign up, we sign up. 0:15:30.036 --> 0:15:32.636 If the default is to stay out, we stay out. 0:15:33.436 --> 0:15:39.716 As I say, inertia is powerful. Psychologists who study accidents 0:15:39.796 --> 0:15:43.396 have a name for a particular form of inertia. They 0:15:43.436 --> 0:15:48.916 call it plan continuation bias. It's best known in aviation. 0:15:49.556 --> 0:15:52.596 Pilots form a plan and then are reluctant to change it, 0:15:53.076 --> 0:15:58.276 even if the circumstances suggest they should. The pilots themselves 0:15:58.316 --> 0:16:03.036 have another name for it, get their itis. The classic 0:16:03.076 --> 0:16:05.836 form of get their itis is an approach to an 0:16:05.836 --> 0:16:09.596 airfield with a storm coming in. If you and well 0:16:09.636 --> 0:16:13.316 before the storm arrives, no problem. If the storm arrives 0:16:13.396 --> 0:16:17.156 before you land, that's not a crisis either. It's a hassle. 0:16:17.396 --> 0:16:20.036 You have to divert to another airfield, with all the delay, 0:16:20.276 --> 0:16:23.916 expense and annoyance that implies. But you do it because 0:16:23.916 --> 0:16:29.196 you don't want to fly into a dangerous storm. The 0:16:29.356 --> 0:16:33.116 risk comes, and the storm is closing in, but there's 0:16:33.156 --> 0:16:37.196 still a window of opportunity to land. The landing strip 0:16:37.276 --> 0:16:41.236 is so close, just minutes away. Tunnel vision sets in, 0:16:41.636 --> 0:16:44.876 people start to hurry, Margins for error are stripped away. 0:16:45.716 --> 0:16:49.076 Usually there's no harm done. The pilot lands just as 0:16:49.116 --> 0:16:53.156 the storm rips across, and congratulates himself or herself for 0:16:53.316 --> 0:16:58.036 keeping cool and showing skill under pressure. But sometimes the 0:16:58.076 --> 0:17:03.196 consequences are more serious. One study of get their Itis 0:17:03.196 --> 0:17:06.836 looked at twenty occasions when thunderstorms had closed in at 0:17:06.876 --> 0:17:13.076 Hartsfield Jackson, Atlanta's major international airport. Again and again, pilots 0:17:13.116 --> 0:17:17.116 decided to chant a risky landing, risky in the sense 0:17:17.196 --> 0:17:21.396 that the Federal Aviation Administration's official guidelines would have advised 0:17:21.396 --> 0:17:25.596 against it. One plane after another would land under ever 0:17:25.836 --> 0:17:31.676 more perilous conditions, until eventually one flight crew would resist 0:17:31.716 --> 0:17:36.036 the inertia and decide to divert elsewhere. At that point, 0:17:36.156 --> 0:17:40.876 every subsequent plane would also decide to divert. The madness 0:17:41.036 --> 0:17:44.836 only ended when someone set an example and changed the plan. 0:17:51.316 --> 0:17:54.356 I'm no airline pilots, but I sometimes suffer from get 0:17:54.396 --> 0:17:57.076 their itis in my own life. Perhaps you do too. 0:17:57.676 --> 0:18:00.996 For me, it tends to emerge when dealing with family logistics. 0:18:01.196 --> 0:18:03.596 I've got three children at two different schools, and they 0:18:03.636 --> 0:18:06.196 all have their hobbies and sports and all usual things. 0:18:06.956 --> 0:18:09.036 I'm sure many parents will be familiar with the play 0:18:09.316 --> 0:18:13.316 spinning that this sometimes involves. But then something goes wrong. 0:18:13.796 --> 0:18:16.116 The cars in the shop to be repaired, No problem, 0:18:16.156 --> 0:18:18.996 we can bike instead. Then someone needs to be at 0:18:19.036 --> 0:18:21.836 home to meet the plumber. We make contingency plans and 0:18:21.916 --> 0:18:24.116 they seem like they'll be fine, but then a fresh 0:18:24.196 --> 0:18:28.716 errand appears, or a babysitter calls to cancel. As complications mount, 0:18:28.756 --> 0:18:32.596 the plan starts to resemble an increasingly precarious assembly of 0:18:32.676 --> 0:18:36.876 stages and steps, lift, swaps and rendezvous. It's a Rube 0:18:36.916 --> 0:18:41.716 Goldberg fever dream of an itinerary. And then, if I'm lucky, 0:18:42.236 --> 0:18:45.396 either I or my wife will find enough headspace to 0:18:45.436 --> 0:18:52.196 say this is crazy. Someone's going to have to skip 0:18:52.276 --> 0:18:54.876 dance class tonight. We'll call the plumber to see if 0:18:54.916 --> 0:18:59.476 tomorrow's okay. Instead, we'll replace the entire time and motion 0:18:59.636 --> 0:19:04.996 nightmare with something radically simpler. But that's hard to do 0:19:05.596 --> 0:19:09.796 because of the inertia, because of the plan continuation by us, 0:19:10.276 --> 0:19:13.276 and the more the pressure mounts, the harder it is 0:19:13.316 --> 0:19:18.116 to see clearly just how precarious everything has become. I 0:19:18.196 --> 0:19:21.636 become so fixated on executing the plan that I don't 0:19:21.716 --> 0:19:25.876 have a moment to realize that it's now a stupid plan. 0:19:29.596 --> 0:19:32.596 Captain Rugiati was under pressure to reach the harbor at 0:19:32.596 --> 0:19:35.156 Milford Haven in time, and had been woken with the 0:19:35.276 --> 0:19:38.516 unwelcome news that the ship was off course too far 0:19:38.596 --> 0:19:42.916 towards the mainland. If he'd stopped to think or to 0:19:42.996 --> 0:19:45.996 talk to his officers, he would have realized that he 0:19:46.116 --> 0:19:49.076 still had time to turn and go the long way 0:19:49.156 --> 0:19:53.196 round outside the Aisles of Scilly. He only had an 0:19:53.196 --> 0:19:56.356 hour or two to spare, but a brief calculation would 0:19:56.356 --> 0:19:59.836 have revealed that the detour would have cost just twenty 0:19:59.876 --> 0:20:04.476 nine minutes. Yet he didn't pause to reflect. He snapped 0:20:04.476 --> 0:20:07.156 at Bonfilio and ordered him to stick to the course 0:20:07.196 --> 0:20:10.916 that would now cut inside the Isles of Scilly. Nor 0:20:10.956 --> 0:20:13.556 did he reflect that, since his ship had already been 0:20:13.556 --> 0:20:16.996 deflected by the current and the wind, those forces might 0:20:17.036 --> 0:20:20.356 well continue to work upon the ship, moving it out 0:20:20.396 --> 0:20:24.356 of its intended position. Under time pressure, he began to 0:20:24.396 --> 0:20:28.836 suffer get their itis. His plan was risky, and his 0:20:28.916 --> 0:20:36.436 plan was not about to change. At eight eighteen am, 0:20:36.476 --> 0:20:40.436 a junior officer calculated their position, this being the days 0:20:40.476 --> 0:20:43.196 before GPS. He did it with the ship's charts, a 0:20:43.276 --> 0:20:47.796 compass bearing, and a radar reading old school, but the 0:20:47.876 --> 0:20:51.516 inexperienced officer was anxious. He wasn't convinced he'd got the 0:20:51.516 --> 0:20:56.356 ship's position exactly right, but he didn't speak up. After all, 0:20:56.356 --> 0:20:58.516 there'd be another chance to take a fix in ten 0:20:58.516 --> 0:21:03.716 minutes or so. Captain Rugiati wasn't speaking up either, as 0:21:03.716 --> 0:21:07.636 the ship steamed north at sixteen knots nearly twenty miles 0:21:07.676 --> 0:21:10.796 an hour. He had already decided which course he would take, 0:21:11.596 --> 0:21:14.436 but he hadn't told his crew, which meant that they 0:21:14.516 --> 0:21:17.356 hadn't had a chance to comment, and they didn't feel 0:21:17.436 --> 0:21:22.396 entitled to ask. Captain Rugatti had actually decided to pass 0:21:22.596 --> 0:21:26.116 through the narrow channel, which involved bending the ship's course 0:21:26.156 --> 0:21:31.156 in a long, slow curve to the left. Why Perhaps 0:21:31.196 --> 0:21:35.076 because it was the most direct route, but mostly because 0:21:35.796 --> 0:21:39.276 well why not? To me? It was, they say, But 0:21:39.476 --> 0:21:42.236 should he not have taken just a few more minutes 0:21:42.276 --> 0:21:45.476 to avoid the narrow route? That was never in my mind. 0:21:47.596 --> 0:21:51.596 That's a revealing turn of phrase. Never, in my mind, 0:21:52.116 --> 0:21:56.436 Pastrenger Rugiati didn't even consider the possibility of going through 0:21:56.476 --> 0:21:59.636 the wider channel. And while that might seem strange to 0:21:59.716 --> 0:22:03.436 you or me, it's a natural feature of planned continuation 0:22:03.556 --> 0:22:07.076 by us. As the tunnel vision develops. We don't even 0:22:07.156 --> 0:22:10.476 think about alternatives to our ishor plan. We don't have 0:22:10.516 --> 0:22:29.916 the bandwidth. We continue to plow on. In two thousand 0:22:29.916 --> 0:22:33.156 and five, a young boy was rushed into a hospital 0:22:33.156 --> 0:22:37.236 emergency room. He suffered from asthma, and he was in distress. 0:22:37.556 --> 0:22:41.196 He was finding it harder to breathe and harder and harder, 0:22:41.396 --> 0:22:46.436 and then his breathing stopped. The medical team quickly strapped 0:22:46.436 --> 0:22:49.316 an oxygen mask on to the boy. That should have helped, 0:22:49.756 --> 0:22:54.036 but instead his heart stopped beating two. There were eight 0:22:54.276 --> 0:22:57.196 trained medical professionals in the room, taking it in turns 0:22:57.236 --> 0:23:01.516 to perform CPR on the boy. Still no pulse, Still 0:23:01.956 --> 0:23:07.436 no breathing. The minutes ticked by a doctor slid a 0:23:07.476 --> 0:23:10.076 breathing tube down the boy's throat. No thing's happening. Is 0:23:10.116 --> 0:23:13.316 the tube in position? The tube's fine? I checked, Is 0:23:13.316 --> 0:23:16.756 there any pulse? Still nothing? Let's take the breathing tube 0:23:16.756 --> 0:23:20.956 out and try the airbag again. It's not helping. No, 0:23:21.156 --> 0:23:24.556 it wasn't helping. And the reason it wasn't helping was 0:23:24.596 --> 0:23:28.476 because the breathing apparatus was broken. It would have taken 0:23:28.516 --> 0:23:31.876 a few seconds to check if any of the five 0:23:31.956 --> 0:23:36.236 nurses or three doctors had thought to check, but they 0:23:36.276 --> 0:23:39.676 didn't think, not until the boy had been deprived of 0:23:39.716 --> 0:23:46.996 oxygen for ten minutes. Thankfully, this wasn't a tragedy. It 0:23:47.116 --> 0:23:50.356 was a training exercise. Instead of a real boy, it 0:23:50.476 --> 0:23:52.476 was a medical dummy that was lying on the bed 0:23:52.796 --> 0:23:57.116 failing to produce a simulated pulse or simulated respiration because 0:23:57.116 --> 0:24:04.956 the medical team didn't step back and think. This training 0:24:04.996 --> 0:24:09.556 scenario was conducted nineteen times, and videos of the exercise 0:24:09.636 --> 0:24:13.876 were studded by Marlist Christiansen, a professor of organizational behavior 0:24:14.556 --> 0:24:19.876 and previously the doctor Professor. Christiansen found that some medical 0:24:19.916 --> 0:24:22.916 teams took just seconds to identify the problem with a 0:24:22.956 --> 0:24:28.356 breathing equipment. This isn't working, it's broken. That's impressive, But 0:24:28.476 --> 0:24:31.996 perhaps more impressive were the teams who started with the 0:24:32.036 --> 0:24:35.036 wrong theory about the problem, but didn't get stuck on 0:24:35.116 --> 0:24:38.676 that idea. They didn't fixate on one possibility, or keep 0:24:38.716 --> 0:24:42.396 repeating the same approach over and over again. They would 0:24:42.396 --> 0:24:45.556 talk through what they were thinking and challenge themselves and 0:24:45.716 --> 0:24:50.716 each other. They could change course, but not every team 0:24:50.796 --> 0:24:54.676 did that. Many teams would hammer away at the same plan, 0:24:55.116 --> 0:24:57.836 regardless of the signs that it wasn't going to work. 0:24:58.356 --> 0:25:01.756 They didn't step back and think, They didn't talk things through, 0:25:02.396 --> 0:25:08.716 They just kept going. Could Captain Rugiati avoid the same fate. 0:25:15.156 --> 0:25:18.916 Captain Rugatti is now trying to curve his ship through 0:25:18.956 --> 0:25:22.236 the narrower channel. He doesn't even have the full six 0:25:22.276 --> 0:25:25.236 and a half miles to aim at because he's approaching 0:25:25.276 --> 0:25:29.196 at an angle. He's left himself precious little margin for error. 0:25:29.756 --> 0:25:33.396 As it is, Torry Canyon is heading straight for the 0:25:33.436 --> 0:25:38.476 submerged rocks at half past eight. As the slow, slow 0:25:38.596 --> 0:25:43.156 turn begins, two fishing boats appear on the radar, the 0:25:43.236 --> 0:25:47.956 two French langoustiers that are watching the oncoming supertanker with astonishment. 0:25:48.916 --> 0:25:52.316 Rugiati had planned to keep turning, but now he has 0:25:52.356 --> 0:25:56.036 to ensure he doesn't hit the boats. Suddenly, floats come 0:25:56.076 --> 0:25:58.756 into view. There are a sign of fishing nets beneath 0:25:58.756 --> 0:26:02.836 the surface. Tory Canyon can't possibly avoid them all and 0:26:03.036 --> 0:26:07.276 slices through one set of nets. Captain Rugiati pauses his 0:26:07.396 --> 0:26:11.916 turn in order not to shred thet He's now heading 0:26:12.076 --> 0:26:14.756 very close to where he thinks the stones are, but 0:26:14.876 --> 0:26:17.116 he still hopes to be able to resume his turn 0:26:17.476 --> 0:26:22.836 after passing the nets. But meanwhile, all the while, the 0:26:22.956 --> 0:26:28.436 current has been gently, insistently pushing Torry Canyon closer and 0:26:28.636 --> 0:26:33.436 closer to the seven Stones. At this point, Rugiati seems 0:26:33.436 --> 0:26:36.396 to have woken up to the danger. He has precious 0:26:36.396 --> 0:26:40.036 little room for maneuver. Rather than curving out of danger, 0:26:40.236 --> 0:26:43.836 he's heading directly towards the seven Stones. He was later 0:26:43.876 --> 0:26:45.876 asked whether he would have been heading that way if 0:26:45.916 --> 0:26:49.356 not for the fishing boats and their nets. No, only 0:26:49.356 --> 0:26:52.756 a madman would have followed. In northern course, Rugiati now 0:26:52.796 --> 0:26:55.996 knows his heading is dangerous. His plan to go through 0:26:56.036 --> 0:27:00.116 the narrow channel is being frustrated, but as the pressure rises, 0:27:00.316 --> 0:27:04.356 he can't step back and form a better plan. Why 0:27:04.396 --> 0:27:07.476 doesn't he slow down? Why doesn't he abandon his plan 0:27:07.596 --> 0:27:11.036 to turn left into the channel and instead turned sharply 0:27:11.116 --> 0:27:15.876 right into deep water. That was never in my mind. Never. 0:27:17.756 --> 0:27:21.116 When get their itis takes hold there are a lot 0:27:21.156 --> 0:27:24.196 of things that should be in our minds but aren't. 0:27:25.676 --> 0:27:29.036 At eight thirty eight am, Captain Ruggiati takes a look 0:27:29.076 --> 0:27:33.316 at the charts. His junior officer has just taken another bearing. 0:27:33.996 --> 0:27:36.876 Ruggiati is an old hand. He can see at once 0:27:36.956 --> 0:27:40.196 that it can't be right. The crosses marking the ship's 0:27:40.196 --> 0:27:44.276 position should be at regular intervals, but they're not. One 0:27:44.276 --> 0:27:48.036 of the bearings is wrong. He doesn't know which. Maybe 0:27:48.036 --> 0:27:52.516 they're both wrong. Captain Ruggiati doesn't know where he is. 0:27:53.676 --> 0:27:56.716 The junior officer takes another bearing with the Captain's help. 0:27:57.276 --> 0:27:59.796 The new fix shows that the ship is closer to 0:27:59.796 --> 0:28:04.356 the seven Stones than they're realized, less than three miles. Remember, 0:28:04.676 --> 0:28:07.276 Torry Canyon takes a mile and a half to make 0:28:07.316 --> 0:28:12.196 a ninety degree turn on his trawler. Watching with horror 0:28:12.796 --> 0:28:17.516 guy Foliage has already concluded that it's all over. Torry 0:28:17.556 --> 0:28:23.636 Canyon can't possibly avoid the rocks, but he's wrong. There 0:28:23.956 --> 0:28:27.476 is still time. There's still time to turn into deep water. 0:28:27.756 --> 0:28:30.556 There's even still time to turn into the channel, which 0:28:30.636 --> 0:28:33.636 is what Pastrengo Rugiati has been trying to do for 0:28:33.716 --> 0:28:36.636