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Speaker 1: Pushkin. Japanese Airlines flight nine oh seven is flying from

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Speaker 1: Tokyo to Okinawa. It took off twenty minutes ago, and

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Speaker 1: it's almost completed its climb to its cruising altitude, close

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Speaker 1: enough that the fastened seatbelt sign has been switched off

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Speaker 1: and the cabin attendants are serving hot tea. The year

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Speaker 1: is two thousand and one. The airspace around Tokyo is busy.

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Speaker 1: Another Japanese Airlines plane, flight nine five eight, is coming

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Speaker 1: in from South Korea. It'll soon begin its descent. The

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Speaker 1: flight paths of nine oh seven and nine five eight

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Speaker 1: are going to cross. That's not a problem, of course,

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Speaker 1: as long as they're at different altitudes. But they're currently

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Speaker 1: on course to be at pretty similar altitudes. No need

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Speaker 1: to panic. This kind of thing happens all the time.

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Speaker 1: We simply need one of the planes to go a

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Speaker 1: bit higher or the other to go a bit lower.

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Speaker 1: As long as they don't both do the same thing,

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Speaker 1: they'll be fine. Modern airplanes have an automated system for

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Speaker 1: situations like this. It's called TEA CASS. The Traffic Collision

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Speaker 1: Avoidance System TEA CASS kicks in now. In the cockpit

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Speaker 1: of flight nine five eight. It tells the pilot to descend, descend, descend, descend.

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Speaker 1: The pilot starts to descend. In the cockpit of flight

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Speaker 1: nine oh seven, Tea cast tells the pilot to climb, climb, climb, climb,

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Speaker 1: but down on the ground. A twenty six year old

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Speaker 1: trainee air traffic controller has also noticed that flights nine

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Speaker 1: oh seven and nine of eight iron a collision course,

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Speaker 1: and he's issued an instruction of his own j A

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Speaker 1: L nine O seven descend and maintain flight level three fifty.

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Speaker 1: Begin descent due to traffic hang on nine O seven.

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Speaker 1: Isn't nine O seven the one that's supposed to be climbing, Yes,

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Speaker 1: it is. The trainee air traffic controller has got his

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Speaker 1: planes muddled up. He meant to say nine eight. So

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Speaker 1: now the pilot of flight nine O seven has got

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Speaker 1: a decision to make. On the one hand, he's got

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Speaker 1: an air traffic controller telling him to descend. On the

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Speaker 1: other hand, Tea Cass is insisting he has to climb, climb, climb, climb.

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Speaker 1: He decides to descend. This isn't good. Both nine O

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Speaker 1: seven and nine five eight and now descending, So there's

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Speaker 1: a real risk that they're going to be at the

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Speaker 1: same altitudes when they're fly paths into sect The trainee

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Speaker 1: air controller's supervisor sees the data and intervenes to put

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Speaker 1: things right. Jine seven, climb and maintain flight level three

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Speaker 1: ninety Hang one, there is no nine five seven. The

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Speaker 1: boss meant to say nine oh seven, but confused her numbers.

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Speaker 1: In the cockpit of flight nine seven, the pilot hears

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Speaker 1: the message and thinks that's not for me. Then he

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Speaker 1: sees flight nine five eight to the cockpit window. It's

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Speaker 1: alarmingly close, and he's heading straight for it. I'm Tim Harford,

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Speaker 1: and you're listening to cautionary tales. In the cockpit of

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Speaker 1: Japanese Airlines flight nine oh seven, the pilot has another

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Speaker 1: decision to make, and this time he has just a

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Speaker 1: split second to make it. How is he going to

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Speaker 1: avoid smashing into flight nine five eight? He slams his

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Speaker 1: plane into a nose dye. Back in the cabin, the

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Speaker 1: passengers who've undone their seat belts are suddenly hurled out

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Speaker 1: of their seats. Some of them hit the ceiling, so

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Speaker 1: do the cabin attendants who are pushing the drinks trolleys.

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Speaker 1: So do the drinks trolleys. Hop tea flies everywhere, the

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Speaker 1: boy is catapulted over four rows of seats, A middle

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Speaker 1: aged woman breaks her leg. A hundred people are injured,

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Speaker 1: nine of them seriously, but at least they're alive. It

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Speaker 1: could have been so much worse. Japan's Ministry of Transport

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Speaker 1: asks its Accidents Investigation Commission to look into what had

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Speaker 1: happened and what might be done to lower the risk

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Speaker 1: that it happens again. One problem, obviously, was that the

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Speaker 1: trainee air traffic controller and his boss had got their

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Speaker 1: flight numbers muddled up. But if you're a loyal listener

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Speaker 1: to cautionary tales, you'll know that there's a common theme

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Speaker 1: in stories about people screwing up. That theme is that

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Speaker 1: people screw up all of us from time to time.

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Speaker 1: So if we want to reduce the risk of a repeat,

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Speaker 1: we can't rely on saying to air traffic controllers do better.

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Speaker 1: We need to look at how they operate. Can we

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Speaker 1: change anything to make it less likely that they'll screw up?

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Speaker 1: And when screw ups happen anyway, as they will, how

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Speaker 1: can we make it less likely that they'll lead to

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Speaker 1: tragic consequences? On that last point, think about the dilemma

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Speaker 1: faced by the pilot of flight nine oh seven. He's

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Speaker 1: got the air traffic controller telling him to descend and

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Speaker 1: Tea Cass telling him to climb. Which one should he

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Speaker 1: listen to? Tea Cass was new enough that this question

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Speaker 1: simply hadn't come up before, But it turns out there's

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Speaker 1: a clear right answer. He should listen to Tea Cass.

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Speaker 1: Like all automated systems, it's not infallible that when two

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Speaker 1: planes are heading straight towards each other and there's less

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Speaker 1: than a minute to keep them apart, Tea Cass is

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Speaker 1: much more likely than a human on the ground to

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Speaker 1: have the latest information and give quick and appropriate instructions.

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Speaker 1: The Japanese investigators can pile a report in which they'll

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Speaker 1: recommend an overhaul in how pilots are trained, so that

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Speaker 1: in future pilots will have no doubt that Tea Cass

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Speaker 1: takes priority. Seventeen months after the near miss, the report

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Speaker 1: is almost ready to be published. Meanwhile, in Moscow, forty

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Speaker 1: six school children aboarding a plane to Barcelona. It's the

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Speaker 1: first of July two thousand and two. The children, mostly teenagers,

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Speaker 1: are excited. They're going to experience Catalan culture and hang

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Speaker 1: out on the beach. They've already traveled hundreds of miles

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Speaker 1: from their home city of Oufar to the east in

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Speaker 1: the Ural mountains. But they're not the only ones on

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Speaker 1: the flight. Spetlana Kalaieva lives in Vladikavkas in the north

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Speaker 1: of Setia Alania Republic. Her husband Vitali, is working as

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Speaker 1: an architect in Barcelona. Spetlana is flying out to visit

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Speaker 1: with their ten year old son and four year old daughter,

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Speaker 1: but they've missed their transfer in Moscow. As luck would

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Speaker 1: have it, there are plenty of spare seats on this

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Speaker 1: charter flight from the kids from Oufar. Sped Lana and

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Speaker 1: the children get on board. The plane takes off from

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Speaker 1: Moscow in the early evening. Three hours later, it's cruising

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Speaker 1: over Switzerland. Out of the cockpit window, the pilot and

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Speaker 1: co pilot see the strobing lights of another plane in

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Speaker 1: the distance. It's hard to judge at nighttime how far

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Speaker 1: away another plane is, or how high it is, or

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Speaker 1: where it's going. But if they need to take evasive action,

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Speaker 1: they'll be told. And sure enough, here comes a message

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Speaker 1: from the air traffic controller in Zurich. Descend flight level

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Speaker 1: three fifty expedite. I have crossing traffic flight level three

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Speaker 1: fifty that means thirty five thousand feet. They're currently at

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Speaker 1: thirty six thousand feet. They start to descend, but then climb, climb, climb, climb.

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Speaker 1: What to do? The pilot and co pilot have both

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Speaker 1: been properly trained in flying their plane, the tv TU

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Speaker 1: one five four, but even if they'd memorize the operating

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Speaker 1: manual word for word, it wouldn't help them much. One

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Speaker 1: section prohibits initiating a maneuver contrary to a t CASS instruction,

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Speaker 1: but another section stresses how important it is to follow

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Speaker 1: the instructions of air traffic control and describes TECSS merely

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Speaker 1: as an additional system taken together that could be clearer.

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Speaker 1: The manual for t CASS itself isn't much better. One

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Speaker 1: part says that if a t CASS instruction is inconsistent

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Speaker 1: with current clearance from air traffic control, the pilot must

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Speaker 1: not delay in following the t CASS instruction, But another

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Speaker 1: part describes te CASS as a mere backup to air

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Speaker 1: traffic control. So you can understand why the pilot and

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Speaker 1: the copilot aren't immediately sure which voice to ignore. The

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Speaker 1: automated voice of Teacas or the human voice of the

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Speaker 1: Zurich air traffic controller. Climb, climb, climb, climb, it's saying, climb,

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Speaker 1: but he's guiding us down. Descend. They keep descending, and

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Speaker 1: here's the air traffic controller again repeating that instruction. Descend

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Speaker 1: level three fifty expedite descend copy. Yes, we have traffic

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Speaker 1: at you're two o'clock. Now at three to sixty. The

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Speaker 1: pilots descend even faster, but two o'clock. That means to

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Speaker 1: the right. They look out of the cockpit window to

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Speaker 1: the right. There's no sign of the other airplane. Where

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Speaker 1: is it here on the left? Increased climb, increased climb,

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Speaker 1: increased climb, it says, climb. There are no more words

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Speaker 1: recorded on the black box, but it does record an action,

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Speaker 1: a desperate tug at the control column. The pilots trying

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Speaker 1: at last to climb, but it's too late. As they

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Speaker 1: cross the path of the other plane, their wing slices

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Speaker 1: into its tail. Their plane breaks up. The plane they

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Speaker 1: hit catches fire. Both tumble from the sky. The wreckage

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Speaker 1: falls over hundreds of square kilometers near Uberlingen, just over

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Speaker 1: the Swiss German border. There are no survivors. How could

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Speaker 1: this happen? It seems incomprehensible. The next day, parents in

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Speaker 1: Oufar receive the devastating news in Barcelona, so does the

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Speaker 1: architect and doting father, Vitali Kaloyev. Cautionary tales will return

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Speaker 1: in a moment. Just eleven days after the crash over Uberlingen,

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Speaker 1: the Japanese investigators publish their report on the near miss.

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Speaker 1: Pilots training needs to change, it says, so they know

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Speaker 1: that Tea Cass Trump's air traffic control when the two

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Speaker 1: give opposing instructions. Now a German investigation team looks into

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Speaker 1: the collision over Uberlingen, among other things. Their report makes

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Speaker 1: much the same point. The instructions for Tea Cass, they find,

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Speaker 1: are not standardized, incomplete, and partially contradictory. The training and

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Speaker 1: instructions have since changed, so no pilot should now make

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Speaker 1: the same mistake, and in case they do, Tea Cass

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Speaker 1: has changed two. It now monitors whether both pilots are

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Speaker 1: obeying it and reverses orders if one is not. In

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Speaker 1: both Japan and Uberlingen, that would have kept the planes apart.

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Speaker 1: At the last moment. The pilot who had been descending

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Speaker 1: because tea cast told them to descend would now be

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Speaker 1: told to climb instead. The pilot who had been descending

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Speaker 1: in spite of Tea Cass would now find tea cast

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Speaker 1: telling them to keep doing what they were doing anyway.

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Speaker 1: But let's not forget that these incidents weren't all down

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Speaker 1: to Tea Cass. It's never just one thing, is it.

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Speaker 1: The floors in Tea Cass came to light only because

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Speaker 1: the air traffic controllers screwed up in Japan, as we've heard,

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Speaker 1: one was still in training. But what went wrong in Zurich.

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Speaker 1: On the evening of July the first, Peter Nielsen turns

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Speaker 1: up for his night shift with Skyguide, the company that

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Speaker 1: runs Zurich's air traffic control. Peter Nielsen is thirty five

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Speaker 1: years old. He's qualified and experienced, His colleagues said the

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Speaker 1: excellent investigators considered him to be a competent, knowledgeable and

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Speaker 1: professional air traffic controller, a team player, a nice guy.

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Speaker 1: The staffing level for night shifts in Zurich had recently changed.

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Speaker 1: In the past, there'd always been three controllers on shift.

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Speaker 1: They'd take turns to go for an extended break in

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Speaker 1: the middle of the shift. And get a bit of

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Speaker 1: sleep in the staff lounge. That was perfectly safe. There

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Speaker 1: went enough planes in the dead of night to keep

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Speaker 1: even two controllers occupied, and the third would return refreshed

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Speaker 1: as traffic picked up in the morning. But Skyguide had

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Speaker 1: become short staffed. They'd started putting only two controllers on

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Speaker 1: at night. The controllers continued their informal arrangement that one

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Speaker 1: would go to the lounge for a snooze. That was

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Speaker 1: considerably less safe. Yes, as long as nothing unusual occurred,

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Speaker 1: one controller could get through the quiet nighttime hours easily enough.

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Speaker 1: But if something out of the ordinary were to happen,

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Speaker 1: the controller would have nobody to turn to for a

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Speaker 1: sense check, and if the low own controller screws up,

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Speaker 1: there's no colleague there to notice. At quarter past eleven,

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Speaker 1: Peter Nielsen and his colleague agree that they'll now be

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Speaker 1: few enough flights coming through that the colleague can retire

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Speaker 1: to the lounge and return in a few hours. There

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Speaker 1: is something unusual happening tonight, though, and Nielsen is already

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Speaker 1: aware of it. Technicians are doing maintenance work on some

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Speaker 1: of the systems. They tell him those systems are now

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Speaker 1: in fallback mode. That's fine, he says. Nobody checks if

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Speaker 1: he understands exactly what fallback mode means. It later transpires

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Speaker 1: that he doesn't. Here's one thing. It means the radar

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Speaker 1: screens no longer display a scale, and Nielsen has to

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Speaker 1: monitor two screens which use different scales. Without the visual aid,

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Speaker 1: there's more risk of misperceiving how far apart planes are. Also,

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Speaker 1: the screens aren't automatically going which blip on the radar

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Speaker 1: corresponds to which plane, and the short term conflict alert

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00:16:16,450 --> 00:16:21,090
Speaker 1: system is partly disengaged. Normally, this system shows a warning

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Speaker 1: on the radar screen with two minutes notice if planes

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00:16:24,490 --> 00:16:26,890
Speaker 1: are on course to pass within a few miles of

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Speaker 1: each other. Now they'll just be an audible alarm if

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Speaker 1: a collision is much more imminent. None of these systems

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Speaker 1: are critical. Nielsen should be able to compensate for their

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Speaker 1: absence by making sure he pays a bit more attention.

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Speaker 1: But he isn't really aware that he needs to. And

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Speaker 1: what's this on his radar screen. It's a plane He

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Speaker 1: wasn't expecting to have to deal with. An airbus that

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Speaker 1: should have landed much earlier but got delayed. Nielsen and

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Speaker 1: his colleague could completely forgotten that the airbus would be

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Speaker 1: coming along. If they'd remembered, the colleague would have stayed

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Speaker 1: for another half hour to handle it. At half past eleven,

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Speaker 1: the Russian plane enters Nielsen's airspace and the pilot checks

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Speaker 1: in with him. It's flying at thirty six thousand feet.

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Speaker 1: The radar shows Nielsen that there's another plane at thirty

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Speaker 1: six thousand feet, a cargo flight from Bahrain to Brussels.

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Speaker 1: The planes are approaching each other roughly at right angles.

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Speaker 1: They're still over fifty miles apart. It sounds like a lot,

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Speaker 1: but there'll be upon each other in barely five minutes.

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Speaker 1: If he'd been paying more attention, Nielsen would have told

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Speaker 1: the Russian pilot to descend, But with so many systems down,

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Speaker 1: he doesn't notice. And now this delayed airbus wants his attention.

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Speaker 1: Nielsen has to move to a different workstation to talk

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Speaker 1: to it and tune into a different frequency. The airbus

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00:17:56,810 --> 00:18:00,730
Speaker 1: wants permission to land on an alternative runway that's a pane.

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00:18:01,210 --> 00:18:03,570
Speaker 1: Nielsen will need to phone the airport to check that

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00:18:03,650 --> 00:18:06,570
Speaker 1: it's okay, and the main phone system is yet another

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00:18:06,690 --> 00:18:10,050
Speaker 1: thing that's down for maintenance. There's a backup phone system

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00:18:10,130 --> 00:18:13,090
Speaker 1: that should still work, but for some reason, Nielsen can't

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00:18:13,130 --> 00:18:19,450
Speaker 1: get through. That's weird. He dials again and again. It

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00:18:19,650 --> 00:18:22,490
Speaker 1: later turns out there's a software glitch with the backup

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Speaker 1: phone system. Nielsen doesn't know that. He assumes he must

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00:18:26,650 --> 00:18:30,130
Speaker 1: be dialing the wrong number. He tries seven times to

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00:18:30,250 --> 00:18:33,450
Speaker 1: get through. He's got half an eye on the radar screen,

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Speaker 1: but it isn't showing any warnings. It would be by

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00:18:37,610 --> 00:18:42,210
Speaker 1: now if the short term conflict alert system was working properly,

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00:18:42,930 --> 00:18:48,210
Speaker 1: but it isn't, and Nielsen doesn't know that. The airspace

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00:18:48,410 --> 00:18:51,850
Speaker 1: next to Zurix is handled by another control center in

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00:18:52,010 --> 00:18:56,330
Speaker 1: Carl's Rue, Germany. The controllers there see the short term

256
00:18:56,490 --> 00:19:00,770
Speaker 1: conflict alert pop up on their radar screens. Remember that

257
00:19:00,970 --> 00:19:04,130
Speaker 1: alert means two planes will be perilously close to each

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00:19:04,170 --> 00:19:08,370
Speaker 1: other in just two minutes. The Carl's Rwer controllers could

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00:19:08,530 --> 00:19:11,450
Speaker 1: jump on the emergency radio frequency to talk to the

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00:19:11,530 --> 00:19:14,570
Speaker 1: two planes, but the rules say they shouldn't do that

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00:19:15,210 --> 00:19:17,650
Speaker 1: for the very good reason that the planes aren't in

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00:19:17,970 --> 00:19:23,170
Speaker 1: their airspace. Instead, the rules say they have to contact Zurich,

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00:19:23,890 --> 00:19:27,490
Speaker 1: so they try, but of course, the phone system in

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00:19:27,570 --> 00:19:35,170
Speaker 1: Zurich isn't working. They try again, and again, they try

265
00:19:35,570 --> 00:19:41,170
Speaker 1: eleven times. Nearly five minutes after the Russian plane entered

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Speaker 1: his airspace, Nielsen suddenly realizes the danger. Descend flight level

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00:19:46,650 --> 00:19:50,850
Speaker 1: pre fifty expedite. I have crossing perfect. The Russian crew

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Speaker 1: don't respond. Why aren't they responding? We know why. It's

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Speaker 1: because the pilot and copilot are busy debating whether they

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Speaker 1: should ignore Nielsen telling them to descend or tea Cass

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Speaker 1: telling them to climb. It hasn't occurred to Nielsen that

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Speaker 1: tea casks will have kicked. And now the audible conflict

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Speaker 1: alert sounds. The two planes are just half a minute

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Speaker 1: from colliding. Nielsen leaps into action. Descend level three fifty expedite. Descend.

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Speaker 1: We have traffic at you're two o'clock now at three sixty.

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00:20:23,210 --> 00:20:27,050
Speaker 1: Nielsen is stressed. He's not thinking straight. He doesn't realize

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Speaker 1: that he's contradicting Tea Cass. But more than that, he

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00:20:30,410 --> 00:20:33,370
Speaker 1: said two o'clock when he meant ten o'clock. It makes

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Speaker 1: the pilots look right when the cargo plane is to

280
00:20:36,410 --> 00:20:39,770
Speaker 1: their left and his radar display is out of date.

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00:20:40,170 --> 00:20:43,450
Speaker 1: The cargo plane isn't now at three sixty. It's been

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Speaker 1: descending because Tea Cass has told it to the Next

283
00:20:47,050 --> 00:20:51,650
Speaker 1: time Nielsen's radar refreshes, it shows the cargo plane level

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Speaker 1: with the Russian plane and descending at the same rate.

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Speaker 1: The pilot of the cargo plane comes on the radio

286
00:20:58,330 --> 00:21:02,650
Speaker 1: two to inform Nielsen that he's descending, but Nielsen doesn't

287
00:21:02,730 --> 00:21:05,730
Speaker 1: see the radar refresh, and he doesn't hear the cargo

288
00:21:05,850 --> 00:21:09,730
Speaker 1: pilot's call because he thinks he's averted the Dane. He's

289
00:21:09,770 --> 00:21:12,690
Speaker 1: gone back to his other workstation to deal with a

290
00:21:12,810 --> 00:21:18,210
Speaker 1: late running airbus. Instead. In Karl's room, the air traffic

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00:21:18,290 --> 00:21:22,130
Speaker 1: controller's watch in horror as the two dots on the

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00:21:22,290 --> 00:21:28,890
Speaker 1: radar collide. By the time Nielsen looks back at his screen,

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00:21:29,610 --> 00:21:33,850
Speaker 1: it's already happened. He tries to call the Russian plane,

294
00:21:34,490 --> 00:21:40,810
Speaker 1: there's no response. Bitari Kaloyev knows his wife and children

295
00:21:40,890 --> 00:21:45,330
Speaker 1: were on that plane. He hurries to Uberlingen, expecting the worst,

296
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Speaker 1: but nothing could have prepared him for the horrors he

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00:21:48,890 --> 00:21:53,570
Speaker 1: was about to see. Rescuers are still searching for all

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00:21:53,610 --> 00:21:58,130
Speaker 1: the bodies. They're scattered over hundreds of square kilometers. The

299
00:21:58,250 --> 00:22:02,370
Speaker 1: body of Kaloyev's wife, swet Lana has landed in a cornfield,

300
00:22:03,170 --> 00:22:06,690
Speaker 1: his ten year old son on asphalt near a bush shelter.

301
00:22:07,610 --> 00:22:10,010
Speaker 1: The little body of his four year old daughter was

302
00:22:10,090 --> 00:22:16,370
Speaker 1: found snagged up in a tree. When Calloiev searches the area,

303
00:22:17,170 --> 00:22:20,610
Speaker 1: he finds her pearl necklace lying on the forest floor.

304
00:22:22,930 --> 00:22:26,370
Speaker 1: Colloiev cleans the bodies and dresses them for the funeral.

305
00:22:28,010 --> 00:22:33,810
Speaker 1: He also asks questions of journalists the air traffic controller

306
00:22:34,850 --> 00:22:46,050
Speaker 1: what's his name and where does he live? Cautionary tales

307
00:22:46,490 --> 00:23:05,850
Speaker 1: will return. The Swiss air traffic control company Skyguide, had

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00:23:05,890 --> 00:23:08,930
Speaker 1: recently come up with new procedures that were meant to

309
00:23:09,090 --> 00:23:13,850
Speaker 1: allow controllers to work safely alone when needed. Swiss regulators

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00:23:13,890 --> 00:23:17,970
Speaker 1: were already worried about those procedures. Were they two las

311
00:23:18,690 --> 00:23:22,970
Speaker 1: too risky? But Peter Nielsen wasn't even working under these

312
00:23:23,090 --> 00:23:26,690
Speaker 1: new procedures. They applied only when there was officially just

313
00:23:27,050 --> 00:23:32,770
Speaker 1: one controller on duty during nightshifts. Officially two controllers were

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00:23:32,810 --> 00:23:35,770
Speaker 1: on duty at all times. The fact that one of

315
00:23:35,810 --> 00:23:39,370
Speaker 1: them always spent a few hours asleep was just an

316
00:23:39,410 --> 00:23:43,250
Speaker 1: informal arrangement, But it was an arrangement that the managers

317
00:23:43,290 --> 00:23:47,530
Speaker 1: at Skyguide knew all about. They'd already had to investigate

318
00:23:47,730 --> 00:23:52,530
Speaker 1: one near miss. When Skyguide came up with their new

319
00:23:52,650 --> 00:23:56,330
Speaker 1: procedures for solo working. They assumed that if only one

320
00:23:56,410 --> 00:23:59,890
Speaker 1: controller was on duty, they'd at least have a supervisor

321
00:23:59,930 --> 00:24:03,090
Speaker 1: they could call on for help. But that didn't happen.

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00:24:03,170 --> 00:24:06,930
Speaker 1: On the night shift. When one controller slept, there was

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00:24:07,050 --> 00:24:12,890
Speaker 1: no supervisor. Nielsen had to supervise himself. The procedures also

324
00:24:12,970 --> 00:24:16,330
Speaker 1: assumed that the controller would have the short term conflict

325
00:24:16,370 --> 00:24:20,610
Speaker 1: alert system to rely on. Taking that system offline for

326
00:24:20,730 --> 00:24:25,530
Speaker 1: maintenance would have breached the procedures, but of course Nielsen

327
00:24:25,690 --> 00:24:30,250
Speaker 1: wasn't protected by these procedures, procedures that the regulators already

328
00:24:30,370 --> 00:24:34,210
Speaker 1: worried might not be safe enough. No wonder the investigation

329
00:24:34,330 --> 00:24:39,410
Speaker 1: report comes across as pretty sympathetic to Peter Nielsen. He

330
00:24:39,610 --> 00:24:42,930
Speaker 1: screwed up, of course he did, but his employers had

331
00:24:42,930 --> 00:24:46,330
Speaker 1: allowed a workplace culture to develop in which screw ups

332
00:24:46,450 --> 00:24:51,610
Speaker 1: were disturbingly likely. Nielsen was not in a position to

333
00:24:51,810 --> 00:24:55,090
Speaker 1: safely execute all the tasks he had been given. The

334
00:24:55,170 --> 00:25:00,090
Speaker 1: investigators found Nielsen was traumatized by his role in the collision.

335
00:25:00,370 --> 00:25:03,290
Speaker 1: He was treated for shock, but after some time off,

336
00:25:03,930 --> 00:25:08,890
Speaker 1: he returned to work. Nearly two years after the accident,

337
00:25:09,450 --> 00:25:12,330
Speaker 1: Peter Nielsen was at home with his wife and three

338
00:25:12,490 --> 00:25:15,490
Speaker 1: children when he saw a middle aged man sitting in

339
00:25:15,570 --> 00:25:19,170
Speaker 1: his front garden. He went outside to find out who

340
00:25:19,290 --> 00:25:23,330
Speaker 1: the man was and what he wanted. His children followed

341
00:25:23,410 --> 00:25:27,250
Speaker 1: him out. He waved them back inside. We don't know

342
00:25:27,410 --> 00:25:31,490
Speaker 1: for sure what happened next. We only have Vitali Kaloyev's

343
00:25:31,530 --> 00:25:34,770
Speaker 1: side of the encounter. He says he tried to say

344
00:25:34,810 --> 00:25:38,610
Speaker 1: the German words for I am from Russia. He says

345
00:25:38,890 --> 00:25:41,490
Speaker 1: he gestured to the front door to show that he

346
00:25:41,610 --> 00:25:45,770
Speaker 1: expected Nielsen to invite him in. He says he tried

347
00:25:45,850 --> 00:25:50,090
Speaker 1: to show Nielsen photos of the bodies of his dead children,

348
00:25:51,010 --> 00:25:54,610
Speaker 1: and he says Nielsen pushed his hand aside and the

349
00:25:54,730 --> 00:25:59,650
Speaker 1: photos fell to the ground. In Kaloyev's telling, what happened

350
00:25:59,730 --> 00:26:04,410
Speaker 1: next is a blank, but Peter Nielsen's wife can pick

351
00:26:04,530 --> 00:26:08,170
Speaker 1: up the story. She heard a scream, she rushed outside

352
00:26:08,210 --> 00:26:12,130
Speaker 1: to find Kaloye of walking calmly away with a switchblade knife,

353
00:26:12,890 --> 00:26:16,490
Speaker 1: and her husband lying in a pool of his own blood.

354
00:26:23,850 --> 00:26:28,010
Speaker 1: It's never just one thing, is it. If Nielsen's colleague

355
00:26:28,050 --> 00:26:31,010
Speaker 1: had stayed for another half an hour, if Nielsen had

356
00:26:31,090 --> 00:26:34,290
Speaker 1: known that the alert system wasn't working, if the backup

357
00:26:34,330 --> 00:26:37,530
Speaker 1: phone line hadn't had a software glitch, if the pilots

358
00:26:37,570 --> 00:26:41,610
Speaker 1: had been trained to prioritize teacass maybe you can think

359
00:26:41,650 --> 00:26:45,570
Speaker 1: of it as a series of dominoes falling one toppling another,

360
00:26:45,810 --> 00:26:50,570
Speaker 1: then another. That's a metaphor one pioneering safety researcher came

361
00:26:50,650 --> 00:26:53,890
Speaker 1: up with Herbert Heinrich in his nineteen thirty one book

362
00:26:54,250 --> 00:26:58,610
Speaker 1: Industrial Accident Prevention. Or think of the Swiss cheese metaphor

363
00:26:58,930 --> 00:27:04,050
Speaker 1: developed more recently by the psychologist James Reason. Each slice

364
00:27:04,090 --> 00:27:07,130
Speaker 1: of cheese is a layer of defense, and each has

365
00:27:07,210 --> 00:27:11,130
Speaker 1: holes in accidents when you have a stack of slices

366
00:27:11,450 --> 00:27:17,250
Speaker 1: and the holes just happen to line up. Peter Nielsen's

367
00:27:17,290 --> 00:27:20,370
Speaker 1: screw up was one hole in a slice of cheese,

368
00:27:20,810 --> 00:27:23,490
Speaker 1: but it wouldn't have mattered if there hadn't been other

369
00:27:23,610 --> 00:27:30,010
Speaker 1: holes in other slices. Sometimes we can reasonably hold people

370
00:27:30,090 --> 00:27:33,810
Speaker 1: responsible for gaping holes in a slice of cheese. A

371
00:27:33,970 --> 00:27:38,130
Speaker 1: Swiss court find managers at Skyguide for having allowed a

372
00:27:38,370 --> 00:27:43,250
Speaker 1: culture of negligence to develop in the workplace. At other times,

373
00:27:43,530 --> 00:27:45,730
Speaker 1: there's really nobody at whom you can point a finger.

374
00:27:46,450 --> 00:27:50,410
Speaker 1: The people who train pilots or right operating manuals hadn't

375
00:27:50,450 --> 00:27:54,290
Speaker 1: been sloppy or reckless. They simply hadn't foreseen that you

376
00:27:54,410 --> 00:27:58,050
Speaker 1: might get dangerous circumstances in which tea cass is saying

377
00:27:58,130 --> 00:28:02,370
Speaker 1: one thing and air traffic controllers are saying another. Once

378
00:28:02,410 --> 00:28:05,010
Speaker 1: it became clear that this could happen, they changed the

379
00:28:05,090 --> 00:28:09,570
Speaker 1: training and rewrote the manuals. That slice of cheese now

380
00:28:09,690 --> 00:28:14,770
Speaker 1: has smaller holes. Still, even when there isn't any one

381
00:28:14,890 --> 00:28:22,250
Speaker 1: obvious to punish, people can get punished anyway. Remember the

382
00:28:22,450 --> 00:28:26,450
Speaker 1: twenty six year old trainee air traffic controller in Japan

383
00:28:26,850 --> 00:28:30,170
Speaker 1: who had said flight nine oh seven when he meant

384
00:28:30,530 --> 00:28:34,890
Speaker 1: flight nine five eight. Remember the supervisor who jumbled her

385
00:28:35,010 --> 00:28:38,850
Speaker 1: numbers and said nine five seven. It's the same kind

386
00:28:38,930 --> 00:28:41,650
Speaker 1: of flub you might think that could happen to anyone,

387
00:28:42,090 --> 00:28:45,210
Speaker 1: and would hardly ever lead to tragedy. They'd usually be

388
00:28:45,370 --> 00:28:48,170
Speaker 1: plenty of other slices of cheese to cover the hole.

389
00:28:49,450 --> 00:28:54,610
Speaker 1: The Tokyo Metropolitan Police Department wasn't so forgiving. It was

390
00:28:54,810 --> 00:28:59,570
Speaker 1: professional negligence, they said. Prosecutors brought the pair to court.

391
00:28:59,930 --> 00:29:04,210
Speaker 1: They demanded eighteen months in prison for the supervisor they

392
00:29:04,250 --> 00:29:06,850
Speaker 1: cut the trainee a bit of slack. They wanted just

393
00:29:07,210 --> 00:29:12,050
Speaker 1: twelve months for him. The case rumbled on for five years,

394
00:29:12,770 --> 00:29:16,570
Speaker 1: during which both kept working at Tokyo Air Traffic Control.

395
00:29:17,650 --> 00:29:22,530
Speaker 1: At last, the district court delivered its verdict, acquitted on

396
00:29:22,690 --> 00:29:28,050
Speaker 1: all counts. The controller's legal ordeals seemed finally to be over,

397
00:29:28,570 --> 00:29:32,170
Speaker 1: and they wrote an open letter to the International Federation

398
00:29:32,370 --> 00:29:36,490
Speaker 1: of Air Traffic Controllers Associations to say thank you for

399
00:29:36,610 --> 00:29:40,370
Speaker 1: all the support they'd received from their professional colleagues around

400
00:29:40,450 --> 00:29:44,530
Speaker 1: the world. The court recognized that it was an accident

401
00:29:44,850 --> 00:29:49,090
Speaker 1: connected with a system rather than individuals. They wrote, we

402
00:29:49,290 --> 00:29:52,370
Speaker 1: think the collision above Uberlingen might have been prevented if

403
00:29:52,410 --> 00:29:55,730
Speaker 1: the causes that led to our accidents had been properly

404
00:29:55,770 --> 00:30:00,250
Speaker 1: clarified at an earlier stage and notified worldwide. This not

405
00:30:00,450 --> 00:30:03,970
Speaker 1: guilty verdict is not only ours, but also for all

406
00:30:04,090 --> 00:30:09,770
Speaker 1: of those who supported us. But the prosecutors lodged an appeal.

407
00:30:10,170 --> 00:30:17,850
Speaker 1: They weren't ready to give up yet. Vitali Kaloyev walked

408
00:30:17,890 --> 00:30:22,010
Speaker 1: back to his hotel, the Welcome Inn, near Zurich Airport,

409
00:30:23,010 --> 00:30:27,170
Speaker 1: having revenged himself upon Peter Nielsen. He was covered in

410
00:30:27,290 --> 00:30:32,290
Speaker 1: the air traffic controller's blood. Somehow the staff didn't see

411
00:30:32,410 --> 00:30:34,730
Speaker 1: him make his way up to his king size room.

412
00:30:35,730 --> 00:30:39,770
Speaker 1: The next day police came to the hotel to arrest him.

413
00:30:40,570 --> 00:30:45,410
Speaker 1: The charge was murder. Peter Nielsen had bled to death.

414
00:30:47,650 --> 00:30:51,170
Speaker 1: Vitali was held at first in a mental hospital, then

415
00:30:51,290 --> 00:30:55,170
Speaker 1: tried and sentenced to eight years in a Swiss prison.

416
00:30:57,170 --> 00:31:01,250
Speaker 1: Just two years later he was out. An appeal court

417
00:31:01,490 --> 00:31:05,490
Speaker 1: decided that he couldn't be held fully accountable for his actions.

418
00:31:07,690 --> 00:31:11,690
Speaker 1: The most shocking thing about Vitali Kaloyev's murder of Peter

419
00:31:11,850 --> 00:31:16,730
Speaker 1: Nielsen isn't the murder itself. The most shocking thing was

420
00:31:16,810 --> 00:31:20,330
Speaker 1: the public reaction to Vitali Kaloyev. When he got out

421
00:31:20,370 --> 00:31:24,170
Speaker 1: of prison and went home to North Ossetia. It was

422
00:31:24,210 --> 00:31:29,330
Speaker 1: a hero's welcome. He got fan mail, letters of support,

423
00:31:29,770 --> 00:31:33,450
Speaker 1: offers of marriage. If more people were like you, wrote

424
00:31:33,530 --> 00:31:36,690
Speaker 1: one woman, the world would be a better place. He's

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Speaker 1: a real man, said one local dignitary. What he did

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Speaker 1: was an act of heroism. Journalists in Ossetia named him

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Speaker 1: Man of the Year. The government of North Ossetia supported

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Speaker 1: Kaloyev two They even appointed him Deputy Minister for Construction

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Speaker 1: When he retired. They gave him the Glory of Ossetia Medal, awarded,

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Speaker 1: among other things, for maintaining law and order. One man's

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Speaker 1: grief fueled madness is understand The support from many others

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Speaker 1: says something more troubling about the human condition. In any accident,

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Speaker 1: there are lots of lessons we might learn about how

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Speaker 1: to make future accidents less likely. Rewrite instructions, change workplace culture,

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Speaker 1: tweak automated systems, but punish people for getting in a muddle.

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Speaker 1: I'm not so sure that helps. The prosecutors in Japan

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Speaker 1: took a different view. They pursued their case against the

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Speaker 1: two air traffic controllers for another five years, until at

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Speaker 1: last the Supreme Court handed down the final verdict guilty.

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Speaker 1: The sentences at least were suspended. They wouldn't go to

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Speaker 1: prison unless they committed some other crime, such as maybe

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Speaker 1: mixing up their flight numbers again. But they wouldn't need

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Speaker 1: to worry about that because as convicted criminals, they lost

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Speaker 1: their jobs. It's never just one thing. But shades of

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Speaker 1: gray aren't satisfying. It seems we thirst for black and white.

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Speaker 1: We want villains, and we want vengeance. For a full

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Speaker 1: list of our sources Please see the show notes at

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Speaker 1: Tim Harford dot com. Cautionary Tales is written by me

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00:33:53,770 --> 00:33:58,450
Speaker 1: Tim Harford with Andrew Wright. It's produced by Alice Fines

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00:33:58,690 --> 00:34:02,890
Speaker 1: with support from Edith Ruslow. The sound design and original

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00:34:03,010 --> 00:34:07,170
Speaker 1: music is the work of Pascal Wise. The show wouldn't

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Speaker 1: have been possible without the work of J. K. Weisberg,

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Speaker 1: Ryan Dilley, Julia Barton, Gretta Cone, Little Millard, John schnars

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Speaker 1: Kylie Migliori, Eric Sandler, Maggie Taylor, Nicole Morano, and Morgan Ratner.

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Speaker 1: Cautionary Tales he's a production of Pushkin Industries. If you

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Speaker 1: like the show, please remember to share, rate, and review.

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Speaker 1: It helps us for mysterious reasons. If you want to

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Speaker 1: hear the show, add free sign up for Pushkin Plus

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Speaker 1: on the show page and Apple Podcasts, or at pushkin

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Speaker 1: dot fm, slash plus