0:15

Pushkin. I

0:20

opened the wrapping paper hurriedly with nervous

0:22

hands, excited to get at the gift inside.

0:25

Little did I know, disaster

0:28

was about to enter my previously happy

0:30

childhood. It wasn't a

0:32

disaster visited on mean or my family.

0:35

It was a catalog of disasters for everyone

0:37

else. For the gift was a

0:39

book, and it was titled,

0:41

in bold letters on a blood red background,

0:44

the World's Greatest Mistakes.

0:47

The stories were set out like a trashy

0:49

and exciting tabloid newspaper. Some

0:52

were absurd, like the bride who

0:54

accidentally married the best man. Some

0:56

of them were famous tragedies, the Titanic

0:59

slipping beneath the icy sea,

1:02

funny or sad. All of them fascinated

1:04

me, and I realized something that has

1:06

guided me throughout my life. From

1:09

other people's mistakes is a lot

1:11

less painful than learning from your own.

1:15

My name is Tim Harford. Some

1:17

people call me the undercover Economist.

1:20

I use scientific ideas to

1:22

help people think more clearly about

1:24

the world in my books, my ted

1:26

Talks, my BBC shows, and my

1:28

column for the Financial Times. That

1:31

may sound all very grown up, but

1:34

part of me is that little boy who

1:36

loved stories of catastrophe,

1:38

mistake, and mayhem.

1:41

So I still seek out and collect such stories.

1:44

But now I probe the details. I

1:47

challenge the Orthodox view and look

1:49

for the root causes and ponder how

1:51

disaster could have been prevented. In

1:54

short, I look for the painless

1:56

lessons they can teach me. And now

1:59

I want to share some of these cautionary

2:01

tales with you too. Each

2:06

story has a moral, each

2:08

story is true, and

2:10

each story, if you're not careful,

2:13

could happen to you. So

2:16

gather closer and I'll begin.

2:30

We pray thee Lord, not that

2:33

rex should happen, but that

2:35

if any Rex do happen,

2:38

thou wilt guide them to the Silly Isles

2:40

for the benefit of the poor inhabitants.

2:45

That's an old prayer from the Isles

2:47

of Scilly. The isles are

2:49

just off the coast of Cornwall, the southwest

2:52

tip of Great Britain, and that

2:54

prayer has been answered many times.

2:57

The rocks around the islands have a

2:59

fearsome reputation and it's

3:01

well earned. One autumn

3:04

night in seventeen oh seven, the

3:06

Royal Navy lost its way in a storm.

3:08

The flag ship HMS Association

3:11

struck a rock and went down. In minutes,

3:14

eight hundred men drowned behind

3:17

it. HMS Saint George hit the rocks

3:20

and became stuck. So did HMS

3:22

Phoenix, so did HMS Firebrow.

3:25

HMS Romney lost her entire

3:27

crew. HMS Eagle was

3:29

shattered on the cruel stone. Hundreds

3:32

more sailors died. That

3:34

Dreadful Night was one of the worst

3:37

disasters in the history of the British

3:39

Navy. Local

3:46

legend has it that there was one

3:48

notable survivor, that the Commander

3:51

in Chief of the British Fleets,

3:53

Sir Cloudsley Shovel, was washed

3:55

up on the beaches of the Aisles of Scilly,

3:58

but was strangled by a local

4:00

woman who fancied wearing

4:03

his emerald ring herself if

4:05

she had been praying the old prayer God

4:09

or the devil had been listening.

4:13

It is a dark tale, but

4:16

the story I shall tell you to day is

4:18

a far stranger one. It

4:23

was some time after dawn on

4:26

Saturday March the eighteenth, nineteen

4:28

sixty seven. Martyr

4:32

Christie was a langoustier, a French

4:34

lobster boat fishing for crayfish

4:36

and crab between the mainland and the Isles

4:39

of Scilly. Twenty one miles further

4:41

west on deck was

4:43

Captain guy Folich, another

4:45

langoustier, was near by, both

4:47

of them enjoying rich pickings. A few

4:50

hundred yards north of the Seven Stones.

4:53

The seven Stones make up a vicious reef

4:55

about one third of the way between the Isles

4:57

of Scilly and the mainland. At

5:00

low tide, the unyielding rocks

5:02

are visible, but even at high

5:04

tide there marked by a lighthouse vessel

5:07

warning ships to stay away. Guifolich

5:11

looked up from his lobster lions to see

5:13

an unexpected sight, a

5:15

vast black hull coming over

5:17

the horizon from an unusual

5:19

direction. He was surprised.

5:22

A major vessel in that position would

5:24

usually have passed outside of the Aisles

5:27

of Silly, rather than squeezing

5:29

between them and the mainland. True,

5:32

a big ship could come between the Aisles

5:35

of Silly and the mainland, passing on either

5:37

side of the Seven Stones, but it

5:39

would be a little on the tight side. And

5:42

this ship, a supertanker,

5:45

was very big. Indeed, in

5:47

fact, it was the thirteenth biggest

5:50

ship in the world. On

5:53

the lighthouse vessel, the two seamen

5:55

on watch saw the tanker approaching too.

5:58

Have you seen this? Have you? Yeah? Look

6:00

at that big baster coming up. Guifolich

6:04

could see the huge ship coming straight

6:07

towards him as he fished kayak,

6:11

but he wasn't worried. In between

6:13

him and the oncoming juggernaut were

6:16

the seven Stones. He

6:18

later said, I was sure that before

6:20

ever eating us, you would go onto

6:22

the rucks. He yelled to his men, stop

6:26

work, You're going to see something extraordinary.

6:30

All seven of them lined up on the rail

6:32

of Marta Christie to watch the oil

6:35

tanker bear closer and

6:37

closer, four

6:39

miles, three miles.

6:43

Folich was sure it was doomed. It

6:45

just wasn't possible to turn a super tanker

6:47

that quickly, was it? Actually?

6:50

Folich wasn't quite right. The

6:53

tanker, whose name was Torry

6:56

Canyon, did still have room

6:58

to turn. This wasn't

7:00

a storm tossed fleet of sailing ships

7:03

fumbling through the darkness. The

7:05

weather was good, the visibility

7:07

was good. Tory or Canyon was

7:09

a superb ship, in fine working

7:12

order and armed with radar. The

7:14

seven Stones were clearly marked on every

7:17

chart, as well as being identified by

7:19

the position of the lighthouse vessel but

7:22

Torry Canyon still wasn't

7:25

turning. Gather

7:28

close and listened to my

7:30

cautionary tail. Nobody

7:43

knew it at the time, but the trouble all

7:45

started with a radio message from Milford

7:47

Haven, the harbor towards which Torry

7:50

Canyon was sailing. Milford

7:52

Haven is a major UK port, and

7:54

the thing you need to know about ports in the UK

7:57

is that the difference between high tide and

7:59

low tide can be enormous. What's

8:02

more, there are high tides and high tides,

8:05

some are higher than others. The

8:07

message from Milford Avon was simple

8:10

enough. Torry Canyon needed

8:12

to hurry. If the ship didn't

8:14

arrive by eleven pm on Saturday

8:16

evening March the eighteenth, nineteen

8:19

sixty seven, it would miss the

8:21

extra high tide and wouldn't be

8:23

able to slip into the harbor and dock. It

8:26

would then have to wait another six

8:29

days before the tide would once

8:31

more be high enough. Missing

8:33

the eleven pm deadline would

8:35

mean a very expensive delay. That

8:39

news put Captain Pastrengo Rujati

8:41

under pressure. He had no more

8:44

than one or two hours margin, not

8:46

a lot, but Rujahti had

8:48

coped with worse He'd been a navigator

8:50

on an Italian submarine during the war,

8:53

had survived a German prison camp, and

8:55

had been commanding oil tankers for twenty

8:57

years. Captain Rujati

9:00

was in many ways a genial fellow, chatty

9:02

and hospitable. He liked to eat good food,

9:05

but insisted he shouldn't be served anything

9:07

that wasn't available to his crew. As

9:09

a result, the men on Torry Canyon

9:12

ate very well. But Rugiahty

9:14

was also a detailsman who kept

9:16

a close eye on his officers. Ruggiastie

9:18

was extremely conscientious. He

9:21

was a man who wanted to know absolutely

9:24

everything. Perhaps because of that, Ruggierhty

9:27

stayed up late on the Friday night before landfall,

9:29

preparing the paperwork for when they docked.

9:32

It was only at half past three in the

9:34

morning that he went to bed, leaving

9:36

instructions that he was to be awakened first

9:38

thing when the Aisles of Silly were sighted.

9:42

It was half past six in the morning when

9:44

the Aisles of Scilly appeared on the radar about

9:47

thirty five miles away. First

9:49

Officer Silvano Bonfiglio was

9:51

on duty, and the position of the ship

9:54

relative to the isles of Scilly was an

9:56

unpleasant surprise. Torry

9:58

Canyon, plowing through the night

10:00

across the ocean had been pushed

10:02

off its intended course by the current

10:05

and the winds. It was now headed

10:08

between the islands and the mainland.

10:11

Bonfilio immediately changed course,

10:13

steering away from the channel, figuring

10:16

that Captain Ruggiati had intended to pass

10:18

outside of the islands, but

10:20

he hedged his bets. Rather

10:22

than heading out to sea or closer

10:24

to the mainland, he was bearing straight

10:27

towards the aisles of Scilly. He

10:30

then woke up Captain Ruggiati. Rugiati

10:33

was angry. Was it because Bonfilio

10:35

had changed course without checking? Was

10:37

it because the new course was neither one thing

10:39

nor another? Or was he just sleep

10:42

deprived? Will our

10:44

original heaving of eighteen degrees be

10:46

free of the cities? Yes? Then

10:48

continue on course eighteen degrees. I

10:50

intend to pass to the starboard of the Silly

10:53

Isles. When

10:55

Filio was so surprised, he had

10:57

to check that it understood the order, which

10:59

irritated Ruggiati. Still. Further still,

11:03

a maneuver shouldn't be too perilous. It

11:06

was perfectly possible to get even a large ship

11:09

through. The

11:14

standard manual for navigating the waters

11:16

around the coast of the British Isles is

11:18

called the Channel Pilot. If

11:21

Captain Rugiati had consulted a copy,

11:23

here's what it would have said. The actual

11:25

width of the channel between the nearest of the Scilly

11:28

Islands and Land's End is twenty

11:30

one miles, but as the route taken

11:32

by all large vessels should be eastward

11:34

of seven Stones light vessel, the navigable

11:37

channel can only be considered as twelve

11:39

miles wide. The lights render

11:41

the passage perfectly simple at night as

11:43

well as by day in ordinarily clear

11:46

weather. But as there is no part

11:48

of the coast of England more subject to sudden

11:50

changes of weather, the greatest vigilance

11:53

is necessary, and a vessel's position,

11:55

even in the clearest weather, should be checked

11:57

by cross bearings at short intervals.

12:01

But Captain Rugiati alas did

12:03

not have a copy of the Channel Pilot

12:05

on board, and so he missed

12:07

two important pieces of wisdom.

12:11

First, if you want to go between

12:13

the aisles of Scilly and the mainland, be

12:15

careful. Second,

12:18

pass between the mainland and the Seven

12:21

Stones. There is an alternative route

12:23

between the Seven stones and the aisles of Scilly themselves.

12:26

But the channel pilot doesn't mention it because

12:28

it's narrower, six and a half miles

12:30

wide rather than twelve. Why

12:33

take the narrower channel when you could take the broader

12:35

one. Of course, you could

12:37

still fit an oil tanker through the narrower

12:39

gap, even an oil tanker that's

12:42

nearly as big as the Chrysler building, but

12:44

you'd be cutting it close. You'd

12:46

be better, and nothing went

12:49

wrong. Inertia

13:07

is a powerful thing. That's

13:09

true for an oil tanker the size of Torry

13:12

Canyon, which needed nearly five minutes

13:14

to make a ninety degree turn, during

13:16

which time it would travel a mile and

13:18

a half at cruising speed. But

13:21

inertia is a powerful thing for humans

13:23

too. We also sometimes

13:26

struggle to change course. Psychologists

13:29

have identified a strong bias towards

13:31

the status quo. For example,

13:34

whether we sign up for a workplace pension

13:36

plan or not seems to depend on whatever

13:38

the status quo is. If

13:41

the default option is to sign up, we

13:43

sign up. If the default is to stay

13:45

out, we stay out. As

13:47

I say, inertia is

13:49

powerful. Psychologists

13:52

who study accidents have a name for

13:54

a particular form of inertia.

13:57

They call it plan continuation

13:59

bias. It's best known

14:02

in aviation. Pilots form

14:04

a plan and then are reluctant to change

14:06

it, even if the circumstances

14:08

suggest they should. The

14:11

pilots themselves have another name for

14:13

it, get their itis.

14:16

The classic form of get their itis

14:18

is an approach to an airfield with a

14:20

storm coming in. If

14:22

you land well before the storm arrives, no

14:25

problem. If the storm arrives before

14:27

you land, that's not a crisis

14:29

either. It's a hassle. You have to divert

14:32

to another airfield with all the delay, expense

14:34

and annoyance that implies, But

14:37

you do it because you don't want to fly into a

14:39

dangerous storm. The

14:43

risk comes, and the storm

14:45

is closing in, but there's still a

14:47

window of opportunity to land. The

14:50

landing strip is so close, just minutes

14:53

away. Tunnel vision sets

14:55

in, people start to hurry, Margins

14:57

for error are stripped away. Usually

15:00

there's no harm done. The pilot lands

15:02

just as the storm rips across. The

15:04

congratulates himself or herself

15:07

for keeping cool and showing gill

15:09

under pressure, But sometimes

15:11

the consequences are more serious. One

15:15

study of get their itis looked at twenty

15:18

occasions when thunderstorms had closed

15:20

in at Hartsfield Jackson, Atlanta's

15:23

major international airport, Again

15:25

and again, pilots decided to

15:27

chant a risky landing, risky

15:30

in the sense that the Federal Aviation Administration's

15:33

official guidelines would have advised

15:35

against it. One plane

15:37

after another would land under ever

15:39

more perilous conditions, until

15:42

eventually one flight

15:44

crew would resist the inertia and

15:46

decide to divert elsewhere. At

15:49

that point, every subsequent

15:51

plane would also decide to divert.

15:54

The madness only ended when someone

15:56

set an example and changed the plan.

16:05

I'm no airline pilots, but I sometimes

16:07

suffer from get their itis in my own

16:09

life. Perhaps you do too. For

16:11

me, it tends to emerge when dealing with

16:14

family logistics. I've got three children

16:16

at two different schools, and they all have their hobbies

16:18

and sports and all usual things. I'm

16:21

sure many parents will be familiar with the plate

16:23

spinning that this sometimes involves. But

16:25

then something goes wrong. The

16:27

cars in the shop to be repaired, No problem,

16:30

we can bike instead. Then someone

16:32

needs to be at home to meet the plumber. We

16:34

make contingency plans and they seem like they'll

16:36

be fine, but then a fresh errand appears,

16:38

or a babysitter calls to cancel. As

16:41

complications mount, the plan starts

16:43

to resemble an increasingly precarious

16:45

assembly of stages and steps, lift

16:48

swaps and rendezvous. It's a Rube

16:50

Goldberg fever dream of an itinerary.

16:53

And then, if I'm lucky, either

16:56

I or my wife will find enough

16:58

headspace to say this

17:02

is crazy. Someone's

17:05

going to have to skip dance class tonight. We'll

17:07

call the plumber to see if to morrows okay. Instead,

17:10

will replace the entire time

17:12

and motion nightmare with something

17:15

radically simpler. But

17:17

that's hard to do because

17:20

of the inertia, because of the

17:22

plan continuation by us, and

17:24

the more the pressure mounts, the

17:26

harder it is to see clearly just

17:29

how precarious everything has become.

17:32

I become so fixated on executing

17:34

the plan that I don't have a moment

17:36

to realize that it's now a

17:39

stupid plan. Captain

17:44

Rugiati was under pressure to reach the

17:46

harbor at Milford Haven in time, and

17:48

had been woken with the unwelcome news

17:50

that the ship was off course too far

17:52

towards the mainland. If

17:54

he'd stopped to think or

17:56

to talk to his officers, he would

17:58

have realized that he still had time

18:01

to turn and go the long way round

18:03

outside the Aisles of Scilly.

18:06

He only had an hour or two to spare,

18:08

but brief calculation would have revealed

18:11

that the detour would have cost just twenty

18:13

nine minutes. Yet

18:16

he didn't pause to reflect. He

18:18

snapped at Bonfilio and ordered him

18:20

to stick to the course that would now cut

18:22

inside the Aisles of Scilly. Nor

18:25

did he reflect that since his ship had already

18:27

been deflected by the current and the wind,

18:29

those forces might well continue to

18:32

work upon the ship, moving it

18:34

out of its intended position. Under

18:36

time pressure, he began to suffer get

18:39

their itis. His plan was

18:41

risky, and his plan was

18:43

not about to change. At

18:48

eight eighteen am, a junior

18:51

officer calculated their position, this

18:53

being the days before GPS. He did

18:55

it with the ship's charts, a compass bearing,

18:58

and a radar reading old school.

19:01

But the inexperienced officer was anxious.

19:04

He wasn't convinced he'd got the ship's position

19:06

exactly right, but he didn't

19:08

speak up. After all, there'd

19:10

be another chance to take a fix in ten minutes

19:12

or so. Captain

19:15

Ruggiaty wasn't speaking up either, as

19:17

the ship steamed north at sixteen

19:19

knots nearly twenty miles an hour.

19:22

He had already decided which course he would

19:24

take, but he hadn't told his

19:26

crew, which meant that they hadn't

19:28

had a chance to comment, and they didn't

19:31

feel entitled to ask. Captain

19:34

ruggati had actually decided to pass

19:36

through the narrow channel, which involved

19:38

bending the ship's course in a long, slow

19:41

curve to the left. Why

19:44

perhaps because it was the most direct route,

19:47

but mostly because, well

19:50

why not? To me? It was the same.

19:53

But should he not have taken just a few

19:55

more minutes to avoid the narrow route?

19:58

That was never in my mind. That's

20:01

a revealing turn of phrase. Never

20:04

in my mind, Pastrenger Ruggiati

20:07

didn't even consider the possibility

20:09

of going through the wider channel. And

20:12

while that might seem strange to you or me,

20:14

it's a natural feature of plan

20:16

continuation by us. As the

20:18

tunnel vision develops, we don't even

20:21

think about alternatives to our initial

20:23

plan. We don't have the bandwidth. We

20:26

continue to plow on. In

20:43

two thousand and five, a young

20:45

boy was rushed into a hospital emergency

20:47

room. He suffered from asthma,

20:50

and he was in distress. He was finding it

20:52

harder to breathe and harder and

20:54

harder, and then his

20:56

breathing stopped. The medical

20:59

team quickly strapped an oxygen mask

21:01

on to the boy. That should have helped, but

21:04

instead his heart stopped beating.

21:06

Two. There were eight trained

21:08

medical called professionals in the room, taking it in

21:10

turns to perform CPR on the boy.

21:13

Still no pulse, Still no

21:16

breathing. The minutes ticked

21:18

by a doctor slid

21:21

a breathing tube down the boy's throat. Thing's

21:23

happening? Is the tube in position? The tube's fine?

21:26

I checked? Is there any pulse? Still

21:28

nothing? Let's take the breathing tube out and

21:31

try the airbag again. It's not helping.

21:34

No, it wasn't helping. And

21:36

the reason it wasn't helping was because

21:38

the breathing apparatus was broken.

21:41

It would have taken a few seconds to

21:43

check if any of the five nurses

21:46

or three doctors had thought to

21:48

check, but they didn't think,

21:51

not until the boy had been deprived of

21:53

oxygen for ten minutes.

21:58

Thankfully, this wasn't a tragedy.

22:00

It was a training exercise. Instead

22:03

of a real boy, it was a medical dummy

22:05

that was lying on the bed failing to produce

22:07

a simulated pulse simulated respiration

22:10

because the medical team didn't

22:12

step back and think. This

22:18

training scenario was conducted nineteen

22:21

times and videos of the exercise

22:23

were studded by Marliss Christiansen, a

22:25

professor of organizational behavior

22:28

and previously a doctor. Professor.

22:32

Christiansen found that some medical teams

22:34

took just seconds to identify the problem

22:36

with a breathing equipment. This isn't working,

22:39

it's broken. That's impressive,

22:42

But perhaps more impressive were

22:44

the teams who started with the wrong theory

22:46

about the problem, but didn't get stuck

22:48

on that idea. They didn't fixate

22:51

on one possibility or keep repeating

22:53

the same approach over and over again.

22:56

They would talk through what they were thinking

22:58

and challenge themselves and each other.

23:00

They could change course, but

23:03

not every team did that. Many

23:06

teams would hammer away at the same

23:08

plan, regardless of the signs that

23:10

it wasn't going to work. They

23:12

didn't step back and think, they

23:14

didn't talk things through, they just

23:17

kept going. Could

23:20

Captain Rugiati avoid the same

23:22

fate. Captain

23:29

Rugiati is now trying to curve

23:32

his ship through the narrower channel. He

23:34

doesn't even have the full six and a half

23:36

miles to aim at because he's approaching

23:39

at an angle. He's left himself

23:41

precious little margin for error. As

23:44

it is, Torry Canyon is

23:46

heading straight for the submerged rocks.

23:49

At half past eight. As the slow,

23:52

slow turn begins, two

23:54

fishing boats appear on the radar, the

23:57

two French langoustiers that are watching

23:59

the oncoming supertanker with astonishment.

24:02

Rugiati had planned to keep turning,

24:05

but now he has to ensure he doesn't hit

24:07

the boats and floats

24:09

come into view. There are a sign of fishing

24:12

nets beneath the surface. Torry

24:14

Canyon can't possibly avoid them all

24:16

and slices through one set of nets.

24:19

Captain Rugiati pauses his turn

24:21

in order not to shred the rest. He's

24:25

now heading very close to where he thinks

24:27

the stones are, but he still hopes

24:29

to be able to resume his turn after

24:31

passing the nets. But

24:34

meanwhile, all the while,

24:36

the current has been gently insistently

24:39

pushing Torry Canyon closer

24:42

and closer to the seven Stones.

24:45

At this point, Rugiati seems

24:47

to have woken up to the danger. He has

24:49

precious little room for maneuver. Rather

24:52

than curving out of danger, he's

24:54

heading directly towards the Seven Stones.

24:57

He was later asked whether he would have been heading

24:59

that way if not for the fishing boats and their

25:01

nets. No, only a

25:03

madman would have followed in northern course. Rugiati

25:06

now knows his heading is dangerous.

25:09

Plan to go through the narrow channel is being

25:11

frustrated, but as the pressure

25:13

rises, he can't step back

25:15

and form a better plan. Why

25:18

doesn't he slow down? Why doesn't

25:20

he abandon his plan to turn left into

25:22

the channel and instead turned sharply

25:25

right into deep water. That

25:27

was never in my mind. Never

25:31

When get their itis takes hold,

25:34

there are a lot of things that should be in our

25:36

minds but aren't. At

25:39

eight thirty eight am, Captain Ruggiati

25:42

takes a look at the charts. His junior

25:45

officer has just taken another bearing.

25:48

Ruggiati is an old hand. He

25:50

can see at once that it can't be right.

25:52

The crosses marking the ship's position should

25:55

be at regular intervals, but they're not. One

25:58

of the bearings is wrong he doesn't

26:00

know which. Maybe they're both

26:02

wrong. Captain Ruggiati

26:05

doesn't know where he is. The

26:07

junior officer takes another bearing with the

26:10

captain's help. The new fix

26:12

shows that the ship is closer to the seven

26:14

Stones than they're realized, less

26:16

than three miles. Remember,

26:18

Torry Canyon takes a mile and a half

26:21

to make a ninety degree turn on

26:23

his trawler. Watching with horror

26:26

Guy Foliage has already concluded

26:29

that it's all over. Torry Canyon

26:32

can't possibly avoid the rocks.

26:36

But he's wrong. There is

26:38

still time. There's still time to

26:40

turn into deep water. There's even still

26:42

time to turn into the channel, which is what Pastrengo

26:45

Ujati has been trying to do for

26:47

the last four miles, and so,

26:49

even though it doesn't really make sense anymore, that's

26:52

what he continues to try to do.

26:54

Houndsman can't do their wheel, Yes, Captain

26:57

hard to part god to three fifty,

27:00

take her to three ft, take her to

27:02

three twenty. Ujiati is ordering

27:05

an ever tighter turn into the channel.

27:09

Captain, Captain, the ship's

27:11

off turning even now,

27:14

there's still time. If

27:17

she's not turning, Captain Rugiati

27:19

needs to think, why isn't

27:22

the ship turning. Perhaps the

27:24

fuel pumps controlling the rudder have broken.

27:26

Rugiati has seen that happen before. He

27:29

tries to dial the engine room, but instead

27:32

he makes the kind of mistake you make

27:34

when you've had three hours sleep and

27:37

you only have seconds to solve a problem.

27:39

He calls the officers dining room. Ah,

27:42

captain, are you ready for breakfast?

27:44

Well? God deal, God

27:48

is a pig. That's some serious

27:50

blasphemy from a good Italian Catholic.

27:53

It's the blasphemy of a man who

27:56

knows time has just

27:58

run out. There's

28:24

a photograph of Pastrenga Rugiati.

28:26

I can't get out of my head. He's

28:29

scrunched up in a confined space,

28:31

his knees tucked into his chest

28:34

as if to protect himself, his eyes

28:36

rolled sharply to one side, his

28:39

face ghoulishly lit from below.

28:42

He's wearing a hospital gown and

28:44

he's hiding under a hospital bed. That's

28:47

where he was when the paparazzi found

28:49

him. He looks terrified.

28:52

He's broken. His

28:55

ship was gone, impaling

28:57

itself onto the seven Stones at full

28:59

speed with a noise. One

29:02

crewman said, look a slab of lead

29:04

being ripped by spikes. Watching

29:09

from his trawler, Gifolich turned

29:12

to his men, that's the end of her.

29:15

She'll never get off. He

29:18

was right. The crew

29:20

escaped safely, but during an attempt

29:22

to refloat the ship, there was a huge

29:24

explosion. One of the salvage

29:27

team was killed. By

29:29

then, Torry Canyon's back was

29:31

already broken and her underbelly

29:34

sliced open by the teeth of the reef.

29:36

She was bleeding one hundred and nineteen

29:39

thousand tons of crude oil into

29:41

coastal waters. It was an

29:43

environmental catastrophe. The

29:46

oil spill was unprecedented. Even

29:49

today, there are places where you can still

29:51

see the dark stain on the coast. Torry

29:54

Canyon was at the time the

29:56

largest shipwreck in history, as

29:59

the largest maritime insurance claim.

30:03

Rugiati took responsibility. He

30:05

was the captain, and he was, he said,

30:08

in charge of the best ship in the world

30:10

for a ship's captain. His ship is

30:13

all and I have lost

30:15

mine. I am terrified

30:17

by the dimensions which the accident

30:19

has assumed. The

30:23

inquiry was conducted in private.

30:25

Journalists weren't allowed in, but

30:28

the manager of the hotel where the proceedings

30:30

were being held, told one of them that

30:32

he had seen Captain Ruggiati. I

30:34

had a glimpse of this man. I

30:37

had the impression of a man finished. He

30:40

very seldom have so strong an impression from

30:42

so short of seeing a man. I must

30:45

answer for everything for

30:47

everyone. I must

30:49

carry the cross alone. I

30:52

wish I could tell the people of Cornwall

30:55

how sorry I am. And he

30:57

really was sorry. It

31:00

was very bad. The

31:05

disaster broke Ruggiati. He

31:08

spent in hospital recovering

31:10

from the strain and the anxiety and the heartbreak,

31:13

which is where the eager photographers

31:16

found him.

31:19

A transcript of the inquiry was

31:21

leaked to the journalist Richard Petro.

31:24

The tanker owners were keen to downplay

31:26

any fault on their part, including

31:28

the fact that the steering had broken in the past,

31:31

confusing Captain Ruggiati when

31:33

the ship had failed to turn. But

31:36

why had the ship failed to turn

31:38

in those last moments? It

31:41

was a small thing. After Ruggiahti

31:44

had accidentally called the officer's dining

31:46

room and slammed down the receiver, he

31:48

looked across the bridge. From

31:50

his position by the telephone, he

31:52

could see that someone had inadvertently

31:55

knocked the steering control lever.

31:57

The ship's steering had simply

32:00

been disconnected. All Ruggiaste

32:02

needed to do was switched the lever back

32:05

and dragged Torry Canyon over

32:07

to port. But he'd lost

32:09

time. With thirty seconds

32:12

more to maneuver, I could have avoided

32:14

the rocks. Ruggierte

32:17

had made a plan, and as one

32:19

small problem after another made

32:21

the plan riskier and riskier,

32:24

he hadn't been able to adjust. Many

32:27

little things added up to one

32:30

big disaster. That's true.

32:33

The deadline, the currants, the fishing

32:35

boats, the error from his junior

32:37

officer, the steering control. It's

32:40

bad luck. Thirty seconds before

32:43

the sheep she was saved.

32:46

But the missing thirty seconds

32:48

aren't what interests me. What

32:51

interests me are the two hours

32:54

that Ruggierte had to save

32:56

his Torry Canyon, the best

32:58

ship in the world. He

33:01

had two hours to re root

33:03

outside the isles of Scilly, two

33:05

hours to slow the ship down, two

33:08

hours to ask for advice or to turn

33:10

towards the wider channel, but

33:12

he didn't do any of those things. After

33:17

the exploitative photograph was released,

33:20

there was a surge of sympathy for Ruggiati

33:22

from around the world. People wrote

33:25

letters of consolation. One

33:27

that caught my eye was from a thirteen year

33:29

old boy from County Cork in Ireland.

33:32

I see beautiful tankers, but I'm

33:34

sure I've never seen one as beautiful as yours.

33:37

I thought and prayed for you. I

33:39

am sure you will sail the seas again. Pastrengo

33:44

Rugiati never did. His

33:46

mistake was just too grave,

33:49

but at the same time it was also all

33:52

too human. After all,

33:55

it's our nature to be slow

33:57

to change course. You've

34:08

been listening to Cautionary Tales

34:10

If you'd like to find out more about the ideas

34:12

in this episode, including links to our

34:14

sources. The show notes are on my website,

34:17

Tim Harford dot com.

34:20

Cautionary Tales is written and presented

34:22

by me, Tim Harford. Our producers

34:24

are Ryan Dilley and Marilyn Rust.

34:27

The sound designer and mixer was Pascal

34:29

Wise, who also composed the

34:32

amazing music. This

34:34

season stars Alan Cumming, Archie

34:37

Panchabi, Toby Stephens, and Russell

34:39

Tovey, with enso Celenti, Ed

34:42

Gochen, Melanie Gutteridge, Mercia

34:44

Munroe, Rufus Wright, and introducing

34:47

Malcolm Gladwell. Thanks

34:50

to the team at Pushkin Industries, Julia

34:52

Barton, Heather Fame, Mia LaBelle,

34:55

Carlie Milliori, Jacob Weisberg

34:57

and of course the mighty Malcolm

35:00

Gladwell. And thanks to my colleagues

35:02

at the Financial Times four