cover of episode DANGER: Rocks Ahead! (Classic)

DANGER: Rocks Ahead! (Classic)

2024/1/5
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Cautionary Tales with Tim Harford

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Malcolm Gladwell
以深入浅出的写作风格和对社会科学的探究而闻名的加拿大作家、记者和播客主持人。
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马尔科姆·格拉德威尔讲述了1967年托里峡谷号超级油轮触礁沉没的故事,这起事故并非由于恶劣天气或机械故障,而是船长帕斯特伦戈·鲁吉亚蒂在时间压力下,受计划延续偏差(plan-continuation bias)和get-there-itis的影响,未能及时改变航向,最终导致船舶撞上锡利群岛附近的七石礁。格拉德威尔分析了鲁吉亚蒂船长在决策过程中面临的压力、时间限制以及信息不足等因素,并指出计划延续偏差是导致事故发生的关键原因。他认为,人们在面临紧急情况时,往往会固执地坚持原有计划,即使有迹象表明该计划存在风险,也难以及时改变。托里峡谷号沉船事件不仅造成了巨大的环境灾难,也深刻地揭示了人类在决策过程中容易犯的错误,以及计划延续偏差对个人和社会的影响。

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The episode explores the disastrous course of the Torrey Canyon, a supertanker that inexplicably steered towards a deadly reef, despite clear warnings and navigational tools at its disposal.

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In 2019, the year that cautionary tales developed from an unsettling thought to a fully-fledged new show, I was on the lookout for disasters. And there are few catastrophes more compelling than the wreck of Torrey Canyon. It's partly the shattering environmental impact of the error. It's partly the tragic figure of Captain Pastrengo Ruggiati.

But above all, what compels me about this story is all the things Torrey Canyon represents as it plows towards an obvious disaster and yet, for some mystifying reason, doesn't seem to be able to change course. We've all set a course for disaster at some stage in our lives and we've all struggled to admit it until it's too late.

We have a treasure chest full of cautionary tales to bring you in 2024, but we also need to take a short rest. So the next two episodes will be classics from our Cautionary Tales vault. I hope you enjoy them, starting with the very first episode of Cautionary Tales that was ever released, Danger, Rocks Ahead. We pray thee, Lord, not that wrecks should happen.

But that if any wrecks do happen, thou wilt guide them to the Scilly Isles for the benefit of the poor inhabitants. That's an old prayer from the Isles of Scilly. The isles are just off the coast of Cornwall, the south-west tip of Great Britain, and that prayer has been answered many times. The rocks around the islands have a fearsome reputation, and it's well earned.

One autumn night in 1707, the Royal Navy lost its way in a storm. The flagship HMS Association struck a rock and went down in minutes. 800 men drowned. Behind it, HMS St George hit the rocks and became stuck.

So did HMS Phoenix. So did HMS Firebrand. HMS Romney lost her entire crew. HMS Eagle was shattered on the cruel stone. Hundreds more sailors died. That dreadful night was one of the worst disasters in the history of the British Navy.

Local legend has it that there was one notable survivor, that the commander-in-chief of the British fleets, Sir Cloudsley Shovel, was washed up on the beaches of the Isles of Scilly, but was strangled by a local woman who fancied wearing his emerald ring herself. If she had been praying the old prayer, God or the devil had been listening. It is a dark tale.

But the story I shall tell you today is a far stranger one. It was sometime after dawn on Saturday, March 18th, 1967. Marta Christie was a langoustier, a French lobster boat, fishing for crayfish and crab between the mainland and the Isles of Scilly, 21 miles further west. On deck was Captain Guy Follich.

Another langoustier was nearby, both of them enjoying rich pickings a few hundred yards north of the Seven Stones. The Seven Stones make up a vicious reef about one third of the way between the Isles of Scilly and the mainland. At low tide, the unyielding rocks are visible. But even at high tide, they're marked by a lighthouse vessel, warning ships to stay away. Guy Follich looked up from his lobster lines to see an unexpected sight –

A vast black hull coming over the horizon from an unusual direction. He was surprised. A major vessel in that position would usually have passed outside of the Isles of Scilly, rather than squeezing between them and the mainland. True, a big ship could come between the Isles of Scilly and the mainland, passing on either side of the Seven Stones, but it would be a little on the tight side. And this ship, a supertanker.

was very big indeed. In fact, it was the 13th biggest ship in the world. On the lighthouse vessel, the two seamen on watch saw the tanker approaching too. Have you seen this, have you? Yeah. Look at that big bastard coming up. Guy Follich could see the huge ship coming straight towards him as he fished. Incroyable. But he wasn't worried. In between him and the oncoming juggernaut were the seven stones.

He later said: "I was sure that before ever hitting us, he would go onto the rocks." He yelled to his men: "Oh, stop work! You're going to see something extraordinary!" All seven of them lined up on the rail of Marta Christi to watch the oil tanker bear closer and closer. Four miles. Three miles. Folic was sure it was doomed. It just wasn't possible to turn a supertanker that quickly, was it?

Actually, Follich wasn't quite right. The tanker, whose name was Torrey Canyon, did still have room to turn. This wasn't a storm-tossed fleet of sailing ships fumbling through the darkness. The weather was good. The visibility was good. Torrey Canyon was a superb ship in fine working order and armed with radar. The seven stones were clearly marked on every chart, as well as being identified by the position of the lighthouse vessel.

But Torrey Canyon still wasn't turning. Gather close and listen to my cautionary tale. Nobody knew it at the time, but the trouble all started with a radio message from Milford Haven, the harbour towards which Torrey Canyon was sailing.

Milford Haven is a major UK port, and the thing you need to know about ports in the UK is that the difference between high tide and low tide can be enormous. What's more, there are high tides and high tides. Some are higher than others. The message from Milford Haven was simple enough. Torrey Canyon needed to hurry. If the ship didn't arrive by 11pm on Saturday evening, March 18, 1967,

it would miss the extra high tide and wouldn't be able to slip into the harbour and dock. It would then have to wait another six days before the tide would once more be high enough. Missing the 11pm deadline would mean a very expensive delay. That news put Captain Pastrengo Ruggiati under pressure.

He had no more than one or two hours margin, not a lot. But Ruggiati had coped with worse. He'd been a navigator on an Italian submarine during the war, had survived a German prison camp and had been commanding oil tankers for 20 years.

Captain Ruggiati was in many ways a genial fellow. Chatty and hospitable, he liked to eat good food, but insisted he shouldn't be served anything that wasn't available to his crew. As a result, the men on Torrey Canyon ate very well.

But Ruggiati was also a details man who kept a close eye on his officers. Ruggiati was extremely conscientious. He was a man who wanted to know absolutely everything. Perhaps because of that, Ruggiati stayed up late on the Friday night before landfall, preparing the paperwork for when they docked. It was only at half past three in the morning that he went to bed, leaving instructions that he was to be awakened first thing when the Isles of Scilly were sighted.

It was half past six in the morning when the Isles of Scilly appeared on the radar about 35 miles away. First Officer Silvano Bonfilio was on duty and the position of the ship relative to the Isles of Scilly was an unpleasant surprise. Torrey Canyon, ploughing through the night across the ocean, had been pushed off its intended course by the current and the winds. It was now headed between the islands and the mainland.

Bonfiglio immediately changed course, steering away from the channel, figuring that Captain Ruggiati had intended to pass outside of the islands. But he hedged his bets. Rather than heading out to sea or closer to the mainland, he was bearing straight towards the Isles of Scilly. He then woke up Captain Ruggiati.

Ruggiati was angry. Was it because Bonfilio had changed course without checking? Was it because the new course was neither one thing nor another? Or was he just sleep-deprived? "Will our original heading of 18 degrees be free of the Scilly's?" "Yes." "Then continue on course 18 degrees. I intend to pass to the starboard of the Scilly Isles." Bonfilio was so surprised he had to check that he'd understood the order, which irritated Ruggiati still further.

Still, a maneuver shouldn't be too perilous. It was perfectly possible to get even a large ship through.

The standard manual for navigating the waters around the coast of the British Isles is called the Channel Pilot. If Captain Ruggiati had consulted a copy, here's what it would have said. The actual width of the channel between the nearest of the Scilly Islands and Land's End is 21 miles, but as the route taken by all large vessels should be eastward of Seven Stones Light Vessel, the navigable channel can only be considered as 12 miles wide.

The lights render the passage perfectly simple at night, as well as by day in ordinarily clear weather. But, as there is no part of the coast of England more subject to sudden changes of weather, the greatest vigilance is necessary. And a vessel's position, even in the clearest weather, should be checked by cross-bearings at short intervals. But Captain Ruggiati, alas, did not have a copy of the Channel Pilot on board. And so he missed two important pieces of wisdom.

First, if you want to go between the Isles of Scilly and the mainland, be careful. Second, pass between the mainland and the Seven Stones. There is an alternative route between the Seven Stones and the Isles of Scilly themselves, but the Channel Pilot doesn't mention it because it's narrower, six and a half miles wide rather than 12. Why take the narrower channel when you could take the broader one? Of course, you could still fit an oil tanker through the narrower gap,

Even an oil tanker that's nearly as big as the Chrysler building. But you'd be cutting it close. You'd be betting that nothing went wrong. AI might be the most important new computer technology ever. It's storming every industry, and literally billions of dollars are being invested. So, buckle up.

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Inertia is a powerful thing. That's true for an oil tanker the size of Torrey Canyon, which needed nearly five minutes to make a 90 degree turn, during which time it would travel a mile and a half at cruising speed. But inertia is a powerful thing for humans too. We also sometimes struggle to change course.

psychologists have identified a strong bias towards the status quo. For example, whether we sign up for a workplace pension plan or not seems to depend on whatever the status quo is. If the default option is to sign up, we sign up. If the default is to stay out, we stay out. As I say, inertia is powerful. Psychologists who study accidents have a name for a particular form of inertia.

They call it plan-continuation bias. It's best known in aviation. Pilots form a plan and then are reluctant to change it, even if the circumstances suggest they should. The pilots themselves have another name for it, get-there-itis. The classic form of get-there-itis is an approach to an airfield with a storm coming in.

If you land well before the storm arrives, no problem. If the storm arrives before you land, that's not a crisis either. It's a hassle. You have to divert to another airfield with all the delay, expense and annoyance that implies. But you do it because you don't want to fly into a dangerous storm. The risk comes when the storm is closing in but there's still a window of opportunity to land.

The landing strip is so close, just minutes away. Tunnel vision sets in. People start to hurry. Margins for error are stripped away. Usually there's no harm done. The pilot lands just as the storm rips across and congratulates himself or herself for keeping cool and showing skill under pressure. But sometimes the consequences are more serious.

One study of get-there-itis looked at 20 occasions when thunderstorms had closed in at Hartsfield-Jackson, Atlanta's major international airport. Again and again, pilots decided to chance a risky landing. Risky in the sense that the Federal Aviation Administration's official guidelines would have advised against it.

One plane after another would land under ever more perilous conditions. Until, eventually, one flight crew would resist the inertia and decide to divert elsewhere. At that point, every subsequent plane would also decide to divert. The madness only ended when someone set an example and changed the plan.

I'm no airline pilot, but I sometimes suffer from get-there-itis in my own life. Perhaps you do too. For me, it tends to emerge when dealing with family logistics. I've got three children at two different schools and they all have their hobbies and sports and all the usual things.

I'm sure many parents will be familiar with the plate spinning that this sometimes involves. But then something goes wrong. The car's in the shop to be repaired. No problem, we can bike instead. Then someone needs to be at home to meet the plumber. We make contingency plans and they seem like they'll be fine, but then a fresh errand appears or a babysitter calls to cancel.

As complications mount, the plan starts to resemble an increasingly precarious assembly of stages and steps, lift swaps and rendezvous. It's a Rube Goldberg fever dream of an itinerary. And then, if I'm lucky, either I or my wife will find enough headspace to say, this is crazy.

Someone's going to have to skip dance class tonight. We'll call a plumber to see if tomorrow's OK instead. We'll replace the entire time and motion nightmare with something radically simpler. But that's hard to do because of the inertia, because of the planned continuation bias. And the more the pressure mounts, the harder it is to see clearly just how precarious everything has become.

Captain Ruggiati was under pressure to reach the harbour at Milford Haven in time and had been woken with the unwelcome news that the ship was off course, too far towards the mainland. If he'd stopped to think...

or to talk to his officers, he would have realised that he still had time to turn and go the long way round outside the Isles of Scilly. He only had an hour or two to spare, but a brief calculation would have revealed that the detour would have cost just 29 minutes. Yet he didn't pause to reflect. He snapped at Bonfilio and ordered him to stick to the course that would now cut inside the Isles of Scilly.

Nor did he reflect that since his ship had already been deflected by the current and the wind, those forces might well continue to work upon the ship, moving it out of its intended position. Under time pressure, he began to suffer get-there-itis. His plan was risky, and his plan was not about to change. At 8:18am, a junior officer calculated their position.

This being the days before GPS, he did it with the ship's charts, a compass bearing and a radar reading. Old school. But the inexperienced officer was anxious. He wasn't convinced he'd got the ship's position exactly right, but he didn't speak up. After all, there'd be another chance to take a fix in 10 minutes or so. Captain Ruggiati wasn't speaking up either. As the ship steamed north at 16 knots, nearly 20 miles an hour, he'd already decided which course he would take.

but he hadn't told his crew, which meant that they hadn't had a chance to comment, and they didn't feel entitled to ask. Captain Ruggiati had actually decided to pass through the narrow channel, which involved bending the ship's course in a long, slow curve to the left. Why? Perhaps because it was the most direct route. Mostly because... why not? To me, it was the same. But should he not have taken just a few more minutes to avoid the narrow route?

That was never in my mind. Never. That's a revealing turn of phrase. Never in my mind. Pastrenga Ruggiati didn't even consider the possibility of going through the wider channel. And while that might seem strange to you or me, it's a natural feature of plan continuation bias. As the tunnel vision develops, we don't even think about alternatives to our initial plan. We don't have the bandwidth. We continue to plough on.

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In 2005, a young boy was rushed into a hospital emergency room. He suffered from asthma and he was in distress. He was finding it harder to breathe and harder and harder and then his breathing stopped. The medical team quickly strapped an oxygen mask onto the boy. That should have helped but instead his heart stopped beating too.

There were eight trained medical professionals in the room taking it in turns to perform CPR on the boy. Still no pulse. Still no breathing. The minutes ticked by. A doctor slid a breathing tube down the boy's throat. Nothing's happening. Is the tube in position? The tube's fine. I checked. Is there any pulse? Still nothing. Let's take the breathing tube out and try the airbag again. It's not helping.

No, it wasn't helping. And the reason it wasn't helping was because the breathing apparatus was broken. It would have taken a few seconds to check if any of the five nurses or three doctors had thought to check. But they didn't think. Not until the boy had been deprived of oxygen for ten minutes. Thankfully, this wasn't a tragedy.

It was a training exercise. Instead of a real boy, it was a medical dummy that was lying on the bed, failing to produce a simulated pulse or simulated respiration because the medical team didn't step back and think. This training scenario was conducted 19 times, and videos of the exercise were studied by Marlis Christiansen, a professor of organisational behaviour and previously a doctor.

Professor Christianson found that some medical teams took just seconds to identify the problem with the breathing equipment. This isn't working, it's broken. That's impressive.

But perhaps more impressive were the teams who started with the wrong theory about the problem but didn't get stuck on that idea. They didn't fixate on one possibility or keep repeating the same approach over and over again. They would talk through what they were thinking and challenge themselves and each other. They could change course. But not every team did that. Many teams would hammer away at the same plan regardless of the signs that it wasn't going to work.

They didn't step back and think. They didn't talk things through. They just kept going. Could Captain Ruggiati avoid the same fate? Captain Ruggiati is now trying to curve his ship through the narrower channel. He doesn't even have the full six and a half miles to aim at because he's approaching at an angle. He's left himself precious little margin for error. As it is, Torrey Canyon is heading straight for the submerged rocks.

At half past eight, as the slow, slow turn begins, two fishing boats appear on the radar. The two French Langoustiers that are watching the oncoming supertanker with astonishment. Ruggiati had planned to keep turning, but now he has to ensure he doesn't hit the boats. Suddenly, floats come into view. They're a sign of fishing nets beneath the surface.

Torrey Canyon can't possibly avoid them all and slices through one set of nets. Captain Ruggiati pauses his turn in order not to shred the rest. He's now heading very close to where he thinks the stones are, but he still hopes to be able to resume his turn after passing the nets. But meanwhile, all the while, the current has been gently, insistently pushing Torrey Canyon closer and closer to the seven stones.

At this point, Ruggiati seems to have woken up to the danger. He has precious little room for manoeuvre. Rather than curving out of danger, he's heading directly towards the Seven Stones. He was later asked whether he would have been heading that way if not for the fishing boats and their nets. No.

Only a madman would have followed a northern course. Ruggiati now knows his heading is dangerous. His plan to go through the narrow channel is being frustrated. But as the pressure rises, he can't step back and form a better plan. Why doesn't he slow down? Why doesn't he abandon his plan to turn left into the channel and instead turn sharply right into deep water? That was never in my mind. Never. When Get There Itis takes hold...

There are a lot of things that should be in our minds, but aren't. At 8.38am, Captain Ruggiati takes a look at the charts. His junior officer has just taken another bearing. Ruggiati is an old hand. He can see at once that it can't be right. The crosses marking the ship's position should be at regular intervals, but they're not. One of the bearings is wrong. He doesn't know which. Maybe they're both wrong.

Captain Ruggiati doesn't know where he is. The junior officer takes another bearing with the captain's help. The new fix shows that the ship is closer to the Seven Stones than they'd realised, less than three miles. Remember, Torrey Canyon takes a mile and a half to make a 90 degree turn. On his trawler, watching with horror, Guy Follich has already concluded that it's all over.

Torrey Canyon can't possibly avoid the rocks.

But he's wrong. There is still time. There's still time to turn into deep water. There's even still time to turn into the channel, which is what Pastranga Ruggiati has been trying to do for the last four miles. And so, even though it doesn't really make sense anymore, that's what he continues to try to do. Helmsman, come to the wheel. Yes, Captain. Hard to port. Go to 350. Yes, Captain. No, take her to 340. Take her to 320. Yes, Captain.

Ruggiati is ordering an ever tighter turn into the channel. Captain, Captain, the ship's not turning. Even now, there's still time. She's not turning, Captain. Ruggiati needs to think. Why isn't the ship turning? Perhaps the fuel pumps controlling the rudder have broken. Ruggiati's seen that happen before. He tries to dial the engine room.

But instead, he makes the kind of mistake you make when you've had three hours sleep and you only have seconds to solve a problem. He calls the officer's dining room. Ah, Captain, are you ready for breakfast? Porco Dio! God is a pig. That's some serious blasphemy from a good Italian Catholic. It's the blasphemy of a man who knows time has just run out.

There's a photograph of Pastrengo Ruggiati that I can't get out of my head. He's scrunched up in a confined space, his knees tucked into his chest as if to protect himself, his eyes rolled sharply to one side, his face ghoulishly lit from below. He's wearing a hospital gown and he's hiding under a hospital bed. That's where he was when the paparazzi found him. He looks terrified. He's broken. His ship was gone.

impaling itself onto the seven stones at full speed. With a noise, one crewman said, "Like a slab of lead being ripped by spikes." Watching from his trawler, Guy Follich turned to his men. "That's the end of her? She'll never get off." He was right. The crew escaped safely, but during an attempt to refloat the ship, there was a huge explosion. One of the salvage team was killed.

By then, Torrey Canyon's back was already broken and her underbelly sliced open by the teeth of the reef. She was bleeding 119,000 tonnes of crude oil into coastal waters. It was an environmental catastrophe. The oil spill was unprecedented. Even today, there are places where you can still see the dark stain on the coast.

Torrey Canyon was, at the time, the largest shipwreck in history and the largest maritime insurance claim. Ruggiati took responsibility. He was the captain, and he was, he said, in charge of... The best ship in the world. For a ship's captain, his ship is all. And I have lost mine. I'm terrified by the dimensions which the accident has assumed.

The inquiry was conducted in private. Journalists weren't allowed in. But the manager of the hotel where the proceedings were being held told one of them that he'd seen Captain Ruggiati. I had a glimpse of this man. I had the impression of a man finished. You very seldom have so strong an impression from so short of seeing a man. I must answer for everything, for everyone. I must carry the cross alone. I wish I could tell the people of Cornwall...

And he really was sorry. The disaster broke Ruggiati. He spent months in hospital, recovering from the strain and the anxiety and the heartbreak, which is where the eager photographers found him. A transcript of the inquiry was leaked to the journalist Richard Petro.

The tanker owners were keen to downplay any fault on their part, including the fact that the steering had broken in the past, confusing Captain Ruggiati when the ship had failed to turn. But why had the ship failed to turn in those last moments? It was a small thing.

After Ruggiati had accidentally called the officer's dining room and slammed down the receiver, he looked across the bridge. From his position by the telephone, he could see that someone had inadvertently knocked the steering control lever. The ship's steering had simply been disconnected. All Ruggiati needed to do was switch the lever back and drag Torrey Canyon over to port, but he'd lost time.

With thirty seconds more to manoeuvre, I could have avoided the rocks. Ruggiati had made a plan, and as one small problem after another made the plan riskier and riskier, he hadn't been able to adjust. Many little things added up to one big disaster. That's true. The deadline. The currents. The fishing boats. The error from his junior officer. The steering control.

It's bad luck. 30 seconds before, the ship, she was saved. But the missing 30 seconds aren't what interests me. What interests me are the two hours that Ruggiati had to save his Torrey Canyon, the best ship in the world. He had two hours to reroute outside the Isles of Scilly.

Two hours to slow the ship down, two hours to ask for advice or to turn towards the wider channel. But he didn't do any of those things. After the exploitative photograph was released, there was a surge of sympathy for Ruggiati. From around the world, people wrote letters of consolation. One that caught my eye was from a 13-year-old boy from County Cork in Ireland.

Pastrengo Ruggiati never did. His mistake was just too grave. But at the same time, it was also all too human. After all, it's our nature to be slow to change course. MUSIC

You've been listening to Cautionary Tales. If you'd like to find out more about the ideas in this episode, including links to our sources, the show notes are on my website, timharford.com. Cautionary Tales is written and presented by me, Tim Harford. Our producers are Ryan Dilley and Marilyn Rust. The sound designer and mixer was Pascal Wise, who also composed the amazing music.

This season stars Alan Cumming, Archie Panchabi, Toby Stephens and Russell Tovey, with Enzo Cellenti, Ed Gochan, Melanie Gutteridge, Mircea Munro, Rufus Wright and introducing Malcolm Gladwell. Thanks to the team at Pushkin Industries, Julia Barton, Heather Fane, Mia Lebel, Carly Migliori, Jacob Weisberg and of course, the mighty Malcolm Gladwell. And thanks to my colleagues at the Financial Times.

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