On Saturday March 18 1967, around half past six in the morning, the first officer of the Torrey Canyon realised that his vessel was in the wrong place. The 300-metre ship was hurrying north past the Scilly Isles, 22 miles off the tip of Cornwall in the south west of England, with more than 119,000 tonnes of crude oil. The aim was to pass west of the islands, but the ship was further east than expected.
The officer changed course, but when the sleep-deprived captain Pastrengo Rugiati, was awoken, he countermanded the order. A two-hour detour might mean days of waiting for the right tides, so Capt Rugiati decided instead to carry on through the treacherous channel between the Scilly Isles and the mainland.
Most serious accidents have multiple causes. A series of mistakes or pieces of bad luck line up to allow disaster. The Torrey Canyon was hampered by an unforgiving schedule, barely adequate charts, unhelpful winds and currents, confusion over the autopilot, and the unexpected appearance of fishing boats in the intended course. But reading Richard Petrow’s contemporary account of the Torrey Canyon disaster, a clear lesson is that Capt Rugiati was too slow to adjust. He had a plan, and saw far too late that the plan was doomed to failure — and with it, his ship.
Some accident investigators call this “plan continuation bias”. Airline pilots sometimes call it “get-there-itis”. The goal appears within touching distance; it’s now or never. Tunnel vision sets in. The idea of a pause or a change of approach becomes not just aggravating, expensive or embarrassing — it becomes literally unthinkable.
In such circumstances aeroplanes have crashed after trying to land in bad weather because the destination airport was so temptingly close. Patients have died of oxygen starvation because doctors and nurses fixated on clearing blocked airways rather than checking whether an oxygen pump was working. And the Torrey Canyon ran aground, producing the world’s first major oil tanker disaster.
We’ve all experienced “get-there-itis”. For me, it tends to emerge when dealing with family logistics. One child needs to go somewhere, another must be picked up from school. Then it turns out that someone needs to be at home to receive a delivery; the car is in for a service; the babysitter calls to cancel.
The plan seems feasible at first, but as complications mount, it starts to resemble an increasingly precarious assembly of stages and steps, lift-swaps and rendezvous, a Rube Goldberg fever-dream of an itinerary.
Read the whole article for more instances, as well as an appraisal around Brexit. My main takeaway is this:
If I’m lucky, someone finds the mental space to see clearly the fragility of it all. Someone suggests a cancellation or two, replacing the entire time-and-motion nightmare with something radically simpler.It’s that moment of clarity that is so often missing. Haste makes things worse …