Cautionary Tales with Tim Harford - The Vigilante and the Air Traffic Controller

Episode Date: March 31, 2023

Air traffic controllers are meant to stop aircrafts from flying into one another... and if they fail, computer systems are installed to warn pilots of a coming collision. But sometimes these humans and computers give conflicting and confusing advice. Who to believe? When a cargo plane and a Russian airliner collided in just such a situation, the authorities scrambled to work out how to prevent a repeat of the disaster... but a grieving father decided to seek revenge on those he held responsible.  For a full list of sources for this episode, go to timharford.com.See omnystudio.com/listener for privacy information.

I'm Paul Moondin, a poet who over the past several years had the good fortune to spend time with one of the world's greatest songwriters, Sir Paul McCartney. We talked through more than 150 tracks from McCartney's songbook and while we did, we recorded our conversations. I mean the fact that I dreamed the song yesterday leads me to believe that it's not just quite as cut and dried as we think it is. And now you can listen to our conversations in our new podcast McCartney, a life. So sour. Uncle Albert. McCartney's been asked many times to write his autobiography,

and he's always declined. But as we ventured out on this journey, line by line, it became clear how much of McCartney's life is indeed embedded in his lyrics. It was like going back to an old snapshot album, looking back on work. I hadn't thought much about for quite a few years. Listen, wherever you get your podcasts, and if you want to binge the entire season, add free right now. Sign up for Pushkin Plus on the McCartney Aliphonderic Showpage in Apple Podcasts or at Pushkin.fm-plus.

Your membership also unlocks access to add free binges from Malcolm Gladwell, Dr. Laurie Santos and many other top hosts. Pushkin Japanese Airlines Flight 907 is flying from Tokyo to Okinawa. It took off 20 minutes ago and it's almost completed its climb to its cruising altitude. Close enough that the Farsen seatbelt sign has been switched off and the cabin attendance are serving hot tea. The year is 2001. The airspace around Tokyo is busy. Another Japanese airline's plane, Flight 958, is coming in from South Korea.

It'll soon begin its descent. The flight paths of 907 and 958 are going to cross. That's not a problem, of of course as long as there are different altitudes. But they're currently on course to be at pretty similar altitudes. No need to panic, this kind of thing happens all the time. We simply need one of the planes to go a bit higher or the other to go a bit lower. As long as they don't both do the same thing, they'll be fine. Modern airplanes have an automated system for situations like this, it's called T-CAS, the Traffic Collision Avoidant System. T-CAS kicks in now. In the cockpit of Flight 958, it tells the pilot to... Descend, descend, descend, descend.

The pilot starts to descend. In the cockpit of Flight 907, T-CAST tells the pilot to... Climb, climb, climb, climb. But down on the ground, a 26-year-old trainee air traffic controller has also noticed that flights 907 and 958 are on a collision course, and he's issued an instruction of his own. JAL 907, descend and maintain flight level 350, begin descent due to traffic. Hang on, 907 isn't 907 the one that's supposed to be climbing? Yes it is. The trainee air traffic controller has got his planes muddled up.

He meant to say, 958. So now the pilot of flight 907 has got a decision to make. On the one hand he's got an air traffic controller telling him to descend. On the other hand, T-Cas is insisting he has to... Climb, climb, climb, climb. He decides to descend. This isn't good. Both 907 and 958 are now descending, so there's a real risk that they're going to be at the same altitudes when their flight paths intersect.

The trainee air controller supervisor sees the data and intervenes to put things right. JAL 957, climb and maintain flight level 390. Hang on. 957? There is no 957. The boss meant to say 907, but confused her numbers. In the cockpit of Flight 907, the pilot hears the message and thinks, that's not for me.

Then, he sees Flight 958 through the cockpit window. It's alarmingly close. And he's heading straight for it. I'm Tim to make, and this time he has just a split second to make it. How is he going to avoid smashing into flight 958? He slams his plane into a nose-dine. Back in the cabin, the passengers who've undone their seat belts are suddenly hurled out of their seats.

Some of them hit the ceiling, so do the cabin attendants who are pushing the drinks trolleys, so do the drinks trolleys. Hot tea flies everywhere. A boy is catapulted of four rows of seats. A middle aged woman breaks her leg. A hundred people are injured, nine of them seriously. But at least they're alive. It could have been so much worse. Japan's Ministry of Transport asks its Accidents Investigation Commission to look into what had

happened and what might be done to lower the risk that it happens again One problem obviously was that the trainee air traffic controller and his boss had got their flight numbers Muddled up, but if you're a loyal listener to cautionary tales You'll know that there's a common theme in stories about people screwing up that theme is that people screw up, all of us from time to time. So if we want to reduce the risk of a repeat, we can't rely on saying to air traffic controllers do better. We need to look at how they operate.

Can we change anything to make it less likely that they'll screw up? And when screw ups happen anyway, as they will, how can we make it less likely that they'll lead to tragic consequences? On that last point, think about the dilemma faced by the pilot of Flight 907. He's got the air traffic controller telling him to descend, and T-Cas telling him to climb. Which one should he listen to? T-Cass was new enough that this question simply hadn't come up before, but it turns out there's a clear right answer. He should listen to T-Cass. Like all automated systems, it's not infallible,

but when two planes are heading straight towards each other and there's less than a minute to keep them apart, T-Cass is much's less than a minute to keep them apart. T-Casts is much more likely than a human on the ground to have the latest information and give quick and appropriate instructions. The Japanese investigators compile a report in which they'll recommend an overhaul in how pilots are trained so that in future pilots will have no doubt that T-CAST takes priority. 17 months after the near miss, the report is almost ready to be published. Meanwhile, in Moscow, 46 school children are boarding a plane to Barcelona.

It's the 1st of July, 2002. The children, mostly teenagers, are excited. They're going to experience Catalan culture and hang out on the beach. They've already travelled hundreds of miles from their home city of Ufar to the east in the Ural Mountains. But they're not the only ones on the flight. Svetlana Kalayava lives in Vladikavkars in the north of Seteja Alanya Republic. Her husband, Vitaly, is working as an architect in Barcelona. Svetlana is flying out to visit with their 10-year-old son and four-year-old daughter. But they've missed their transfer in Moscow. As luck would have it, there are plenty of spare seats on this charter flight from the kids from Ufah.

Svetlana and the children get on board. The plane takes off from Moscow in the early evening. Three hours later, it's cruising over Switzerland. Out of the cockpit window, the pilot and co-pilot see the strobing lights of another plane in the distance. It's hard to judge at nighttime how far away another plane is, or how high it is, or where it's going. But if they need to take avasive action, they'll be told. And sure enough, here comes a message from the air traffic controller in Zurich.

Descend flight level 350 expedite, I have crossing traffic. Flight level 350, that means 35,000 feet. They're currently at 36,000 feet. They start to descend. But then? Climb, climb, climb But then, what to do? The pilot and copilot have both been properly trained in flying their plane, the Tu-154. But even if they had memorized the operating manual, word for word,

it wouldn't help them much. One section prohibits initiating a maneuver contrary to a T-Cas instruction, but another section stresses how important it is to follow the instructions of air traffic control, and describes T-Cas merely as an additional system. Taken together, that could be clearer. The manual for T-Cas itself isn't much better. One part says that if a T-Cas instruction is inconsistent with current clearance from air traffic control, the pilot must not delay in following the T-Cas instruction. But another part describes T-Cas as a mere backup to air traffic control.

So you can understand why the pilot and the co-pilot aren't immediately sure which voice to ignore. The automated voice of T-Case or the human voice of the Zurich air traffic controller. Climb, climb, climb, climb. It's saying climb, but he's guiding us down. Descend? They keep descending. And here's the air traffic controller again, repeating that instruction.

Descend level 350, expedite descent. Copy. Yes, we have traffic at your two o'clock, now at 360. The pilots descend even faster. But two o'clock, that means to the right. They look out of the cockpit window to the right, there's no sign of the other airplane. Where is it? Here on the left.

Increase climb, increase climb, increase climb. It says climb. There are no more words recorded on the black box, but it does record an action. A desperate tug of the control column, the pilots trying at last to climb, but it's too late. As they cross the path of the other plane, their wing slices into its tail. Their plane breaks up, the plane they hit catches fire. Both tumble from the sky. The wreckage falls over hundreds of square kilometers near Uberlingen, just over the Swiss German border. There are no survivors. How could this happen? It seems incomprehensible. The next day, parents in Ufar receive the devastating news.

In Barcelona, so does the architect and doting father, Vitaly Kaloyev. Corsion retails will return in a moment. I'm Paul Monde, a poet who over the past several years had the good fortune to spend time with one of the world's greatest songwriters, Sir Paul McCartney. We talked through more than 150 tracks from McCartney's songbook, and while we did, we recorded our conversations. I mean, the fact that I dreamed the song yesterday leads me to believe that it's not just quite as cut and dried as we think it is. And now you can listen to our conversations in our new podcast, McCartney, A Life in Earth. McCartney's been asked many times to write his autobiography, and he's always declined.

But as we ventured on this journey, line by line, it became clear how much of McCartney's life is indeed embedded in his lyrics. It was like going back to an old snapshot album, looking back on work. I hadn't thought much about for quite a few years. Listen, wherever you get your podcasts and if you want to binge the entire season, add free right now. Sign up for Pushkin Plus on the McCartney Aliphon Derrick's show page

in Apple Podcasts or at pushkin.fm-clash-plus. Your membership also unlocks access to ad-free binges from Malcolm Gladwell, Dr. Laurie Santos and many other top hosts. Just 11 days after the crash over Uberlingan, the Japanese investigators published their report on the near miss. Pilots training needs to change, it says, so they know that T-CAS trumps air traffic control when the two give opposing instructions. Now a German investigation team looks into the collision over Uberlingen.

Among other things, their report makes much the same point. The instructions for T-Cas they find are not standardized, incomplete, and partially contradictory. The training and instructions have since changed, so no pilot should now make the same mistake. In case they do, T-Casts has changed too. It now monitors whether both pilots are obeying it and reverses orders if one is not. In both Japan and Uberlingan, that would have kept the planes apart at the last moment. The pilot who'd been descending because T-Cast told them to descend would now be told to climb instead.

The pilot who'd been descending in spite of T-Cast would now find T-Cast telling them to keep doing what they were doing anyway. But let's not forget that these incidents weren't all down to T-Cast. It's never just one thing, is it? The flaws in T-Cas came to light only because the air traffic controllers screwed up. In Japan, as we've heard, one was still in training. But what went wrong in Zurich? On the evening of July the 1st, Peter Nielsen turns up for his night shift with Skyguide, the company that runs Zurich's air traffic control.

Peter Neilsen is 35 years old. He's qualified and experienced. His colleagues, said the accident investigators, considered him to be a competent, knowledgeable and professional air traffic controller, a team player. A nice guy. The staffing level for night shifts in Zurich had recently changed. In the past, there had always been three controllers on shift. They'd take turns to go for an extended break in the middle of the shift and get a bit of

sleep in the staff lounge. That was perfectly safe. There went enough planes in the dead of night to keep even two controllers occupied, and the third would return, refreshed as traffic picked up in the morning. But skyguide had become short-staffed. They'd started putting only two controllers on at night. The controllers continued their informal arrangement that one would go to the lounge for a snooze. That was considerably

less safe. Yes, as long as nothing unusual occurred, one controller could get to the quiet night-time hours easily enough. But if something out of the ordinary were to happen, the controller would have nobody to turn to for a sense check, and if the lone controller screws up, there's no colleague there to notice. At quarter past eleven, Peter Neilsson and his colleague agree that they'll now be few enough flights coming through that the colleague can retire to the lounge and return in a few hours. There is something unusual happening tonight though, and Neilsson is already aware of it. Technicians are doing maintenance work on some of the systems.

They tell him those systems are now in fallback mode. That's fine, he says. Nobody checks if he understands exactly what fallback mode means. It later transpires that he doesn't. Here's one thing it means. The radar screens no longer display a scale, a Neelson has to monitor two screens which use different scales. Without the visual aid, there's more risk of miss perceiving how far apart planes are. Also, the screens aren't

automatically showing which blip on the radar corresponds to which plane. And the short-term conflict alert system is partly disengaged. Normally, this system shows a warning on the radar screen with two minutes notice if planes are on course to pass within a few miles of each other. Now, there'll just be an audible alarm if a collision is much more imminent. None of these systems are critical. Neilson should be able to compensate for their absence by making sure he pays a bit more attention.

But he isn't really aware that he needs to, and what's this on his radar screen? It's a plane he wasn't expecting to have to deal with, an airbus that should have landed much earlier, but got delayed. Neelson and his colleague had completely forgotten that the airbus would be coming along. If they'd remembered, the colleague would have stayed for another half hour to handle it. At half past eleven, the Russian plane enters Neelson's airspace, and the pilot checks in with him, it's flying at 36,000 feet. The radar shows Neelsund that there's another plane at 36,000 feet, a cargo flight,

from Bahrain to Brussels. The planes are approaching each other, roughly at right angles. They're still over 50 miles apart. It sounds like a lot, but they'll be upon each other in barely five minutes. If it had been paying more attention, Neelson would have told the Russian pilot to descend. But with so many systems down, he doesn't notice. And now this delayed airbus wants his attention. Neelson has to move to a different workstation

to talk to it and tune into a different frequency. The airbus wants permission to land on an alternative runway. That's a pain. Neelson will need to phone the airport to check that it's okay, and the main phone system is yet another thing that's down for maintenance. There's a backup phone system that should still work, but for some reason, Nielsen can't get through. That's weird. He dials again. And again. It later turns out there's a software glitch with the backup phone system. Nielsen doesn't know that. He assumes he must be dialing the wrong number. He tries seven times

to get through. He's got half an eye on the radar screen, but it isn't showing any warnings. It would be by now if the short term conflict alert system was working properly, but it isn't. And Nielsen doesn't know that. The airspace next to Zürichs is handled by another control center in Karlsruhr, Germany. The controllers there see the short-term conflict alert pop up on their radar screens. Remember, that alert means two planes will be perilously close to each other in just two minutes. The Karlsruhr controllers could jump on the emergency radio frequency to talk to the two planes, but

the rules say they shouldn't do that. For the very good reason that the planes aren't in their airspace, instead the rules say they have to contact Zurich, so they try. But of course, the phone system in Zurich isn't working. They try again and again. They try 11 times. Nearly five minutes after the Russian plane entered his airspace, Neelson suddenly realizes the danger. Descend flight level 350 expedite. I have crossing traffic. The Russian crew don't respond.

Why aren't they responding? We know why. It's because the pilot and copilot are busy debating whether they should ignore Neilson telling them to descend or T-Cas telling them to climb. It hasn't occurred to Neilson that T-Cas will have kicked in. And now, the audible conflict to learnt sounds, the two planes are just half a minute from colliding. Neilsson leaps into action.

Descend level 350, expedite descend. We have traffic at your two o'clock, now at 360. Neilsson is stressed, he's not thinking straight. He doesn't realise that he's contradicting T-Casts. But more than that, he said two o'clock, when he meant ten o'clock. It makes the pilots look right when the cargo plane is to their left. And his radar display is out of date. The cargo plane isn't now at 360. It's been descending because T-Cas has told it to.

The next time Nielsen's radar refreshes, it shows the cargo plane level with the Russian plane and descending at the same rate. The pilot of the cargo plane comes on the radio too to inform Neelson that he's descending, but Neelson doesn't see the radar refresh and he doesn't hear the cargo pilot's call because he thinks he's averted the danger, he's gone back to his other workstation to deal with the late, running airbus instead. In Karlsruhe, the air traffic controllers watch in horror as the two dots on the radar collide. By the time Neelson looks back at his screen, it's already happened. He tries to call the Russian plane. There's no response.

Vitaly Kaloyev knows his wife and children were on that plane. He hurries to Uberlingan, expecting the worst. But nothing could have prepared him for the horrors he was about to see. Rescuers are still searching for all the bodies, they're scattered over hundreds of square kilometers. The body of Kaloyev's wife, Svetlana, has landed in a cornfield. His 10-year-old son, on asphalt, near a brush shelter.

The little body of his four-year-old daughter was found snagged up in a tree. The little body of his four-year-old daughter was found snagged up in a tree. When Colloyev searches the area, he finds her pearl necklace lying on the forest floor. Colloyev cleans the bodies and dresses them for the funeral. He also asks questions of journalists. The air traffic controller, what's his name? Where does he live? Corsion retails will return. Hi, I'm Michael Lewis.

My first book, Lyres Poker, told the story of my time in Solomon Brothers, which was then one of the world's most powerful banks. In three years, I went from trainee to successful banker. It felt back then like a modern day gold rush. I thought at the time I was documenting like an unprecedented event that would never repeat itself. It turned out it was just the beginning of an era that never ended. I've recorded for the first time a full audiobook version of Liars Poker.

You can get it now at pushkin.fm The Swiss Air Traffic Control Company, Skyguide, had recently come up with new procedures that were meant to allow controllers to work safely alone when needed. Swiss regulators were already worried about those procedures. Were they too lax? Too risky? But Peter Neilsen wasn't even working under these new procedures.

They applied only when there was officially just one controller on duty. During night shifts, officially, two controllers were on duty at all times. The fact that one of them always spent a few hours asleep was just an informal arrangement, but it was an arrangement that the managers at Skyguide knew all about. They'd already had to investigate one near miss. When Skyguide came up with their new procedures for solo working, they assumed that if only one controller was on duty, they'd at least have a supervisor they could call on for help.

But that didn't happen on the night shift when one controller slept. There was no supervisor. Nielsen had to supervise himself. The procedures also assumed that the controller would have the short-term conflict alert system to rely on. Taking that system offline for maintenance would have breached the procedures. But of course, Neelson wasn't protected by these procedures. Procedures that the regulators already worried might not be safe enough. No wonder the investigation report comes across as pretty sympathetic to Peter Neilsson.

He screwed up, of course he did. But his employers had allowed a workplace culture to develop in which screw-ups were disturbingly likely. Neilsson was not in a position to safely execute all the tasks he had been given, the investigators found. Neilsson was traumatized by his role in the collision. He was treated for shock, but after some time off, he returned to work. Nearly two years after the accident, Peter Nielsen was at home with his wife and three children

when he saw a middle-aged man sitting in his front garden. He went outside to find out who the man was and what he wanted. His children followed him out. He waved them back inside. We don't know for sure what happened next. We only have Vitaly Koloyev's side of the encounter. He says he tried to say the German words for I am from Russia. He says he gest to say the German words for I am from Russia. He says he gestured to the front door to show that he expected Nielsen to invite him in.

He says he tried to show Nielsen photos of the bodies of his dead children. And he says Nielsen pushed his hand aside and the photos fell to the ground. In Kalojev's telling what happened next is a blank. But Peter Neilson's wife can pick up the story. She heard a scream, she rushed outside to find Kaloyev walking calmly away with a switchblade knife, and her husband lying in a pool of his own blood. It's never just one thing, is it? If Neilson's colleague had stayed for another half an hour, if Neilson had known that the alert system wasn't working,

if the backup phone line hadn't had a software glitch, if the pilots had been trained to prioritize T-Cas. Maybe you can think of it as a series of dominoes falling, one toppling another, then another. That's a metaphor one pioneering safety researcher came up with, Herbert Heinrich in his 1931 book, Industrial Accident Prevention. Or think of the Swiss cheese metaphor, developed more recently by the psychologist James Reason. Each slice of cheese is a layer of defense, and each has holes in. Accidents happen when you have a stack of slices, and the holes just happen to line up.

Peter Nielsen's screw-up was one hole in a slice of cheese, but it wouldn't have mattered if there hadn't been other holes in other slices. Sometimes we can reasonably hold people responsible for gaping holes in a slice of cheese, a Swiss court find managers at Skyguide for having allowed a culture of negligence to develop in the workplace. At other times, there's really nobody at whom you can point a finger. The people who train pilots or write operating manuals hadn't been sloppy or reckless, they simply hadn't foreseen that you might get dangerous circumstances in which T-Casey's saying one thing,

an air traffic controllers are saying another. Once it became clear that this could happen, they changed the training and rewrote the manuals. That slice of cheese now has smaller holes. Still, even when there isn't anyone obvious to punish. People can get punished anyway. Remember the 26-year-old trainee air traffic controller in Japan, who'd said, flight 907, when he meant flight 958? Remember the supervisor who jumbled her numbers and said 957. It's the same kind of flub you might think that could happen to anyone, and would hardly

ever lead to tragedy. They'd usually be plenty of other slices of cheese to cover the whole. The Tokyo Metropolitan Police Department wasn't so forgiving. It was professional negligence, they said. Prosecutors brought the pair to court. They demanded 18 months in prison for the supervisor. They cut the trainee a bit of slack. They wanted just 12 months for him. The case rumbled on for five years, during which both kept working at Tokyo air traffic control. which both kept working at Tokyo Air Traffic Control. At last, the District Court delivered its verdict, acquitted, on all counts.

The controllers' legal ordeal seemed finally to be over, and they wrote an open letter to the International Federation of Air Traffic Controlers' Associations, to say thank you for all the support they'd received from their professional colleagues around the world. The court recognised that it was an accident connected with a system rather than individuals, they wrote. We think the collision above Ubalingen might have been prevented if the causes that led to our accident had been properly clarified at an earlier stage and notified

worldwide. This not guilty verdict is not only ours, but also for all of those who supported us. But the prosecutors lodged an appeal. They weren't ready to give up yet. Vitaly Kaloev walked back to his hotel, the welcome in near Zurich Airport. Having revengeed himself upon Peter Neilsson, he was covered in the air traffic controllers blood. Somehow, the staff didn't see him make his way up to his king-size room. The next day, police came to the hotel to arrest him. The charge was murder.

Peter Neilsson had fled to death. Vitaly was held at first in a mental hospital, then tried and sentenced to eight years in a Swiss prison. Just two years later, he was out. An appeal court decided that he couldn't be held fully accountable for his actions. The most shocking thing about Vitaly Kaloyev's murder of Peter Neilsson isn't the murder itself. The most shocking thing was the public reaction to Vitaly Kaloyev when he got out of prison and went home to North Ossetia. It was a hero's welcome.

He got fan mail, letters of support, offers of marriage. If more people were like you, wrote one woman, the world would be a better place. He's a real man, said one local dignitary. What he did was an act of heroism. Journalists in Ossetia named him Man of the Year. The government of North Ossetia supported Caloyev too. They even appointed him deputy minister for construction. When he retired, they gave him the glory of a settier medal, awarded among other things for maintaining law and order. One man's grief-fueled madness is understandable.

The support from many others says something more troubling about the human condition. In any accident, there are lots of lessons we might learn about how to make future accidents less likely. Re-write instructions, change, workplace culture, tweak automated systems. But punish people for getting in a model? I'm not so sure that helps. The prosecutors in Japan took a different view. They pursued their case against the two air traffic controllers for another five years, until at last the Supreme Court handed down the final verdict. Guilty. The sentences at least were suspended. they wouldn't go to prison, unless they committed some other crime, such as maybe mixing up their flight numbers again.

But they wouldn't need to worry about that, because as convicted criminals, they lost their jobs. It's never just one thing. But shades of grey aren't satisfying, it seems. We thirst for black and white. We want villains, and we want vengeance. For a full list of our sources, please see the show notes TimHalford.com Corsinary Tales is written by me TimHalford with Andrew Wright. It's produced by Alice Fines with support from Edith Ruslo. The sound design and original music is the work of Pascal Wise. The show wouldn't have been possible without the work of Jacob Weisberg, Ryan Dilly, Julia Barton, Greta Cohn, Little Malade, John Schnarrs, Cahley Migliori, Eric Sandler, Maggie Taylor, Nicole Marano

and Morgan Ratner. Corsely Tales is a production of Pushkin Industries. If you like the show, please remember to share, rate and review. It helps us for, you know, mysterious reasons. And if you want to hear the show, add free. Sign up for Pushkin Plus on the show page and Apple podcasts or at Pushkin.fm-plus. Hi, I'm Michael Lewis. My first book, Lyres Poker, told the story of my time in Solomon Brothers, which was then

one of the world's most powerful banks. In three years, I went from trainee to successful banker. It felt back then like a modern day gold rush. I thought at the time I was documenting at like an unprecedented event that would never repeat itself. It turned out it was just the beginning of an era that never ended. I've recorded for the first time a full audiobook version of Liars Poker. You can get it now at pushkin.fm

dot fm.