A Small Incident with Big Lessons

I had just taken over the Air Force Station at Jamnagar as its Air Officer Commanding (AOC).   My wife Leena was still in Delhi tending to the children who could not shift as they were half way through their school/college term.   Jamnagar has one of the busiest air firing ranges of the country; flying units from all over the country send detachments to Jamnagar for an intensive camp of air to ground and air to air firing practice.   Soon after my arrival, a detachment from the Fighter Training Wing (FTW) Hakimpet arrived with their Polish made Iskra aircraft for their routine armament training.    For those readers who are not familiar with the structure of the Air Force let me explain that the FTW trains new young pilots into elements of fighter flying after they graduate from the Air Force Academy.   Such detachments from FTW to Jamnagar are routine affairs and take place normally twice a year.   All arrangements are pre-set.   The instructors from the FTW are normally familiar with Jamnagar and they do their own training without any interference form the station.   Jamnagar just has to provide the flying environment and the range firing facility.   I was therefore not bothered about the presence of a big bunch of very young pilots on my base.

At about eleven in the morning one day I received a call from the Air Traffic Control.   An incident had taken place.   A trainee pilot had entered a disused taxi track by mistake and the wing tip of his aircraft had struck a traffic light post on the edge of this taxi track which was now being used as a road.   The wing tip had been dented.   I let the matter take its own course.   About half an hour later, the Station Flight Safety Officer along with the Station’s Chief Engineer Officer (C Eng O) and the Officer in charge of the FTW detachment came to my office.   All of them had a big smile painted on their faces.   The incident had apparently been dealt with.   The C Eng O explained how he had taken the leading edge cover out and had the dent beaten out.   The aircraft is not damaged any more.   Therefore, they felt that the incident was no more an incident.    Under these circumstances, they wanted to know, was there a need to report the (non) incident and degrade the flight safety statistics for the station as well as the visiting unit?   The detachment commander added for emphasis that he had already taken the silly pilot to task and had given him a dressing down for his stupidity.   Was there any need therefore to take this (non) incident any further?   Their implied appeal was forceful.

Over the years of my association with Flight Safety, I had developed a philosophy that we need to pay special attention to the small and insignificant incidents.   Major accidents take place as a culmination of multiple failures where one or two major causes hide all the other smaller failures.   The small and insignificant incidents give us the opportunity to examine the many small failures that allowed the incident to occur.  Since the damage caused is nil or negligible, we are not under any pressure to ‘catch and fix’ any ‘culprit’.   It is then possible for us to examine the causative factors dispassionately and learn our lessons.  I was permitted to have my quirks and pet obsessions; after all, I was the AOC and I was also an ex director of Flight Safety for the Air Force!    I smiled and shook my head in the negative.

My visitors were clearly disappointed.   In the 1980s, Flight Safety statistics were a prize passion of the flying units and stations.    Tarnishing the statistics ‘avoidably’ was almost a criminal offence!   I was however a new entity on the station and practically unknown to my staff.   It was difficult to take liberties with me.   They did not quite know how to dissuade me from inflicting ‘unnecessary takleef’ on them in the form of instituting a court of inquiry and also spoil the station’s safety record in the bargain.    Tough luck!   I was the boss and I had my way.  I however felt a little sorry for them and gave them a sop by saying   ‘Withhold the reporting procedure till I see the report of the court of inquiry.   I will then decide on further action to be taken.’

The Court of inquiry was recorded in double quick time as the story was quite simple.   (Please see the attached picture for better comprehension)

 

 

Jamnagar Airfield

 

• The young pilot was authorised for a range firing sortie.
• At the take off point on dumbbell 24 the tyre checker noticed a fuel leak from the aircraft and informed the pilot.
• The pilot informed the Air Traffic Control and requested permission to enter the runway and roll down to the detachment dispersal located on the 06 end of the runway.
• The ATC accepted his request.
• The pilot entered the runway, but because of his inexperience on a new airfield took a long time to get on to the runway and start rolling.   He also taxied on the runway very slowly.
• A commercial civil aircraft on a scheduled landing at Jamnagar reported long finals 24 and requested for a direct landing.   The ATC asked him to continue and asked the Iskra pilot to ‘expedite’.
• The Iskra failed to accelerate.  Perhaps the pilot did not understand the situation or the instruction from the ATC.
• The ATC now asked the Iskra to clear the runway left on the cross runway.   The pilot obeyed.   The civil aircraft was allowed to land.
• Instead of stopping on the cross runway to turn around and re-enter the runway behind the civil aircraft, the pilot rolled on and reached the parallel taxi track.
• At the parallel taxi track the Iskra turned right on the taxi track.    This was against the current traffic.   Very soon he found another Iskra coming head on going to the take off dumbbell (24).
• This other aircraft was on a dual instructional sortie.    The instructor on board was annoyed at finding an aircraft on the taxi track heading in the wrong direction.    He asked the erring pilot to clear to taxiway left.   He wanted the aircraft to turn on the taxi track parallel to the cross runway.   He did not specify because another taxi track emanating from that spot was a closed path and was marked as such.
• The young pilot was confused.   He entered the abandoned taxi track and struck a traffic lamp post planted just off the taxi track.  (A road also crossed the same spot to cross the runway controlled by the traffic light.)
• The Iskra was asked to switch off.   A Jeep was sent to fetch the pilot.   He was suitably instructed about his ‘idiocy’ by his superiors.

When the Court of Inquiry Proceedings came to my hand I did not know whether to laugh or cry.   I called for a conference of the entire flying and admin wings and asked the gathered gentry to pinpoint the various failures that led to the final situation.    It was indeed a surprisingly long list.

• At the tyre check point when a fuel leak was noticed, according to the Standard Operating Procedure (SOP) the aircraft should have been switched off.
  1. The pilot should have known the SOP and acted accordingly
  2. The tyre checker should have signalled ‘switch off’, which he had not.
  3. The duty ATC officer should have rejected the pilot’s request to go back to dispersal and should have asked him to switch off.
  4. There was a Duty Instructor at the ATC.   He should have noticed the incorrect action by the pilot as well as the ATC and should have intervened.   He had not.

• The ATC was aware of the civil aircraft movement.    The aircraft was painting on radar.   Even though the civil aircraft had not called in, it was certainly expected.   It was unwise for the ATC to assume that the trainee pilot will smartly enter the runway and go down the runway at a high speed so that the incoming traffic was not held up.   His decision to allow the Iskra to enter the active runway was incorrect.
• Having committed his initial mistake(s), the ATC had no business to ask the trainee pilot to ‘expedite’.   A trainee pilot should not be hurried.
• After the trainee pilot cleared the active runway on to the cross runway, no one kept an eye on him.   By rolling on the cross runway he was going away from his destination.   Neither the ATC nor the duty instructor noticed this error by the pilot.   The pilot should have been stopped and prevented from entering the parallel taxi track in the wrong direction.
• The location of the traffic light was too close to the shoulder of the taxi track.  Even though the taxi track was closed, it was used for ground handling aircraft for taking it to the butt testing point at the end of the taxi track.   It was also not necessary to locate the traffic light there.   The traffic light could have been located across the parallel taxi track on the road before entering the runway crossing.
• The marking on the closed taxi track had faded and had not been refreshed.
• The failure of the trainee pilot to follow the SOP was a serious lapse.
  1. His knowledge of SOP was not tested properly
  2. If he knew about the SOP then his operational discipline was suspect
  3. Allowing a pilot to be in command of an aircraft under such conditions spoke ill of his supervisors.

During the discussion that ensued, it was suggested that the pilot may have been afraid that if he switched off the aircraft at the dumbbell he would be stuck in the hot sun for a long time because aircrew transportation was inadequate.   This might have prompted the pilot to go against the SOP and opt to taxi back.

The first part was true and was accepted as a possible contributory factor.   The second part fell afoul of the standard of his self discipline and was not accepted.   If this part was true then it also reflected on his safety consciousness because the SOP was designed to prevent chances of fire with a fuel leak.

The group discussion was very instructive.    Every one who had any failure attributed to him admitted to his fault without hesitation!    Every one was amazed at the huge number of persons contributing to the incident.    It was instructive to realize that ANY ONE of this large number of people could have prevented the incident simply by doing what he was expected to do correctly!

In my comments on the Court of Inquiry I described the analysis made by the station group and stated that since every person concerned had been suitably educated about their individual failures, no further action was considered necessary.   Since there was no ‘Cost of Damage’ involved, the happening could not be counted as an accident.   It was however fit to be counted as an incident.   I then sent the Court of Inquiry up to the Command HQ.     My boss there, the AOC in C Air Marshal JR Bhasin was another die hard Flight Safety man, being another ex Director of Flight Safety.   He was not amused.   In his view, if something untoward happens, a ‘culprit’ has to be found and taken to task.   That philosophy differed fundamentally from mine.   I felt (and continue to feel) that education producing understanding is superior to retribution producing fear for the purpose of preventing accidents and enhancing efficiency of operations.

At the level of the Air HQ, I had many a ‘smiley’ thrown back at me when the Court of Inquiry finally reached there.   I hope that by this exercise I and my fellow aviators in Jamnagar at that time managed to avoid some other incidents and accidents in our later lives.

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