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)
- 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.
- The pilot should have known the SOP and acted accordingly
- The tyre checker should have signalled ‘switch off’, which he had not.
- The duty ATC officer should have rejected the pilot’s request to go back to dispersal and should have asked him to switch off.
- 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.
- His knowledge of SOP was not tested properly
- If he knew about the SOP then his operational discipline was suspect
- 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.
This is so exemplary of the way our lives were dealt with when we were ‘fledgling pilots’ in the flight of life, starting out from home. I remember that each probable ‘accident’ whether it was of action, speech, behaviour or fact, was first brought into the collective discussion by those ‘in a position to instruct, prevent or mitigate’ the circumstances leading up to the ‘incident’! We were taught the fact that any small action or word or even indication, no matter how insignificant or ‘not really my job exclusively’ it may seem to be, could actually make the difference between a ‘non-incident’, an ‘incident’ and, heaven forbid, an ‘accident’! They were lessons we learnt well, the acceptance of responsibility comes easily to all of us now and has made it easier by far to deal with those in error, whether by design or inadvertently.
Knowing the people involved in the incident mentioned here, another thing that I feel sure of is that each one of them went away from that court of inquiry with a sense of self worth and a renewed sense of responsibility towards his task. It was inevitable-so often we look at our part of a large jigsaw as a relatively unimportant piece of activity-too little to make a difference to the final picture, but we tend to forget that without the canvas, that is there unstated and unseen, the colours and patterns would have no place to glow!
Lessons in life come from the most unexpected encounters-I do not know the young pilot in question, but twenty four years down the line I hope he learnt a lesson too that day!
i must salute you for having been such a ‘stickler’ in the incident that you described. In cases of ‘near-miss’ or ‘minor’ incidents, it is rather easy to get lulled by the fact that consequences were so insignificant as to not matter in any way. Actually in most incidents/accidents it has been found that rather than a single ‘error’, a ‘chain of errors’ has been a causative factor.
The action that you initiated, imho,helped to unearth a chain of errors; and i am convinced must have helped all persons concerned to achieve higher safety records later, most of all the trainee pilot concerned.
Safety is not just a set of procedures, but a philosophy of existence; especially in high risk activities.
Your other point, regarding ’cause-finding’ v/s ‘blame fixing’ is extremely pertinent to creating and fostering a safety culture.
Who should have taken responsibility for a Traffic Post being in the position it was?
Mark: I had a word with my Chief Adm Officer who had finally OK’ed the location. He agreed with the consensus that it should have been better located.
In aviation we now strive to imbibe this “safety culture” early in our careers, and hopefully it is leading to tangible improvements.
But it needs to become a part of the general education system…its absence is very obvious when we look at our road accident statistics
When we implemented ISO 1400 (safety) way back in 1995 in Larsen and Toubro, the most important feature of this exercise was to document “near misses” incidences. All departmental heads are duty bound to document all near misses and initiate CIP (continual improvement programme). Any willful omission if found was delt with severely as breach of discipline.
Now CIP is a very painful affair for any departmental head. All CIP has a control number . This control number is assigned by head of quality Assurance. It follows a scientific methodology. The steps are like this.
• A team is formed with time bound assignment
• Defining the scope of the CIP and result expected
• Data collection
• Data analysis
• Defining counter measures
• Implementation of counter measures
• Result derived
• Future scope
Once in every three months Unit conducts “Management review meetings” where all the dept.heads gives presentation on ISO related issues including status of CIP on near misses. In the meeting decision would be taken whether to conclude the CIP or to extend it further.
What you did is exactly on these lines. Only the difference is court of inquiries does not give guarantee that all the recommendations have been implemented with desired result. ISO ensures that.
Jamnagar has a romantic interlude in my life. I got married on 19th nov.1972. She was with me at Jamnagar only for one month. She went back as she had to complete her B.SC with mathemetics honours. That one month was definitely one of the most defining moment of my life.