MORAL DILEMMA

 This article was published in the Sep 2020 issue of Flight Safety Journal ,"Blue Glory" of the Indian Air Force  . This is the original article  sent to the editor. The published one had few minor differences in syntax. 

MORAL DILEMMA

THE INCIDENT

          It happened during night flying training sortie, with a young pilot in AN-32, when I was the CO of the Squadron (year 2006). After about 30 minutes of flying, the ATC informed about a metal piece found on the runway resembling aircraft part. I checked all parameters which were normal, but carried out a precautionary landing as we were the only aircraft flying that time.  The aircraft was switched off and I waited in the bay for the object to reach me for recognition. It was a metal rod which is part of the lashing mechanism to tie down the aircraft on ground. It is screwed in the upper part of the undercarriage bay for tying one end of the metal string whose other end is fixed to the mooring points on ground. This part along with the strings is removed and stored close to the bay before startup. I immediately looked at the spot next to the bay where the lashing material is stored and found the metal rod missing. It was clear that we took off with the piece and it fell off during flying.

THE AFTERMATH

          It is the responsibility of the seeing off team to ensure that all lashing material is removed before the aircraft is started. It appeared to be easy to locate the person responsible.  However no one from the shift owned up to the mistake. I did not expect this and expressed my disappointment to the STO, exhorting him to impress upon all that as we have landed without any mishap idea was to learn from it. I further told him to convey that no action would be taken if the person is forthright and honest and also that I would not be even interested in knowing the identity of the person as aim was to fix the error and not the person. I soon heard that the mistake had been owned up.

WHAT HAPPENED

          While driving to the flight line for the sortie I was called by Flt Cdr IL76 regarding some problem with the ex India commitment for the next day. I went straight to the DSS of that aircraft (the Sqn had two types of ac on its inventory). Since the task at hand was likely to take time I sent a message to the crew to carry out briefing and wait for my arrival. It took me more than an hour to resolve the issue. I set off directly for the aircraft after sending the message to the crew to be ready for an immediate take off. The aircraft was still picketed as per local orders due to prevalence of gale during that time of the year. DSS had detailed two technicians to see off the aircraft. One of them, due to uncertain delay from my side, went to the other aircraft for some rectification. In the mean time the crew informed DSS that I was reaching directly to the aircraft and to prepare the aircraft quickly. The IC promptly sent the technician who was in the DSS to the aircraft and went to the tarmac to inform the second technician to attend the aircraft. Now this removal of the rod requires two people. One has to climb on the tires to reach the upper portion of the undercarriage bay to unscrew the rod and thereafter hand over to the other technician so that he can come down from the tire. The lone technician saw the urgency and proceeded to do it alone considering that I was about to reach the aircraft. He climbed on the tire, unscrewed the rod and kept it between the lower portions of the undercarriage strut and descended. The moment he came down he was confronted by the young pilot who found some oil splashes in nose oleo. He went with him to the front portion and consoled the pilot that it was normal. In this distraction he forgot to take the metal rod down from the strut where it sat precariously. He quickly went to the other side to remove the lashing where he was joined by the other technician. He took his help there and told him that the other side has been removed by him.

MY REACTION

          I heard the STO and asked him to inform the technician that nothing would happen to him and he can go and relax. The STO was instructed to work out a strategy so as to avoid reoccurrence of such events like having a large red cloth flag on the metal rod and some cross check to see that the lashing stuff is stored before waving off the chocks. The STO and Flight Commander were instructed to inform all type Squadrons about the incident in the night itself.

REACTION AT STATION LEVEL

          Next morning, in the station briefing room, the AOC was at his furious best and ordered me to initiate inquiry against the technician. I confronted him after the briefing and gave my version along with the post incident task of informing all operators and also coming up with methodology to avoid such occurrences. I buttressed the fact that the technician did his job with best intentions and his aim was not to delay the aircraft for which he even risked personal injuries by climbing alone and risking a fall. That, the metal piece could have been left was due to an unfortunate coincidence of pilot interrupting him at a critical juncture when he was about to take it down from the struts. I also confessed to the fact that I had exonerated the technician. I concluded my argument stressing that in an imperfect world we cannot expect people to perform perfectly always, and in this incident if someone has to be blamed it was me. I did not do the externals and made everyone to rush. I must appreciate my AOC, a rather strict and stickler for rules, as he immediately calmed down and told me that he respects my decision. The incident was over.

THE TECHNICIAN

         It was after few days that I was told by PA that a technician wants to see me. The technician, whom I immediately recognized as one of the most sincere and professional airman, came in almost trembling with fear and broke down in tears saying that he was the one responsible for the incident. He confessed to being severely depressed due to the guilt and shame of putting the aircraft into a situation which could have resulted in killing all of us. His feeling of guilt further multiplied when he found out that he has been exonerated without even an admonishment from my side. I consoled him that it was more of my fault who hurried up all and explained that the rod could not have resulted in any serious mishap as it was loosely kept on the struts and it fell the moment we opened power for takeoff. The metal rod was found at the beginning of the runway. I patted him and looking into his eyes told him that I was, as always, proud of him. From a shattered man who entered my room just ten minutes back, he walked out of my room as a proud air warrior with his head held high. 

THE DILEMMA

         The incident, though, was far from over for me and often inundated me with troubling questions over the, spur of the moment, decision I took that night of acquitting the guilty unconditionally without any understanding/inquiry.  Can a guilty be just left without any punishment? Wasn’t my decision contrary to organizational ethos? Did I set a wrong precedence? Could my decision stand the legal scrutiny? As a Commanding Officer where I was the judge and jury did I do justice? And, after all what is the RIGHT THING to do in these circumstances? There was no easy answer to this moral dilemma. Normative ethics is the branch of Moral Philosophy that provides a frame work for deciding what is right and wrong. The two most common frameworks are the Deontological and Utilitarianism ethics. Deontological ethics, often associated with philosopher Immanuel Kant, places emphasis on duty, rules and professionalism. Accordingly, the right thing to do as per this school of thinking is to follow the rules. This approach is simple, avoids subjectivity and uncertainty, as it just require people to follow set rules. It is evident that I failed on this count. The technician did not follow the proper rule to disarm the lashing hence he was guilty and need to be punished following due service rules and procedures. Such line of thinking would have been also more in tune with the ‘Service line’. The other school of thought called Utilitarianism, advocated by Philosophers Jeremy Bentham and John Stuart Mill, determines right and wrong by looking at the consequences of the action. As per this school the most ethical choice is the one which produces the greatest good for the greatest number. My act of pardoning the accused unconditionally could have projected Organization as the one which understands human limitations and encourages honesty and openness. On the other hand some could view it negatively as accepting and encouraging substandard behavior due loss of fear of punishment. Even the father of behaviorism BF Skinner advocated punishment as a means to extinguish unwanted behavior via his theory ‘operant conditioning’. My journey into the philosophical world left me even more confused but, finally, I did find solace many years after the incident.

          In 2006 when the incident occurred I had never heard about the concept of Just Culture which is now being aggressively advocated by many organizations including aviation. My interest in the subject got aroused by reading the book “Just Culture: Balancing Safety and Accountability” by Sidney Dekker which got popularized as the book which Sully Sullenberger was reading when he pulled off that miracle landing in River Hudson. Sidney Dekker, in the book, says that incidents must not be seen as a failure/ crisis but a free lesson and opportunity to focus attention and learn collectively. Aviation is inherently dynamic and complex routinely throwing new challenging circumstances. It is almost impossible to anticipate or avoid all errors/incidents in the dynamic and complex world of aviation where unexpected situations emerge often. Safety culture can be enhanced only if people are free to disclose, discuss and learn from errors in this challenging and ever changing world. Just culture is all about trust and faith where people are encouraged to share their errors or provide essential safety related information without fear of getting punished. Criminalizing human error is bad for safety as it makes people defensive and would not be forthcoming with their errors and mistakes. Our safety and future lies in open reporting about errors, mistakes and potential errors.

          It was liberation time for me to learn that the action I took that day would, IMHO, contribute to openness in accepting mistakes and errors and was a step towards just culture where honest mistakes are not criminalized.

“The question that drives safety work in a just culture is not who is responsible for failure, rather, it asks what is responsible for things going wrong. What is the set of engineered and organized circumstances that is responsible for putting people in a position where they end up doing things that go wrong?” –Sidney Dekker, Just Culture.