When lapses (be it safety or security) have been found, the rational and natural approach is to take actions to "plug" the lapses. However, in my opinion, the issue of determining responsibility, accountability and culpability will determine the effectiveness of the "lapses-plugging-actions". To put it in another way, what "personnel-related-actions" to take on those who are responsible, accountable and culpable will have an effect on how the "lapses-plugging-actions" are being carried out. If the "personnel-related-actions" are not perceived to be fair and just, "lapses-plugging-actions" will be carried out half-heartedly. So what do I mean about who are responsible, accountable and culpable? Here's my definition:
Responsible - the person who is actually carrying out the job, e.g. the Gurkha Contingent (GC) guards and Special Duty Operative (SDO) or, in my line of work, the technician who does the repair work.
Accountable - the person whom those responsible reports to. This person may not be actually doing the job of escort or repair but has to account for how well or badly was the job done. These people include supervisors, management staff, auditors, independent checkers etc.
Culpable - When there are procedures to be followed but the person chose to do otherwise, in maintenance, we call it non-conformance (to procedures). However, that person is not culpable (of misdeeds) yet. If his non-conformance is due to malice, intent to sabotage, wanting the adverse consequences to happen or clearly defies commonsense, then we would deem this person to be culpable. Rightfully, he should be removed from his job or face other severe disciplinary actions because he is a threat to himself, his colleagues and the organisation. However, if his non-conformance is due to a misunderstanding of the procedure, or even lack of clear procedures, inadequate resources, etc or when his non-conformance is actually a "cultural norm" (everyone else does it)... well, what action should we take? I'll come to that later on.
Back to Mas Selamat's case...
There were "no evidence of connivance, collusion, or assistance given to Mas Selamat" nor "malice or criminal liability on the part of any officer implicated"(Ministerial Statement). Thus, in my opinion, no one is culpable, not even the GC guards and SDO operative, based on my description of culpability. However, that does not mean that no one is held responsible or accountable for the lapses leading to Mas Selamat's escape. Looking the COI's recommendations, clearly the lapses went beyond the escorts' not keeping line of sight of the detainee, un-grilled window and weakness in the perimeter fencing. The COI's key recomendations include,
1) Centralised Command and Control
2) Enhance Communication Coordination
3) Regular Exercises and Audits
4) New Detention Facility
These recommendations suggest that there are "high level" weaknesses. There are people, most likely high up, who are responsible for effective command and control, communication and coordination etc and even higher up who are accountable for the "need-to-be-improved" areas. There are people who have to be responsible and accountable for the weaknesses.
So what "personnel-related-actions" should be taken? If no one is culpable of intentionally assisting Mas Selamat's escape directly or indirectly, does it mean that no (disciplinary) action will be taken on anyone? No. The personnel-related-actions can include re-train and re-educate, stoppages of leave/offs/bonus/promotion for a fix period of time etc for all those responsible and accountable for the lapses and weaknesses. This is to send a clear message that lapses cannot be condone, whether it was done intentionally or not. Since these disciplinary actions are not permanent, it gives hope to the staff that they have an opportunity to do better in future.
On top of that, the disciplinary actions must be seen to be fair and not exonerate anyone, especially the top management. If not, all the talks and recommendations about centralised command and control, enhancing communications and coordination will turn into "blah blah blah" in the ears of the lower ranking staff. All the weaknesses will still be present.
Should anyone be sacked or asked to leave? Since the COI and CID did not find any evidence of connivance, collusion or malice, I don't think anyone should be sacked. In fact, sacking someone or making someone resign is really a simple way out. That person will take away a full load of knowledge and experience about the "honest mistakes" he made. I would even advocate that everyone should stay on, from the director of ISD to the GC and SDO. Stay on to make things right. Stay on to ensure that the correct ways of doing things are materialised.
A punitive culture within any organization is always counter-productive. It will not only make everyone shirk responsibilities - such a culture "encourages" people to cover-up or even distort truths. In such a cultures, those directly responsible (normally the lower ranking staff) for the lapses are removed immediately but the indirect causes e.g. inadequate tools, ambiguous procedures, crazy-boss-who-make-me-repair-the-nuclear-reactor-in-5-minutes etc are unchecked and unrectified. Someone else is bound to make the same mistake, again. Weaknesses will occur and go undetected, unreported, waiting to blow up on anyone "suay" (unfortunate) enough to step on it at the wrong moment.