Yawning Bread. 22 April 2008

The great hunt: more management failures than guards' lapses




In order to be fair to Wong Kan Seng in my comment here, I spent a couple of hours watching all the videoclips available on Channel NewsAsia before penning this. What I saw was a minister trying to be humble in giving Parliament a report on Mas Selamat's escape from the Whitley Road Detention Centre. Where he was armed with the findings from the Commission of Inquiry, he was forthright, but where he was not, he fumbled.

First however, for the benefit of any reader who may chance on this essay a year or two from now, I will provide a brief summary of what the Minister for Home Affairs told Parliament on 21 April 2008. If you're familiar with his statement, please skip this section.

At about 3:30 pm on 27 February a female Special Duty Operative activated 2 Gurkha guards to collect Mas Selamat Kastari from his cell in preparation for a 4 pm visit by his family. He was taken to a locker room where he changed into civilian clothes, according to standard practice. He went behind a set of lockers for privacy and the Gurkha guards lost their line of sight to him, contrary to standard operating procedure. The civvies consisted of a pale yellow baju kurong (a Malay shirt) and greenish grey trousers.

After changing into civvies, Mas Selamat should have handed his detention uniform over to the guards, but this apparently was not done. It is possible that he wore his civvies over the uniform, but one cannot be absolutely sure now.



Then he was taken, apparently blindfolded as per normal practice, to the visitor's block. There he was allowed to use a toilet to shave and freshen up. This toilet was really meant for staff and visitors, but over time, it had become unremarkable for detainees to be allowed to use it when they were in the visitor's block too.

One guard followed him into the toilet, the other stayed outside, as did the ISD's Special Duty Operative.

From an illustration I saw on TV, the toilet had 2 cubicles with folding doors. Rather unusually, the urinals were not in the open part of the toilet, but were in one of the cubicles. After shaving, Mas Selamat asked to use a urinal and was allowed to. He closed the urinal cubicle door (again, very unusual that it had a door), resulting, for the second time, in a loss of the line of sight. The guard later reported that the greenish grey trousers were flipped over the door. As Member of Parliament Baey Yam Keng later pointed out in his question, a man does not need to take off his trousers to use a urinal. Why didn't it "lead to some suspicion on the guard's side?" Apparently not, for the guard did not react.

The guard heard the sound of running water, but did not react to that either.

After about 5 minutes, the guard finally felt that Mas Selamat was taking unusually long. Apparently at this point, the guard still didn't imagine that the prisoner had escaped (he might have thought he had fainted). He then went out of the toilet to inform the other Gurkha guard who informed the Special Duty Operative. She then felt that as a female, she should not enter the men's toilet and went to look for an Assistant Case Officer to help. It was this officer who kicked down the cubicle door, only to discover the detainee missing.

Eleven minutes elapsed between the moment Mas Selamat entered the toilet to freshen up and the kicking down of the door.

The cubicle had a high window for ventilation. The glass pane of this window was open, and there was no grille over the window. When plans were made in 2004 to renovate the Whitley Road Detention Centre's visitor's block, putting grilles on all windows was among the objectives. However when the work was done in 2007 there was a "miscommunication" between the Internal Security Department (in charge of the Detention Centre) and the contractor and at least for that window, no grilles were installed.

The outside wall of the toilet


The lapse was pointed out to the superintendent of the Detention Centre in April or May 2007, but the superintendent merely instructed that the handle to the window pane be sawed off, hoping to render the window inoperable.

The escapee climbed down a rainwater pipe from the window, as indicated by hand smudges and a large bag of 7 toilet tissue rolls thrown onto the ground below the pipe, probably to cushion his jump.

Which direction Mas Selamat took after climbing out of the window could not be ascertained by the Commission of Inquiry. There was double fencing around the complex but the investigators could not pinpoint how he got over it. 

One possibility was that he somehow managed to climb onto the roof of a covered walkway. This walkway converged with the perimeter fence (which was no higher than the roof) a little further on, and it might be possible for someone to use the inside of the fence to climb onto the roof, then to walk on it to outside the perimeter. The investigators found on reenactment that someone could do that in 49 seconds.

Photo from 'Today' newspaper, red man added by Yawning Bread

On discovery of Mas Selamat's escape, the Detention Centre was immediately locked down and within 10 minutes (if I heard correctly) a squad was already combing the bush outside the fence.

Tracker dogs were either never used or were ineffective. Wong said he was advised that with so many people trampling through the bush, the dogs would have been confused.

The area through which he climbed out would normally be within the field of vision of 2 closed-circuit TV cameras. However, during the period in question, these were not operational. They had been disabled for an upgrading involving the addition of motion detectors.

At some point, Wong mentioned that Mas Selamat's baju jurong shirt was found amid the foliage, but it wasn't clear to me whether it was the same day or some days later.

The Commission of Inquiry found that Mas Selamat had used the same toilet on previous family visit days. However, he was guarded by different sets of guards, it being policy to rotate the guards so that they would not become too familiar with the detainee. It emerged that the other guards had also observed him using the urinal, closing the cubicle door behind him and turning on the tap. This suggested that Mas Selamat had been planning his escape and had been testing the guards for their responses. However, as the guards were rotated, one set did not inform the other set of their observations.

The Commission of Inquiry and a separate investigation by the Criminal Investigation Department found no evidence that anyone inside or outside the Detention Centre assisted Mas Selamat in his escape.

* * * * *

Wong laid equal blame on complacency by the guards and the weaknesses of the physical security. He repeatedly referred to the Gurkha guards' and the Special Duty Operative's failure to adhere to standard operating procedures (SOP).

One interesting point the Commission noted was how security for the facility had been shared between the Gurkha Contingent and the Internal Security Department (ISD), with the former in charge of providing human security and the latter in charge of the physical arrangements. Wong said that the incident showed how the guards assumed that the toilet was physically secure, such they might have thought losing the line of sight was a small matter, while the ISD assumed that human security would never fail, so having an unsecured window was a small matter.

I thought Wong's equal apportionment of blame was incorrect. It's always easy to point to how people on the spot didn't do their jobs properly at the time in question. Instead, I was left with the strong impression that the supervisory, management and policy-making levels had been both sloppy and tunnel-visioned, and Wong failed to put sufficient emphasis on this.

In designing any system, it is foolish to assume that humans will do their jobs perfectly all the time. Not being machines, they cannot be expected to be 100% consistent. In an unexpected situation, e.g. someone taking longer than expected in a toilet, all the more, human behaviour can be unpredictable. Any system must therefore be designed to tolerate human failures to a fair extent and in the case of a detention facility, this means the physical security must be robust, for it is the physical security that can be planned well in advance and tested in good time. The failure to do so suggests a basic weakness in management and policy-making.

It is incredible that sawing off the handle of a window pane was considered good enough. It is incredible that no one in all these years thought it a risk to have the covered walkway converge with the perimeter fence. It is incredible that installation of a motion-detector system meant the CCTV should be shut off. Did no one think about parallel implementation which is done all the time in commercial enterprises?

Nominated Member of Parliament Gautam Bannerjee asked a good question: Was the system ever stress-tested? Wong admitted, no. "There were plans, but there weren't exercises like this."

Security plans and reviews are largely paper exercises, where somebody looks at the drawings and written procedures, at most doing a walk-around. A stress-test is a completely different thing. It is one in which an independent antagonist team is put together to try to defeat the system.

However, Wong assured the House, "From now on, they will make sure that they will conduct such tests and exercises."

Even the security planning had been focussed on stopping people from trying to get into the detention centre than people trying to get out. I almost burst out laughing when I heard this. Our top honchos evidently believed that al Qaeda and the like were more likely to storm the detention camp than anyone inside try to get out.

This comes from a systemic belief among policy-makers in Singapore that people are obedient: Once inside, no one would think about escaping. It's like how we pass laws against smoking, against pornography, against littering.... and never expect to need to enforce them. Why? Because they've been made illegal already, haven't they?

Never mind stress tests, even something as basic as a security audit seemed new to the Home Ministry. Workers' Party leader Low Thia Khiang asked this question, and Wong gave a neither-here-nor-there answer. He said the detention centre "should have done regular audits [but] this was not done in the regular way. What they did was a security audit when they did the renovation, but despite that, for example, the fencing and the covered walkway was not detected."

Then he went on: "But it doesn't mean that there are no procedures. There are a number of procedures," he said, moving quickly to dwell on human procedures again and pointing out how junior level guards didn't do their jobs.

To Baey Yam Keng's question about the police putting out misleading information, Wong's answer was even worse. Why, the MP asked, some "four or five days" after the escape, did the police put out information about him wearing the baju kurong shirt and greenish grey trousers? "It appears to be a bit inaccurate," Baey pointed out, "because the pants were all along hanging in the toilet."

Wong replied: "The police needed to determine that indeed that baju kurong belonged to Mas Selamat. There was no clear indication at the time." It wasn't until "after some time that, through DNA analysis, it was determined" that it they had indeed been worn by him.

Listening to that, I am not sure whether Wong was referring to the shirt found in the forest or the pants found over the door.

As for misleading the public days later, "I think that is something that is beyond me," said the minister. "The officers concerned must have had a lot of confusing information at the time. And in this whole process they did not have the accurate information."

Why didn't they? What sort of answer is that?

* * * * *

You can understand how the Gurkha guards failed to follow standard operating procedures; people take short cuts when something becomes very routine. They shouldn't have, but the system should have anticipated some degree of failure since humans were involved.

What you cannot understand is how the more senior levels, in planning the physical security of the place, could have been so sloppy about windows, fencing design and CCTV shut-downs. Unlike the guards' failures, these decisions were taken away from the heat of the moment with plenty of time for reflection.

Nor can you excuse how lackadaisical they had been about security audits and ignorant about stress-testing. Not to mention the way they misdirected themselves, more concerned about people breaking into a place of detention than people breaking out.

Finally, you definitely cannot understand how the police can continue to give out misleading information about Mas Selamat's clothes days after his escape. Surely, by that point -- an emergency having been declared -- public communication would have been channelled through the highest levels of control. If it wasn't, then you have a failure in crisis management. If it had been channelled through the senior levels and yet been as wrong as this, then ... duh... you still have a failure in crisis management.

Yawning Bread 









Photo from the Straits Times