Parliamentary Statements
Ministerial Statement by Minister for Defence Dr Ng Eng Hen, on Findings and Follow-up Actions on National Service Training Death for Parliamentary Sitting
6 May 2019
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Thank you, Mr Speaker. In February this year, I made a Ministerial Statement on the death of CFC (NS) Aloysius Pang which had occurred on 23 January 2019. Therein, I gave as much detail as was known then about the incident without prejudicing the due process as prescribed by the SAF Act for an independent Committee of Inquiry (COI) to investigate thoroughly the factors leading to the death. The COI has completed its investigations and in this statement, I will present the findings of the COI as submitted to the Armed Forces Council.
The COI comprised five persons, none of whom are employed by the Ministry of Defence (MINDEF) or the Singapore Armed Forces (SAF) – they were a judge nominated by the State Courts as Chairman; a consultant medical specialist; a member nominated by the External Review Panel on SAF Safety (ERPSS); a member drawn from the Workplace Safety and Health Council; and a senior-ranked national serviceman.
I remind MPs that COIs are convened under the SAF Act, empowering it to fact-find. The COI has no mandate to determine the culpability of individuals. Indeed, Section 8C of the SAF Act specifies that no statements made to the COI shall be admissible as evidence in the court martial or for any subsequent disciplinary proceedings that may take place. To keep within this remit, I will not provide specific names of other individuals involved in the incident in my statement, apart from CFC(NS) Pang. Prosecution of any persons will be conducted separately, which I will elaborate later.
COI’s Findings
Let me first take MPs through the COI’s findings. I intend to quote from their report predominantly and the dates and times stated in their report are in New Zealand local time.
“On 5 January 2019, CFC(NS) Pang left Singapore for Exercise Thunder Warrior at Waiouru Military Training Area, New Zealand as part of his seventh In-Camp Training (ICT) and the unit’s eighth ICT. Exercise Thunder Warrior is a live-firing exercise. On 19 January 2019 at about 1900hrs, CFC(NS) Pang sustained an injury while carrying out maintenance work on a Singapore Self-Propelled Howitzer (SSPH) involved in Exercise Thunder Warrior.
CFC(NS) Pang was assisting in maintenance work in the SSPH when the gun barrel was lowered and he was caught between the flick rammer and the slew ring of the SSPH turret. I draw Members’ attention to the slide which I made in the Ministerial Statement in February and if we look at the picture on the top left hand corner, the flick rammer is in the middle of the picture, the slew ring is above it. When the gun is lowered and the flick rammer goes up, he was caught between the flick rammer and the slew ring. CFC(NS) Pang was attended by the Battery Medic on site and evacuated to the Battalion Casualty Station (BCS) at 1910hrs. He was assessed and stabilised at the BCS before being evacuated to the Waiouru Base Medical Centre at 1950hrs. At 2150hrs, CFC(NS) Pang was heli-evacuated to Waikato Hospital where he was operated on at around 0100hrs. CFC(NS) Pang underwent two more surgeries on 21 and 22 January before his condition deteriorated.
On 24 January 2019, CFC(NS) Pang succumbed to his injuries. CFC(NS) Pang died from severe sepsis arising from his severe chest and abdominal injuries as a result of being trapped between the flick rammer and the slew ring in the SSPH.”
The COI next established a detailed chronology of events leading to the injury and subsequent death of CFC(NS) Pang. To recap from my statement in February – the configuration, the safe positions and location of key features within the SSPH gun accompany the summary of events which we will distribute now, with your permission Mr Speaker. Let me take Members through the events.
On 19 January 2019, CFC(NS) Pang had responded to the call from the gun detachment commander, a 3SG NSman, for assistance to conduct corrective maintenance on his SSPH gun. The bearing of the gun was beyond the allowable error and needed to be rectified to resume live-firing. CFC(NS) Pang was an Armament Technician from the Forward Maintenance Platoon designated to perform such work. But as CFC(NS) Pang could not resolve the issue, a Regular Military Expert 2 Technician was despatched to join him to perform the maintenance work on the gun. I draw Members’ attention that there were only three persons in the gun when the injury occurred – CFC(NS) Pang, the 3SG(NS) Gun Commander (GC), which I will now subsequently refer to as GC, and the Regular ME2 technician, whom I will refer to as ME-Tech.
The GC explained the fault to the ME-Tech. To rectify the fault, the plan was to change the Central Processing Unit (CPU) card on the Motor Drive Control Unit – Ammo Handling System (AHS) box. The box was located near Safe Position 3. If you remember the previous slide that was shown, the flick rammer is on the bottom left hand corner and the box is as indicated near Safe Position 3.
The ME-Tech briefed the GC to turn off the AHS, to lock the gun barrel, turn off the engine, and turn off the master switch. To lock the gun barrel required it to be first lowered to the near horizontal “standby” position.
The ME-Tech then proceeded to stand at the designated Safe Position 3 and started to loosen the screws in the AHS box to carry out maintenance work. The ME-Tech also saw CFC(NS) Pang removing the screws on the right-hand side of the box. CFC(NS) Pang was not in a designated safe position and his back was to the barrel of the gun.
Based on the COI’s findings, the ME-Tech informed CFC(NS) Pang in a mix of Mandarin and English that the gun barrel was going to be moved to the standby position and told CFC(NS) Pang to move either closer to him or to a safe position. CFC(NS) Pang replied in Mandarin that it was fine and that the gun barrel would not hit him.
Before he moved the gun barrel to a standby position, the GC said he checked if the path was clear and did see CFC(NS) Pang standing near the gun barrel. As the gun barrel was in the highest elevated position, the GC wrongly assumed that CFC(NS) Pang would have time to move away given that it would take some time for the barrel to move into the standby position. The GC proceeded to shout “standby, clear away” before activating the control to move the gun. This was heard by the ME-Tech, as well as personnel who were standing outside the gun.
As the flick rammer was moving up, CFC(NS) Pang was still removing the screws on the box and looking back at the barrel at the same time. He initially made no attempt to move away.
The GC noticed that CFC(NS) Pang was making some evasive movements as the barrel was moving closer to him. The ME-Tech was shocked to see CFC(NS) Pang still in the path of the gun and tried to use his hands to push against the barrel to stop the movement.
As the gun barrel made contact with CFC(NS) Pang, the COI opined that instead of activating the Emergency Stop (E-stop) buttons, both the ME-Tech and the GC panicked and acted irrationally. The ME-Tech tried to push the gun barrel with his hands while the GC went to the main control screen to try to stop the barrel movement. As a result, CFC(NS) Pang was wedged between the flick rammer and the slew ring.
These were the detailed events as determined by the COI that led to the serious injuries and untimely death of CFC Pang. The COI opined that “the precipitating cause of the incident was due to the lowering of the gun barrel without ensuring that everyone was in their safe positions:
CFC(NS) Pang was standing in the path of the moving barrel and not in a safe position prior to the gun barrel being moved.
CFC(NS) Pang did not move to a safe position, despite receiving warning that the gun barrel was going to be moved to a standby position.
The ME-Tech did not ensure that CFC(NS) Pang moved to a safe position despite knowing that the gun barrel would be moved.
The GC proceeded to move the gun barrel, despite noticing that CFC(NS) Pang was not in a safe position.
Both the GC and the ME-Tech failed to press the E-stop buttons to halt the movement of the gun barrel.”
The COI determined there was non-compliance with the Standard Operating Procedures (SOP) and safety breaches. “These breaches have contributed to the cause of the incident and are preventable.
Non-enforcement of the Safe Positions in the SSPH. The Gun Detachment Commander, ME-Tech and CFC(NS) Pang did not follow the strict requirement that everyone must be in the safe positions during the movement of the gun barrel. (Safe Positions 1, 2 and 3 in your handout.) The ME-Tech was standing slightly away from the Ammo Loader’s position, which is Safe Position 3, and CFC(NS) Pang was standing in the path of the gun barrel. Although the GC had shouted “standby, clear away” and the ME-Tech had told CFC(NS) Pang to move closer to him or to move away from the path of the gun barrel, both the GC and the ME-Tech did not ensure that CFC(NS) Pang was at a safe position before the gun barrel was lowered. The GC also did not adhere strictly to the SOP for lowering the gun barrel. Although the GC had shouted “standby, clear away” before lowering the gun barrel, he should have waited for CFC(NS) Pang to be in a safe position before moving the gun barrel to the standby position but this was not adhered to. This requirement is provided in the SSPH Operator’s Manual, “that no personnel should be in the travel path of the barrel or rammer tray”. The GC and the ME-Tech also did not activate the E-stop buttons when the barrel was being lowered.
Non-compliance with the Maintenance Manual for SSPH Technicians. It is clearly stated in the Maintenance Manual for SSPH Technicians to ensure that before they embark on the maintenance work to replace the interface card in the MDCU-AHS, the gun must be in a parked position with the gun barrel locked. On the day of the incident, the ME-Tech did not ensure that the gun barrel was in a locked position before replacing the interface card. Instead, the ME-Tech had started to dismantle the mountings on the gun even though the gun barrel was not in a standby or locked position.”
The COI opined that a combination of the following factors contributed to the cause of the incident:
Lack of co-ordinated safety control procedure between the gun crew and the maintenance crew during maintenance work on the SSPH. There was a lack of clarity on who should be in the gun, the command and control, and whether there was a need for acknowledgement before the gun barrel is moved. It is the COI’s opinion that the gun commander should take command and control to supervise and execute all preventive maintenance and corrective maintenance tasks, as well as ensure safety in the gun, as stated in the SSPH Operator’s Manual. However, this does not absolve the person activating the gun barrel movement of his responsibility to ensure that everyone is in a safe position before moving the gun barrel.
Commencing maintenance work before the gun barrel was in a locked position. The ME-Tech had commenced removing the mountings on the MDCU-AHS box even before the gun barrel was in a locked position to get on with the job quickly.
Misjudgement of time and space by personnel in the SSPH. Both the ME-Tech and the GC had miscalculated the time it took for the flick rammer to hit CFC(NS) Pang.
Emergency Stop buttons were not activated to stop the movement of the gun barrel. In their state of panic when the flick rammer hit CFC(NS) Pang, both the ME-Tech and the GC acted irrationally instead of activating the E-stop buttons.”
The COI found “no evidence indicating that CFC(NS) Pang’s death involved foul play or was caused by any deliberate acts. However, the COI found that the incident was due to the lapses of all the servicemen who were in the gun at the time of the incident, i.e., GC, ME-Tech and CFC(NS) Pang.” Let me repeat this because this is the final conclusion of the COI. The COI found that the incident was due to the lapses of all the servicemen who were in the gun at the time of the incident, the GC, the ME-Tech and CFC(NS) Pang.
The COI also commented on factors related to but non-contributory to the incident or outcome. Before Exercise Thunder Warrior, the SSPH guns were certified Fit For Firing (FFF) in Singapore by the technicians. The guns were certified FFF again in New Zealand before the live-firing exercise. It has been established that there was no mechanical fault with the gun that had directly caused the accident. The incident in this case was not due to the serviceability of the SSPH.
On the post-incident medical care, the COI is of the opinion that in view of the extenuating circumstances caused by the distance and the availability of the helicopter, the medical care provided was adequate but can be improved. However, the COI is also of the opinion that this did not cause or contribute to the demise of CFC(NS) Pang.
Members of this House, I have presented the COI’s findings. It is sad but undeniable that the direct causes determined by the COI that resulted in the death of CFC(NS) Pang were preventable had there been compliance to safety rules. It was not for lack of knowledge of these rules or inexperience of personnel working on the SSPH gun. The COI determined that prior to the incident, all the three personnel in the gun – CFC(NS) Pang, the GC and the ME-Tech – had received adequate training to be aware that whenever the gun barrel is moved, they must be in a safe position. It was clear to the ME-Tech that CFC(NS) Pang was not in a safe position. Notwithstanding this, the ME-Tech merely told CFC(NS) Pang to move closer to him or move away, instead of stopping the gun movement. When CFC(NS) Pang replied that the gun barrel would not hit him and did not move away from where he was, the ME-Tech could have ensured that CFC(NS) Pang moved away to a safe position or pressed the E-stop button.
The GC shouted “standby, clear away” before he commenced lowering the gun barrel. At the same time, he saw that CFC(NS) Pang was not standing in a designated safe position. Instead of ensuring that CFC(NS) Pang was in a safe position before lowering the gun barrel, he thought that there was sufficient time for CFC(NS) Pang to move away as the gun barrel was lowered. If the GC had ensured that CFC(NS) Pang was in a safe position before activating the gun barrel to standby position, the incident would not have happened.
From the accounts of CFC(NS) Pang’s peers to the COI, CFC(NS) Pang had a positive work attitude and was very helpful to others when it came to work. He was also very professional when executing his tasks. CFC(NS) Pang started his Full-Time National Service in October 2008. He had attended several courses and training during his Full-Time National Service, graduating with an overall “A” grade from the Armament Basic Technician Training (Turret). He had also attended the Maintenance Vocational Training on his sixth ICT in February 2018 in preparation for Exercise Thunder Warrior. He was also professional when executing his tasks and was seen by his superiors as someone who would not cut safety corners when working.”
Nevertheless, the COI found that the incident was due to lapses of all the servicemen who were in the gun at the time of the incident.
Recommendations
The COI proposed the following recommendations aimed at preventing similar incidents in the future and enhancing the safety system, which I report in full.
Enhance Army Safety Culture by Ensuring that All Servicemen of the SAF and Especially NSmen take Personal Ownership of Safety. The Army safety culture should be enhanced and special emphasis should also be placed on the safety culture of the NSmen who must be equally cognisant of all safety regulations and procedures. The SAF could involve NS commanders in the review of Training Safety Regulations (TSRs) as this will instil greater ownership by NSmen in terms of safety. A more comprehensive risk assessment for high risk activities should be conducted, and all near misses must be reported and archived.
Review Standard Operating Procedures / Emergency Drills. The SAF should review all SOPs and drills to ensure that there are proper procedures in mixed-crew operations. SOP for maintenance work involving gun crew and maintenance crew should be established, including hand-over procedures. Emergency drills or SOPs should be developed to educate operators on the application of E-stop buttons during gun barrel movements.
Ensure Compliance to TSRs, SOPs and Operator Manuals. All systems should be operated in the manner required by their design and a new risk assessment should be conducted if any part of the system is to be used differently. There is also a need to ensure that the SOPs relating to the operations of the gun are complied with and operations should be halted whenever the SOPs are not complied with. Similarly, there must be strict enforcement that the equipment conditions as mandated in the maintenance manual is adhered to before the commencement of maintenance work.
Enhance Existing Training/ Safety Support Especially for Maintenance Related Work. A safety checklist briefing before the start of any maintenance works could be introduced, with emphasis on the number of maintenance crew needed to work inside the gun. There should be continued education on compliance with the TSR, and this should be incorporated into the quarterly Army Safety Seminars. There could also be a safety officer appointed during peacetime live-firing exercises to oversee safety and further develop the Safety Management Plan with regard to maintenance work and the maintenance crew’s interaction with the gun crew.
Enhance Training of Medical Officers for Aero-medical Evacuation and Pre-Hospital Care. Given the extended distances to definitive care (one of the principal considerations in the Medical Support Plan), the use of helicopters for casualty evacuation to a higher echelon care is a given. A familiarisation of the RSAF heli-evacuation protocols should be considered for both NSF and NSmen Medical Officers posted to this specific area of training. NSmen Medical Officers could also re-familiarise themselves with acute trauma care by being given temporary registration as observers either in the emergency and surgery departments during call-ups.
Improve Protocols for Communications Within Hospitals Caring for Injured Servicemen Overseas. It may be useful to formalise arrangements between the SAF and receiving hospitals at the appropriate level in the hospital administration so that our Singaporean doctors attached to care for the injured servicemen overseas can be kept abreast of clinical developments and can contribute more effectively.
Formalise Protocols for Overseas Hospitals Following Death of SAF Personnel. A reference guideline should be drawn up with details on the protocol for the management of the remains of the demised serviceman on overseas exercises.”
External Review Panel on SAF Safety (ERPSS) Comments
I have concluded presenting the COI’s findings and now turn to the ERPSS’ comments in their written report, on the COI’s findings for CFC(NS) Pang. Mr Speaker, I ask your permission to distribute that.
The ERPSS agrees with the COI’s findings on the incident, and supports the proposed recommendations raised by the COI to prevent a similar incident from occurring.
The ERPSS also expressed concern about the safety lapses and weaknesses in safety culture that have been surfaced, and made several recommendations that would help the SAF to build a stronger safety culture.
First, it is important for commanders to exercise leadership in safety and impress upon their subordinates the need to properly implement safety policies and procedures, build a strong safety culture, and inculcate stronger safety ownership at both team and individual levels, especially amongst NSmen.
Second, the SAF should do more to improve knowledge retention and safety awareness in its soldiers.
Third, it is vital to accord the same high level of emphasis on maintenance safety, as is accorded to training safety today.
Last, it is crucial to strengthen safety procedures for mixed-crew operations, which can be potentially risky if differences in practices across vocations are not properly addressed.
Ingrain Safety Culture in the SAF
Mr Speaker, the SAF accepts both the COI and ERPSS’ recommendations to improve the safety culture. The SAF Inspector-General’s Office (IGO), set up in end February this year after this incident, will ensure that all recommendations are followed through.
Specifically, the IGO has identified the need for the SAF to improve in three key areas: Command emphasis on safety, Safety as a mission outcome, and Team safety culture. The SAF has to ensure that there is an internalisation of safety as a mission outcome across all levels of command. All commanders must adopt a zero accident mindset and set it in the heart of their unit safety culture. When coupled with a healthy open reporting culture, we can prevent the next accident from happening as our units share with others lessons learnt from safety incidents and near misses.
Another key element of a strong safety culture is team safety. Our commanders need to build a strong culture of team safety, where soldiers take responsibility for their own safety, look out for their buddies and keep each other safe during all training and mixed crew activities. These behaviours must be ingrained into every soldier, sailor and airman so that safety rules are observed at all times.
Measures to Enhance Training Safety Systems and Processes
Following this incident, the SAF has also taken specific steps to strengthen personal ownership of safety and enhance safety for maintenance-related training or tasks:
Specifically a Think-Check-Do drill will be implemented as a routine part of pre-maintenance task checks. As part of the drill, technicians will plan and brief all personnel of their expected roles and tasks. A dry run of team-based maintenance tasks will be conducted to ensure tight integration. The positions of E-stop buttons will be re-emphasised together with E-stop procedures and rehearsed as part of pre-ops drills.
Safe areas and hazardous areas will be further emphasised through bold markings on platforms as part of safety enhancements.
The SAF will entrench safety ownership at the team level so that it will become ingrained for soldiers to take care of themselves, their servicemen, and their buddies. Safety advocates will be appointed in the units to emphasise safety and conduct checks.
All soldiers will be required to take a safety awareness test annually, which commanders and trainers now take.
NSmen will be actively involved in safety reviews where they can give feedback on safety matters before, during and after each training activity, and this feedback will be incorporated in our TSR reviews.
Medical Officers will be required to undergo refresher training on heli-evacuation processes prior to their deployment for overseas medical support. New initiatives will also be explored to enhance their exposure to acute trauma care.
We need a strong SAF that can defend Singapore but it must and can be built up without compromising the safety and well-being of our national servicemen. The SAF is committed to continue strengthening its safety systems at all levels, down to our soldiers, aircrew and sailors.
Judicial Process
I want to put on record our appreciation to the COI members that put in much effort and time to thoroughly investigate this tragic incident. In that process, they interviewed more than 20 persons involved with the incident, reviewed voluminous documents related to the event and manuals related to instructions and safety procedures.
Mr Speaker, let me conclude by outlining the subsequent judicial processes to be taken. CFC(NS) Pang’s death occurred in New Zealand, which therefore has state jurisdiction and not our Police or State Coroner. However, the New Zealand Attorney-General exercised his discretion not to undertake any inquiry for CFC(NS) Pang’s case. Under our military law, it therefore falls on the SAF’s Special Investigation Branch (SIB), with the jurisdiction to investigate CFC(NS) Pang’s death.
The SIB has nearly completed its investigations and will report directly to the Chief Military Prosecutor, who is a senior legal officer deployed to MINDEF by the Legal Service Commission headed by the Chief Justice. It will decide if any servicemen are to be prosecuted in a military court for offences related to CFC(NS) Pang’s death. The military court is presided over by former or serving State Court judges as Presidents of the General Court Martial. The General Court Martial (GCM) will have full access to the witnesses to independently make their own findings and conclusions on the culpability of the individuals who may be charged. The GCM need not take into account anything in my Statement in Parliament today.
In the mean-time, servicemen under investigation are reassigned to administrative duties, and if found to have been culpable, will be charged and punished accordingly.
Conclusion
Mr Speaker, let me conclude now by expressing this House’s deep condolences to the late CFC(NS) Aloysius Pang and his family, we know that it is a difficult time for them. CFC(NS) Pang was by all accounts a motivated and competent soldier. He was well-liked, he was trusted by his peers. He cared deeply for his fellow soldiers. The loss of a good soldier like CFC(NS) Pang is deeply grievous to us. There was an outpouring of grief from many Singaporeans as a result of his untimely and tragic demise. The SAF has updated CFC(NS) Pang’s family on the COI’s findings and the actions taken to deal with the lapses and to prevent recurrences. MINDEF and the SAF will continue to do all we can to help his family through this difficult period.
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