Ministerial Statement by Minister for Defence Dr Ng Eng Hen, on National Service Training Deaths for Parliament Sitting

Speaker sir, first let me thank the Leader and the members of this House for allowing me to make this statement on National Service (NS) training deaths in the midst of the debate on President's Address. I have requested to do so to address the concerns of members here and the public over this matter and I think we are right to be concerned as every NS death should be treated with utmost seriousness, whether it is in Parliament, the Singapore Armed Forces (SAF) or the Home Team.

Any death among SAF soldiers or Home Team personnel is grievous. These are our security forces who serve this nation with loyalty, commitment and pride. They keep us safe, they defend our island home, often in challenging and dangerous circumstances knowing the risks to themselves. Especially painful is when young National Servicemen who are serving their full-time (NS) die – all of us feel it acutely. This House offers our deepest condolences to the families of 3SG Gavin Chan, CFC Dave Lee and from the SCDF, CPL Kok Yuen Chin. We know that no words can replace their loss. We grieve together with them even as we honour the memory of their precious sons who served and sacrificed for our country. The SAF and the Home Team will continue to assist their families as best we can.

Commanders on the ground fully recognise this heavy responsibility, of keeping every son of Singapore safe during their NS training, whether it is in the two years that they come full time for intensive training or each time they are called up after that. We must strive hard for zero training deaths because any death is one too many. And I believe it can be done, even as National Servicemen train realistically and effectively to protect us and defend Singapore. But achieving zero fatalities can only be achieved with constant vigilance, no lesser.

Because on any given day, thousands of National Servicemen run around in challenging conditions. They move vehicles on air, land and sea, in Singapore and overseas. In the SAF, modern military platforms travel at high speeds and our exercise tempos are very quick. Our Terrexes can move at 100km/hr. Our armoured vehicles can move at 70km/hr. All of us recognise the higher risks in military training because even for mass civilian activities, whether it is marathons, swims (or) cycling events, fatalities occur. We read about them and (they occur) for a variety of innocent reasons. But we must design our safety systems and enforce them so that training deaths within the SAF can be eliminated. It is a difficult goal to achieve – to get it right every time, whether it is a platoon or company that go out in exercise, whether it is day or night. But we must constantly improve the rigour of our safety systems to reach that goal because if we do not, it may mean another precious son lost to a family.

Investigative findings

Members of this House Mr Dennis Tan, Mr Henry Kwek, Mr Vikram Nair, and Mr Ganesh Rajaram, have filed questions on two recent NS deaths within the SAF and on general matters related to training safety. I propose to address their queries in this statement. Here I want to beg the House's indulgence and patience. I will give details as much as we know. In September last year, 3SG Gavin Chan died when the Bionix vehicle he commanded rolled over and in April this year, CFC Dave Lee died from complications of a heat stroke. Both were serving their full-time NS – 3SG Chan had served for one year and eight months and CFC Lee for four months.

We treat each training-related death with utmost seriousness. We deal with it at the highest level within the SAF and the Ministry of Defence (MINDEF). This is the Armed Forces Council (AFC) that convenes an independent Committee of Inquiry (COI) to examine thoroughly the circumstances leading to the incident. It is a four-member team chaired by a senior civil servant from outside MINDEF and includes a senior doctor from the public sector. The COI has full powers. It can access all relevant information and call up any personnel to investigate the circumstances leading to death, and they will determine events that contributed or persons that contributed to the death, and make recommendations to rectify any lapses found.

Separately from the SAF and MINDEF, the police conduct parallel investigations and the Coroner may decide to hold a public inquiry.

Death of 3SG Gavin Chan

Let me first share the detailed findings for the late 3SG Chan for which all investigative processes have been completed, including those by the Queensland authorities because the incident occurred in Shoalwater Bay, and therefore governed under the law of Australia. Speaker, with your permission, I would now like to ask the clerk to distribute the report from the Queensland Coroner. This report from the Coroner was provided to 3SG Chan's parents. 3SG Chan's parents have given us permission for it to be distributed to members of this House, except for the post-mortem findings which are redacted out of respect for the privacy of 3SG Chan and his family.

The Queensland Coroner's report provides the circumstances leading to the death of 3SG Chan as a result of multiple injuries sustained from motor vehicle trauma. I will read excerpts, which you can follow in the distributed report.

[From the Queensland Coroner's findings (Form 20A):

"On 15 September 2017, Sergeant Chan, who was participating in "Exercise Wallaby", which is an annual unilateral training exercise conducted by Singapore Armed Forces at Shoalwater Bay Training Area, near Rockhampton in Queensland, died after the infantry vehicle (known as a BX) he was commanding rolled and he suffered significant injuries.

The police conducted an investigation into the circumstances of the incident. The police found no defect with the infantry fighting vehicle. The police found from scene evidence and witness information, that its path forward was halted due to an obstruction. Sergeant Chan, who was commander of the vehicle, gave orders for the driver to reverse slowly down the hill. The commander who was stationed in the turret, with his upper body clear of the vehicle structure, was giving instructions to the driver directing him to reverse and where to reverse. All confirmed that the driver was continuing to reverse slowly, and in accordance with the commander's instructions, when the vehicle traversed over a flat granite rock for about 4 metres before the vehicle became stuck on a large boulder, holding up the vehicle undercarriage. The commander instructed the driver to turn the steering wheel in an attempt to gain traction when suddenly the vehicle dropped down over the rock rolling sideways before coming to rest further down the slope. Sergeant Chan was ejected from the vehicle and suffered significant injuries. Life support was commenced at the scene before he was airlifted to hospital where he was later pronounced deceased.

The police investigation established that there was no defect with the vehicle, and there was no suggestion that the driver was doing anything other than reversing very slowly, and at the specific direction of Sergeant Chan. The police considered that it was likely that the incident occurred because of the commander's decision to reverse on a slightly different path down the hill and that his choice to be positioned with part of his body outside the vehicle exposed him to greater risk of injury. The Singapore Armed Forces recommendation is only the head and shoulders be outside the turret of the vehicle during operations. The police considered it was a very unfortunate incident whilst deployed in difficult terrain in 'Black Out' conditions. It was noted by the police that the driver was driving in compliance with Singapore Armed Forces policy at the time of the incident, and under the specific instruction from Sergeant Chan."]

These are the findings of the Queensland authorities. The COI here appointed by the AFC corroborated from their own investigations the findings by the Queensland authorities. The COI further determined that 3SG Chan and his platoon mates were sufficiently trained and qualified to participate in the exercise. They had no mental and physical conditions that could have affected their fitness to participate. The medical and safety coverage provided was found to be timely, adequate and proper.

In addition, the COI conducted interviews with SAF soldiers at the exercise to piece together the chronology of events that led to the Bionix overturning. The mishap occurred during night training for Bionix units. For members' information, Armour units do this regularly, because they have to become proficient to fight at night or under conditions of poor visibility. That is something that they must learn to do.

Safety lapses were identified by the COI. First, the Night Vision Device (NVD) of 3SG Chan's vehicle was not working. They are issued a NVD which allows them to see in darkness but it was not working. It is needed if armoured vehicles are to move at night.  Without NVD, armoured vehicles can move, but only with the driver's hatch open and headlights switched on for better visibility. That is in the training safety regulations. However, according to the driver, 3SG Chan felt that the headlights "would give away their position to the enemy" and decided to continue training without headlights.

Accounts from his platoon mates to the COI attest to 3SG Chan's strong motivation and high standards of performance during training. 3SG Chan was zealous in his training and probably wanted to complete the night mission assigned to their armour unit. Unfortunately, in the darkness, the vehicle entered an area with a steep incline and boulders. At that point, 3SG Chan stopped the vehicle, dismounted to assess the surroundings and found that a boulder was blocking the vehicle. He re-mounted the Bionix, sitting on the top edge of the vehicle commander hatch, and told the driver to open his hatch and switch on the vehicle's headlights so that they could reverse away from this area. Unfortunately, as they were doing so, the vehicle overturned on the steep embankment. The three other soldiers in the Bionix did not suffer any injuries. The COI concluded that 3SG Chan's injuries resulted from him being thrown out of the vehicle as it overturned, causing his demise.

The Queensland Coroner's report agreed that this was the cause of the event –

[From the Queensland Coroner's findings (Form 20A):

"…in the circumstances I find that Sergeant Chan died when he was ejected from the vehicle which he was directing. It is unfortunate that he took the decision to position himself with a significant portion of his body exposed outside the vehicle. …..the incident is none other than a very unfortunate accident due to the nature of the difficult terrain and the operation then being performed."]

Arising from their investigations, the Queensland Police found no basis to charge any person. The COI also found no negligence, foul play or misconduct, but recommended that the SAF review its training safety regulations on the position of the armoured fighting vehicle commander – so that the vehicle commander is able to execute the overturning drill, which means that he is able to drop quickly into the vehicle. If he cannot do this, because you are much better protected inside the vehicle than out, the vehicle must stop. The COI also recommended stronger compliance and checks on NVDs, and to enforce to wearing seatbelts rule for passengers when the vehicle is moving.

The SAF has followed up and implemented additional training for armoured vehicle commanders on uneven terrain. Training safety regulations have been tightened to limit exposure of the body of the vehicle commander to waist level when executing certain operational tasks. The SAF has also implemented drills for day-to-night and night-to-day transitions, and this includes NVDs and other night fighting equipment on the checklist that need to be in working order. Wearing seatbelts are enforced, with disciplinary actions taken against those who have not done so.

3SG Chan's death was classified as a training-related incident and compensation offered to the family. 3SG Chan's parents accepted the honours of a military funeral. The armour formation paid their last respects to a dedicated commander whom they are proud to call one of their own. 3SG Gavin Chan is a good soldier.

Death of CFC Dave Lee

Let me now turn to CFC Dave Lee. To investigate CFC Lee's death, all the processes that I have described for 3SG Chan – the COI, the police investigations and Coroner's inquiry – are yet to be completed, his death was about two weeks ago. So, I will only share information from our own internal investigations and when members have clarifications later, I ask you to ask for clarifications, I will share what we have with some caveats, that the COI and independent Coroner's inquiry, if held, and police investigations will have to come to their own facts.

On 18 April this year, CFC Lee displayed signs of heat injury after completing an 8km fast march in Bedok Camp. An SAF medic attended to CFC Lee to bring down his core temperature and he was evacuated to the camp's Medical Centre where body cooling measures and treatment were instituted by the SAF medical team there. He was brought to Changi General Hospital (CGH) and warded in the Intensive Care Unit. Unfortunately, CFC Lee's condition deteriorated, and he passed away on 30 Apr at CGH, about 12 days after his admission.

Following the incident, the Army declared a safety timeout for all training and also specifically reviewed training that pose risks of heat injuries. During the timeout, commanders were reminded of the importance of safety measures which includes hydration regime, temperature taking regime, management of the Work-Rest Cycle – I will explain what this means – and identification of personnel who could be at greater risk of heat injuries. These are currently in place; these are preventive safety measures against heat injuries.

While the SAF has not had any death from heat stroke since 2009, heat injuries do occur each year. We are at risk. We are a tropical island, hot (and) humid. So, in 2010, the SAF convened a workgroup which included many external experts to address this specific problem. The workgroup recommended clinical practice guidelines that were endorsed by the Ministry of Manpower and the then-Singapore Sports Council. These guidelines form the regimes which I have just mentioned, against heat injuries, and they include mandatory water parades before, during, and after a training activity. We take temperature before the training and any soldier with a temperature above 37.5C is not allowed to train. In addition, we take the recorded ambient temperature. If it exceeds a certain level during training, rest periods are mandated at appropriate intervals to allow soldiers to cool down. This is one of the recommendations of the Expert Panel, which the SAF follows dutifully. And it is not just taking a thermometer; we use a Wet Bulb Globe Temperature Heat Stress Monitor. It is a hand-held device (which) will give you the ambient temperature, calculated with the humidity and based on that, the SAF institutes work-rest cycles. So, if it is below a certain temperature, for instance you can exercise for 30 minutes, but you must rest for 15 (minutes). Above 33C, you exercise for 15 (minutes) and rest for 30 (minutes), so on and so forth.

Commanders and soldiers are reminded to look out for signs and symptoms of heat injury during training. In the event of a heat injury, we have on-site cooling measures which include the removal of clothes (and) application of ice or water to the affected serviceman. The SAF medical centres have customised-built evaporative body cooling units for heat injuries. Our commanders, soldiers, regulars, Full-time National Servicemen (NSFs) and Operationally Ready National Servicemen (NSmen) know from their own experience that it is the consistent practice for these processes and precautions to be carried out.

We must press on to achieve zero fatalities from heat injuries. The SAF is currently evaluating the use of individual wearable devices to monitor a soldier's condition real time. MINDEF will also commission an External Medical Panel, as we did in 2010, to review the SAF's policies and measures for the management of heat injuries, and recommend improvements. This panel should consider further steps, especially when recorded temperatures in Singapore over the last two decades have gone up, increasing the risk of heat injuries.

Independence of Investigative Processes for Training-Related Deaths

As these two cases show, after every training-related death, independent (and) impartial investigative processes will determine the key facts, arrive at the appropriate conclusions, and we will take corrective measures to prevent mistakes from being repeated. And, this includes punishing those who contributed to the death through reckless and negligent acts.

SAF Servicemen can be charged and punished in the civilian criminal courts, even if their acts were committed within the SAF, as part of their duty. I have said so in this House previously but these examples bear repeating for their salutary warnings. In 2012, an SAF vehicle overturned during an exercise and it caused the death of a soldier. The Conducting Officer who appointed a serviceman to drive the military vehicle even though the Conducting Officer knew that the serviceman did not have a military driving licence was convicted in the criminal courts and sentenced to 6 months' imprisonment. The officer was found to have committed a rash act and attempted to pervert the course of justice. In 2005, the Supervising Officer, the Conducting Officer and instructors who were involved in the death of a trainee who was submerged in water during a Combat Survival Training course were sentenced to 6 to 12 months' imprisonment.

In all cases, prosecutions of SAF Servicemen in criminal courts are based on independent police investigations, and when the AGC decides that there are sufficient grounds to prosecute. It will be the criminal courts that determine the level of culpability and commensurate punishments. Separately, the Coroner may hold an inquiry to determine the causes of death and contributory factors. The SAF fully accepts these judicial processes and indeed deems them necessary to achieve and maintain a zero fatality training safety system.

I know that there are accusations against the commanders of CFC Lee but we should let the independent COI and police investigations fully investigate the circumstances to establish the facts.  We will deal with any wrong-doing thoroughly. Those that deserve to be punished will be punished.

If any persons are found to have been negligent or culpable, they will be punished according to the law, both in civilian and military courts. But we must be careful not to discourage or unfairly punish commanders who are executing their responsibilities dutifully. Because many commanders are National Servicemen too, who take seriously this mission we in society have imposed on them – to train capable fighting units able to defend Singapore against all threats. And he is serious about his duty and he wants to build a fighting unit, we must be careful that we do not discourage them or punish them unfairly. Indeed we have many positive examples of commanders who risk their own safety to protect trainees – in 2013, NSF commander 2LT Kamalasivam pulled a recruit down to take cover in the grenade throwing bay. The recruit was new, held the grenade, took out the safety pin and released the grenade lever. 2LT Kamalasivam's first instinct was to tell the recruit to throw the grenade and pull the recruit down (and) cover himself over them. Thankfully, both suffered minor injuries which they recovered from. 

Even if there was no ill intent, are NSF commanders trained adequately, and do they have the maturity to exercise good judgment and consciousness regarding training safety? This is what Nominated Member of Parliament Ganesh Rajaram asked.

All commanders undergo safety training in both the Specialist Cadet School (SCS) and (the) Officer Cadet School (OCS). In addition we have Unit Safety Officers, and these are ex-regulars who have held senior appointments, who support the safe conduct of exercises. And these Unit Safety Officers do not just have book learning, they have actual experience having conducted and taken part in training and operations. But Unit Safety Officers cannot be everywhere all the time. So, for instance Ex Wallaby, we send four to five thousand men down to Shoalwater Bay, to train.

A strong safety culture and zero fatality training system can only be achieved if every soldier has that ingrained concern for the well-being of himself and his peers. And on the ground, it is the creed of commanders to take care of their men. If you do not know how to take care of your men and you have shown that you do not know how to take care of your men, we will remove your command position and we will remove your rank. Commanders are taught to encourage their men and buddies to flag out when they do not feel well. Individual soldiers are advised to highlight risky behaviour and safety breaches and they can report them to their superiors without fear of reprisal. There is a 24-hour training safety hotline for commanders and soldiers to report safety incidents and near-misses. So not only when something happens, but a near-miss, report it.

We have another External Review Panel on SAF Safety (ERPSS), they consist of prominent safety experts and professionals outside the SAF, and it helps MINDEF scrutinise our safety management system. I have attached a list of its members; the current chairman is Mr Heng Chiang Ngee who was also Chairman of the Workplace Safety and Health Council till March this year. This panel reports to the Minister on the rigour of the system and presents recommendations to improve. These are qualified eminent members and I would like this ERPSS to do more.

So for a start, MINDEF has discussed with the Chairman of the ERPSS who has agreed to include one of their members in the COIs for all-training related deaths. In addition, the COI will now submit its full report to the ERPSS for further questions, comments and views. In turn, the ERPSS will provide a written report on the COI findings, which will be made public.

With these multiple layers of safety and with experts within and outside assisting the SAF, we can move decisively to make zero training deaths the norm. I know it is difficult but it must be done. Over the last two decades, we have had on average about one NS training-related death a year. From 2013 to 2016 we had no NS training deaths. Four years, none. And this shows that zero fatalities can be achieved with effort. The Chief of Defence Force, the Service Chiefs have assured me that safety has always been, and will continue to get their highest command attention, to achieve zero fatalities. But we need every level to play their part, down to the individual commander and soldier to protect their own well-being and that of their men and their buddies.

Conclusion

Our SAF commanders know that precious sons are entrusted to us when they train during NS. Our commanders take this seriously, and never take this trust for granted. We will do our very best to achieve zero fatalities in training. We will work in unison and instil in every commander and soldier a strong sense of responsibility in ensuring training safety at all levels.

Mr Speaker and members of this House, I have taken this opportunity to put as much relevant details as MINDEF and SAF has involving the deaths of NSFs 3SG Chan and CFC Dave Lee. I would encourage Members in this House to seek any clarification because Parliament is a critical and appropriate forum to ensure that we have done all that is possible to make safety a top priority so that every soldier is well protected as they defend Singapore. Our soldiers deserve no less.