OPENING REMARKS BY MINISTER FOR DEFENCE, RADM (NS) TEO CHEE HEAN, AT THE PRESS CONFERENCE ON TRAINING DEATHSGood morning. Thank you for coming to MINDEF. Last month, I made a statement in Parliament about the deaths of three SAF servicemen during 3 unrelated training incidents. I informed Parliament that MINDEF had convened independent inquiries into these cases. These inquiries have since been completed, and I would like to give you an update on the findings of these inquiries. The SAF will also give you an update on the steps they have taken.
First, the case of 2SG Rajagopal Thirukumaran. He was a regular serviceman who collapsed on 3 September after completing a 5km run in the Ranger course selection test. The Higher Board of Inquiry submitted its report on 16 October. It found no evidence of foul play or negligence that may have contributed to 2SG ThirukumaranÂ’s death.
Second, the case of Recruit Andrew Chew Heng Huat. Recruit Chew was 30 metres short of completing his 2.4km run in the IPPT categorisation when he collapsed and died on 23 September. The Commission of Inquiry submitted its findings on 10 November. The COI found no indication of foul play, nor evidence of negligence or non-compliance that could have contributed to Recruit Andrew ChewÂ’s death.
On the cause of death of 2SG Thirukumaran and Recruit Andrew Chew: after thorough post-mortem examinations including toxicology studies, the forensic pathologist of the Health Sciences Authority (or HSA) found that there was no evidence of any traumatic cause or any unnatural cause that could have resulted from heavy physical exertion, such as heat stroke, that could have led to their deaths. The pathologist has also ruled out infective causes, such as myocarditis (which is a viral infection of the heart muscle).
The forensic pathologistÂ’s opinion is that the most probable cause of death for both 2SG Thirukumaran and Recruit Chew was the onset of a sudden cardiac arrythmia. What this means is that the heart began to beat irregularly and therefore could not effectively sustain the supply of oxygen to vital organs such as the brain, kidney and heart.
The HSA is now conducting further studies to conclusively determine whether there were any underlying medical reasons for the sudden cardiac arrythmia which resulted in the deaths of 2SG Thirukumaran and Recruit Chew. The forensic pathologistÂ’s final reports on the cause of deaths will be submitted to the State Coroner who will consider the reports and other relevant circumstances and facts. The State Coroner will hold the CoronerÂ’s Inquiry as soon as the reports and investigations are completed. This is a matter now for the State Coroner to decide.
The third case is that of 2SG Hu Enhuai. He died on 21 August during a Combat Survival Training (CST) course. I had informed Parliament on 16 October that an initial Higher Board of Inquiry and Commission of Inquiry found that 2SG HuÂ’s death from asphyxia and near drowning followed from non-compliance with the approved lesson plans during the conduct of the water treatment phase of the CST course. I told Parliament then that MINDEF would convene a second Higher Board of Inquiry to ascertain when the unauthorised water treatment started in the conduct of the CST course and how such a practice was allowed to creep into the lesson. The HBOI submitted its report on 6 November.
The HBOI found that water treatment, as specified in the lesson plan, had been part of the CST since the course was first conducted in 1993. Generally, from 1993 to 1997 the water treatment was carried out according to the lesson plan. This involved dousing the trainees with cold water, with the intent of showering them.
However, the HBOI found that, in some CST courses in 1998 and 1999 and regularly from 2000 onwards, the CST trainees had their heads placed under a running tap and their faces submerged in a washing bay which contained about 7 to 10 cm of water. From the 78th Course in April 2003, the traineesÂ’ heads were submerged in a tub which held about half a metre to one metre of water. These practices are not approved and not in accordance to the lesson plans.The HBOI found that individual instructors conducting this training failed to refer to the approved lesson plan although they should have done so. New instructors also did not refer to the CST lesson plan. The preparation for the new instructors and those newly appointed to supervise and conduct a CST course, consisted mainly of observing the conduct of a previous course. Since new personnel were trained to conduct the course by being shown how the CST was conducted, these new personnel would subsequently use the methods shown to them when they ran their courses. Since instructors did not refer to the approved lesson plans, unauthorised methods of water treatment that had been used in a prior course could be perpetuated in subsequent courses.
The lesson plan was last reviewed in January 2001, by the School of Commandos. However, this variance in practice from the approved lesson plan was not detected.
Independent investigations by the CID and by the State Coroner into the death of 2SG Hu are in progress. The law will have to take its course. In the meantime, as I informed Parliament, we have suspended all the instructors directly involved in using the unauthorised method of training, and replaced those senior commanders who allowed these unauthorised methods to continue to be used so that the School of Commandos and the formation can conduct its review.
The SAF has taken a number of measures to rectify the shortcomings identified by the HBOI. I will now ask the Chief of Defence Force, Major-General Ng Yat Chung, to speak to you about the approach the SAF is taking to address these issues. After that, Colonel Hugh Lim, the ArmyÂ’s Assistant Chief of General Staff for Operations, will brief you on the ongoing efforts to improve training and safety management in the Army.
So perhaps, I should wrap up. I would just like to say that weÂ’ve had these committees of inquiry, the higher boards of inquiry in order to the bottom of these issues so that we can uncover what went wrong that day. Once we uncover what has gone wrong, then we are able to take the correct measures to put them right.
The SAF has briefed you on what measures they have already taken and what measures will be taken within the next three to six months to put these things right. The SAF is committed to ensuring that what happened to 2SG Hu is not repeated.
I also like to add that the response from the members of Parliament as well as the public has been a very mature and a very supportive one. And I appreciate that and the SAF appreciates that. Both CDF and I have been to visit the Commandos and I think they understand and appreciate the support that the public has for them and that gives them the strength to be resolved, to do what is necessary to put things right and to carry on doing their duty for the country.
And I would like to thank the public for their continued support and encouragement for the SAF, Army and the Commandos.
SAF Reviews Training Safety System
http://www.mindef.com.sg/display.asp?number=1951