Defence Minister Ng Eng Hen revealed in Parliament today
that there were breaches of training safety regulations in the deaths of
two full-time National Servicemen in separate training incidents this
year, and detailed the actions taken following the findings reported by
the Committees of Inquiry (COI).
A Commanding Officer has
been replaced and other commanders have been redeployed, for the
regulations breached under their watch. Investigations are ongoing to
see if they should be prosecuted in the military or civil courts.
The following is Dr Ng's statement in full:
Mr Speaker, Sir, I would like to report to this House the findings
from the Committees of Inquiry (COI) that were convened after the
deaths of two full-time National Servicemen in separate training
incidents in April and May this year. Before I begin, I want to offer my
deepest condolences to the families of PTE Lee Rui Feng Dominique
Sarron and 3SG Tan Mou Sheng. The SAF and MINDEF are deeply sorry for
the untimely and tragic loss of PTE Lee and 3SG Tan and the anguish and
distress it has brought to their families.
The COIs were
convened by the Armed Forces Council to investigate the circumstances
surrounding the deaths of PTE Lee and 3SG Tan. COIs are chaired by
senior civil servants outside MINDEF. Members include one or two medical
specialists, who would be able to provide professional expertise. The
COI has full powers and access to information and personnel to
independently investigate fully the circumstances leading to death, to
determine the contributory events or persons and make recommendations to
rectify lapses, if any. MINDEF and the SAF treat COI reports with
utmost seriousness so that we can avoid similar occurrences.
In the cases of PTE Lee and 3SG Tan, their respective COIs have
uncovered clear breaches of training safety regulations in the events
that led to their deaths. I will now brief the Members of the House on
their key findings, and the follow up measures the SAF will take in
response.
PTE Lee Rui Feng Dominique Sarron
First, the main findings from the COI report on PTE Lee. On 17 Apr
2012, PTE Lee participated in an exercise at the Murai Urban Training
Facility at Lim Chu Kang. Smoke grenades were thrown outside a building.
PTE Lee entered one of the rooms of that building, and experienced
breathing difficulties after exposure to the smoke. He was immediately
accompanied away from the smoke but lost consciousness outside the
building. He received Cardio Pulmonary Resuscitation on the spot and was
evacuated in a safety vehicle to the Sungei Gedong Medical Centre,
before being sent to the National University Hospital (NUH) in an SAF
ambulance. Resuscitative efforts by an SAF medical officer continued
throughout the journey and at NUH. The COI found that "the medical aid
rendered was timely, adequate and proper". Regrettably however, PTE Lee
was pronounced dead after these attempts failed.
Cause of Death
The cause of death was certified by the forensic pathologist of
the Health Sciences Authority (HSA) to be due to an "acute allergic
reaction to zinc chloride due to inhalation of zinc chloride fumes".
Zinc chloride is a primary component of smoke grenades currently used in
the SAF.
Safety Breach
The COI found that the number of smoke grenades used in the
exercise exceeded the limit specified in training safety regulations.
The Training Safety Regulations (TSR) stipulate that the minimum
distance between each thrown smoke grenade should be not less than 20m
and that the minimum distance between troops and the thrown smoke
grenade should not be less than 10m. Based on the exercise layout, not
more than two smoke grenades should have been used, but the Platoon
Commander had thrown six grenades instead. The COI opined that "if the
TSR had been complied with, PTE Lee and his platoon mates would not have
been subjected to smoke that was as dense as that during the incident,
and ... for as long as they were during the incident" and that "reduced
exposure to smoke would have reduced the risks of any adverse reactions
to the smoke." The COI concluded that "the cause of death of PTE Lee
resulted from inhalation of the fumes from the smoke grenades used in
the incident".
Platoon Commander "Negligent"
The COI is of the opinion that the actions of the Platoon
Commander, a Regular Captain, were negligent as he was aware of the
specific TSR but did not comply with it.
Other considerations - Asthma
PTE Lee's pre-enlistment medical screening records revealed that
he had a history of asthma. The COI found that PTE Lee's medical
classification and vocational assignment were appropriate, based on the
severity and control of his asthma condition. The COI was unable to
establish with certainty if PTE Lee's history of asthma was a
contributory factor to his death. First, the COI noted that the specific
effects of zinc chloride fumes on asthmatics had not been reported in
medical literature. Second, adverse reactions to zinc chloride can occur
even in individuals without asthma. Third, the other platoon mates with
asthma had developed only mild symptoms after the exposure to the zinc
chloride fumes in the exercise.
Recommendations of COI
To prevent a recurrence, the COI recommended measures to ensure
compliance with TSRs through strengthening the role of the Safety
Officer and educating commanders and troops on the TSR.
Sir, I have concluded the findings and recommendations from the COI and
would like to now brief members on SAF's and MINDEF's measures in acting
on the report.
First, on the use of smoke grenades in
training. Sir, smoke grenades which produce zinc chloride fumes have
been in use by the SAF since 1970s. They are also used by other
militaries and agencies such as the United States and the Republic of
Korea militaries because in acceptable concentrations of exposure, these
smoke grenades are safe. Lung injury following exposure to zinc
chloride fumes, and even deaths, have been reported in international
literature but the numbers are few and mainly occur after exposure to
high concentrations of zinc chloride fumes. In fact, PTE Lee's death
directly attributable to zinc chloride inhalation is the first on SAF's
records.
To update our TSR for smoke grenades, MINDEF had
in 1998 commissioned the Department of Community, Occupational and
Family Medicine of the National University of Singapore to conduct a
detailed technical evaluation of smoke grenades. Specifically,
concentrations of zinc chloride fumes were measured at different
distances from the thrown smoke grenades to determine the corresponding
safety parameters. The findings of that study form the current TSR for
smoke grenades that I have previously detailed.
Smoke
grenades, which have zinc chloride fumes, are still safe to use if TSR
are observed. However, despite these assurances, I can understand the
anxiety of our soldiers and their families, arising from this isolated
incident of a death due to inhalation of zinc chloride fumes. So that
our soldiers can train with confidence, MINDEF would like to address
these concerns directly.
Following PTE Lee's death, the SAF
has suspended for training exercises the use of the smoke grenades,
which produce zinc chloride fumes. The suspension will continue as the
SAF is studying using smoke grenades which do not produce zinc chloride
for training exercises. For missions, we will continue to use zinc
chloride smoke grenades as they are judged still to be the most
operationally effective.
The second public concern is due
to asthma as a significant proportion of National Servicemen - one in
five - have asthma, albeit often in a mild form. The SAF convened a
Respiratory Medicine Specialist Advisory Board of five senior
respiratory medicine specialists to study this issue, taking into
account the COI report. The Advisory Board concluded that the SAF
medical classification guidelines on asthma are relevant, up to date and
in line with national and international standards. It is still safe for
servicemen with a history of asthma to undergo training with smoke
grenades if the TSR are followed. I thank the COI and Board for their
valuable work.
MINDEF has relieved the exercise Chief
Safety Officer, Captain Chia Thye Siong and the Platoon Commander who
threw the smoke grenades, Captain Najib Hanuk Bin Muhamad Jalal, of
their duties. They have been re-deployed to assignments which do not
oversee soldiers in training or operations. Following procedures and due
process, the Chief Military Prosecutor will determine if these
personnel should be subject to a General Court Martial (GCM), to
establish their degree of culpability and if it finds them guilty to
mete out the appropriate punishment. Police investigations are also
on-going to determine whether to prosecute the personnel involved in
Civil Court.
3SG Tan Mou Sheng
Let me now present the COI findings on the death of 3SG Tan. 3SG
Tan was an instructor of a Reconnaissance Commanders' Course held at the
Marsiling training area on 11 May 2012. He was travelling with other
instructors in a scout jeep and seated at the rear of the jeep. When the
jeep overturned, 3SG Tan was thrown out and pinned under the jeep. 3SG
Tan was extricated, attended to by a medic and evacuated in the safety
vehicle to the Nee Soon Camp Medical Centre. The duty Medical Officer
immediately accompanied 3SG Tan to Khoo Teck Puat Hospital via SAF
ambulance. 3SG Tan underwent emergency surgery but despite this
succumbed to his injuries. According to the HSA, the cause of death as
certified by the forensic pathologist was "haemorrhage from severe
pelvic crush injuries".
The COI was of the opinion that
specific instances of individual negligence and breaches of safety had
contributed to 3SG Tan's death. First, the jeep driver was not licensed
to drive. The Conducting Officer had assigned the jeep driver to drive
without checking if he had a license. Neither did the assigned jeep
driver highlight to his superior that he was not licenced to drive a
jeep. Second, the two rear passengers, one of whom was 3SG Tan, were not
wearing helmets or lap belts. The Vehicle Commander did not ensure that
the jeep passengers wore their helmets or lap belts.
The
COI found that Combat Intelligence School (CIS), the school conducting
this training package, had a weak safety culture. In the course of its
investigations, the COI uncovered other previous instances of unlicensed
driving. The vehicle management system was also not satisfactory, with
lax access to vehicles by servicemen in the field during training.
Shortly after the incident, MINDEF removed the Commanding Officer
(CO) of the CIS, Lieutenant-Colonel Vincent Lam Fei Liong, from his
command and appointed a new CO. Several personnel in the CIS have also
been relieved of their duties:
a) The Head of the Reconnaissance, Surveillance, and Target
Acquisition Wing, Major Poon Chen Song;
b) The School Sergeant Major, 1st Warrant Officer Lim Ser Wei;
c) The exercise Supervising Officer, Lieutenant Marcus Koh Men;
and
d) The exercise Conducting Officer, Master Sergeant Lee Kong Kean.
All these personnel have been re-deployed to assignments where
they willnot be supervising soldiers for training or operations.
As in the previous case, the Chief Military Prosecutor will
determine if these personnel should be subject to a General Court
Martial (GCM).
Police investigations are also on-going to
determine whether to prosecute the personnel involved in Civil Court.
This includes the unlicensed driver of the jeep, 3SG Cavin Tan.
The vehicular management system in the CIS has been tightened. The
SAF has also reviewed other units to ensure that unauthorised driving
does not occur during field training. It is now mandatory for drivers to
display their driving license visibly on the vehicle dashboard. All SAF
units have now tightened control over the use and movement of vehicles
so that keys are not inadvertently handed to unlicensed drivers.
Strengthening Safety Across the SAF
While the SAF has a robust training safety system in place, these
two incidents show that more needs to be done. The SAF is determined to
put things right and correct any inadequacies uncovered. More
importantly, we want to ensure that these lax attitudes toward training
safety remain isolated instances and do not take root in our system.
Specifically, after these two incidents, we have already tightened
the control and management of SAF vehicles in units and during field
training. We will explore safer alternatives to the existing type of
smoke grenade for use in training. We will also reinforce measures to
ensure safe management of servicemen with a history of asthma. We will
also ensure that the TSR are adhered to on the ground.
But
beyond the specific measures, the SAF will also make three key systemic
changes to strengthen training safety across the whole SAF.
First, we will deploy more safety officers on the ground. They will be
designated as full-time Unit Safety Officers whose primary role will be
to ensure that units and servicemen comply with safety measures.
Second, an Army Safety Review Board (ASRB) chaired by a senior
civil servant outside MINDEF has been set up to review the Army's
overall safety structure, processes and culture.
Third, the
SAF will set up an SAF Inspectorate, reporting directly to the Chief of
Defence Force. The SAF Inspectorate will set the safety culture across
the entire SAF and oversee the individual inspectorates of the three
services. It will promulgate best practices and ensure that safety
related policies are up to date and sound throughout the SAF.
Conclusion
Every Singaporean son is precious and any injury or death in the
SAF is one too many. But to prevent injuries and death, our commanders
and soldiers must observe training safety regulations. Any commander who
ignores safety regulations, whether wilfully or negligently, puts his
soldiers at risk and is not fit for command. Our soldiers can train
realistically and safely - there need not be a compromise. Indeed, the
more we ensure that conditions are safe, the greater confidence our
soldiers will have in training. These two deaths could have been avoided
if safety instructions had been followed. The SAF will learn from the
incidents, correct any inadequacies and punish those who disregarded
safety regulations.
It's all fun and games until someone dies. Then scramble to find the scapegoats to satisfy public fury.
as an army reservist.. or NSF.. is important the soldier knows the TSR and the common sense to apply it.
Once out field training, very heavy thunderstorm, our excercise we climbing up and dowm, and OC not around. We decided to cut the excercise ourselves...
Due to later in the day, some VIP will be visiting us.. TA Major run to us and ask why we stop.. we explained.. He then proceed to order us to continue.. we refuse and he start to pull rank.. the conversation goes somethg like this..
Maj: Get back to your vehicle and contine with the dry run
Me: Sir, heavy rain and now is Cat 1..
Maj: shouted at us.. continue with excercise
Me : (he got me very pissed) Sir, I do not acknowledge your authority over us. Please convey your orders to OC and in turn OC will give us the order.
OC : came running, what happen?
(we explain etc etc)
OC: instruct us go shelter to take cover from rain
Maj: (super pissed) shouted at our OC and radio CO to come over
CO : told our OC to continue
OC : told CO is loud voice. Sir I hereby wish to informed you that TSR states, Cat 2 CO have discrettion to continue, Cat 1 even CO no authority to override TSR.....If order is to continue, please give me MINDEF orders to continue, otherwise... my men will take cover...........
This happen in reservist... so ultimately we will discharge.. so can you imagine NSF with regular officers? doubt will end up continuing training