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.