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The Minister for Defence (Dr Ng Eng Hen): 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. I will now ask the Clerk to distribute the facts of these two cases [copies of factsheet were distributed to hon. Members].
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 also 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 this House on their key findings, and the follow-up measures the SAF will take in response.
First on PTE Lee Rui Feng Dominique Sarron. The main substantive findings from the COI report on PTE Lee. On 17 April 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.
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.
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 20 metres and that the minimum distance between troops and the thrown smoke grenade should not be less than 10 metres. 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".
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.
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 same exercise.
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 Training Safety Regulations.
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 safety parameters. The findings of that study now form the TSR for smoke grenades that I have previously detailed.
Smoke grenades, which have zinc chloride fumes, are still safe to use if the 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 arising from this case 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, consisting of five senior respiratory medicine specialists to address this issue, taking into account the COI report. The Advisory Board concluded that the SAF medical classification 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 found guilty to mete out the appropriate punishment. Police investigations are also ongoing to determine whether to prosecute the personnel involved in Civil Court.
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 this year. 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 Health Sciences Authority, 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 licence. Neither did the assigned jeep driver highlight to his superior that he was not licensed 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 in question which conducted 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 Combat Intelligence School, Lieutenant-Colonel Vincent Lam Fei Liong, from his command and appointed a new Commanding Officer. Other personnel in the Combat Intelligence School 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 SAF personnel have been re-deployed to assignments where they will not 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 ongoing 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 licence visibly on the vehicle dashboard. All SAF units have now tightened control over the use and movement of vehicles so that the keys of that vehicle are not inadvertently handed to unlicensed drivers.
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 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. In this way, it will promulgate best practices and ensure the robustness of safety related policies, that they are up to date and sound throughout the SAF.
Mr Speaker, Sir, 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, 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. I am happy to answer clarifications.
Ms Ellen Lee (Sembawang): Thank you, Mr Speaker. On behalf of the GPC for MINDEF, Foreign Affairs, as well as for Members of this House, I would like to express our condolences to families of Pte Lee and 3SG Tan who were involved in the accidents during the SAF training. We were very saddened by the loss. Both their cases remind that we should never take safety for granted, and complacencies always creep in after a long period of non-fatal accidents. We welcome the Minister’s statement which demonstrates MINDEF and SAF’s claims to be open and transparent, as well as the follow-up measures that have been placed to strengthen the SAF safety system.
I wish to ask Minister two clarifications. One, on the trend of the fatal accidents during the training in the SAF, what has been the trend like in the last 10 years? Two, how is SAF going to ensure that the cycle of complacency does not creep in again?
Dr Ng Eng Hen: Mr Speaker, let me give a direct response to Ms Ellen Lee’s question on the trends of training-related deaths for national servicemen. We have on average a handful of deaths. On average, two over the last decade for training deaths involving national servicemen.
Now, Sir, when I give that number, I do not want to give the impression that we are satisfied with the number. But having said that, one recognises that our safety standards are fairly high, comparatively. Again, I am not saying that that is a figure we accept. We are always striving to zero injuries and deaths, but that is the figure as it is. The two-per-year is to be taken in the context of how many servicemen we have in training. We have 40,000 full-time national servicemen. Each year, about 180,000 NS men come back for their In-Camp Training for a few days to a few weeks. We will continue to strengthen the safety system, so that we can keep the numbers to as low as possible.
Mr Low Thia Khiang (Aljunied): Sir, I welcome the Ministerial Statement on the Report of the COI. This is a sign that SAF is being more transparent. Sir, I have one clarification to make. In the case of Pte Lee, at that grenade-throwing training session, was there the presence of a safety officer? If it is so, when the platoon commander breached TSR, was he advised accordingly?
Dr Ng Eng Hen: The answer is yes. There was a safety officer. The Committee of Inquiry ascertained and asked the platoon commander did he know of the Training Safety Regulations. The platoon commander who threw the grenade said he was aware of the training safety conditions, but did not comply with them.
Mr Nicholas Fang (Nominated Member): Mr Speaker, I join the Minister and other Members in expressing my condolences to the two families. I have two supplementary questions. The first: especially in the case of the smoke grenade, it does appear that an error in human judgment was exercised on the part of the commanders. Do we have an indication of timeline as to when a decision on whether further proceedings, general courts martial will be carried out on the responsible personnel, given that deaths occurred? There is a need to re-assure the public, other servicemen and their families that SAF does take this very seriously. The fact that they were redeployed to non-command positions is a good step forward, but I think families and parents would appreciate knowing that the people who are responsible are held to task.
My second question pertains to the fact that huge raft of measures are put in place to ensure that TSR and the safety culture is improved and maintained. How is the Ministry going to ensure that this then balances against training realism, and the need to ensure that training is kept up to certain standards to maintain the effectiveness of the SAF?
Dr Ng Eng Hen: Sir, with regard to the first question, it will follow due process, where the Chief Military Prosecutor will decide based on the investigations if the case is to be put to the general court martial. In an independent track, on the parallel track, the Police investigations will then be submitted to decide whether there will be civil prosecution. In addition, coroner may decide to hold an open inquiry, and that will take its course. So, while we want closure to the aspects, I think we want to also ensure that due process is followed.
For the second question: here, we have been very clear, as I have said in my statement, that we do not want to send the impression that realistic training needs to be dangerous training. In fact, that is not the message. It is a false dichotomy. If we look at these two incidents, they are not high-risk training aspects – driving in a jeep, clearing a room in an urban training set-up. Within the SAF, we do much riskier exercises, in that sense – live-firing, we jump off helicopters, we take deep dives. And it is not the risk of that activity that set the people at risk. It was just disregard for safety instructions. And the message to commanders is if you disregard safety instructions, you put men at risk, you are not fit for command. Two, realistic training does not have to be unsafe training. In fact, the opposite is true. If you make training conditions safe, soldiers will train with greater confidence.
Mr Seah Kian Peng (Marine Parade): I have a few clarifications for Minister. The first is the TSR breaches. I wonder whether Minister could share with us what the trend has been in SAF, with regard to TSR breaches. Secondly, I also hope that beyond instilling the safety culture in SAF, I would like to suggest that the SAF also encourages a system of reporting near misses. Through that, there is a lot of useful lessons which could help SAF minimise future accidents from happening.
Regarding the weak safety culture in the Combat Intelligence School (CIS), I would like to ask whether, beyond CIS, what is the record like in other units? And is this isolated or also the case in some other units? Finally, one of the things that Singaporeans are very proud of is a strong SAF, and also, for the parents and sons, a safe SAF. There must also be steps to restore these two pillars of what the SAF means to Singapore and to Singaporeans.
Dr Ng Eng Hen: Sir, the Member asked about what the trends were. I do not have all the figures here. Let me just say that it is related to the second question on the open reporting culture, which means that we do not want to only encourage them to be conscious of safety regulations breaches, but even when they have followed safety regulations when there are near misses, as the Member said, in countries or agencies with good safety culture, that open reporting system is indeed the hallmark of one. And we have started that. The Army established a safety hotline in November 2011, where soldiers can ring the hotline and report safety problems. And since then, nearly a year, we have received about 100 calls. They report, exactly as the Member said, unsafe practices, near misses or safety hazards. So we will continue to encourage that. In addition to the Army hotline, there are 1800 numbers, so that we want to have an open reporting system.
The Member also asked if what happened in the Combat Intelligence School was a systemic one, and that was the question we ourselves asked in MINDEF. Was this just an isolated incident or was this one example of a systemic problem? The Chief of Army has assured me that this is an isolated problem. His assurance or his judgment is based on the Army Safety Inspectorate that does routine inspections. My other source of assurance is the fact, in terms of our training or vehicle accident rate, it is fairly low, it is something in the order of 0.5 to 0.6 accidents per 100 thousand kilometres. Now that is not a sure sign, and I know some Members will say maybe, "They do not report it". But be that as it may, it gives you a rough gauge of the accident rate, which is fairly low. And also, my fourth assurance is what the COI uncovered. In this particular incident, there were two jeeps for the second incident. The jeep which Third Sergeant Tan was in had an unlicensed driver, and did not wear any helmets or lap belts. The jeep in front of them, all four wore helmets, lap belts and a licensed driver. So I think it is an isolated incident but, nonetheless, we want to continue to step up checks and make sure that that kind of lax attitude towards safety regulations does not spread.
Mr Christopher de Souza: Mr Speaker, I would like to take up the point on whether this incident or incidents will spur us from accident reporting to incident reporting, and near misses. I know the Minister has replied to that saying "yes, it will". My further question is whether that can be shared between the services. For example, in the Army where there is a safe land movement unit and they have a good safety record, would they be willing to share with the Air Force or the Navy, where there are less land movement exercises to be performed? Cross service sharing of best practices and near misses, arising out of the new inspectorate.
Dr Ng Eng Hen: Indeed that is one of the main tasks for the SAF Inspectorate. The SAF looked at it, and decided it needed an inspectorate that reports directly to the Chief of Defence Force (CDF) for accountability and responsibility, that oversees the three services, and first of all inculcates and embeds a high safety culture within the SAF and that inculcates safety habits into individual commanders and men, as well as − what the Member Christopher de Souza has suggested − to just share best practices across Services.
Mr Gerald Giam Yean Song: Sir, I too extend my deepest condolences to the family of 3SG Tan and Pte Lee. My question for the Minister is what were the other findings that led the COI to conclude that the Combat Intelligence School had a weak safety culture, because that is a very serious accusation?
Dr Ng Eng Hen: The COI concluded this from interviews with servicemen. It was on various aspects. One, in terms of the vehicle safety management. It was in response to whether conducting officers checked whether drivers were licensed in the first place. Two, their procedures in terms of vehicular movements in the training field. And I would agree with the COI in terms of that conclusion. Independently, the Army Safety Inspectorate has done a review of that, and recommended to SAF, MINDEF the removal of certain personalities from command. And as I have mentioned, the SAF has acted on that.
Mr Alex Yam (Chua Chu Kang): Mr Speaker, I join the House in offering condolences to the families of PTE Lee, 3SG Tan as well as the other servicemen who have passed away this year.
As an active reservist and having been on two reservist stints this year, I think there have been improvements. Drivers are now required to show their driving licence whenever they board their vehicles. I would like to ask two supplementary questions and make one observation. One, is that in 2010, there were no accidents or deaths reported; 2011, there were three; and in this year alone, there have been five fatalities. I would like to ask the Minister whether there have been any COI or BOI findings that the overall safety awareness in the SAF may have fallen? And what steps will be taken to address this?
The second is will the SAF consider making BOI and COI findings, the investigation findings public. We are a largely citizens army, not a professional army and so the sharing of information through the public media may be helpful for us, the wider public, to understand the lessons learnt.
The third observation is that based on a cursory count since 2001 till date, 16 SAF servicemen have passed away or encountered accidents on Fridays. This is the highest daily fatality rate of any given day within the week. Is it possible that safety has become lax due to the fact that this is the last training day of the week, and whether any measures should be taken to address this?
Dr Ng Eng Hen: Sir, the Member asked if there has been any study conducted to suggest the trend that safety standards have dropped. No, there is not but I do not need the study to act. I think once we have an incident, we put in place these measures that I talked about. The Member’s point about Friday, I would have to check that up; but if that is true, I think that is a useful point. The Member also talked about the number of deaths, whether we could make the release of BOIs and COIs routine.
I would have to say that of the two deaths that I talked about each year, the majority of them are not in these cases where there are clear breaches of safety instructions. Some of them were really medically related. For example, cardiomyopathy or viral infections which when after the COI has ascertained all the facts and whether we could have done anything different, and we have asked the medical specialist board, the answer is no. That is the extent of our technological ability and its inability to just determine before the incident whether anything could have been done to prevent it. Some were acts of God, for example, like the tree falling on the soldier outside the training grounds, and completely unforecasted or hard to predict. But when it comes to cases which are of public interest and significance, the SAF and MINDEF will share these cases, as I am doing for these two cases in this House.
Mr Png Eng Huat (Hougang): As a point of clarification, is it a standard protocol that all injured and national servicemen will be sent to a military medical centre before they are sent to the hospital, regardless of how serious the injuries are, because sometime time is of the essence?
Dr Ng Eng Hen: The answer is no, it is not a matter of procedure. The overriding principle is one of fastest evacuation to a facility that has the capabilities to resuscitate the injured. The Member would, of course, be aware that time is of the essence. For example, whether they are bleeding or they have an airway obstruction. And some of the trips back to, say a hospital, may take a longer time. And so the principle is they will be evacuated to the nearest either medical centre or hospital facilities which can provide that resuscitation.
Sir, I want to just comment that while we have shared these findings with the House, we know that the loss of any servicemen is deeply distressing, and what we say here will never fully comfort their grieving families. I think it will be especially difficult when servicemen lose their lives under circumstances that could have been prevented. I want to assure this House and the members of the public that – some Members mentioned restoring confidence; I think Member Seah Kian Peng made that point – and I think the first step is, as Member Low Thia Khiang said, to be open, to be transparent, to leave no stone unturned to discover why and how it happened. And then correct the lapses and continue to report to the public and to families the measures that we have taken and the progress of these measures. I know that this is not a one-off exercise that we conduct; this is a long-term exercise that we need to inculcate a better safety culture. I want to assure this House that SAF will learn from this and put things right. After all that is said and done, I think what will show is what happens on the ground that will give confidence to our men. And we want to assure the families that we give safety top priority so that their sons, husbands and brothers can return to them safely after their NS training.