National Service Training Deaths and Safety Enhancements for the SAF

The Minister for Defence (Dr Ng Eng Hen): Mr Speaker, before I begin my Statement, allow me on behalf of all Members in this House, to offer our deepest condolences to the family of the late CFC(NS) Aloysius Pang. There was an outpouring of sympathy from Singaporeans all across the island on CFC(NS) Pang's passing as we shared the grief of the family's tragic loss. I pray that the passage of time will bring some comfort to the Pang family as well as to the other families affected by the recent deaths of national servicemen. Your questions today as Members of Parliament (MPs) are an important part of holding MINDEF and the SAF accountable for the safety of our servicemen, and will strengthen our collective resolve to make SAF training as safe as possible, and prevent such tragic deaths from occurring again.

My Statement today will cover three areas: first, the death of CFC(NS) Aloysius Pang; second, the Committee of Inquiry (COI) findings of CFC Liu Kai; and third, safety enhancements by the SAF following recent NS training deaths.

Let me first address questions from Members on CFC(NS) Pang who died on 23 January this year. A Committee of Inquiry has been convened by the Armed Forces Council (AFC) on 25 January 2019. All five members of the COI are from outside MINDEF and the SAF. They comprise the chairperson who is a judge nominated by the State Courts, a consultant medical specialist, a member nominated by the External Review Panel on SAF Safety (ERPSS), a member of the Workplace Safety and Health Council and a senior-ranked National Serviceman.

The COI has started its investigation to determine the circumstances and contributory factors which led to the demise of CFC(NS) Pang. When completed, the COI will submit its findings to the Armed Forces Council and the ERPSS. The ERPSS will in turn provide its comments on findings and both their comments and the findings will be made public.

However, as CFC(NS) Pang's death occurred in New Zealand, neither the Police Force nor the State Coroner have jurisdiction for deaths outside Singapore. Investigations to determine any culpability in this case will be left to the SAF's Special Investigation Branch (SIB) which has jurisdiction under military law.

Based on SIB's investigations, the Chief Military Prosecutor will decide if any servicemen are to be prosecuted for criminal or military offences in a military court. The military court is presided over by the State Court judges appointed as Presidents of the General Court Martial.

In this Statement, I will give as much information as possible without prejudicing the COI and SIB's investigations, whose findings in due course will be authoritative and conclusive. To preserve the integrity of the process, I will only state facts in reply to Parliamentary Questions (PQs) and consciously not draw any inferences or conclusions on the incident involving CFC(NS) Pang. I ask Members here to observe the same. We should also be mindful of the need to be sensitive to the family's feelings as we honour the memory of CFC(NS) Pang. With these caveats, let me begin.

CFC(NS) Aloysius Pang, aged 28, an Armament Technician, was participating in Exercise Thunder Warrior at Waiouru Training Area in New Zealand this year.

On 19 January this year, three SAF personnel were in the cabin of the Singapore Self-Propelled Howitzer (SSPH) to carry out repair works on the gun's calibration system for accurate firing. The three SAF personnel were CFC(NS) Pang, a Regular Armament Technician holding the rank of Military Expert (ME)2 with more than 16 years in service, and third, the Gun Detachment Commander, who is a Third Sergeant NSman.

Mr Speaker, I have asked for your permission to display some slides. Can I ask for the first slide to be displayed?

Mr Speaker: Please proceed. [Slides were shown to hon Members.]

Dr Ng Eng Hen: Thank you. Let me orientate Members to first of all the cabin of the SSPH. The cabin is 2.3 metres in height, 2.44 metres from front to rear, and 2.64 metres from side to side. That gives you the dimensions of the cabin within. The gun barrel, which, on the left-hand side of the screen is now in the inclined position and therefore is lowered in the rear, divides the cabin into two. There is space for the three persons within the cabin to occupy positions on either side of the gun as shown in the diagram – 1, 2 and 3, and looking towards the SSPH from the back, about 1.55 metres on the left side, Safe Position 1 and 2; and 0.9 metres in width on the right side, Safe Position 3. These so-called Safe Positions are designed to be occupied by the gun commander, the ammo loader and charge loaders, but for the purpose of the Statement, I will refer to them as "safe positions".

The gun barrel is usually tilted upwards for firing – that is the picture shown on the top, smaller picture on the left; the gun barrel at the inclined position with the gun pointed up. The gun barrel is usually tilted upwards for firing but needs to be lowered for some types of maintenance work. When the gun is lowered, the flick rammer at the rear end of the barrel goes up and ends about 10 cm below the top rim of the cabin. I will have some more pictures to make it more clear later. Because of this, no one should be behind the barrel when the gun is being lowered. Unfortunately, CFC(NS) Pang was caught between the gun barrel and the interior of the SSPH as the gun barrel was lowered and sustained compression injuries to his chest and abdomen.

After he sustained these injuries, CFC(NS) Pang was treated on-site by the SAF Medical Officer and evacuated to Waiouru Camp Medical Centre. He was heli-evacuated to Waikato hospital in Hamilton, New Zealand, which is a regional trauma centre, where surgeons decided that he needed an operation to treat his injuries. Prior to his first surgery, CFC(NS) Pang was conscious and speaking. At the first operation, the surgical team found that a number of organs were damaged and treated them accordingly. After the first surgery, CFC(NS) Pang did not require any ventilation and his vital signs were stable. In fact, after the first surgery, he spoke with his mother who had been flown over to New Zealand.

A "second-look" surgery had been planned for CFC(NS) Pang on 21 January 2019, two days after the first surgery. According to the surgeons there, this was to detect further injuries, as damage from compression injuries may only show up later. No further damage was discovered at the second-look surgery, but despite this, CFC(NS) Pang's condition subsequently deteriorated. Despite being placed on artificial life support and further treatment, CFC(NS) Pang passed away on 23 January 2019, four days after the primary incident in the SSPH.

I propose now to deal with Members' questions which fall in three broad categories: first, what was the experience and state of the maintenance crew? I have the second slide. CFC(NS) Pang had arrived in New Zealand on 6 January 2019 and had begun maintenance work from 10 January 2019. So, on 6 January, he arrived; he began maintenance work on 10 January. This was CFC(NS) Pang’s seventh In-Camp Training (ICT). He had been trained to perform maintenance and repair for the SSPH since he was a full-time national serviceman. In addition, during his previous ICT in February 2018, he had attended a two-day refresher Maintenance Vocation Training on the basic functional checks and troubleshooting for the SSPH. That course also included safety procedures during gun movements. Before participating in Exercise Thunder Warrior this year, CFC(NS) Pang had undergone refresher training on maintenance tasks in New Zealand. For this exercise, CFC(NS) Pang was involved in the preparation of more than 10 SSPHs, which included servicing and maintaining of the guns. The other two servicemen were also similarly qualified. The Gun Commander was in his eighth ICT and had undergone refresher training prior to his deployment in the exercise. The Regular technician has eight years of working experience on the SSPH and it was his sixth time participating as a technician in Exercise Thunder Warrior.

Let me explain how maintenance work on the SSPH is conducted when the unit is deployed in the field. There are two levels of maintenance support – basic and higher. Basic support is provided by the SSPH battalion's organic Forward Maintenance Platoon, made up of national servicemen. CFC(NS) Aloysius Pang was part of this Forward Maintenance Platoon. If the repair works exceed the scope of the Forward Maintenance Platoon, more complex maintenance is requested from and performed by technicians in the higher maintenance echelon, and this is called the Forward Support Group, who are made up of Regulars. So, basic support made up of national servicemen, more complex maintenance made up of Regulars in the Forward Support Group.

In this particular incident, CFC(NS) Pang was first activated. But as he was unable to resolve the fault, CFC(NS) Pang requested and received the help of Regular technicians from the Forward Support Group. CFC(NS) Pang and one Regular technician of ME2 rank were inside the cabin of the SSPH with the Gun Commander, a Third Sergeant NSman, when the incident happened. These are the three persons I referenced in the beginning of my Statement.

Second, the adequacy of safety protocols and whether the maintenance crew were familiar with them during this ICT. A number of Members of Parliament have asked for this, Miss Cheryl Chan Wei Ling, Prof Fatimah Lateef, Mr Darryl David, Miss Cheng Li Hui, Mr Dennis Tan Lip Fong and Ms Joan Pereira. Let me show a third slide. I will focus on the relevant safety instructions during maintenance work, because this is the reason for the presence of these three people in the SSPH, and in particular when the gun is lowered. There are safety procedures taught to all maintenance and SSPH operating crew. The ME2 regular technician is overall in charge because he comes from the Forward Support Group and he is in charge of more complex repair works – so he is in charge. For the repair work in this case, the maintenance manual indicates that it is the responsibility of the technician in charge to ensure that the gun has been lowered and fixed in place before any maintenance works can begin.

Further, the safety instructions specify safe positions within the SSPH cabin for soldiers to occupy during the gun lowering, as well as safety precautions to be taken. In operations or during maintenance, it is the Gun Commander who lowers the gun. From his Safe Position 1, indicated in the middle of this slide, the picture of the tank with the gun pointing forward or pointing up, the Gun Commander must first check to ensure that the gun barrel area is free from obstacles and that no persons are in the travel path of the barrel.

The other persons in the cabin are to occupy Safe Positions 2 or 3, on the left side and the right side respectively. The Gun Commander then gives the signal "clear away", "clear away" to warn the technicians about the barrel movement. He should visually check to ensure no persons are in the travel path of the barrel and all crew are in Safe Positions. After which, the gun commander should shout "standby" before moving the barrel. In the event of any danger, there are also three emergency stop buttons in each of the safe positions inside the SSPH and they are indicated as the red buttons in each of the Safe Positions. There are three of them.

In the operators' manual, there is a standard warning, and I quote it, it is boxed in the Safety Manuals, printed in bold, quote, "Failure to observe the above warnings, may result in serious injury or death to crew". The warning is repeated for a variety of drills that the SSPH crew must undertake.

Next, I will show a video of this safety drill prescribed during the gun lowering – and it will be shown in actual speed, with your permission, Mr Speaker. [A video was shown to hon Members.]

It takes about nine seconds for the gun to be lowered to the horizontal position for maintenance. All three persons who were in the cabin in this incident had been trained specifically on the SSPH and had conducted similar maintenance on it in the past. During this exercise, both CFC(NS) Pang and the Regular technician had conducted maintenance works on the guns daily.

Following the incident, the SAF's immediate task was to ensure that there was no systemic machine malfunction of the SSPH, which would otherwise have put maintenance crews at risk. Inspections of the SSPH have not detected any machine malfunction of the gun lowering mechanism.

Third, was there a design flaw of the SSPH? Member Assoc Prof Daniel Goh asked this. The SSPH was designed and developed to international military standards for System Safety and Human Factor Engineering. Many other militaries operate tracked 155mm guns with similar gun lowering mechanisms, this includes the United States, South Korea and Germany. The SSPH prototype platform underwent extensive trials and evaluations from Year 2000 to 2002 before its introduction in 2003.

So, it has been in operation for the last 15 years. Over the last 15 years, more than 1,000 national servicemen and Regulars have been trained to operate the SSPH, and about 12,500 rounds fired. There has not been any reported injury of servicemen due to the gun lowering for maintenance, or operating in or firing of the SSPH.

I have stated the facts that MINDEF/SAF are aware of, in reply to Members' questions. They include Mr Christopher de Souza, Mr Pritam Singh and Er Dr Lee Bee Wah. We must now leave it to the independent five-member COI led by the State Court judge to determine the factors which led to the death of CFC(NS) Pang. The COI has full access to material and witnesses to determine the facts for themselves. For avoidance of doubt, let me reiterate that the COI need not take into account anything in my Statement in Parliament today.

Everything asked for by the COI will be released to them. I do not foresee needing to withhold any information for security reasons. The COI will also make specific recommendations to rectify any systemic or human lapses found. In the meantime, the two other servicemen deployed from have been re-deployed from their operational roles. We owe it to CFC(NS) Pang and his family, indeed to all Singaporeans, to get to the bottom of what happened, and make things right, to ensure the safety of the NS training system as a whole. I ask that all of us respect these objective and impartial processes that are underway, to reserve our judgement and wait for the conclusions of the COI, which will be presented in Parliament subsequently.

Let me now share the COI's findings on CFC Liu who died on 3 November 2018 after a Bionix reversed into a Land Rover of which he was the driver. As explained earlier in the House, the COI is enabled and governed by the SAF Act. Its mandate is fact finding and not to determine culpability of individuals.

To determine culpability, separate and independent from the COI, Police investigations are on-going. Thereafter the Attorney-General's Chambers (AGC) will decide if any persons should be prosecuted. Internally, MINDEF will conduct its own investigations and may charge persons who breach military law in the Military Court, even if the AGC does not file criminal charges.

The COI of CFC Liu Kai will take into account findings from these various judicial processes before finalising its report.

On 3 November 2018, the 42nd Battalion Singapore Armoured Regiment (42 SAR) was conducting a two-sided company mission exercise at the Jalan Murai training area. As with all such exercises, a Regular trainer of Captain rank from the Active Unit Training Centre was assigned to evaluate the exercise troops. The trainer used a Land Rover whose driver was CFC Liu, a Transport Operator.

Let me orientate Members to the Bionix's crew. [Slides were shown to hon Members.] This is the Bionix and the crew comprises four persons. For this particular incident, a full-time national serviceman who was in the position of the vehicle commander (Second Lieutenant), a rear guide when the vehicle reverses, he was the Third Sergeant NSF, the driver and the gunner who were both Corporals.

The COI determined that the servicemen involved were qualified to participate in the exercise having undergone the requisite training for their roles. On 2 November 2018 the trainer met the Bionix vehicle commander to understand their manoeuvre plan for the next day’s exercise. The COI was of the view that the servicemen involved had had their rest in accordance to the Training Safety Regulations (TSR), and that their mental and physical states were fit for participation in the activity and did not appear to have an effect on their attention to safety protocols.

The COI also found that the Land Rover that CFC Liu was driving was serviceable.

The Land Rover has two cameras – one that records events in front of the vehicle and the second that records events inside the cabin of the Land Rover. The COI was able to piece together a detailed chronology from these camera recordings and statements from multiple witnesses. I will bring Members through the events in detail by showing a series of graphics.

The exercise started on the morning of 3 November 2018 at 7 o'clock. CFC Liu and the trainer were in the Land Rover following their assigned Bionix. At around 9.58, the Bionix crew spotted several vehicles passing by at the junction ahead of it and stopped the Bionix, as ordered by the vehicle commander. Responding to this, the Land Rover driven by CFC Liu also stopped.

The COI found that the trainer had instructed CFC Liu to move the Land Rover forward to overtake the Bionix. Just as CFC Liu started to move forward slowly, shots were fired as part of the exercise. Upon hearing the gunshots, CFC Liu stopped the Land Rover behind the Bionix and based on the COI's calculations, this final position of the Land Rover would have been at a distance of "at most 19.8m from the Bionix, but short of the safety distance of 30m stated in the Training Safety Regulations (TSR)."

Four seconds after the Land Rover had stopped, the Bionix started to reverse as part of the extrication drill ordered by the Bionix vehicle commander, in responding to the shots. Let me explain a little bit about extrication drills. How well and quickly armour combat crews can extricate themselves when fired upon, can make a big difference as to whether they survive an enemy onslaught or are captured or destroyed. The COI acknowledged the need for this type of training, even though it is high risk.

The Bionix as part of the prescribed drill had to reverse so that its guns could continue to fire forward at the enemy. As the driver of the Bionix is unable to see behind him or behind the vehicle, the rear guide directs the driver in reversing the vehicle. You remember the picture I showed the Bionix with the driver in front – he can see forward. It is the rear guide who must guide him in reversing. As the Bionix reversed, the Land Rover was initially not in its path. The COI found that the Bionix had "drifted" in reversing and the driver made a slight steer to correct this drift. This steer brought the Land Rover into the path of the Bionix. The COI did not find any mechanical problems with the Bionix's steering equipment.

Almost immediately after the Bionix started reversing, the video recordings from the Land Rover's front facing camera show the Third Sergeant rear guide of the Bionix, quote, "gesturing at the Land Rover to move away and then pushing the mic of his helmet closer to his mouth". The COI found that the rear guide issued stop commands into the intercom of his helmet set when the Bionix started reversing and did so repeatedly. The intercom of the helmet is the rear guide’s only means of communication with the other crew members in the Bionix. However, the Bionix continued to reverse.

The video recording of the interior of the Land Rover cabin showed the Captain trainer tapping CFC Liu and signalling him to reverse the Land Rover. From the beeping sounds, it also indicated that CFC Liu did engage the reverse gear. Both the trainer and CFC Liu also shouted and gestured with their hands for the Bionix to stop and the trainer also attempted to reach for the handset of the radio set to communicate with the Bionix crew.

Approximately eight seconds after it started reversing, the Bionix collided into the Land Rover and mounted the driver's side before coming to a stop. The trainer could extricate himself but CFC Liu remained trapped. The trainer notified the Conducting Officer of the exercise who immediately ordered the exercise to cease.

A medic on board a nearby Bionix immediately tended to CFC Liu. The SAF Emergency Ambulance Service (EAS), unit medical officer and Singapore Civil Defence Force (SCDF) were activated and arrived on site. Unfortunately, CFC Liu succumbed to his injuries. He was pronounced dead by the unit medical officer on site at around 1035 hours. The cause of death as determined by post-mortem was traumatic asphyxia.

The COI noted that the rear guide had repeatedly given the order for the driver to stop reversing through the intercom via his helmet. The COI noted that the intercom system was working earlier in the exercise. The COI has asked for an independent technical assessment report on whether the intercom system was working properly all the time. In parallel, Police investigations too are also focused on the communications between the Bionix crew and whether this was affected by the equipment. This is, of course, an important point that needs to be resolved but we will have to await the outcome of the Police investigations.

The COI made several findings in their report: first, the COI noted that ensuring the safety distance is the responsibility of the vehicle commander of the Land Rover. In this case, the Land Rover ended up in a position that was less than the required safety distance from the Bionix; second, the reversing of the Bionix from the simulated enemy encounter brought the Land Rover into the path of the Bionix.

The COI found that a safety management plan was included as part of the exercise, and in line with standard practice. The COI also found there was adequate deployment of medics and medical equipment as part of this plan for medical response.

I now share the ERPSS' written report on the COI findings, and it will be distributed to Members, with the Speaker's permission, and be public subsequently. [Handouts were distributed to hon Members. Please refer to Annex 1.]

To summarise the report, they agreed with the COI's findings on the incident and proposed improvements that could be made to the safety management, emergency response system and combat vehicle safety, and the details are in the report. Much of what the ERPSS commented, I have already outlined in my Ministerial Statement.

It will now be up to the AGC to decide if there are grounds to prosecute any person in the criminal Courts for the death of CFC Liu Kai. If no criminal charges are filed, MINDEF will take disciplinary measures for lapses identified in this incident in our military court. We will update Members and the public on these disciplinary measures. In the meantime, the servicemen involved in this incident have been re-deployed to non-operational roles.

Mr Speaker, CFC Liu Kai was a well-liked and respected soldier. He served with pride and was remembered by his peers for his dedication and commitment. We mourn the loss of this precious son. And we hope that the measures the SAF has put in place will prevent a similar incident in the future.

And these are questions that Members, including Mr Desmond Choo, have asked. In response to the COI's findings and its own internal review, the following measures have or will be put in place by the SAF.

First, in addition to the existing emergency horn (e-horn) activation button in the front for the vehicle commander, two more e-horn buttons have been installed in the rear of all Bionix vehicles used for training. So, before the incident there was one in front; now two more have been put in the rear of the Bionix for training vehicles. This is to sound the alarm in the event of an intercom failure.

Second, from March this year, rear-view cameras will be progressively installed into our training fleet of Bionix vehicles, so that the driver can see during reversing. The Army will study if these new features – the safety horns and the camera, the rear-view camera – ought to be incorporated for the operational vehicles as well. All heavy-wheeled vehicles, such as five-tonners, will also be progressively installed with rear-view cameras and mirrors to reduce blind spots.

Third, as with live firing exercises, the Army will also now conduct safety Table Top Exercises for all high risk non-live firing exercises before the actual execution. I think some Members asked about this. This includes familiarisation with emergency measures and evacuation plans.

Fourth, more experienced Regulars have been added as trainers.

Fifth, starting from March this year, medics will upgrade their skills in resuscitation and handling of emergencies through attachments to hospital emergency departments or ambulances.

Sixth, vehicle and equipment serviceability will be improved based on recommendations of the external panel.

Finally, with regard to the safety distance between vehicles. In an exercise area, vehicles are used for a variety of administrative, safety and training purposes. The current distance of 30 metres was prescribed after evaluation and tests and in general, assessed to be adequate for safety and still allow supporting elements to be responsive to events on the ground. But where vehicles have to reverse such as in extrication drills, the Army has put in new measures to enhance safety.

First, trainers will no longer travel in Land Rovers but will join exercise troops in the combat vehicles during high risk training.

Second, for all reversing manoeuvres including extrication drills, the driver can only move the vehicle backwards with the explicit clearance of the rear guide. These two measures, together with the extra emergency horn buttons, will enhance safety and still allow armour units to practise extrication drills. Further, the Army will ensure that only essential vehicles are allowed into the exercise area to minimise the risk of accidents.

Apart from these specific measures, in response to the recent NS deaths, the SAF has decided that for the safety system as a whole, a dedicated unit will be set up at the highest level to drive and supervise a safety culture and enforcement against slack practices. This move also responds to ERPSS finding that while the safety policies and management systems of the SAF are largely in place, there was a need for more compliance checks and ground level audits.

In line with this objective, the SAF will undertake the following systemic measures:

The current Safety and Systems Review Directorate (SSRD) will be expanded and elevated to an Inspector-General Office under the Chief of Defence Force (CDF) to oversee all Services. The Office will be headed by the SAF Inspector-General. The Chief of Staff-Joint Staff (COS-JS), which is an existing appointment of a Service Chief equivalent, will concurrently be the Inspector-General. This dual function is synergistic as the COS-JS has an overview of all operations and as Inspector-General, will have the authority to ensure that Safety First habits and processes are incorporated at all levels of training. More safety officers will be deployed to assist individual units and supervise training activities. There will be more safety audits of units by inspection teams in the Services and supervised by the Inspector-General Office (IGO).

Second, commanders of units which do not meet standards and have committed lapses in safety procedures and processes will have this marked against them in their performance reviews. Let me emphasise that such commanders will be deemed to have performed unsatisfactorily even if accidents have not occurred. This is the right emphasis to prevent accidents.

In the past few weeks, the CDF reduced the tempo for every unit to review its processes, and to emphasise to the troops a safety consciousness to protect themselves and their buddies. Units that are on live operations such as those protecting key installations are not affected by this measure and will continue to be vigilant. Basic types of training have resumed since 7 February. Individual units will continue to be audited and will resume realistic training when safety processes are assessed to be in place.

Some Members – Mr Darryl David, Mr Chong Kee Hiong and Mr Leon Perera – have asked if external agencies review our system to detect root issues. The ERPSS, which consists of prominent safety experts and professionals outside the SAF, is tasked primarily with this mission. The SAF's safety system is aligned to international frameworks and regulations, such as the Occupational Health and Safety System framework (OHSAS 18001). It comprises: rules that mitigate safety risks in the conduct of all training; processes and training to build up competency of our servicemen and to make sure that the rules are properly applied; inspections and reporting mechanisms to ensure that the rules are followed; and consequences if they are not followed.

Quite a few Members – Prof Fatimah Lateef, Miss Cheng Li Hui, Ms Joan Pereira and Miss Cheryl Chan – have asked even with safety instructions are adequately in place, how do we ensure that national servicemen are familiar and safety conscious. It is an important question. And also if the SAF has taken into account the abrupt switch from civilian environment to military training where there are much larger and potentially dangerous equipment. Another good question.

These are important issues that need to be factored into our safety systems. One suggestion has been to outsource all maintenance work with heavy vehicles or machinery. This is not possible. Complex maintenance tasks that require specialised tools and equipment are already outsourced. But we still need national servicemen technicians to be with their units to perform basic maintenance so that their equipment can function during operations.

We do cater time for NSmen soldiers to adjust from their civilian settings. Before any activity commences, a safety brief is held and inspections conducted to check that soldiers are in good physical state, and that vehicles and equipment are serviceable. Soldiers must also complete an individual risk assessment checklist and raise safety concerns to their superiors for mitigation before any activity begins.

NS training is conducted progressively starting with refresher training for individual skills and proficiencies before any operations are conducted. Prior to their deployment, further training, such as with a simulator, is conducted. I think one Member asked about this.

The IGO will review if further mitigating measures are needed to help NSmen adjust from civilian life to in-camp training.

Members have asked, and this includes a question from Member Er Dr Lee Bee Wah, if we punish safety lapses, even when they do not lead to injury. Over the past three years, an average of 2% of servicemen a year was punished under the SAF Act for safety lapses – 2 %. Their punishments ranged from a fine to detention and administrative penalties such as delays in promotion and reduction in benefits.

At the same time, we reward servicemen who demonstrate safe behaviour. Units and individuals are recognised during the Service’s respective annual Safety Day. Member Mr Mohamed Irshad enquired about this.

If we are to achieve zero fatalities during NS training, we must have a strong safety culture in all our units and safety consciousness down to the last soldier. Commanders and supervisors must lead by example to emphasise safety and all commanders undergo safety training, and must know that safety lapses will affect their performance review. Safety Officers who are former senior commanders help ensure the safe conduct of training. Experienced Regular trainers partner the national servicemen commanders to design training and safety plans. Soldiers must have a strong respect for safety rules, take care of one another and speak out on safety concerns. Incentives and disincentives must be aligned to achieve the right safety outcomes. Our safety system must weed out unsafe practices, even when they do not lead to accidents. This was a point, I think, in the question of Member Ms Irene Quay Siew Ching.

Individual soldiers are encouraged to report unsafe practices and risky behaviour to their superiors without fear of reprisal, or regardless of rank, to call for an immediate stop to training. We do not reward, nor should signal that we reward adventurous behaviour. And this is in the Training Safety Regulations. So, let me quote it in full. It is in chapter 1, section 2, paragraph 11: "Anyone who spots a safety breach or unsafe practice can call for an immediate stop to it, rectify when possible and report to the Conducting Officer. Once notified, the Conducting Officer should verify the report and when necessary rectify the safety breach or unsafe practice. The Conducting Officer must update the Supervising Officer on the measures taken to rectify the safety breach or unsafe practice."

Anyone who spots the safety breach, not only commanders, but anyone.

Servicemen can also report safety incidents and near-misses through a 24-hour safety hotline. This safety hotline receives about 140 calls a year.

Ultimately, safety is both a command and individual responsibility and everyone needs to play their part because precious lives depend on it. It is not true that we cannot train safely if we want to train realistically.

If we have a strong safety culture and safety systems, it will give soldiers greater confidence to train hard and realistically. SAF commanders are convinced that it can be done, and these measures I have outlined today, will lead us to that goal of zero training fatalities.

Mr Speaker, the loss of any soldier is devastating. It leaves a void that cannot be filled in the lives of family members and friends, and its impact is deep and far-reaching. It will take much time for their grief to run its course.

Members Ms Anthea Ong and Mr Chong Kee Hiong have asked about assistance when a death occurs. Within the SAF dedicated grief counsellors are assigned to provide support to the serviceman’s family members in the aftermath of their loss. For our soldiers, a team of psychologists, counsellors and psychiatrists are deployed to assist unit commanders and servicemen in their recovery from the stress in such incidents. MINDEF does take the families' request into consideration when deploying a deceased serviceman's immediate family members during their NS.

Over the past 17 months, four national servicemen have passed away during training. In 2012, the SAF also experienced four training fatalities that year. But from 2013 to 2016, we had none. How did this turnaround occur? This was probably due to multiple factors, but I think the new safety measures we put into place after the devastating incidents of 2012 had an effect. If we put our minds and efforts to achieve zero training fatalities, it can be achieved.

Four families have experienced much sorrow after their irreplaceable loss these past months. Singapore has lost precious sons. As deep as the hurt, as great the loss, we must not forget why we suffer them. When the founding generation pledged themselves to build a strong SAF, they were fully conscious that a strong military is only possible with fully committed national servicemen drawn from every family in Singapore. They knew the costs and sacrifice that would be required. Not only in resources that we invest in at every Budget, but much more precious would be the time, the sweat, the tears, even the lives of precious sons.

Inherently, military training poses risk. On any given day within the SAF, thousands of national servicemen train hard, amid moving tonnes of steel, bullets, munitions and other explosives. Why do our national servicemen do it? They do it to protect Singapore. Because without national servicemen, we cannot have an SAF or the Home Team that can deter terrorists from attacking Changi Airport or Jurong or harming innocent civilians in shopping malls and crowded places. Without national servicemen and the SAF, potential aggressors would not shy away from simply marching into and occupying today’s affluent Singapore, as Iraq did to Kuwait. Without a strong defence, our air and shipping routes in and out of Singapore could easily be blocked – as Qatar now faces. These are not imaginary security threats that our national servicemen train for but real – they have happened elsewhere and can occur to Singapore too.

We must never give up on National Service that forms the backbone of our SAF for national defence. This imperative of National Service and our national defence does not absolve or reduce the accountability of MINDEF and the SAF in any way, to ensure safe training. On the contrary, it compels MINDEF and the SAF to do all that is humanly possible to prevent training deaths for national servicemen because precious sons have been entrusted to us by their families. MINDEF and the SAF will hold ourselves accountable for every single national serviceman entrusted to us. I am deeply sorry for the loss of four precious national servicemen in the last 17 months. The SAF will strengthen its safety systems. Even as we honour those who died in service of our country, we must soldier on, to build a strong defence, to protect Singapore and to protect every national serviceman during training. Thank you, Speaker.

1.19 pm

Mr Alex Yam (Marsiling-Yew Tee): I thank the Minister for his comprehensive response and Ministerial Statement. I have three supplementary questions.

With regard to the safety timeout called this time for CFC(NS) Aloysius Pang, how does this compare to the length of time of safety timeout called for previous training incidents, and whether there were any reasons for calling for a longer or shorter timeout?

I also understand that from 7 February, the safety timeout is progressively being lifted. With the time that has passed since the incident and the timeout was originally called for, I do hope that the SAF and the commanders will also observe as much safety precautions as possible as men catch up on the training that they have missed out during this period of time.

The second question is with regard to further assuring Singaporean parents. CFC(NS) Aloysius Pang was my resident. Fellow residents in my constituency knew him well. Over the course of the last few weeks, as I visited families in their flats as we held gatherings, many parents have come up to me and asked about safety, about reassurances for their children. But what I am heartened by is that none of the parents that have spoken to me have ever said we should do away with National Service. Many of them prefaced their statement by saying that we have also served and we know that the SAF takes safety seriously. But with four recent incidents, they are worried. So, how do we reassure them that safety is paramount, that their children will be taken care of.

Lastly, I welcome Minister's announcement that rear-view cameras, reverse cameras, will be installed in the Bionix as well as the five-tonners. I was previously with the Transport Section of the 328th Battalion Singapore Combat Engineers. I looked after the five-tonners as well as other transport equipment. These equipment are huge. Although we go through vigorous training and we ensure that there is always a vehicle commander or a safety officer to ensure that when we reverse these vehicles, there are occasions where lapses do occur and minor accidents do happen, fortunately not involving human lives.

So, I do ask if the SAF will consider installing these cameras in all our SAF vehicles eventually, so that it includes an additional safety element for the driver on top of all the other safety features, as well as the vehicle commander and safety officers that we already practise today.

Dr Ng Eng Hen: Mr Speaker, let me take the questions in turn.

How different is this timeout from previous timeout? It is significantly different. Previously, there was a period and then units would revert back to their original activity. But as the Member rightly pointed out, after four deaths, old practices must be changed. You must start with the basis that there might be something wrong and look for that factor, whatever that factor is, and that is just a precaution.

So, the difference is units on operations carry on. We had a period of safety timeout but it has been lifted only for certain activities. More complex ones, more high-risk ones, CDF and his commanders want to be satisfied that not only are the training safety regulations in place, but that there is adequate behaviour, adequate culture in that unit, before you undertake them; and I fully support that. So, there is not as if after a certain period, behaviours will automatically correct.

Rear-view cameras for all vehicles. Intuitively and in principle, it makes sense. But as you can well imagine, the SAF runs platforms of various generations. In fact, the most recent generations, the Terrexes, even our Leopard tanks, have rear-view cameras. But you inherit a long tail and the Bionix was in operation since, I think, the 1990s. With this incident, we decided that we will do it for training vehicles; we are reviewing if we should also do it for operational. So, I would say, in principle, yes, but there are other considerations. But, in principle, I think that is what we want to do and, certainly, as I said, for those that need to reverse, that are reversing, we will put in not only rear-view cameras but mirrors to reduce blind spots.

There was another question of reassurance of parents. How do you reassure parents that their sons will be safe? And I am glad what the Member Mr Alex Yam has said, that no parent has come to him to say they want to do away with NS. The parents want to know that you are doing your level best, and that you will pay attention. Singaporeans are reasonable, they know that we want to train.

But let me give you another perspective as well. In these two incidents and a number of incidents that I shared in this House. I shared with you the incident of Gavin Chan, who was training overseas as well when his Bionix overturned. And I gave you the findings of the COI. When asked by his crew to switch on the headlights, he said "We should not do it. It would give our position away to the enemy". In the case of Dave Lee, the heatstroke, he pushed himself beyond what he was able. In this case, Liu Kai, they wanted to be realistic, extrication drills.

We have come very far when national servicemen say, "I want to train as realistically as I can". What if we had the reverse situation where everyone attends training but nobody trains? I think we have to take what is good in our system and respond practically. The results must be the ultimate comfort for parents. We will do as much as we can practically each time our COIs tell us there is a lapse or a weakness that needs to be addressed, but I need at every level a safety consciousness, a safety culture. And I tell you, it does not come overnight and may not come even after many years, to raise the level of safety culture.

I had been the Minister for Manpower, and you will remember the particular period, the Nicoll Highway collapse, the Fusionopolis incident, the COIs that we had. In order to strengthen our system, we went overseas to the Nordic countries, to some European countries, which have higher standards than us. They told me a very interesting example of a particular bridge that was built by two Nordic countries. I will not name them because there are implications which will be explained once I have shared. Two Nordic countries building a bridge to connect the two. Same specifications, they will meet in the middle. One country had half the number of deaths and injuries of the other country. All comes down to culture. And who decides the culture? It is all of us, our children, our friends, our relatives.

I have said very clearly and in no uncertain terms that anyone can stop unsafe training. If you think it is unsafe for your buddies, for yourself, raise it. If you think that somebody is pushing beyond his means to physical harm, do so. I think, that way, we maintain realistic training and give comfort to our parents.

Mr Dennis Tan Lip Fong (Non-Constituency Member): I thank the Minister for his answers. The Minister mentioned that for the commanders of units where there are some safety breaches, there will be a mark on their record. Can I ask the Minister at what level would this be? Would it be at the battalion level, the brigade, or the division, formation level?

Related to this, I note that the NS training deaths in recent years have involved different vocations, different formation and command. I think in some of these cases where disciplinary actions have been taken, they were taken against junior or mid-level commanders. Moreover, each COI usually does not go beyond the remit of that particular incident in question. So, at what point and at what stage would the Government think that it would be necessary to send a signal to the entire Force when they recognise that there may be a problem at the systemic or a greater level requiring a senior officer, whether at formation, army, SAF or beyond, to take responsibility on this?

I say this, bearing in mind some examples from overseas. In 2013, a Taiwanese conscript died after being physically punished by his superiors. Four officers were charged and the Defence Minister was also quick to take responsibility. In 2017, the US Pacific Seventh Fleet commander was relieved of his command after four accidents involving the Seventh Fleet. The reason given was that there was a loss of confidence in his ability to command. At the same time, while each of these four incidents is unique, they cannot be viewed in isolation – that was the reason given. Also, the US Navy went on to say that there will be a deliberate reset of all the ships, focus on navigation, mechanical systems and bridge resource management.

Dr Ng Eng Hen: Mr Speaker, there are two main questions, one for commanders with safety lapses. As I have said, even those that do not lead to accidents will affect their performance review, and so that signal is quite clear. How high should you go up? I think we want to be careful that we do what we think works and makes a difference. If senior leadership has to go because they have been involved or have been derelict, then I do not think our population will stand for that. And if you think that that improves the system, push for it. But let us deal with the issue on the ground. I have presented the facts as much as I can. We have had independent reviews, people outside the SAF and MINDEF all looking into the problem. And if they decide that a change of the most senior leadership makes a difference, well it is up to them to recommend. But, for MINDEF and the SAF, we want to deal with day-to-day issues, aligning our incentives and disincentives so we get the whole system moving and making sure that the effect is felt on the ground, rather than posturing or politicking.

Mr Vikram Nair (Sembawang): I thank the Minister. As a serving NSman, I think incidents like this move us very strongly because we know it could be us or any other people serving with us. In relation to this, I have two questions: in any organisation like the army, we know the work we do is inherently risky and if any human error is made, incidents can happen. Are there any other models of other armies, for example, where they have been able to achieve zero training deaths? I think Minister mentioned as Minister for Manpower, he looked at other countries – are there any armies we can learn from? That is the first question.

And the second, if this incident is the result of, say, human error rather than systemic lapses, is there a need to halt training across the whole system? My concern, of course, is the message we may send to other parties who would be looking at us to see whether the Singapore army is able to deal with adversity? I think most serving NSmen I have spoken to remain ready to serve and ready to go forward.

Dr Ng Eng Hen: I thank Mr Vikram Nair for his reassuring comments. Can we learn from other militaries? We have looked at figures to see what injury and fatality rates for other militaries are. And, of course, we want to benchmark and make sure that we are somewhere there. But that is difficult because you cannot compare like and like. Systems with conscript systems, Taiwan and South Korea, their data is shared in different ways so that is not comparable. There is a military that we can sort of compare training and that is the UK but that is not conscript, that is regular service. And over a 10-year period, our safety records are just slightly better than theirs but that is not a reflection. They may have different terrain and so on and so forth.

I think we have to ask ourselves, where is our system at? Is this a systemic flaw? And when we ask these questions, remember as you said, so many of us here have or are serving National Service. We know what it is about and some of you even blog your experiences when you go to NS. It is not divorced from reality where there is one group doing National Service and another group just commenting on it. The very people who comment are the ones who do it every year when you go in and you know what the reality is. If you think that the system has degraded to a point, point out where it is and we will fix it.

But, if we are experiencing injuries and deaths as a result, as the Member said, human error, then neither should we punish indiscriminately, even those who are not involved nor degrade what has taken years for us to achieve. That does not bring anyone any comfort or positive results.

Deal with the issue, strengthen the system bit by bit and it will take years. You know how it is with some commercial companies. Before every board meeting, they repeat the same thing over and over again – the safety instructions, they tell you where the exits are. And I was told that even in some countries, the safety officer saw some chap walking up the stairs not using the stair rail and says, "This is a safety breach – you should use the stair rail because you can fall." You say it may be overboard, but there is a meaning to it, I think. And I think that can help. You need to have proper instructions and each time something happens, we must be open, we will review it, get independent parties to look at it, and then strengthen it.

Do we want a system where everyone is afraid? You walk into a room and everyone is frightened that if anything happens, his head will be chopped, more heads will be chopped, up, down. I have dealt with many organisations, both in my private life and in Government. I noticed that the best organisations run not ones which are on tenterhooks, fearful of reprisals so that they dare not do anything, and not ones that are slack. In fact, a slightly busy outfit is the best outfit. Too little, some things happen, too busy. You go into any organisation, you want people who are professional, who know what they do, who are conscious, who are not out just to punish unfairly, but to say how do I make this system better because it will take time, it will take effort, and it will take the part of everybody in their organisation to do so.

Mr Christopher de Souza (Holland-Bukit Timah): I thank the Minister for his strong statement. Indeed we must strive to marry safety and creating a real operational environment. As a suggestion, would MINDEF consider re-employing retired officers and specialists who have operational and safety experience to train our NSFs and NSmen on what risks to look out for prior to on-the-ground missions? These retired or near to retirement SAF officers and Specialists have a wealth of experience to share; this could be a body separate from the IGO.

Dr Ng Eng Hen: Mr Speaker, not only will we take up the suggestion, we are already doing it. That is exactly one of the resources that we looked upon. But even that is in short supply – retired, experienced WOs, officers. And you remember the committee to strengthen National Service that we started up a couple of years ago where we wanted to put more trainers instead of national servicemen, we wanted to put those with the experience and that is exactly what we did. We extended the terms of service for the retired Warrant Officers because they serve as a valuable resource. So, because of this, we have redeployed, put safety as a priority, but we will also look for other avenues where we can put more experience on the ground to help our national servicemen as well as young officers build up the training and safety capabilities.

Mr Pritam Singh (Aljunied): Mr Speaker, just two questions for the Minister. My first pertains to the non-operational responsibilities on NSmen and NSFs such as NDP and Army Half Marathon. Some would be of the view that some aspects of organising such events could be undertaken by the private sector. To that extent, is MINDEF, as part of this safety review, looking into the time NSFs and NSmen have, to focus on training, maintenance and other operational responsibilities? So, that is the first question.

The second one pertains to the handout that Minister gave. This was the External Review Panel's report on the Committee of Inquiry's preliminary findings on the death of CFC Liu Kai. Paragraph 6(b) states that the SAF's medical response is based on the concept of rapid evacuation to the next echelon of care, however, such a response may not be adequate when a casualty cannot be evacuated promptly as in CFC Liu Kai's case. Can the Minister share why CFC Liu Kai was not evacuated promptly even though it does state earlier in the report that even if he could have been evacuated, he probably still would have demised from his injuries.

Dr Ng Eng Hen: I agree with the Member that we want to be careful as we are moving in this safety journey to allow time for units to focus on safety and if they are administrative aspects that deter them from it, then we should be prepared to relook. But this is a Command decision. CDF, the Commanders, the COs of the units must themselves come to and decide which is the tempo and you are quite right. For certain activities, they have relooked it, I will leave it to them to announce what they are not going to do so that it gives them enough bandwidth to focus on safety. That is a clear response to that.

For CFC Liu Kai's extrication, Members will understand why I have not gone into details but it was difficult to extricate.

Er Dr Lee Bee Wah (Nee Soon): I would like to ask Minister, just now Minister mentioned that anybody can stop training if they find that it is not safe. I would like to ask, how to stop training, is there a hotline, or is there a whistle-blower hotline? How to assure them that they will not be dealt with unfairly later on if they were to report or being "tekan"? In fact, recently, quite a number of mothers and grandmothers came to talk to me because their son or their grandson are going into NS, so they worry about this culture. So, can Minister address that please?

Dr Ng Eng Hen: I think the reassurance is what the Members have asked in this House and what I have said, I stated very clearly there is a TSR that anyone can stop. On the ground, usually in activities, you have a safety officer and a conducting officer. But even the CO of the activity who is supervising and the other conducting officers, if you bring it up to them, we want to have a culture where the person can assess the safety and risks. So, on the ground, there are avenues, that is in real time. But apart from that, if there is a recurrent safety lapse or risky behaviour, we have safety hotlines which you can call anonymously or you can write and we will take action. I think the message is very clear to the units after this Statement. It has always been, but if it needs to be clearer because of the reiteration, then remember that unsafe practices will not be tolerated.

Ms Joan Pereira (Tanjong Pagar): I met a family of a deceased soldier about two years ago and his mother told me it is hard for the pain to go away. In fact, she told me, it will never go away. As a mother, I felt for her and I can understand fully her pain. I know Minister highlighted earlier about the support through grief counsellors given to the platoon mates and to the families of the deceased soldiers. However, I would like to know if such emotional and psychological support is sufficient and if, indeed, more can be done to provide such support to the families?

Dr Ng Eng Hen: All of us can imagine how difficult it is for any parent and mothers to have to lose their sons. And all we can do is to pray that there will be some comfort. I have already shared how we provide relief by grief counsellors but even our efforts need to be very sensitive. Not all families can accept it at the time but we should always just be there to offer the help and be consistently there if it is needed. This is an area which you want to retain people in and yet you hope that you do not need their services. We are striking that balance and I have asked them to train a cadre of grief counsellors that can have institutional memory and that can help others in this similar type of vocation be able to assist those who have been bereaved.

Ms Anthea Ong (Nominated Member): I have two questions. The first one is when can we expect the findings of the COI on CFC (NS) Pang's case, if there is an indication to when the findings will be released?

The second is, we all know there cannot be total safety without psychosocial safety. Could the Minister share a little bit of the elements within this safety culture we are building that relates to the psychosocial safety climate, please?

Dr Ng Eng Hen: The COI is independent, so they take as much time as they need and I have no control over how fast or how quickly they want to conclude it. If they find that they need more information or facts, we will give them the fullness of time that they require. But normally, as was the case with CFC Liu Kai, it takes a number of months, from anything from two to four months.

The psychosocial aspect is incredibly important and we are not dealing with something which is esoteric. Safety cultures occur in many industries. The need for safety, whether it is construction, heavy machinery, and the same challenges we face in the workplace also apply to both military and civilian settings. So, it is a science and there are experts at it; and there are benchmarks. As I have said, this is intangible of safety culture. And in these conversations like I had, like many of you had over this Chinese New Year period when we talked about why this is happening, and there is always somewhat a tendency to say, "Well, one generation is different from the other."

In the Merdeka Generation, in the Pioneer Generation, it is more of aware of risks, because when we grew up, when we crossed roads, it was always a run or very hazardous. But a newer generation lives in a more structured environment. I do not know what the truth is. We will just have to deal with it and keep strengthening and keep tightening where we feel that it has to be and continue to move it. And if more people buy into this safety culture, I think it will help. But it cannot be dependent on that. It is very clear this is a Command responsibility. Commanders will be taken to task if they ignore safety instructions or have a poor safety culture.

Mr Speaker: Prof Fatimah Lateef.

Prof Fatimah Lateef (Marine Parade): Mr Speaker, I listened to the Minister's explanation with great interest. Also, being a Director of Quality, Clinical Service and Patient Safety in Emergency Medicine and Trauma, so that really has got a synergy between the two. The fact that the Minister mentioned that the incorporation of safety culture practices into the whole organisation is welcomed.

But more than that, I think, looking at the examples given by the Minister and the whole description, it is actually about human factors – human factors and human errors. So there are people who study human factors, human factor science, human factor analysis and perhaps, this is one area of focus, not just after an incident happens but also perhaps as a preventive measure to get human factor specialists to actually study some of the more high-risk activities. Probably, you will not be able to study all the activities that go on in the SAF just as we cannot do it in medicine but perhaps the more high risk activities that people are going to be involved in, and especially, compared to medicine, you are involved with more heavy machinery and equipment. So, how do we use human factor specialists to help us with this?

Dr Ng Eng Hen: The Member has raised a very important, relevant point and it is incorporated. Some of you would remember that the RSAF in the 1990s, had a spate of very difficult incidents. It was gut-wrenching – pilots. And today, the RSAF is a far cry from that. And that is exactly what they have incorporated, where they report near misses for equipment and near misses arising from human error. They separate it because the solutions are different. All our services do it, to some extent, but Army is a much larger machinery. Many tens of thousands people running around. But we have got to get that into our system at every level. And it will be up to commanders and they are going to give it their all because they know this is their moral responsibility; this is their professional accountability and this is something that we must get right.

Mr Speaker: Mr Liang Eng Hwa.

Mr Liang Eng Hwa (Holland-Bukit Timah): Sir, the Minister mentioned about the Inspector-General Office (IGO). I would like to ask the Minister how more effective can the IGO be than the current set-up. I believe you have the SSRD. What difference, how much more different and how much effective can it be?

Secondly, the Minister mentioned about servicemen being able to report near misses or incidents. I know some servicemen, for some reasons, may not want to report some of these incidents because of unit cohesion and other matters as well. Can I ask the Minister: is there a way, whether MINDEF or SAF would, maybe go directly to the servicemen to do surveys to get an overall sense of training risks and then from there, perhaps to get to be more aware of incidents that could happen on the ground?

Dr Ng Eng Hen: Mr Speaker, the Member has asked about these so-called "silent" surveys, and we have them in the civilian settings – the Mystery Shopper, for example. And yes, there is much on the cards where you do safety audits and you check; you have now hotlines that people can call in. So, that will be part of the menu of things that we will have to ramp up. It already exists but we want to make sure that it is more accessible and the message gets through.

How effective is the Inspector-General? Well, when the Inspector-General, who is the Chief of Staff-Joint Staff (COS-JS) calls you, you listen, and you better listen.

Mr Speaker: Assoc Prof Walter Theseira.

Assoc Prof Walter Theseira (Nominated Member): Thank you, Mr Speaker. I refer to the instruction given by the trainer to CFC Liu to move the Land Rover forward and overtake the Bionix. What is known about the reasons why this instruction was given? And second, was the trainer and CFC Liu briefed on the expected manoveurs during the exercise, including the possibility of an extrication drill happening?

Dr Ng Eng Hen: Mr Speaker, I presented what the COI found. And for the first question why he asked him to move forward, it was not clear to the COI and we have to leave it to the Police. That has got legal implications. Second, was CFC Liu familiar with these aspects? He was attached to an Armour Unit. As I have said, extrication drills are part and parcel of the exercise.

Mr Speaker: Order. End of Ministerial Statement.