SINGAPORE: The training accident that led to the death of national serviceman Aloysius Pang in January was due to lapses by Pang and two other servicemen who were in the Singapore Self-Propelled Howitzer (SSPH) at the time, a Committee of Inquiry (COI) has found.
The five-member committee, which interviewed more than 20 people involved in the incident, also found no evidence indicating that the accident was caused by foul play or deliberate acts, Defence Minister Ng Eng Hen told Parliament in a ministerial statement on Monday (May 6).
Corporal First Class (National Service) Pang died after sustaining serious injuries during a Singapore Armed Forces (SAF) training exercise in New Zealand. Pang was crushed between the gun barrel and cabin while carrying out maintenance work in an SSPH.
Pang was inside the SSPH with a gun detachment commander, a Third Sergeant national serviceman, as well as a technician, a Military Expert 2 who is a regular serviceman.
The COI found the “precipitating cause” of the incident was that the gun barrel was lowered without ensuring that everyone was in a safe position:
- Pang was standing in the path of the moving barrel and not in a safe position prior to the barrel being lowered;
- Pang did not move to a safe position despite being warned that the barrel was going to be lowered to a standby position;
- The regular technician did not ensure that Pang moved to a safe position despite knowing that the barrel would be lowered;
- The gun commander proceeded to move the barrel despite noticing that Pang was not in a safe position, which goes against a requirement stated in the SSPH operator’s manual;
- Both the gun commander and regular technician failed to press the emergency stop buttons to stop the barrel movement.
The COI also said that a combination of factors contributed to the incident:
- There was a lack of clarity on who should be in the gun and whether acknowledgement was needed before the barrel was moved, pointing to a lack of coordinated safety control procedure between the gun and maintenance crew;
- The regular technician had started on a specific maintenance task before the barrel was in a locked position, which goes against a requirement stated in the maintenance manual for SSPH technicians, to “get on with the job quickly”;
- The regular technician and gun commander had miscalculated the space in the cabin and the time it took for the flick rammer (the rear end of the barrel in the cabin) to hit Pang;
- In their state of panic, the regular technician and gun commander had “acted irrationally” instead of pressing the emergency stop buttons when the flick rammer hit Pang.
READ: 'Safety lapses, weaknesses in safety culture': External panel raises concerns following Aloysius Pang death
As for the judicial process, Dr Ng said the SAF’s Special Investigation Branch has “nearly completed” separate investigations into the incident, and will report directly to the Chief Military Prosecutor to decide if any servicemen will be prosecuted in a military court for related offences.
“Servicemen under investigation are reassigned to administrative duties, and if found to have been culpable, will be charged and punished accordingly,” he added.
Dr Ng gave a “detailed chronology of events”, established by the COI, leading up to Pang’s injury and subsequent death.
On Jan 19, Pang and a regular technician in an SSPH were conducting corrective maintenance on its gun.
This involved changing a card on the motor drive control unit – ammunition handling system (AHS) box inside the gun.
To do so, the gun barrel had to be lowered to the near-horizontal standby position and locked.
READ: Death of NSman Aloysius Pang: SAF investigation branch looking at possible military, criminal prosecution
But Pang, who had already started loosening screws on the box, was not standing in a designated safe position and had his back facing the barrel.
In a mix of Mandarin and English, the regular technician told Pang that the barrel was going to be moved. He also told Pang to move closer to him or to a safe position. Pang replied in Mandarin that it was fine, and that the barrel would not hit him.
Before moving the barrel, the gun commander said he checked if the path was clear and saw Pang standing near the barrel. The gun commander assumed that Pang would have time to move away, given that it would take some time for the barrel to move from its highest elevated position to the standby position.
The gun commander then shouted, “Standby, clear away”.
It was only when the barrel moved closer to Pang that he began to make some “evasive movements”, the gun commander said.
The regular technician, shocked to see Pang still in the path of the barrel, tried to use his hands to push against the barrel. The gun commander also tried to stop the barrel using the main control screen.
“As the gun barrel made contact with CFC (NS) Pang, the COI opined that instead of activating the emergency stop buttons, both the technician and the gun commander panicked and acted irrationally,” Dr Ng said.
“As a result, CFC (NS) Pang was wedged between the flick rammer and the slew ring,” he added, referring to a cylindrical structure surrounding the cabin.
When asked as to whether the COI found if communication issues, specifically differences in language, affected the servicemen's reaction time, Dr Ng said he would not raise new information to keep within the remit of the COI.
"But there was no indication that communication because of language was an issue within the turret," he added.
"The COI made explicit reference that they knew the safety rules. There was no indication that CFC (NS) Pang did not understand, or took a longer time to understand, that the gun barrel was moving into him and he was in the path."
According to Dr Ng, the COI also did not indicate that time pressure to carry out the maintenance work was "in any way contributory to the injury or death".
Pang was injured on Jan 19 at about 7pm New Zealand time (3pm Singapore time). He was then attended to by the battery medic on site before being evacuated to the battalion casualty station 10 minutes later. There, he was assessed and stabilised before being evacuated to the Waiouru Base Medical Centre at 7.50pm.
At 9.50pm, he was heli-evacuated to Waikato Hospital, where he was operated on at around 1am. Pang underwent two more operations on Jan 21 and 22 before his condition deteriorated.
Pang died two days later from “severe sepsis arising from his severe chest and abdominal injuries”, as a result of being caught between the flick rammer and slew ring in the SSPH.
INCIDENT WAS PREVENTABLE IF SAFETY RULES WERE FOLLOWED
The COI also commented on factors related to but not contributory to the incident or outcome.
It found that there was no mechanical fault with the SSPH gun that had directly caused the incident, adding that technicians certified the guns fit for firing both in Singapore and New Zealand before the exercise.
The COI also said the post-incident medical care was “adequate but can be improved”, given the extenuating circumstances caused by distance and the availability of the helicopter.
However, the COI is also of the opinion that "this did not cause or contribute to” Pang’s death, Dr Ng said.
Dr Ng stated that it was “sad but undeniable” that the direct cause that resulted in the death was “preventable had there been compliance to safety rules”.
“It was not for lack of knowledge of those rules or inexperience of personnel working on the SSPH gun,” he added. “The COI determined that prior to the incident, all three personnel in the gun had received adequate training to be aware that whenever the gun barrel is moved, they must be in a safe position.”
READ: Aloysius Pang first soldier to be injured operating Singapore Self-Propelled Howitzer, MINDEF says
Dr Ng said Pang attended several courses during his full-time national service, graduating with an overall “A” grade from the armament basic technician training (turret). Last February, he attended a maintenance vocational training course during his sixth in-camp training in preparation for the overseas exercise.
Pang also had a positive work attitude and was “very helpful” when it came to work, Dr Ng said, citing accounts by his peers to the COI. “He was also professional when executing his tasks and was seen by his superiors as someone who would not cut safety corners when working.”