'Safety lapses, weaknesses in safety culture': Panel raises concerns following Aloysius Pang death

'Safety lapses, weaknesses in safety culture': Panel raises concerns following Aloysius Pang death

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 committee 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 May 6, 2019.

SINGAPORE: An external panel has expressed concerns about “safety lapses and weaknesses in safety culture" in the Singapore Armed Forces (SAF) that have come to light following the death of national serviceman Aloysius Pang.

The External Review Panel on SAF Safety (ERPSS), commenting on Committee of Inquiry (COI) findings on the incident, recommended that the SAF do more to improve safety awareness among its soldiers, Defence Minister Ng Eng Hen told Parliament in a ministerial statement on Monday (May 6).

ERPSS chairman Heng Chiang Gnee said the panel established that while SAF's command position is strong when it comes to having a good safety culture, "it has got to permeate down the line".

"If you look at what has come out of the COI, quite clearly there’s a need to further enhance and develop the culture aspect within the SAF, especially the Army," he said in an interview on Monday.

Nevertheless Mr Heng, who was once chairman of the Workplace Safety and Health Council, said leading organisations around the world have safety hiccups from time to time.

"It is through such hiccups that the organisation should come out stronger in terms of enhancing themselves in the various areas that have been identified as weaknesses," he added.

With that, the ERPSS stressed the importance of commanders showing leadership in safety and said it was “vital” that maintenance safety got the same level of emphasis as training safety.

READ: Aloysius Pang death: COI finds accident due to lapses by Pang, 2 other servicemen

READ: Aloysius Pang's death: What happened in the Singapore Self-Propelled Howitzer

In its report, the COI also recommended improvements in the Army’s safety culture and compliance with operator manuals, and a review of standard operating procedures.

Pang died in January after sustaining serious injuries during a training exercise in New Zealand. He was carrying out maintenance work in a Singapore Self-Propelled Howitzer (SSPH) when the incident happened.

The external panel, whose primary role is to review safety practices in the SAF, said it supported the COI’s proposed recommendations to “prevent a similar incident from occurring”.

When asked if it would be useful to install a sensor that automatically stops the gun barrel when detecting an obstruction, Dr Ng said this could be done on training platforms.

"Our equipment must function in war," he stated. "You build enough automatic stop systems, when we have to push the button and go, we have to push many buttons to start deactivating things that we have put into place."

Nevertheless, Dr Ng vowed that equipment safety will be taken seriously, especially as "we know the cost of the SAF, not only in terms of money and resources, but persons".

"We will design our systems to design away flaws as much as we can, always with the eye that it mustn't render us operationally incapable or put as at a disadvantage," he added.

READ: SAF to set up Inspector-General’s Office to 'scrutinise and enforce' safety processes: MINDEF

Dr Ng said the SAF’s Inspector-General’s Office will also ensure the COI's and ERPSS' recommendations are followed through, as he laid out six “specific steps” the SAF has taken to improve safety for maintenance-related training or tasks.


As part of safety enhancements, safe and hazardous areas in certain Army platforms, including the SSPH, will be clearly marked out.

This comes as the COI found that the “precipitating cause” of the incident was the lowering of the SSPH gun barrel without ensuring everyone was in a safe position.

The safe areas in the SSPH will now be marked with a bold, green line labelled with the word “safe”, while hazardous areas will be marked with industrially recognised yellow and black markings.

Howitzer safety markings
Markings showing the safe and hazardous areas inside the SSPH cabin. (Photo: MINDEF)

Howitzer safety markings for hazards
Hazardous areas are marked with yellow and black markings. (Photo: Jeremy Long)

Hazardous areas currently marked out on other platforms include high voltage areas.


Medical officers will be required to undergo refresher training on heli-evacuation processes before being deployed for overseas medical support.

This comes after the COI said that the post-incident medical care in Pang's accident was “adequate but can be improved”.

READ: Aloysius Pang death: Our responsibility to ensure safety of our children, says Chief of Defence Force

The COI also recommended formalising arrangements between the SAF and overseas hospitals caring for injured servicemen, so Singaporean doctors caring for them can be updated on clinical developments and contribute more effectively.

In addition, the COI recommended that national servicemen (NSmen) medical officers re-familiarise themselves with acute trauma care by being allowed to observe in emergency or surgery departments.

Dr Ng said the SAF will explore new initiatives to improve medical officers’ exposure to acute trauma care.


"Safety advocates" will be appointed on the ground to emphasise safety and conduct checks. These advocates can also gather feedback from personnel on safety lapses and relay them to ground commanders.

SAF maintenance work bionix trainer
A regular technician (second from left) looking on as full-time national servicemen go through their pre-maintenance routine. (Photo: Jeremy Long)

This could be useful among smaller groups of servicemen, to help those who might be reluctant to report lapses through existing channels for fear of being unfairly singled out.


NSmen will be “actively involved” in safety reviews before, during and after in-camp training activities. This is aimed at encouraging them to voice out and identify lapses.

READ: Greater weight to be given to safety compliance when assessing SAF unit commanders

Commanders will ensure safety is discussed and include feedback in reviews of training safety regulations.


All servicemen will be required to take the safety awareness test, currently taken by trainers and commanders, annually. The test will also be tailored to units and their activities.

For instance, servicemen taking the Individual Physical Proficiency Test (IPPT) will answer questions on the amount of rest needed before the test, and more general questions like whether activities can continue in inclement weather.


A “think-check-do” safety drill will be implemented before maintenance tasks are conducted. This is aimed at helping servicemen internalise safety measures and take more ownership of safety on the ground.

SAF maintenance work bionix drill card
Maintenance personnel are now required to carry a safety drill card. (Photo: Jeremy Long)

As part of the drill, servicemen will plan tasks and review mitigation measures like emergency stop (e-stop) drills, check equipment and the physical state and competency of those around them, and conduct dry-runs of procedures before executing tasks according to sequence and plan.

“The positions of e-stop buttons will be re-emphasised together with e-stop procedures and rehearsed as part of pre-ops drills,” Dr Ng said.

During a demonstration of the safety drill, three full-time national servicemen (NSFs) studied a step-by-step overview of a maintenance task involving the use of a mobile crane to replace a 35kg generator in a Bionix vehicle. The servicemen then discussed their roles and ran through the tasks and emergency procedures involved.

SAF maintenance work bionix trainer nsf
Private Miteshravin Ravindran (right) guiding the Bionix generator. (Photo: Jeremy Long)

Private Miteshravin Ravindran, one of the NSFs involved, said the drill was “very effective in painting the picture of how you're supposed to work safely”. 

“If it wasn't there, I think there'll be a lot of complacency,” the 21-year-old added. “Maybe you have some sort of simple knowledge of safety, but it's not fully realised.”

Source: CNA/hz