Defence Minister Ng Eng Hen spoke in Parliament on May 6 to present the Committee of Inquiry's (COI) findings pertaining to Aloysius Pang's death.

The independent COI was set up to investigate the circumstances of the incident, which took place within the Singapore Self-Propelled Howitzer (SSPH) on Jan. 19 in New Zealand.

Pang, an armament technician, was attempting to repair a technical fault in the SSPH.

Safety lapses

According to the COI, the incident was due to the lapses of all three servicemen who were in the cabin at the time of the incident.

The other two Singapore Armed Forces (SAF) personnel at the time of the incident were:

• The gun commander, or GC.
• The Military Expert 2 technician, or ME-Tech.

According to the COI, it was found that there were safety breaches and non-compliance with the standard operating procedure.

Here's a step-by-step timeline of how the incident occurred.

1. Pang asked to help resolve technical malfunction

The GC, a 3SG NSman, was having difficulty with his Singapore Self-Propelled Howitzer gun during the exercise.

As an armament technician, Pang was asked to help solve the problem so the gun could resume live firing.

As he couldn't resolve it by himself, a Regular Military Expert 2 Technician (ME-Tech) was dispatched to join Pang.

At the time of the incident, only these three men were in the gun.

To fix the fault, the CPU card of the Motor Drive Control Unit - Ammo Handling System box needed to be changed.

The box was near Safe Position 3, on one side of the gun.

2. ME-Tech told Pang to move, but Pang did not do so

The ME-Tech briefed the GC to turn off the ammo handling system, lock the gun barrel, turn off the engine and the master switch.

In order to lock the barrel, it needed to be lowered to its near-horizontal "standby" position.

While the ME-Tech was working on the left side of the box, Pang was working on its right side.

However, he was not standing in a designated safe zone, and his back was to the gun barrel.

According to the COI's findings, the ME-Tech told Pang in a mix of Mandarin and English that the gun barrel was going to move, and told him either to shift closer to him, or to a safe position.

According to the COI, Pang did not do so.

Instead, he replied in Mandarin that it was 'fine', claiming that the barrel would not hit him, according to the COI findings.

3. GC proceeded to move the gun barrel, thinking Pang would have time to move away

Before moving the barrel, the GC said he checked to see if the path was clear.

However, despite noticing that Pang was not in a safe position, the GC proceeded to move the gun barrel.

He saw that Pang was standing near the gun barrel, but wrongly assumed that since the barrel was in the highest elevated position, Pang would have enough time to move away before the barrel went into standby position.

The GC shouted "Standby, clear away" before activating the control to move the gun.

This was heard by the ME-Tech and other personnel outside the gun.

As the flick rammer was moving up, CFC (NS) Pang was still removing the screws on the box and looking back at the barrel at the same time.

He made no attempt to move away at first, but the GC noticed that Pang made some evasive movements as the barrel moved closer to him.

4. Did not hit the E-stop buttons

The ME-Tech was shocked to see that Pang was still in the path of the gun and tried to use his hands to push against the barrel to stop the movement.

The ME-Tech tried to push the gun barrel with his hands while the GC went to the main control screen to try to stop the barrel movement.

As a result, Pang was wedged between the flick rammer and the slew ring.

As the gun barrel made contact with Pang, the COI stated that instead of activating the Emergency Stop (E-stop) buttons, both the ME-Tech and the GC panicked and acted irrationally.

The COI also determined that all the following breaches, which contributed to the cause of the incident, are preventable.

Pang passed away on Jan. 23 due to severe sepsis arising from his severe chest and abdominal injuries.

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Top image via Wee Jia Hui