On Jan. 23, the Ministry of Defence announced that an independent Committee of Inquiry (COI) would be set up to investigate the circumstances of the death of Aloysius Pang, who was killed while on reservist training in New Zealand.

The COI, made up of five people who are neither employed by the Singapore Armed Forces (SAF) nor Mindef, has concluded its work.

The COI members include:

• A judge nominated by the State Courts, Chairman.
• A consultant medical specialist.
• A member nominated by the External Review Panel on SAF Safety (ERPSS).
• A member from the Workplace Safety and Health Council.
• A senior-ranked national serviceman.

The findings were presented by Defence Minister Ng Eng Hen in Parliament on May 6.

COI different from giving evidence in court

Before laying out a detailed timeline of the events that transpired, Ng reminded the House that the COI does not determine culpability, and that no statements made to the COI shall be admissible as evidence in court.

As such, Ng did not provide the names of the personnel involved.

Timeline of events

On Jan. 19, Pang was performing reservist duties in New Zealand.

The COI established a detailed chronology of events that lead to Pang's injury and subsequent death.

Pang was not in a safe position

At the time of the incident, three people were involved:

• Pang, a CFC NSman.
• A gun detachment commander, a 3SG NSman (GC).
• A Military Expert 2 Technician, a regular (ME-Tech).

Pang and the ME-Tech attempted to fix a malfunction in the Ammo Handling System (AHS) box in a Singapore Self-Propelled Howitzer (SSPH) gun during a live-firing exercise.

However, the gun barrel was lowered while Pang was in its path.

Pang was trapped between the gun's flick rammer and the slew ring of the SSPH turret.

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

Main points

According to the COI, the "precipitating cause" of the incident that led to Pang's death was due to the lowering of the gun barrel without ensuring that everyone involved was in their safe positions.

1. Pang was not in safe position

Pang was standing in the path of the moving barrel, and not in a safe position prior to it moving.

2. Pang did not move to a safe position

Pang did not move to a safe position even though he was warned that the barrel was going to move to standby position.

3. ME-Tech did not ensure Pang was in a safe position

The ME-Tech did not ensure that Pang moved to a safe position, even though he knew the barrel was going to move.

4. GC moved gun barrel despite Pang not in safe position

Although he noticed that Pang was not in a safe position, the GC moved the gun barrel.

5. Did not hit E-stop buttons

Both the GC and ME-Tech did not hit the E-stop buttons to stop the gun barrel.

Safety breaches

Ng said:

"The COI determined that there was non-compliance with the standard operating procedures and safety breaches.

These breaches have contributed to the cause of the incident, and are preventable."

The COI pointed out that all three people involved did not adhere to the strict requirement of being in the safety positions while the gun barrel was moved.

The GC did not wait for Pang to move to a safe position before moving the gun barrel, even though he had shouted the "clear away" order.

The ME-Tech also did not comply with the Maintenance Manual, which states that before replacing the card in the AHS box, the gun should be in a parked position with the gun barrel locked.

And neither the GC nor the ME-Tech activated the Emergency Stop (E-stop) buttons to stop the gun.

Contributing factors

The COI listed (in their opinion), four factors that contributed to the incident:

1. The lack of a coordinated safety control protocol between the gun crew and the maintenance crew, while maintenance work was carried out.
2. Starting maintenance work before the gun barrel was locked.
3. Misjudgment of time and space, miscalculated how long it would take for the flick rammer on the barrel to hit Pang.
4. In their state of panic, the other two personnel acted irrationally and did not activate the E-stop buttons.

In order to enhance safety measures and prevent future incidents, the COI gave a number of recommendations.

Mindef and the SAF took their recommendations, as well as those of the External Review Panel on SAF Safety, into account.

They then implemented a range of measures to strengthen their safety measures.

No evidence of foul play

Ng said that the COI did not find any evidence that foul play was involved in Pang's death, or that it was caused by deliberate acts.

The COI found that the incident was due to the lapses of all the servicemen in the gun at the time.

Judicial process moving forward

Ng pointed out that the incident and Pang's death occurred in New Zealand, and therefore it was under their state jurisdiction, not the Singapore police or its State Coroner.

However, the New Zealand Attorney-General did not direct an inquiry into the case.

Under military law, it falls upon the Special Investigation Branch with jurisdiction to investigate, and they have done so.

Their investigations are nearly complete, and will report to the Chief Military Prosecutor.

This senior legal officer, deployed to Mindef by the Legal Service Commission, will decide if any serviceman should be prosecuted in a military court for offences related to Pang's death.

The military court is presided over by former or serving State Court judges.

Ng concluded by expressing the House's condolences to Pang's family.

He said:

"The loss of a good soldier like CFC (NS) Pang is deeply grievous to us. There was an outpouring of grief from many Singaporeans as a result of his untimely and tragic demise.

The SAF has updated CFC (NS) Pang’s family on the COI’s findings and the actions taken to deal with lapses and prevent recurrences. Mindef and the SAF will continue to do all we can to help the family through this difficult period."

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Top image via Gov.sg on YouTube