SINGAPORE - Critical safety procedures were not followed when the accident which led to the death of two SMRT maintenance staff members happened, SMRT said on Monday (April 25) after completing its investigations into the mishap near Pasir Ris MRT Station on March 22.
The investigations found that the deaths of Nasrulhudin Najumudin, 26, and Muhammad Asyraf Ahmad Buhari, 24, could have been avoided had safety measures been put into place.
Before a work team is allowed onto the track, protection measures must be taken. This includes setting the speed limit on the affected track sector to 0 kmh so that no train can enter on automated mode, and deploying watchmen to look out for approaching trains .
The SMRT's Accident Review Panel comprised members of the SMRT Board Risk Committee and three independent experts from Keppel Corporation, Transport for London which runs the London Underground, and a former staff member of Hong Kong's Mass Transit Railway Corporation.
The panel determined that these vital safety protection measures were not taken.
It also said that the effectiveness of such protection before entry into the work site was not ensured as required under existing procedures, directly causing the accident.
SMRT said that its report has been submitted to the Ministry of Manpower, Singapore Police Force and Land Transport Authority to help with their statutory investigations.
In the course of the review, the Accident Review Panel set out to examine the internal investigation findings - including the chronology of events leading up to the accident and its causes - and put forth recommendations to prevent a recurrence.
On the day of the accident, a joint engineering team comprising six signal staff members, including four trainees, and nine permanent way staff members - including two trainees - were tasked to examine a signaling monitoring device along the tracks near Pasir Ris MRT Station.
The device had earlier registered a warning of a possible fault that could affect train service.
The engineering team made its way to the device in single file along the maintenance walkway. As they approached the device, the signal team, led by a supervisor, stepped onto the track before the protection measures were implemented.
The supervisor narrowly avoided being hit by the oncoming train, but Nasrulhudin and Muhammad Asyraf, who were second and third in line, were unable to react in time.
There were also other factors identified as areas for improvement, namely track access management controls, communication protocols and track vigilance by various parties.
The Accident Review Panel concluded that while existing safety protection mechanisms are adequate, and current operating procedures continue to be relevant and applicable, they can be improved for greater clarity and ease of ground implementation.
In a statement to the media on Monday ( April 25),the rail operator said that it "deeply regrets" the failure to put into place safety procedures that led to the two deaths.
"SMRT Trains has taken immediate steps to ensure stricter enforcement of procedures, strengthened system ownership and control across levels and work teams, and tightened supervision within teams to prevent a recurrence," it said, adding that it was "comprehensively reviewing" all safety structures, processes and compliance.