Each of the three soldiers in the cabin of an artillery gun that was being rectified on Jan 19 this year, including the late Singapore actor Aloysius Pang, committed safety lapses that eventually led to his death, an independent Committee of Inquiry (COI) has found.
Among other breaches, the three men - including the gun commander and a regular technician - failed to follow the requirement that everyone must be in safe positions during the movement of the gun barrel.
The regular technician also did not ensure the gun barrel was locked before starting the maintenance work of replacing the interface card found in the cabin.
Revealing the findings of the COI in Parliament yesterday, Defence Minister Ng Eng Hen said: "It is sad but undeniable that the direct cause determined by the COI that resulted in the death of Corporal First Class (NS) Pang was preventable, had there been compliance with safety rules.
"It was not for lack of knowledge of these rules or inexperience of personnel working on the SSPH (Singapore Self-Propelled Howitzer) gun."
Meanwhile, several measures have been put in place to make training and operations safer.
The five-member COI was set up on Jan 25 to investigate the circumstances leading to CFC Pang's death, after he was injured during a live-firing exercise in New Zealand while in the SSPH.
His death on Jan 23 was the fourth reported since September 2017, following four preceding years of zero fatalities related to training and operations in the Singapore Armed Forces. It sparked an outpouring of grief and led to a review of training safety.
After interviewing more than 20 people and reviewing documents and manuals related to the incident, the COI found no evidence that the incident involved foul play.
Giving fresh details on the incident, Dr Ng said the regular technician had asked CFC Pang, 28, to get out of the way as the gun barrel was going to be lowered to a standby position, but the latter merely said it would not hit him.
The gun commander saw that CFC Pang, an armament technician on reservist duty, was still standing near the gun barrel's end, but continued to lower it, flouting safety rules. When the barrel began to make contact with CFC Pang, the gun commander and regular technician panicked and responded "irrationally" instead of pressing the emergency stop buttons.
The regular technician tried to stop the barrel with his hands, while the gun commander tried to do so using the main control screen, but their actions did not stop CFC Pang from being wedged between the barrel and the cabin's interior.
The SAF Special Investigation Branch, which has nearly completed its investigations, will report directly to the Chief Military Prosecutor, who will decide if any serviceman will be prosecuted in military court for offences related to the death.
"In the meantime, servicemen under investigation are reassigned to administrative duties and, if found to have been culpable, will be charged and punished accordingly," added Dr Ng.
A raft of measures has been implemented by the SAF: adding markings to indicate safe and hazardous areas in the SSPH, implementing drills on the use of its emergency stop buttons before operations and training, and a Think-Check-Do safety drill for all soldiers doing maintenance work.
Nominated MP Walter Theseira asked whether there might be any reasons why the standard operating procedure for moving the gun barrel was not followed.
Dr Ng replied that the reason given was that they wanted to "get on with it". "They couldn't wait for those few seconds," he added.
While operationally ready national servicemen or crew operators might understand that when the gun is being fired at great speeds, that could result in serious injury, the risk might be underestimated during maintenance, said Dr Ng.
"So that just drives home the point that you have to observe safety rules rigorously."