Aloysius Pang's death was preventable if all in howitzer gun complied with safety rules: COI
SINGAPORE — The death of CFC (NS) Aloysius Pang was preventable had there been compliance with safety rules by all personnel inside the self-propelled howitzer (SSPH) that Pang was trapped in, the Committee of Inquiry (COI) into his death found.
Sharing the committee's findings in Parliament on Monday (6 May), Defence Minister Ng Eng Hen said "the COI found that the incident was due to lapses of all the servicemen who were in the gun at the time of the incident".
Quoting from the COI findings, Dr Ng said the "precipitating cause of the incident was due to the lowering of the gun barrel without ensuring that everyone was in their safe positions".
Furthermore, the other two people inside the SSPH - the gun commander and a technician - "panicked and acted irrationally" when the gun barrel made contact with Pang, the COI found. Both men didn't activate the emergency stop buttons that were within their reach.
Pang, 28, had been taking part in Exercise Thunder Warrior, a live firing exercise, at Waiouru Military Training Area in New Zealand as part of his seventh In-Camp Training when he was injured while carrying out maintenance work on an SSPH on 19 January at about 7pm.
He was trapped between the flick rammer and the slew ring of the SSPH turret, and suffered severe chest and abdominal injuries.
The national serviceman was evacuated by medics to the Battalion Casualty Station at about 7.10pm. He was evacuated to Waiouru Base Medical Centre at about 7.50pm, and heli-evacuated to Waikato Hospital at 9.50pm.
Pang underwent surgery at around 1am and again over the next two days, but died from severe sepsis on 24 January.
The COI found no evidence to indicate that Pang's death involved foul play or was caused by deliberate acts.
What happened inside the gun
An SSPH gun detachment commander had requested for rectification work on his gun. The bearing of the gun was beyond the allowable error and he could not carry on with live firing.
Pang, an armament technician, could not resolve the issue. A Military Expert 2 (ME2) technician joined him in the maintenance work.
To rectify the fault, the plan was to change the CPU card on the Motor Drive Control Unit (MDCU)-Ammo Handling System (AHS) box.
The ME2 technician, a regular officer, briefed the gun commander, holding the rank of 3SG (NS), to turn off the AHS, lock the gun barrel, turn off the engine, and turn off the master switch. In order to lock the gun barrel, it had to be lowered to the near-horizontal standby position.
The ME2 tech then went to the designated safe position and started to loosen screws from the AHS box. He saw Pang also loosening screws from the box while not in a safe position and with his back to the gun barrel.
The ME2 told Pang in a mix of Mandarin and English that the gun barrel was going to be lowered and to move either closer to him or to a safe position. But Pang replied that it was fine and the gun barrel would not hit him.
Meanwhile, the gun commander checked the path inside the confined SSPH. He saw Pang standing near the gun barrel and wrongly assumed that Pang would have time to move away once the barrel was lowered. The gun commander then shouted "standby, clear away" before activating the control to move the gun.
As the flick rammer moved up, Pang was still removing the screws on the AHS box and looking back at the gun barrel at the same time. He initially made no attempt to move away.
The gun commander then noticed Pang making some evasive movements as the barrel moved closer to him. The ME tech was shocked to see Pang still in the path of the gun and tried to use his hands to push against the barrel to stop its movement.
As the gun barrel came into contact with Pang, both the ME tech and the gun commander panicked and acted irrationally. The ME tech tried to push the gun barrel with his hands while the gun commander went to the main control screen to try to stop the barrel movement. Pang was wedged between the flick rammer and the slew ring.
Safety breaches
The COI determined that the personnel did not comply with standard operating procedures.
It is clearly stated in the maintenance manual for SSPH technicians that the gun must be in a parked position with the gun barrel locked before they start maintenance work to replace the interface card in the MDCU-AHS.
However, the ME tech started dismantling the mountings on the gun even though the gun barrel was not in a standby or locked position.
The gun commander, ME tech and Pang also did not follow the strict requirement that everyone must be in a safe position during the movement of the gun barrel.
The gun commander should also have waited for Pang to be in a safe position before moving the gun barrel. This requirement is provided in the SSPH's operator's manual.
And although the gun commander and the ME tech had told Pang that the gun would be lowered, they did not ensure that he was in a safe position before the gun barrel was lowered.
The gun commander and ME tech also did not activate the emergency stop buttons.
SIB investigations not yet completed
Chaired by a judge, the COI comprised five people outside the military and defence ministry.
The COI has no mandate to determine culpability, and statements made to the committee are not admissible as evidence for disciplinary proceedings or for court martial.
As Pang died in New Zealand, Singapore's police and State Coroner do not have jurisdiction over the death.
Meanwhile, New Zealand's Attorney-General has not directed for a coroner's inquiry into Pang's death.
Under military law, the Singapore Armed Force's Special Investigation Branch (SIB) has jurisdiction to investigate Pang's death.
Once SIB completes its investigations, it will report directly to the Chief Military Prosecutor, who is deployed to the defence ministry by the Legal Service Commission which is headed by the Chief Justice.
The Chief Military Prosecutor will then decide if any servicemen are to be prosecuted in military court for offences related to Pang's death.
The military court is presided by former or serving State Court judges as Presidents of the General Court Martial.
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