Review of 22 March fatal accident: Vital safety protection measure was not applied

Vital safety protection measure was not applied in the case of the fatal accident on 22 March, allowing the train to enter the tracks in its automated mode where the SMRT staff were.

Train operator, SMRT has completed its investigations into the fatal accident near Pasir Ris MRT Station on 22 March 2016 that killed two of its staff, Nasrulhudin and Muhammad Asyraf, following a review by an Accident Review Panel.

The Accident Review Panel comprised members of the SMRT Board Risk Committee and three independent experts: one each from Keppel Corporation and Transport for London (which runs the London Underground), and a third who was formerly with Hong Kong’s Mass Transit Railway Corporation.

The Accident Review Panel is set out to examine the internal investigation findings, including the chronology of events surrounding the accident and its causes, and put forth recommendations to prevent a recurrence.

The findings of the report is as follow;

On the day of the accident (22 March), a joint engineering team comprising six Signal staff (including four trainees) and nine Permanent Way staff (including two trainees) were tasked to examine a signaling condition 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 their way to the device in single file along the maintenance walkway.

As they approached the device, the Signal team, led by the supervisor, stepped onto the track before 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.

Before a work team is allowed onto the track, protection measures must be applied. This includes code setting the speed limit on the affected track sector to 0 km/h so that no train can enter on automated mode, and deploying watchmen to look out for approaching trains and provide early warning to the work team.

The Accident Review Panel determined that this vital safety protection measure was not applied, ie setting the code so that the train entering the track will stop and only be able to be operated in manual mode by the train captain. When the incident happened, the train was on automated mode. When the train captain saw staff on the track, he immediately applied emergency brakes but was unable to prevent the accident.

When the incident happened, the train was in automated mode. When the train captain saw staff on the track, he immediately applied emergency brakes but was unable to prevent the accident.

This is said to directly causing the accident and concluded that while existing safety protection mechanisms are adequate.

There were also other factors identified as areas for improvement, namely track access management controls, communication protocols and track vigilance by various parties.

SMRT states in its press statement that it deeply regrets that the failure to apply a vital safety procedure led to the tragic accident. It states that 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.

SMRT had also said in an earlier statement, “We take responsibility and apologise for the tragic accident. We express our deepest condolences to the families of Nasrulhudin and Muhammad Asyraf in their time of grief,”

Separately, SMRT is saying that it is comprehensively reviewing all its safety structures, processes and compliance to ensure that safety continues to be accorded the highest attention and priority in its operations and maintenance services.

The report has been submitted to the Ministry of Manpower, Singapore Police Force and Land Transport Authority to assist with their statutory investigations.