CHAPTER 1
COMMITTEE OF INQUIRY: APPOINTMENT AND TERMS OF
REFERENCE
Introduction
1 There were two major disruptions to train services on the North-South
Line (NSL) operated by SMRT Trains Ltd (SMRT) on 15 and 17 December
2011. On 15 December 2011, the first of four trains stalled at 6.47 pm and train services in both directions between Marina Bay station to Bishan station were disrupted. South-bound service from Toa Payoh station to Raffles Place station resumed at 8.30 pm. Full service on the NSL resumed at 11.40 pm. On
17 December 2011, the first of five trains stalled at 6.44 am and train services in both directions between Marina Bay station and Toa Payoh station were disrupted. Partial north-bound service from Raffles Place station to Jurong
East Station resumed at 8.29 am. Full train service on the NSL resumed at 1.53 pm.
2 The two incidents affected more than 200,000 commuters. An estimated 127,000 commuters were affected by the service disruption on 15
December 2011, whereas about 94,000 commuters were affected by the service disruption on 17 December 2011.
Appointment and constitution of the Committee of Inquiry
1
3 Minister for Transport Lui Tuck Yew appointed a Committee of
Inquiry (COI) on 29 December 2011 under Section 9 of the Inquiries Act, Cap
139, to inquire into the disruptions. 9
4 Chief District Judge Tan Siong Thye chaired the COI with two other members, namely Professor Lim Mong King from the School of Mechanical and Aerospace Engineering of the Nanyang Technological University, as well as Mr Soh Wai Wah, the Director of Prisons.
5 The Chairman and members were selected by the Minister for
Transport for their relevant legal, operational and technical expertise. The
Inquiries Act requires at least one of them to be qualified as a District Judge.
Prof Lim has published papers on a broad spectrum of applied mechanics and his focussed research topics include structural dynamics modelling, as well as noise and vibration control problems and designs. Prof Lim’s expertise was sought as a member on two previous COIs in 1992 and 1994. He lent his expertise on engineering and technical aspects for this Inquiry. Mr Soh was the Chief of Staff in the Singapore Police Force (SPF) until December 2009.
While in SPF, he held various operational appointments including Head of
Contingency Planning, Commander of Clementi Police Division and Director of Operations. He has been deployed for various major incidents such as the
Hotel New World collapse, the SQ 117 hijack and the Nicoll Highway collapse incidents. He lent his expertise on incident management aspects for this
Inquiry.
Terms of Reference
6 The COI’s Terms of Reference were to:
9 See Annex A - Ministry of Transport press release, “Appointment of a Committee of Inquiry into Disruption of MRT Train Services on 15 and 17 December 2011”, 29 December 2011 2
(a) Inquire into and determine the sequence of events that led to the
disruption of MRT train services on the NSL on 15 and 17
December 2011;
(b) Establish the cause(s) and any other contributory factors for the
two incidents, including factors that may have endangered
public safety;
(c) Make recommendations to minimise the recurrence of such
incidents;
(d) Make recommendations to improve the management of similar
incidents;
(e) Make any observation or opinion on matters relating to the two
incidents which the COI should, in its opinion, bring to the
attention of the Minister for Transport;
(f) Conduct itself in accordance with the provisions of the Inquiries
Act, in particular the Schedule thereto, and consider the
evidence put before the COI as led by the Attorney-General or
his designates; and
(g) Make and submit a report of its proceedings, findings and
recommendations to the Minister for Transport.
7 On 9 January 2012, Minister Lui delivered a statement on the train service disruptions in Parliament, 10 and highlighted some aspects on which the COI should focus its attention:
10 See Annex B - Ministerial Statement on the Disruption of MRT Services on 15 and 17 December 2011. 3
10 ... Under its Terms of Reference, the COI will conduct an independent investigation into both technical and non-technical aspects of the incidents of 15 and 17 December. The Committee will investigate the sequence of events leading to the disruptions, as well as establish the technical, systematic and other causes that may have contributed to the disruptions. Based on these findings, it will make recommendations to minimise the recurrence of similar incidents, as well as improve the management of such incidents.
11 ... The extent and severity of the service disruptions on 15 and 17
December, and the potential safety risks that they posed are what warrant an independent inquiry into the causes of the disruptions. The
COI should focus on investigating the core issues related to the 15 and
17 December incidents, report on its findings and make their recommendations accordingly. However, if there are any previous incidents or events which are relevant or contributed to the incidents of
15 and 17 December, the COI has the latitude and indeed the obligation to consider them.
...
17. ... [T]he quality and adequacy of the maintenance regime, be it for preventive or corrective maintenance, are areas that will be closely scrutinised by the COI...
...
25 ... Future exercises would therefore be conducted using more challenging scenarios to test the readiness of the operators and improve the multi-agency coordination needed to enhance emergency
4
preparedness and crisis response. I believe that this is something that
the COI will look into as well.
It was on this basis that the COI proceeded to conduct the Inquiry.
Assistance to the COI
8 The COI derived invaluable assistance from a myriad of sources, which enabled it to conduct the Inquiry according to the prescribed Terms of
Reference.
Secretary and resource persons
9 Mr Sidney Koh from the Ministry of Transport was Secretary to the
COI, who provided the necessary administrative and co-ordination support to the COI. He was assisted by Mr Luke Tay from the Ministry of Transport. The
COI also tapped on a panel of resource persons from the Subordinate Courts of Singapore, namely District Judge Chia Wee Kiat, District Judge Paul Quan and District Judge Crystal Ong.
Investigation Team
10 The Criminal Investigation Department (CID) of SPF was also empowered to investigate any matter relevant to the Inquiry regarding the incidents. The Lead Investigator was ASP Roy Lim, assisted by ASP Alvin
Phua Kia Jong and ASP Jessica Ang Wan Ting. CID was in turn assisted by the Air Accident Investigation Bureau of Singapore (AAIB), namely Mr Chan
Wing Keong, Mr David Lim, Mr Michael Alan Toft, Ms Pang Min Li, Mr
Bryan Siow Yao and Mr Steven Teo.
Parties
5
11 The State was represented by Second Solicitor-General Mr Lionel Yee from the Attorney-General’s Chambers (AGC), assisted by Deputy Chief
Counsel Ms Hoo Sheau Peng, Deputy Senior State Counsel Mr Edwin San,
State Counsel Mr Fu Qijing, and State Counsel Mr Zheng Shaokai.
12 SMRT Corporation was represented by Senior Counsel Mr Cavinder
Bull and Ms Kong Man Er from Drew and Napier LLC, assisted by Ms Pricilla
Lua, Mr Daniel Cai, Mr Jonathan Lim and Mr Darryl Ho. The Land Transport
Authority of Singapore (LTA) was represented by Mr Andrew Yeo and Mr
Ramesh Selvaraj from Allen & Gledhill LLP, assisted by Mr Jason Chan, Ms
Lee Bik Wei, Mr Joseph Tay and Mr Ramesh Kumar.
Public feedback
13 The COI invited public feedback through three press releases to the media. 11 Feedback from 36 members of the public was received. The feedback was in turn channelled to CID for its consideration and determination on whether such members of the public should be called as witnesses at the
Inquiry. Most were unwilling to provide written depositions to CID.
11 See Annex A – Ministry of Transport press release, “Appointment of a Committee of Inquiry into Disruption of MRT Train Services on 15 and 17 December 2011”, 29 December 2011; Annex C – Press release “Committee of Inquiry into MRT Disruptions to Commence Hearing on 16 April 2012”, 16 February 2012; Annex D – Press release, “Committee of Inquiry into MRT Disruptions to Commence Hearing on 16 April 2012”, 11 April 2012. 6
CHAPTER 2
ACTIONS UNDERTAKEN BY THE COI BEFORE THE INQUIRY
Introduction
14 In order to fully understand the events leading to the serious disruptions of train services on 15 and 17 December 2011, the COI had to undertake some preparatory work. These included attending a preliminary briefing by LTA shortly after the incidents occurred and making three site visits. The COI also held three Pre-Inquiry Conferences (PICs) to ensure that the Inquiry would be carried out efficiently, effectively and smoothly.
15 Such actions taken before the Inquiry enabled the COI to equip itself with the necessary contextual and technical information for the Inquiry, as well as to ensure that parties were adequately prepared for the Inquiry.
LTA briefing
16 LTA gave a short preliminary briefing to the COI on 30 December 2011, which included: (a) train and system design; (b) the sequence of events relating to the two incidents; (c) the Third Rail Support Assembly (TRSA) including the fastener and claw; as well as (d) the follow-up actions undertaken by SMRT after the service disruptions.
Site visits
17 The COI made three separate site visits to:
• Bishan Depot and the SMRT Headquarters on 11 January 2012;
• City Hall and Orchard underground tunnels in the early morning
on 21 March 2012 during engineering hours; as well as 7
• Another visit to Bishan Depot on 5 April 2012.
First site visit to Bishan Depot/SMRT Headquarters on 11 January 2012
18 During the visit to the Bishan Depot, the COI was shown:
• The third rail from which a train draws power;
• The current collector device (CCD) assembly, in particular the
“shoe”, through which a train draws power from the third rail
when the shoe contacts the third rail;
• The driver cab of a train: The COI noted that the line voltage
indicator is situated behind the Train Officer (TO)’s seat. The TO
will not know when a particular CCD shoe loses contact with the
third rail. The TO will not be alerted to any loss of power and will
only know that the train has lost power when the inevitable occurs;
and
• The emergency ramp that is deployed to de-train passengers from
the train to the track.
19 At the SMRT Headquarters, the COI was shown:
• The TRSA, in particular the “claw” that holds the third rail: The
COI noted that such a hold was achieved by the weight of the third
rail that is exerted on the claw;
• The NSEWL Operations Control Centre (OCC): The COI noted that
the NSEWL OCC had a rather dated appearance. The NSEWL OCC
essentially relies on accurate information relayed by the TOs. The
8
OCC will not know when a train loses power unless it is informed
by a TO.
Second site visit to City Hall/Orchard underground tunnels on 21 March 2012
20 The COI visited the incident sites, in particular the north-bound tunnel north of City Hall station (chainage 61220 to 61263) and the south-bound tunnel north of Orchard station (chainage 63960 to 63933).
21 It was observed that cameras were installed after the incidents to monitor the new claws at the incident sites.
22 The visibility in the tunnels was also noted to be poor. There are tripping hazards such as the running rails and sleepers in the tunnel. These will be the challenges faced by commuters during a train-to-track detrainment.
23 The tunnels were also observed to be stuffy and warm. The ventilation fans were not switched on during the visit. When switched on, the tunnels were reported to be dusty.
Third site visit to Bishan Depot on 5 April 2012
24 During the visit to the Bishan Depot on 5 April 2012, the COI was shown a train that was operating on auxiliary power with only the emergency lights and ventilation switched on. A power outage was also simulated and conditions in the cabin were noted to deteriorate after a short while.
25 The COI was also shown the extent to which a CCD shoe could be extended.
9
26 The COI was also shown the Multi-Function Vehicle (MFV) and the relevant devices inside the MFV. There are only two of such vehicles – an older MFV for the NSEWL and a new MFV for the Circle Line. The MFV checks the third rail as well as the running rail. A light source is reflected by a mirror into a camera, which in turn translates into graph measurements.
When the NSEWL MFV was deployed on 17 December 2011, one of its mirrors cracked and manual check of the third rail was done.
27 The COI was also shown the “Evidence Room”, which houses the physical evidence that was collected following the two incidents. These included damaged CCDs, third rail covers, as well as parts of the damaged third rail. While the CCD shoes were designed to break off at the frangible link, a number of them did not break off completely as they were held on by the copper conductor strip. Hence, they became twisted instead, destabilizing and causing further damage to the third rail. The Investigation Team was able to match the damaged CCDs found with the affected trains that were involved in the service disruptions on 16 and 17 December 2011. Ideally, the recovery personnel should have properly documented and matched the damaged CCD shoes to the affected trains.
Pre-Inquiry Conferences
28 The COI held three PICs to prepare parties for the public Inquiry.
First PIC on 20 January 2012
29 After consultation with the interested parties, the COI decided that the
Inquiry would commence on 16 April 2012 for a duration of six weeks with an additional two weeks as reserve. The parties were informed to give a progress update on their preparations and their readiness to exchange documents at
10
the second PIC. Documents and the final list of witnesses were to be exchanged by the third PIC.
Second PIC on 19 March 2012
30 CID informed the COI that more than 200 witnesses had been interviewed to date. Statements would be prepared for these witnesses for the
Inquiry. SMRT and LTA were likely to call only a handful of additional witnesses, if any.
31 The parties’ expert witnesses would work out joint statements on the areas of agreement during their private discussions for use at the witness conferences during the Inquiry. Parties would report to the COI on the arrangements by the third PIC.
32 A visit by the COI to the incident sites would also be arranged.
Third PIC on 2 April 2012
33 CID informed the COI that investigations were still ongoing as new developments had emerged.
34 AGC’s experts’ reports would be delayed due to slightly delayed submission of the SMRT and LTA experts’ reports. AGC provided an exhaustive list of exhibits, from which a core bundle of exhibits would be distilled.
35 SMRT would circulate its maintenance and incident management experts’ reports by 11 April 2012. LTA would also circulate its internal investigation report in addition to its experts’ report on railway engineering and vibration.
11
36 99 witnesses were expected to be called, of whom 88 were factual witnesses and 11 were expert witnesses. Six volumes of statements were prepared:
• Volumes 1 and 3 consist of statements from the TOs, and
maintenance staff;
• Volumes 2 and 4 consist of statements from the Station Managers
and personnel who were activated when the Rail Incident
Management Plan kicked in; and
• Volumes 5 and 6 consist of statements from SMRT’s senior
management and the Investigation Team.
37 AGC proposed that the railway engineering and vibration experts confer among themselves during the week of 23 April 2012, with Professor
David Ewins to chair the conference. As for the railway incident management experts for SMRT and AGC, they would likely be available to meet during the week of 7 May 2012. The Scott Schedules setting out the areas of convergence and divergence in the experts’ views could then be presented to the COI on 14 and 15 May 2012, with 25 May 2012 set as reserve.
38 The parties were to discuss AGC’s proposal further and propose a protocol for the witness conferences, including involvement of Counsel, for the COI’s consideration prior to the conferences.
39 The COI would sit from 9.30 am to 1 pm and from 2.30 pm to 6 pm on weekdays. The COI would also sit on Saturdays if necessary.
40 Counsel did not anticipate raising issues beyond the COI’s Terms of
Reference.
12
CHAPTER 3
THE INQUIRY
41 The Inquiry was conducted in open court and was a public proceeding.
The COI sat for a total of 29 hearing days every weekday from 16 April 2012 to 25 May 2012 in Court 1 of the Subordinate Courts of Singapore. The
Inquiry commenced at 9.30 am and concluded at 6 pm on most days.
42 ASP Roy Lim was the first witness, who gave evidence about the outcome of CID’s investigations into the incidents, as well as contextual and technical information relating to the incidents.
43 Witness conferences were held for the expert witnesses. Two separate conferences were held – one for the experts who gave evidence relating to incident management, and another for the experts who gave evidence relating to rail engineering and vibration. The incident management experts were in agreement with each other and gave a joint presentation before attending to questions by the COI. As for the rail engineering and vibration experts,
Professor David Ewins presented an overview of the findings on behalf of the other experts before attending to questions by the COI. Clarifications were then sought from the experts on the areas of divergence set out in the Scott’s
Schedule.
44 A total of 116 witnesses were called during the Inquiry. 12 The exhaustive list of documents is marked ‘COI’. 13 The exhibits tendered by
AGC, LTA and SMRT are marked ‘E’, ‘L’ and ‘S’ respectively. 14
12 See Annex E for the list of witnesses 13 See Annex G 14 See Annexes G, H and I respectively 13
CHAPTER 4
RELATIONSHIP BETWEEN LTA AND SMRT AND THEIR RESPECTIVE
ROLES
Introduction
45 The roles of LTA and SMRT are separate and distinct. LTA’s role is that of a regulator whereas SMRT is a private rail operator. SMRT operates the
NSEWL under a licence granted to it by LTA. The powers of LTA to regulate
SMRT 15 are set out in the Land Transport Authority of Singapore Act (Chapter
158A) (the LTA Act), the Rapid Transit Systems Act (Chapter 263A) (the RTS
Act), the Licence and Operating Agreement 16 (LOA) signed between LTA and
SMRT on 1 April 1998 17 and the Lease and Maintenance Agreement (LMA) signed between LTA and SMRT dated 22 May 2000.18
46 LTA was set up on 15 September 1995 to take overall charge of improvements to Singapore’s land transport system. LTA’s mission, as stated by LTA Chief Executive Chew Hock Yong (W108), is to provide an efficient and cost-effective land transport system for Singapore. 19 LTA plans for
Singapore’s long-term transport needs, including the planning and construction of new MRT lines, roads and related facilities. Further, LTA regulates all aspects of Singapore’s land transport system, including the public transportation system which comprises of rail, buses and taxis, and private vehicles as well.20
15 ES82 at paras 14 and 15 16 E40 17 Including subsequent versions as may be amended 18 Including subsequent versions as may be amended 19 ES108 at para 2 20 ES108 at para 2 14
47 It should be noted as a matter of background that the predecessor to
LTA is the Mass Rapid Transit Corporation (MRTC), which was established in
1983. 21 The MRTC Act, which established MRTC, was repealed with the passing of the RTS Act in 1995. The RTS Act therefore provides for the transfer of the functions, assets and liabilities of MRTC to LTA.
48 In 1987, the MRTC set up SMRT Corporation to operate the first stretches of the North-South line. SMRT Corporation has been a holding company listed on the Singapore Exchange since 2000. Today, it owns 100% of
SMRT Trains Ltd, which is the train operations arm of the SMRT group of companies. The group structure of SMRT Corporation is shown in Figure 1:
Figure 1: Organisation structure of SMRT Corporation
21 MRTC took over the roles and responsibilities of the Provisional Mass Rapid Transit Authority, which had been set up in 1980 to plan and design the MRT network. 15
LTA’s approach to regulatory oversight
49 LTA Chief Executive Chew Hock Yong (W108) explained that LTA’s approach is two-pronged, comprising:
(a) an outcome-based approach; and
(b) necessary intervention in the public interest.22
50 With regard to an outcome-based approach, LTA’s main focus is on commuter satisfaction and other commuter-oriented outcomes, including the preservation of commuters’ safety and well-being. This is achieved through a set of Operating Performance Standards (OPS) imposed on SMRT, for which
SMRT needs to submit monthly reports to LTA. LTA also continually reviews the prescribed OPS. The financial penalty for any breach of the OPS also affords SMRT an incentive, and not just the responsibility, to carry out proper maintenance so as to avoid contravening the OPS.
51 Insofar as necessary intervention in the public interest is concerned,
LTA requires SMRT to provide it with timely and sufficient information so that LTA could assess whether such intervention was necessary. For instance, in the context of maintenance, LTA reviews SMRT’s 2-yearly maintenance plans and provides feedback to SMRT. If necessary, SMRT would have to change these plans on the basis of the feedback.
52 In addition, LTA Deputy Director Transit Regulation Soo Weng Tuck
(“DDTR Soo”) (W82) explained that LTA also considers feedback from public channels, for example, the media. 23 Where such feedback is relevant, LTA has
22 ES108 at para 15 23 ES82 at para 34 16
the discretion to require SMRT to address such issues.24 LTA Chief Executive
Chew Hock Yong (W108) testified that LTA receives approximately 3,500 instances of such feedback daily. He further explained that LTA senior management will act on such feedback where necessary and cited two recent examples, namely the malfunction of the air-conditioning system on certain trains on the East-West line and the complaints on high noise levels from running trains.25
53 LTA Chief Executive Chew Hock Yong (W108) testified that LTA’s regulatory approach is similar to that adopted in other jurisdictions, for example, Hong Kong.26
Statutory provisions
The LTA Act
54 Sections 6(1)(k) and 6(1)(l) of the LTA Act state that it shall be the function and duty of LTA to “plan, design, construct, manage, operate and maintain the railway in accordance with this Act and the RTS Act” and to
“approve and regulate the operation of the railway in accordance with this
Act and the RTS Act”.
The RTS Act
55 Section 12(1) of the RTS Act states that no rapid transit system shall be operated without a licence and section 13 of the RTS Act sets out the power of
LTA to grant a company a licence to operate a rapid transit system for the period specified in the licence. Section 14 of the RTA Act states that LTA, in exercising its discretion to grant a licence to operate any rapid transit system,
24 ES82 at para 34 25 ES108 at para 25 26 ES108 at para 15 17
“shall have regard to the financial standing of the applicant and its ability to maintain an adequate, satisfactory, safe and efficient service”.
56 Section 15(1) of the RTS Act states that in granting a licence, LTA may impose such conditions as it think fits such as those relating to “the extent, hours and general level of services”,27 “the maintenance and operation of the railway relating to the rapid transit system”, 28 and “the standard of performance to be complied by the licensee in the maintenance or operation of the rapid transit system or the provision of rapid transit system services”.29
57 Section 17 of the RTS Act states that LTA may issue or approve codes of practice in connection with, for instance, the maintenance or operation of rapid transit systems and equipment,30 and the provision of services for the carriage of passengers on a rapid transit system.31
58 Further, section 18 of the RTS Act sets out the power of LTA to give directions to be observed by licensees in respect of, amongst others, the extent, hours and general level of the services to be provided by licensees,32 and the maintenance and operation of the rapid transit system.33
59 Section 19A of the RTS Act states the power of LTA to make a provisional order for securing a licensee’s compliance with the conditions of its licence.
27 Section 15(1)(a) of the RTS Act 28 Section 15(1)(c) of the RTS Act 29 Section 15(1)(h) of the RTS Act 30 Section 17(1)(a) of the RTS Act 31 Section 17(1)(b) of the RTS Act 32 Section 18(1)(a) of the RTS Act 33 Section 18(1)(c) of the RTS Act 18
60 Under section 19 of the RTS Act, if SMRT fails to comply with any of the conditions of its licence,34 code of practice,35 or direction,36 LTA may, by notice in writing and without any compensation, do all or any of the following:37
(a) Suspend or cancel the licence;
(b) Forfeit the whole or any part of any security deposited with
LTA by SMRT or by its bank pursuant to a bank guarantee; and
(c) Require SMRT to pay, within a specified period, a financial
penalty of such amount not exceeding S$1 million as LTA thinks
fit.
61 LTA Chief Executive Chew Hock Yong (W108) testified that LTA accepts that there is scope for improvement in the regulatory framework and that a comprehensive review of the same has started. One of the recommendations that LTA is considering is the enhancement of the penalty framework so as to ensure that the penalty sufficiently reflects the impact on commuters. This enhancement may include the recalibration of fines and an increase in the maximum penalty.38
Codes of Practice, Directions and Provisional Orders 39
Codes of Practice
62 Section 17 of the RTS Act states that LTA may issue codes of practice. A total of 7 Codes of Practice have been issued:
34 Section 19(1)(a) of the RTS Act 35 Section 19(1)(c) of the RTS Act 36 Section 19(1)(d) of the RTS Act 37 Section 19(1)(i) to 19(1)(iii) of the RTS Act 38 ES108 at para 55 39 ES82 at paras 16 to 19 19
(a) Code of Practice for the Maintenance of Structures in the Rapid
Transit System (CP1); 40
(b) Code of Practice for the Maintenance of Permanent Way in the
Rapid Transit System (CP2); 41
(c) Code of Practice for Advertisements in Rapid Transit Systems,
Stations, Trains and Tunnels (CP3); 42
(d) Code of Practice for Modification of the Working Network in the
Rapid Transit System (CP4); 43
(e) Code of Practice for Operation, Maintenance and Safety of the
Rapid Transit System (CP5); 44
(f) Code of Practice for Security Standards in MRT Systems (CP6); 45
and
(g) Code of Practice on Incident Management during Train Service
Disruptions on MRT Systems (CP7). 46
63 Codes of Practice are applicable to all licensees who have been given a licence under section 13 of the RTS Act.
64 CP7 was issued subsequent to the disruptions on 15 and 17 December
2011. Prior to the issuance of CP7, CP5 was the only Code of Practice pertaining to incident management. CP7 is more specific than CP5 as it sets
40 E47 41 E48 42 E49 43 E50 44 E51 45 E52 46 E53 20
out, for instance, the requirement for the licensee to report to LTA’s Land
Transport Operations Centre (LTOC) every 15 minutes on the status of an incident and the requirement for the first bridging bus to arrive at each station within 30 minutes.47 These requirements were not stated in CP5.
Directions
65 Under Section 18 of the RTS Act, LTA is empowered to issue directions to any specific licensee in respect of, inter alia , the maintenance and operation of the rapid transit system. No such directions have been issued by LTA to date.
Provisional orders
66 Section 19 of the RTS Act sets out LTA’s power to issue a provisional order in a situation where a licensee has breached or contravened a condition of its license but LTA is of the view that it should not immediately suspend or cancel the license. In such a situation, the provisional order gives the licensee a chance to rectify such breach or contravention and to be heard by LTA. LTA has not issued any provisional orders to date.
The LOA
67 The original 10-year LOA was signed between the MRTC and
Singapore MRT Ltd. (the former name of SMRT) in respect of the NSEWL on
27 August 1987. It was to expire on 26 August 1997. Pending the negotiation of a new LOA, the original LOA was extended to 31 March 1998.
68 A new 30-year LOA was subsequently executed by LTA and SMRT.
Pursuant to this LOA between LTA and SMRT dated 1 April 1998, SMRT has
47 E52 at para 10.2 21
a licence to operate the NSEWL. The significant aspects of the LOA are as follow:
(a) SMRT would lease the infrastructure 48 from LTA;49
(b) SMRT would purchase and own the operating assets;50
(c) LTA would grant SMRT a 30-year licence, with effect from 1
April 1998, to operate the NSEWL;51
(d) SMRT shall at its own cost and expense develop, document and
implement a Safety Management System for operating and
maintain the working network and for ensuring passenger and
employee safety;52
(e) SMRT must operate the NSEWL in compliance with the OPS set
out in the LOA;53
(f) If the performance of SMRT fails to meet the standards
prescribed in the OPS, SMRT shall be liable to pay a penalty not
exceeding S$1 million for each occurrence of failure;54 and
48 Clause 1 of the LOA defines “infrastructure” as: buildings, stations, depots, sub-stations, roads, viaducts, permanent way, tunnels and like structures such as (but not limited to) lighting and cable towers, foot and road bridges, underpasses and accesses and cable and ventilation shafts and includes integral structural elements there (including roofs, shelters, support and foundations) but excludes non-structural elements such as (but not limited to) escalators, lifts, wiring and air-conditioning systems 49 Clause 3 of the LOA 50 Clause 6 of the LOA. Clause 1 of the LOA defines “operating assets” as: all assets (other than infrastructure) required to operate the MRT system 51 Clause 2 of the LOA 52 Clause 8 of the LOA 53 Clause 19 of the LOA 54 Clause 10(2) of the LOA as amended by the Supplemental Agreement to the LOA dated 22 May 2000 22
(g) SMRT must maintain the working network, which comprises
both the operating assets and the infrastructure elements.55
69 With regard to maintenance of the working network, Clause 12(2) of the LOA states:
“SMRT shall diligently and regularly inspect, continuously maintain
and repair, at its own cost and expense, the working network and keep
the same in good, safe and efficient working condition and shall from
time to time as may be necessary replace, renew, refurbish, rehabilitate,
make good or reinstate all or any part of the working network.
Notwithstanding the foregoing, SMRT may request LTA to consider
funding for any major replacement or renewal of part of whole of the
infrastructure.”
70 Clause 12(4) of the LOA states that SMRT has to submit an updated maintenance plan to LTA every 2 years at such frequency as LTA may deem necessary. Further, clause 12(5) of the LOA states that SMRT has to investigate any serious damage, deterioration or defect which may cause serious danger, risk or hazard to the MRT system and submit a written report to LTA on the problems and actions taken or proposed to be taken.
71 Insofar as modifications to the working network are concerned, clause
12(10) of the LOA states that SMRT must obtain clearance and approval from
LTA before any such modifications can be implemented.
72 Clause 14 of the LOA provides that LTA may cancel SMRT’s licence if, inter alia , SMRT fails to comply with any of the conditions of the licence,56
55 Clause 12 of the LOA. “Working network” is defined in the LOA as: all assets required to operate the MRT system comprising the operating assets and the infrastructure and shall constitute the essential operating assets of the MRT system for the purposes of the RTS Act 23
breaches any of the provisions of the RTS Act 57 or fails to provide and maintain an adequate, safe, satisfactory and/or efficient service or fails to comply with the OPS.58
73 According to LTA Chief Executive Chew Hock Yong (W108), under the
LOA, the obligation and responsibility to maintain the working network is put on SMRT because SMRT, being in possession of the infrastructure (which includes tracks and tunnels) and the operating assets, is best placed to carry out proper and timely maintenance. Furthermore, given that SMRT owns the operating assets and has a substantial 30-year licence to operate the NSEWL, it has an incentive, in addition to its responsibility, to carry out corrective and preventive maintenance of the working network. After all, if proper maintenance was not carried out, this could lead to deterioration and operational problems such as disruptions and delays, SMRT would also risk incurring additional costs to resolve deterioration problems over a long licence period. It may also breach the OPS for which penalties could be imposed.59
OPS 60
74 LTA Chief Executive Chew Hock Yong (W108) explained that OPS serve as a way for LTA to measure SMRT’s operating performance. The original set of OPS were included in the LOA after a survey was done on the performance standards of other transit systems in jurisdictions such as Hong
Kong, Japan and Germany.61
56 Clause 14(1)(a) of the LOA 57 Clause 14(1)(b) of the LOA 58 Clause 14(1)(c) of the LOA 59 ES108 at para 15 60 E44 61 ES108 at para 17 24
75 DDTR Soo (W82) further explained 62 that OPS are intended to set minimum performance standards for key indicators, including:
(a) Train service availability;
(b) Schedule adherence;
(c) Train headway;
(d) First and last train service;
(e) Train passenger loading;
(f) Severity of service disruption covering delays affecting more
than 20,000 persons per incident;
(g) Frequency of occurrence of incidents exceeding 30 minutes;
(h) Key equipment availability;
(i) Personal injury rate; and
(j) Mainline service collisions.
76 Note 3 to the OPS states that SMRT shall submit to LTA monthly reports on the OPS. DDTR Soo (W82) explained that LTA monitors and regulates SMRT’s compliance with the stated OPS by reviewing SMRT’s monthly OPS submissions and taking necessary action where there are breaches by SMRT. DDTR Soo (W82) further explained that in reviewing
SMRT’s monthly OPS submissions, LTA will send queries to SMRT to seek an explanation if there is a deterioration in performance.
62 ES82 at paras 23 to 27 25
77 LTA Chief Executive Chew Hock Yong (W108) testified that the review of SMRT’s monthly OPS submissions is carried out by the Deputy Director for
Transit Regulation and his team from the Vehicle & Transit Licensing Group of the Transit Regulation Division.63
78 Clause 10(2) of the LOA states that if SMRT fails to meet the OPS, it is liable to pay a penalty as imposed by LTA, up to a maximum of S$1 million.
Note 1 to the OPS states that in calculating the penalty to be paid, LTA shall consider mitigating factors such as constraints of the relevant working network and infrastructure as well as passenger intervention, which are beyond SMRT’s control.
79 LTA Chief Executive Chew Hock Yong (W108) explained that if the
Transit Regulation Division finds that there has been a breach of the OPS and that a penalty should be imposed, the matter will be discussed with the
Director for Public Transport Regulation and the Group Director for the
Vehicle & Transit Licensing Group. Thereafter, a paper will be submitted to
LTA’s Corporate Management Meeting (CMM),64 before being submitted to the LTA Board for its final approval.
LTA’s monitoring regime
80 Apart from the monthly OPS submissions, DDTR Soo (W82) explained 65 that SMRT is also required to submit the following:
(a) An updated maintenance plan, every two years;66
63 ES108 at para 21 64 The CMM is LTA’s Executive Management Committee, as explained in ES108 at para 11 65 ES82 at paras 28 to 31 66 As provided for under Clause 12(4) of the LOA 26
(b) A periodic structural inspection report by a professional
engineer appointed by SMRT, every five years;67
(c) An audit report on SMRT’s Safety Management System by an
independent safety assessor appointed by SMRT,68 every five
years;
(d) A maintenance report for Permanent Way (P-way),69 every four
months;
(e) A maintenance report for tunnels, viaducts and stations,70 every
four months; and
(f) Slope inspection reports,71 every six months.
81 In addition to these reports which are mandated to be submitted by
SMRT, LTA also conducts the following checks and inspections:
(a) An audit of SMRT’s Safety Management System,72 every two
years;
(b) Tracks and tunnel inspections, approximately every two
months; and
(c) Station inspections for 16 MRT stations every quarter.
Relationship between LTA and SMRT in relation to incident management 73
67 As provided for under Clause 12(9) of the LOA and paragraph 7 of Code of Practice for the Maintenance of Structures in the Rapid Transit System (CP1) 68 As provided for under paragraph 19 of Code of Practice for the Operation, Maintenance and Safety of the Rapid Transit System (CP5) 69 As provided for in a letter from SMRT to LTA, Annex I to ES82 70 As provided for in a letter from SMRT to LTA, Annex I to ES82 71 As provided for in letters from SMRT to LTA, Annex J to ES82 72 As provided for under Clause 8(3) of the LOA 27
82 LTA Chief Executive Chew Hock Yong (W108) testified that LTA imposes an obligation on SMRT to:74
(a) Have in place an Emergency Preparedness plan which includes:
i. Business continuity plan;
ii. A Rail Incident Management Plan (RIMP);
iii. Recovery plans; and
iv. Emergency resource plans.
(b) Review and update these plans as and when necessary;
(c) Conduct at least one major exercise annually to test its
Emergency Preparedness plans and other related Standard
Operating Procedures (SOPs) for its operations staff;
(d) In the event of service disruptions, to:
i. Make prompt public address announcements in stations
and on trains;
ii. Set up and coordinate effective and efficient
communication means with bus operators and/or other
rapid transit system licensees at interchange stations, as
appropriate, to keep commuters informed of the
incidents and expected duration of delay.
83 DDTR Soo (W82) explained 75 that the RIMP is part of SMRT’s Safety
Management System and comes under the charge of SMRT’s Rail Operations
73 E37 74 ES108 at para 37 28
Division. SMRT is responsible for drafting the RIMP and for reviewing and updating the RIMP, together with any SOP where necessary.76
84 The RIMP will then be sent to LTA for its approval. Separately, LTA also reviews the RIMP through table-top exercises carried out together with other operators and agencies to ensure that SMRT is able to manage the incidents and coordinate with other operators and agencies. The RIMP is further tested in exercises conducted by SMRT as well as joint exercises between SMRT and other agencies such as LTA and the Singapore Civil
Defence Force (SCDF). In addition, LTA also conducts ad hoc meetings with
SMRT to improve SMRT’s incident management processes.
75 ES82 at paras 36 to 46 76 As provided for under paragraph 26 of Code of Practice for Operation, Maintenance and Safety of the Rapid Transit System (CP5) 29
CHAPTER 5
TRAIN OPERATIONS
Introduction
85 The train network run by SMRT comprises the following lines:
(a) The North-South Line (NSL);
(b) The East-West Line (EWL);
(c) The Circle Line (CCL); and
(d) The Bukit Panjang Light Rail Transit (LRT) Line.
The disruptions to train services on 15 and 17 December 2011 occurred on the
NSL. The affected portion of the NSL is depicted in Figure 2:
Figure 2: Portion of NSL affected by disruptions to train services on 15 and 17 December
2011 30
In particular, the first incident on 15 December 2011 occurred on the north- bound track between Dhoby Ghaut and City Hall stations, whereas the second incident on 17 December 2011 occurred on the south-bound track after
Newton station just before Orchard station. The specific incident sites on 15 and 17 December 2011 are shown in Figure 3:
Figure 3: Incident sites on 15 and 17 December 2011
Trains
Configuration
86 The typical configuration of the trains operating on the NSEWL is shown in Figure 4:
31
Figure 4: Train configuration
A train comprises two Electrical Multiple Units (EMUs). Each EMU consists of one Driving Trailer (DT) as well as two motorcars, M1 and M2. The two
EMUs are coupled at M2, forming a six-car train. The DT is the nerve-centre of the train. The DT in the direction of travel controls the train. The motorcars are fitted with propulsion motors to drive the train.
Types of trains
87 There are four types of trains operating on the NSEWL as shown in
Figure 5:
Train Year Generation Manufacturer Number of introduced type trains in into service service
Kawasaki First Heavy 1987 66 generation Industries (KHI)
Second 1995 Siemens (SIE) 19 generation
Kawasaki- Third 2000 Nippon 21 generation Sharyo (KNS)
32
Kawasaki- Fourth SiFang 2011 22 generation Consortium (KSF)
Figure 5: Types of trains operating on the NSEWL
A comparison of these four types of trains is shown in Figure 6:
First Second Third Fourth generation generation generation generation Length of DT: 23.6m DT: 23.6m DT: 23.8m DT: 23.8m one car M1/M2: M1/M2: M1/M2: M1/M2: 22.8m 22.8m 22.8m 22.8m Length of 6- 138.5m 138.5m 138.8m 138.8m car Battery type Ni -Cd 80AH Ni -Cd 80AH Ni -Cd 110AH Ni -Cd 110AH (5-hr rating) (5-hr rating)
Figure 6: Comparison of types of trains
Parts of a train
Driver cabin
88 The Train Officer (TO) operates the train from the cabin (cab) found at the front end of the DT. Each cab has an access door for the TO as shown in
Figure 7:
33
Figure 7: Access door of the Cab
The Cab is separated from the saloon or the passenger space by a partition door as shown in Figure 8:
Figure 8: Partition door separating the cab from the Saloon
89 The schematic diagram and the components of the cab console can be seen in Figures 9 and 10:
34
Figure 9: Cab console
Figure 10: Components of cab console
90 The schematic diagram of the back indicator panel found in the cab can be seen in Figure 11:
35
Figure 11: Back indicator panel
Bogie and wheels
91 The bogie carries an assortment of items required to propel the train, such as the axles and wheels, suspension, brakes, CCDs, fuse box and shock absorbers, as shown in Figure 12. A powered bogie also carries traction motors.
Figure 12: Bogie
36
92 The flanges of the wheels of the trains run on the inner side of the running rails as shown in Figure 13. The wheels may skid along the running rails during braking, causing areas of uneven wear and affecting the roundness of the wheels. This will lead to “wheel flats”. Wheel flats cause vibration and increased noise levels of the train. Wheels with such flats have to be re-profiled regularly for optimal performance.
Figure 13: Wheels of train
CCDs
93 The function of the CCDs is to make conductive contact with the power-supplying “third rail”, drawing power to drive the train and its systems. Each car, including the DT, is fitted with four CCDs, with two CCDs on each side of the car as shown in Figure 14:
37
Figure 14: Arrangement of CCDs
Each train is therefore fitted with a total of 24 CCDs, twelve on each side of the train. The CCDs of the motorcars draw power to propel the trains; whereas the CCDs of the DTs draw power to operate other necessary systems, such as the compressors for pneumatic devices.
94 The various components of a CCD are shown in Figure 15:
Figure 15: Components of the CCD 38
The springs mounted on the CCDs provide the upward spring-force to ensure positive bottom contact with the third rail vi a CCD “shoes” as illustrated in
Figure 16:
Figure 1 6: Contact with third rail via CCD shoe
A CCD shoe has a maximum depressed range of about 50 mm, beyond which it is designed to break off from the assembly at the fran gible link as shown in
Figure 17:
Figure 17 : Depressed range of CCD shoe 39
Auxiliary power supply and emergency battery
95 The auxiliary power supply converts the electrical current from the third rail so that stabilised voltages are supplied to operate the train. This also charges the emergency battery shown in Figure 18, which is used to power communications equipment and emergency ventilation and lighting in the event that a train is unable to draw power from the third rail.
Figure 18: Emergency battery
Multi-Function Vehicle
96 The running and third rails are checked by a Multi-Function Vehicle
(MFV), shown in Figure 19:
Figure 19: Multi-function vehicle 40
Because the MFV can only propel itself at a maximum speed of 18 km/h, it is usually coupled with two l ocomotives as shown in Figure 20 so that it can move at higher speeds. This configuration is k nown as an MFV consist .
Figure 20 : MFV consist configuration
97 Two tests are performed simultaneously when the MFV is run to check the running and third rails, namely Track Geometry Measurement (TGM) and
Rail Flaw Detection (RFD ). RFD checks the core of the running rails for flaws or cracks by means of ultrasound technology.
98 TGM checks:
(a) The top of the running rails for undulations;
(b) The distance between running rails;
(c) Rail curvature;
(d) Angular measurement between axles;
(e) Difference in height between the two running rails;
(f) Lateral aspect of the third rail in relation to the running rail; and
(g) Height aspect of the third rail in relation to the running rail.
The MFV checks the third rail by m eans of a light shone onto a mirror affixed to the MFV that is positioned about 50 mm directly under the third rail, as shown in Figure 21. The light reflected from the third rail is then recorded and
41
measured with a camera and computers on board the MFV. There is one such mirror on each side of the MFV to allow checks on the third rail to be conducted, regardless of which side the third rail is on in relation to the MFV.
Figure 21: MFV mirror
99 Before the start of TGM, the operator will key in the chainages demarcating the two ends of the track segment being checked. At the end of the test, the operator will then print out the Track Parameter Plot for the track segment tested and identify any parameters that have exceeded the tolerance limit. Any such parameters will then be reported for the P-way personnel to follow up on.
Third rail
100 The third rail is a power conductor rail made of an aluminium “I” section with a stainless steel laminate on the underside which carries a 750 V
DC electric current, as shown in Figure 22: 42
Figure 22: Cross-section of third rail
The third rail is located on the right side of the train in the direction of travel, but at stations where platforms are on the right, the third rail will be located on the left of the train in the direction of travel.
Third Rail Support Assembly
101 The third rail runs alongside the running rail, elevated by the Third
Rail Support Assembly (TRSA) as shown in Figure 23:
Figure 23: Third rail support assembly 43
The “claw” of the TRSA is held firmly in place on the fastener by the weight of the third rail as shown in Figure 24:
Figure 24: How the third rail is held by the claw of the support assembly
Fastener and claw design
102 Different fastener and claw assembly designs are currently used by
SMRT. There are about 30,000 claws on the NSEWL. The 1985 design based on
Berlin’s metro system is shown in Figure 25:
Figure 25: 1985 design 44
103 However, during commissioning trials, it was discovered that some claws were dislodged on Floating Slab Tracks (FSTs). The 1985 design was then modified to include a spring clip to prevent claws from dislodging as shown in Figure 26. The additional spring clip was added to assemblies in selected vulnerable locations such as FSTs and high-speed ramps.
Figure 26: Modified 1985 design
104 A hybrid design was adopted in 1987 during the second phase of the
MRT project, consisting of the 1985 design’s claw combined with a 1987 design fastener as shown in Figure 27:
Figure 27: 1987 hybrid design 45
105 After further experiences with dropped claws, the design was modified in 1995 to include a steel cap to be used on the fastener and claw counterweight was also added to the claw and this d esign was used
Woodlands Extension.
Figure 28: 1995 design
106 In 1987, the claw and fastener design was modified by the manufacturer to include a split-pin as shown in Figure 29. Only a few of these were used on the NSEWL, although this design is used in the Taiwanese rail network system.
Figure 29: 1987 design
107 In 1996, the claw and fastener was re -designed into a single piece to achieve a more secure locking of the third rail as shown in Figure 30 . 46
design is used o n the Changi Extension, Boon Lay Extension, Circle Line and
Downtown Line.
Figure 30: 1996 design
Tracks
108 Three types of tracks are used o n the NSEWL:
(a) Ballasted track;
Figure 31: Ballasted track
(b) Fixed/Concrete slab track
Figure 32: Fixed/concrete slab track
47
(c) FST
Figure 33: Floating slab track
The incidents on 15 and 17 December 2011 occurred on FSTs. These tracks are used at sections of the rail network located beneath densely populated and built-up areas to alleviate vibration and noise transmission to neighbouring buildings, by means of interposing rubberised supports between the tunnel wall and the tracks.
109 The track together with the third rail forms part of SMRT’s fixed stock.
OCCs
110 The OCCs are the nerve centres of SMRT’s rail operations. They coordinate and supervise the operation of train services on each line during revenue hours, as well as maintenance activities during engineering hours.
111 The organisation structure of the NSEWL OCC is shown in Figure 34:
Figure 34: OCC organisation structure 48
The responsibilities of the various NSEWL OCC staff are briefly outlined below:
(a) Manager OCC (MOCC): Provide guidance to the Chief
Controller (CC)
(b) CC (Operations), also referred to as CC (Trains): Overall in-
charge of the day-to-day operations in the OCC:
• Supervise the Train Service Controllers (TSCs);
• Maintain maximum safe service during service
disruptions;
• Incident/delay reporting;
• Liaise with maintenance and station staff and external
agencies during major incidents; and
• Monitor all track access through TSCs.
(c) CC (Area): Co-ordinate information dissemination to all
relevant staff and passengers during a train service delay or
disruption, attend to public complaints and queries at the stations,
monitor train service delays exceeding two minutes, as well as advise
station staff to make public announcements during peak hours
(d) TSCs: Monitor and control all trains travelling along the
following four sectors:
• Between Pasir Ris and Redhill stations, including Expo
and Changi Airport Stations;
49
• Between Joo Koon and Queenstown stations;
• Between Marina Bay and Yio Chu Kang stations; and
• Between Khatib and Jurong East stations
(e) TSC (Liaison): Assists the CC (Area) in information
dissemination management, alarm and fault reporting
management, track access management, station matters, security
matters, as well as staff recall management during major
incidents;
(f) TSC (Float): Assists or relieves any TSCs during the first and
second shift.
112 The layout of the NSEWL OCC is shown in Figure 35:
Figure 35: OCC layout
50
113 Each CC and TSC’s workstation is equipped with:
(a) An Autom atic Train Supervisory System (ATSS ) terminal;
(b) A Radio Communication Command Pa nel (RCCP);
(c) A c omputer terminal for acc ess to technical knowledge; and
(d) A Closed-circuit T elevision (CCTV) screen that shows live feed
from any selected camera at any NSEWL station .
114 TSCs monitor the locations of trains on the NSEWL by way of the
ATSS terminal as well as the NSEWL train loc ation mimic board, and regulate train service intervals to comply with safety and service standards.
115 TSCs communicate with TOs through the RCCP . TSCs are able to communicate with and relay instructions to either all trains simultaneously or specific trains.
116 There are also Facilit ies and Structure Controllers (FSRTCs ) present in the OCC. They monitor and control the NSEWL power supply system as well as the Environment Control System.
Stations
117 The organisation structure at each station is shown in Figure 36 :
Figure 36 : Organisation structure at train stations 51
118 The duty Station Manager (SM) oversees the day-to-day operations of a station. All Customer Service Leaders (CSLs), Customer Service Officers
(CSOs) and Customer Service Ambassadors (CSAs) report to the SM. The SM handles all incidents and emergencies at his assigned station. During service disruptions, the SM will:
(a) Deploy staff to assist passengers;
(b) Ensure that appropriate signage is displayed so that passengers
are kept duly informed of the current situation; and
(c) Act on instructions from the OCC.
TOs
119 TOs operate their trains while receiving instructions, if any, from the
TSC. During normal train operations, TOs:
(a) Run their trains on auto mode;
(b) Monitor passenger embarkation/disembarkation and manually
control train doors at stations;
(c) Activate the Automatic Train Operation system, which enables
trains to automatically move off from stations to the optimal
speed prescribed by the Automatic Train Protection (ATP)
system and to decelerate before coming to a complete stop
automatically at the next station;
(d) Attend to any activation of the Emergency Communication
Button (ECB); and
52
(e) Monitor their trains’ back indicator panels. In the event that a
fault is indicated, a TO will report the nature of the fault to the
OCC. The OCC will in turn direct the TO and attempt to isolate
and rectify the fault locally. For minor faults that cannot be
rectified, the TO will either switch off the affected component(s)
or leave it alone. For major faults that cannot be rectified, the TO
will move the train to the nearest station and detrain passengers.
120 In exceptional circumstances, a TO can run a train in two non-auto modes, namely:
(a) Coded Manual (CM) mode, where the TO moves the train using
the Master Controller Handle (MCH) on the cab console, subject
to the speed limit protection afforded by the ATP system, for
instance during rainy days or when instructed by the OCC to
carry out a “line-clear” to check for track abnormalities; and
(b) Restricted Manual (RM) mode, where the TO has actual control
of the train and is not subject to the speed limit protection
afforded by the ATP system, for instance when the TO is asked
to perform a “wrong direction” movement. However, trains are
programmed to travel up to a maximum of 18 km/h in this
mode.
Maintenance
Organisation structure
121 The organisation structure of the SMRT Engineering and Projects team, which takes charge of the maintenance of rolling stock and P-way, is shown in
Figure 37:
53
Figure 37 : Organisation structure of SMRT engineering and projectsprojects team
Maintenance regime
122 Ther e are two types of maintenance regimes, namely pre ventive maintenance and corrective maintenance . The preventive maintenance regime comprises pre-scheduled periodic checks whereas the corrective maintenance regime comprises rectification works done when a fault or defect is reported.
123 SMRT’s maintenance schedules for the third rail, CCDs and the emergency b atteries are shown in Figures 38 to 40 :
Maintenance activity SMRT maintenance Manufacturer’s regime recommendation Turnout third r ail high speed Monthly Yearly ramp bolt re-torque (including taking out of cover for inspection) Third r ail high speed ramp Yearly Yearly and normal conductor rail re-torque Third rail expansion joint 18 monthly (under a Yearly servicing recommendation from
54
a consultancy study in 2000) Third r ail high speed ramp 6-monthly Yearly wear check Third rail insulated rail joint 3-monthly Yearly servicing Third r ail insulator cleaning 3-monthly Yearly Third rail fishplate joint Yearly Yearly inspection Third r ail gauging by MFV 6-monthly - Track inspection by Weekly - patrolmen
Figure 38: Maintenance schedule for third rail
Maintenance Applicable train Maintenance activity type types 3-weekly All trains • Visual checks on all CCD inspection components • Cleaning of all CCD components 4-monthly P M KHI and SIE • Visual checks on all CCD components • Function checks on the CCD retraction feature 6-monthly PM KNS and KSF • Visual checks on all CCD components • Function checks on the CCD retraction feature and check CCD height CM All trains • Perform CCD height check and adjustment after wheel- profiling, wheel-set change out or overhaul
Figure 39: Maintenance schedule for CCDs
Maintenance Applicable train Maintenance activity type types 3-weekly All trains • Visual inspection of physical
55
inspection condition of batteries • Measurement of electrolyte level • Measurement of charging voltage and battery voltage • General cleaning 6-monthly PM • Comprehensive inspection and serving of entire battery banks, individual cells, connectors, cable, compartments, mounting etc • Inspection, service and 6 Monthly PM measurement of individual cell voltages
Figure 40: Maintenance schedule for train emergency batteries
124 SMRT also uses a computerised system, known as the Maintenance
Management System, which allows the integration of maintenance scheduling, supply chain procurement and human resource management.
Maintenance budget
125 SMRT’s repair and maintenance cost per train-km remained fairly constant from 2003 to 2011. However, SMRT increased its capital expenditure between 2007 and 2010 to carry out mid-life upgrades of the first and second generation train cabins. The repair and maintenance costs and capital expenditure per train-km from 2003 to 2011 are shown in Figure 41:
56
Figure 41: Repair and maintenance cost and capital expenditure per train-km from 2003 to
2011
57
CHAPTER 6
INCIDENT ON 15 DECEMBER 2011
Summary of events
126 On 15 December 2011, during the evening peak hour, three north- bound trains packed with passengers lost power inexplicably and stalled within a span of eight minutes at various locations between City Hall and
Braddell stations on the NSL. A fourth train, despatched as a rescue train, unfortunately also found itself stranded in the tunnel as it lost power and stalled.
127 The first train that ran into problem was T134. It lost power at 6.47 pm and stalled in the tunnel between City Hall and Dhoby Ghaut stations.
Minutes later, T139 lost power at 6.49 pm and came to a halt in the tunnel between Somerset and Orchard stations, some 150 metres short of the
Orchard station platform. This was followed by T133, which stalled at about
6.55 pm at Braddell station. At 7.20 pm, T128 (re-designated as T928 to rescue
T133), also lost power and came to halt in the tunnel between Toa Payoh and
Braddell stations. The sequence and location of the breakdowns are tabulated in Figure 42.
Train Time Location where train stalled T134 6.47 pm Tunnel between City Hall and Dhoby Ghaut stations T139 6.49 pm Tunnel between Som erset and Orchard station s T133 6.55 pm Braddell station T128 /T928 7.20 pm Tunnel between Toa Payoh and Braddell station s
Figure 42: Sequence and location of breakdowns
58
128 As the events were unfolding, T118 was despatched by the OCC to push T134 to Dhoby Ghaut station. T118 (re-designated as T918 to rescue
T134) left City Hall station at about 7.07 pm towards T134 to do a 2-train
“push-out”. After travelling for about 50 metres from City Hall station, the
TO noticed that a section of the third rail ahead of his train had sagged and appeared to be touching the sleepers of the track. Immediately, he halted his train and reported the matter to the OCC.
129 When it became apparent that there was no way to haul T134 to the nearest station, the OCC instructed T134 to perform a train-to-track detrainment for its passengers. A train-to-track detrainment is only undertaken as a last resort as the process is slow and higher-risk. As a safety measure, the power supply to the third rail has to be switched off before passengers are evacuated onto the tracks.
130 At 7.23 pm, the OCC activated the RIMP. When the RIMP is activated, key SMRT personnel have to report immediately to their respective duty posts to assist in managing the situation and the recovery of service.
131 The successive breakdown of trains at the height of the evening rush hour led to a disruption of train services on a scale never before encountered by SMRT. Services in both directions of the NSL ground to a halt between
Marina Bay and Bishan stations. For many commuters, it was an exasperating experience. Bus bridging services were activated but the buses took some time to arrive at various stations and were unable to cope with passenger volumes.
There was also confusion among commuters as a result of a lack of information at stations on the bus bridging services. For those trapped in the trains which stalled in the tunnel, the experience was even more distressing.
59
132 Three of the stalled trains – T134, T139 and T133 - were each carrying some 1,300 to 1,400 passengers when they broke down. 77 The fourth train,
T128, had earlier reported intermittent power faults to the OCC when it was travelling between Dhoby Ghaut station and Toa Payoh station. While approaching Toa Payoh station, it could only move at a speed of up to 40 km/h, down from the usual speed of 60 to 80 km/h. Upon reaching Toa Payoh station, it lost power completely and the train’s emergency lights were activated. The TO then obtained approval from the OCC to detrain the passengers of T128. After the detrainment was completed, the OCC re- designated T128 as a rescue train – T928 – since it had regained traction power. T928 was then despatched to rescue T133 which was stalled at
Braddell station. However, soon after departing Toa Payoh station, T928 lost power completely and could not proceed further.
133 Passengers onboard T133 were unaffected by the breakdown of T928 as
T133 had fortunately stalled only when it arrived at Braddell station. They were able to get onto the station platform when it stalled.
134 However, passengers onboard T134 were less fortunate as they had to endure the discomfort of being trapped in a poorly-ventilated train packed with people. The initial plan to rescue T134 had to be aborted as the extensive sagging of the third rail prevented T118 from getting to T134. In the meantime, T134 was operating on backup battery power which sustained only the emergency lights, ventilation, radio communication set and the fault indicators. With only the ventilation system and not the air-conditioner operating when on backup power, the passenger cabin was getting stuffier by the minute. Despite the trying circumstances, the TO did his best to calm the distressed passengers. He advised the passengers over the PA system to calm
77 E60 at para 11 60
down and be patient. He also opened up his cabin door to assure the passengers that he was still in the train together with them. While walking through the train to assess the situation, he came across an asthmatic passenger and brought her to his cabin to rest.
135 About half an hour after T134 stalled, the OCC instructed the TO to prepare for train-to-track detrainment. When the OCC informed the TO that it was safe to go onto the track, the TO opened the emergency detrainment hatch at the front of the train. While ushering the passengers down the ramp, he kept apologising for the breakdown of the train and reminded the passengers to walk cautiously. Halfway through the process, SCDF officers also arrived at his train with stretchers and breathing apparatus to assist in the detrainment. The SCDF officers entered the train using the detrainment ramp and came out shortly after with a female passenger on the stretcher.
That was when the TO realised that someone had fainted in his train. The detrainment process took nearly an hour to conclude. It was about 8.05 pm by the time all the passengers of T134 arrived at Dhoby Ghaut station.
136 The OCC also despatched T112 from Newton station in the south- bound direction, crossing over to the north-bound track to haul T139 into
Orchard station so that passengers could be detrained directly onto the station platform. While waiting for T112, T139 experienced a blackout and loss of ventilation in the three cars at the back of the train due to a failure of the backup battery. This led a commuter to break a train window with a fire extinguisher. Passengers onboard T139 had earlier complained to the TO via the ECB that the train was getting very warm but the TO assumed that the lights and air-conditioner were still operating as the line voltage indicator was illuminated. The TO was unaware of the blackout and loss of ventilation in the rear three cars. He did not perform a physical check of the passenger
61
section due to his concern for his security, nor did he look through the louvers on the cabin door to check on conditions in the passenger section. T139 was eventually coupled with T112 and hauled to Orchard station where the passengers detrained onto the platform. SCDF officers conveyed a female passenger who had fainted in the train to the Singapore General Hospital.
137 At 8.30 pm, south-bound passenger service up to Raffles Place station was resumed so that trains arriving at Raffles Place station could cross over to the west-bound track, proceed to Jurong East Station, before crossing back to the south-bound NSL track. Full passenger services were only resumed at
11.40 pm that night after the sagged third rail had been repaired and the defective trains rescued.
Chronology of events
138 A detailed chronology of events for the incident on 15 December 2011 prepared by the CID Investigation Team was submitted to the COI in Part I of
CID’s Investigation Report.78 The chronological order of events was pieced together by the Investigation Team through extensive interviews conducted with TOs, SMs and staff from the OCC. SMRT train-movement logs were also scrutinised by the Investigation Team for this purpose. 79 The chronology, which provides a useful overview of the confluence of events that unfolded in the evening of 15 December 2011, is reproduced at Annex J.
139 SMRT also submitted to the COI, as part of its Internal Investigation
Team (IIT)’s report 80 , a chronological account of major and significant events that occurred during the disruption on 15 December 2011. This provides a
78 ES1 Annex E 79 ES1 Annex E para 4.1.2 80 E59 62
useful compendium to the detailed chronology put up by CID and is reproduced at Annex K.
Accounts of witnesses
140 In addition to the various investigation reports that were submitted to the COI, the COI also heard the testimonies of a number of witnesses of fact.
They included the TOs of the trains which stalled, SMs and station staff from affected stations, officers from the SMRT OCC who were on duty and commuters who were affected by the disruption. A summary of the witnesses’ accounts in chronological sequence is provided below.
Around 6.40 pm – Sparks seen coming out from the right side of T133
141 The first sign of a problem occurred when T133, operated by TO
Muhammad Yassin Bin Yazid (“TO Yassin”) (W2), was travelling along the north-bound track about 50 metres from Dhoby Ghaut station. In his testimony, TO Yassin (W2) told the COI that he saw sparks coming out from the right side of the train but did not report this incident to the OCC as it was normal to see sparks from underneath the train.
Around 6.41 pm – Burning smell detected in T133
142 After T133 departed Dhoby Ghaut station and travelled approximately
200 metres, TO Yassin (W2) again noticed sparks at the same location on the right side of the train. Further, he heard an “arking” sound and also detected a burning smell. This time, he reported the problem to the TSC stationed at the OCC via the train radio communication set. Apart from stating that there was a burning smell lingering in the air, TO Yassin (W2) also informed the
TSC that the various fault indicators, i.e. the master, air-conditioner, compressor (local), compressor (train) and converter fault indicators had lit
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up. As he was communicating with the TSC, the compressor (local) and compressor (train) fault lights went off and he updated the TSC accordingly.
The TSC asked where the burning smell emanated from, but he was unable to answer that question. Pursuant to the instruction of the TSC, TO Yassin (W2) reset the system by pressing the “auxiliary on” button and the fault lights for the air-conditioner and converter then went off. Shortly after, T133 left
Somerset station for Orchard station.
143 After T133 left Somerset station, TO Yassin (W2) noticed that the movement of T133 between Somerset station and Orchard station was jerky.
Along the way to Orchard station, the same fault indicators lit up again. TO
Yassin (W2) tried to contact the TSC via the train radio communication set but was unsuccessful. The TSC did not respond to him. TO Yassin (W2) then communicated with the OCC via the Emergency Channel, and this time, the
OCC responded. TO Yassin (W2) reported the fault light indications accordingly, and the TSC directed him to reset the system upon arriving at the next station, i.e. Orchard station.
144 According to the testimony of 15 December 2011 afternoon shift CC
(Trains) Moksin Bin Mahsan (“CC Moksin”) (W8), burning smells in trains are not unheard of, as these smells could sometimes be caused by the application of brakes, especially the emergency brakes. However, it was important to find out whether there was any smoke in the driver’s cabin or the passenger carriages. Station staff at Orchard station had boarded T133 to conduct a check but no abnormalities were found. CC Moksin (W8) also requested the
SM of Dhoby Ghaut station to go to the tailwall of the station’s north-bound platform to check if there were any abnormalities, and also to observe whether there were any sparks emanating from the arriving trains.
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Around 6.43 pm – Fault lights illuminated in T139
145 T139 had departed from City Hall station and travelled about 200 to
300 metres along the north-bound track towards Dhoby Ghaut station when
TO Hady Bin Afandie (“TO Hady”) (W4) noticed that the master fault indicator had lit up in red. TO Hady (W4) turned to check the rear panel and discovered that the fault lights for the power and converter were both lit in orange, indicating that there was a fault. The line voltage indicator however was lit in green which indicated that there was electrical supply to the train.
TO Hady (W4) informed the OCC of the fault lights and was instructed to rectify the problem at Dhoby Ghaut station. When T139 was about 150 to 200 metres away from the station, the compressor (train) and air-conditioner fault lights also illuminated. TO Hady (W4) informed the OCC of the faults and was again instructed by the OCC to rectify the problem at the next station.
When T139 arrived at Dhoby Ghaut station, TO Hady (W4) pressed the reset button and “auxiliary-on” button and all the faults were cleared. He informed the OCC and was instructed by the OCC to continue operating T139 along the north-bound track towards the next station.
146 At around this time, T134, operated by TO Mohamad Alwi Bin Sirat
(“TO Alwi”) (W5), was approaching Dhoby Ghaut station. CC Moksin (W8) directed the TSC to instruct T134 to perform a line-clear to check for abnormalities on the track.
Around 6.44 pm – Fault lights illuminated in T128
147 As T128 was travelling between Dhoby Ghaut and Somerset stations,
TO Zainal Bin Rahmat (“TO Zainal”) (W3) noticed four fault indicators for air-conditioning, converter, compressor (local) and compressor (train) lighted up. TO Zainal (W3) testified that he communicated the problem to the TSC
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over at the OCC through his train radio communication set but was told by the TSC to monitor the situation since T128 was still able to operate normally.
Around 6.45 pm – Loud dragging sound heard just before T134 stalled
148 TO Alwi (W5) testified that shortly after T134 departed City Hall station, he heard the TSC from the OCC calling out his call-sign via the train radio communication set just as his train passed by the passenger alarm limit marker in the tunnel which is about 133 metres from the headwall of City Hall station. Before he could respond to the TSC’s call, he suddenly heard a continuous loud sound coming from the outside of his train from the back.
TO Alwi (W5) was shocked to hear this sound as it was different from the screeching noise that was usually caused by frictional contact between a train and the metal track. Instead, the loud noise sounded like plastic being dragged. A few seconds later, T134 began to gradually slow down from about
70 km/h, coming to a complete stop about 150 metres from the tailwall of
Dhoby Ghaut station. TO Alwi (W5) noticed that the master fault light indicator was lit. He checked the rear panel and discovered that the air- conditioner fault indicator and the converter fault indicator were both lit. He pushed the master fault reset button and the converter fault light then went off. However, the air-conditioner fault indicator remained lit up. This meant that one or more of the air-conditioners in the train were faulty. He further noticed that the line voltage indicator was not lit up. He understood this to mean that there was no electrical power being channelled to T134 and that the train was operating on backup battery power which sustained only the radio communication set, emergency lighting and fault indicators. He looked through the louvers of the door between the TO cab and the passenger section. He observed that there were only emergency white lights on and that
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the train was packed with passengers. He was beginning to perspire as it was getting warm.
149 TO Alwi (W5) contacted the TSC and informed him that T134 was not able to move as there was no line voltage and the air-conditioner was also not working. He also informed the TSC that his train was about 150 metres away from the tailwall of Dhoby Ghaut station on the north-bound track. The TSC then instructed TO Alwi (W5) to make an announcement over the PA system of T134 to inform all passengers of the delay. TO Alwi (W5) did so accordingly and informed the passengers that T134 would be delayed due to a train fault.
Around 6.46 pm – Fault lights lit up again in T139
150 After T139 had travelled about 200 metres away from Dhoby Ghaut station towards Somerset station, TO Hady (W4) noticed the same four fault indicators lighting up at the same time. He informed the OCC of the matter and was instructed to perform a reset at the next station and to monitor the situation at the same time. When T139 arrived at Somerset station, TO Hady
(W4) managed to clear all the fault lights after pressing the power reset button and the “auxiliary-on” button. He informed the OCC that the problem had been resolved and was directed to continue to operate T139 along the north- bound track towards the next station. He proceeded to do so accordingly, and
T139 then departed from Somerset station.
Around 6.48 pm – Fault lights illuminated again in T128; commuters onboard stalled T134 activated ECB; T139 stalled in tunnel after leaving Somerset station
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151 In the course of the journey from Somerset station to Novena station,
TO Zainal (W3) observed that the line voltage indicator kept flickering and alternating between on and off. After T128 departed from Novena station for
Toa Payoh station, TO Zainal (W3) noticed that the fault indicator with respect to the battery charge also lit up. He understood this to be an indication that there was a fault with the battery charge. The battery charge, if in good condition, would be able to provide the train with backup power for
45 minutes in the event of any fault in the emergency system, e.g. a power failure from the third rail. TO Zainal (W3) reported the faults to the TSC and was advised by the TSC to monitor the situation and operate T128 as per normal.
152 At around the same time, shortly after T134 stalled in the tunnel between City Hall station and Dhoby Ghaut station, several commuters activated the ECB but the TO could not make out what they were trying to say. According to the testimony of TO Alwi (W5), he addressed the passengers over the PA system of T134 once again advising them to calm down and be patient while he awaited instructions. He further explained to the passengers that the train was not able to move and it would therefore be futile for them to activate the ECB. TO Alwi (W5) then opened his cabin door to assure the passengers that he was still in the train together with them. A man came up to him and asked him what the problem was. TO Alwi (W5) told him that the train was faulty and the man informed TO Alwi (W5) that he had been prescribed medication and needed to return home urgently. One after another, passengers started coming into his cabin and complaining to him. All TO Alwi (W5) could do was to tell them to calm down as he tried his best to find a solution for the stalled train. He also conveyed to the TSC that many passengers were complaining about the stuffiness.
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153 TO Alwi (W5) testified that he then decided to walk through the train to assess the situation. Even though everyone was concerned about the stuffiness, they were calm nevertheless. There was a switch in the TO’s cabin which could be turned on with the permission of the TSC in order to activate the ventilation fan to provide ventilation in the event of a fire emergency but it did not cross his mind to do so at that time. As TO Alwi (W5) was walking through the train, he was approached by a group of Malay female passengers.
One of them told him that she had an asthmatic condition and could not breathe. TO Alwi (W5) brought her to his cabin where there was more space and allowed her to rest.
154 All this while, the TSC repeatedly asked him if the line voltage indicator had lit up in green, and he replied that it had not. According to TO
Alwi (W5), he had tried all means to restore power to the train but the TSC did not seem convinced that he had done all he could in troubleshooting.
155 Meanwhile, after T139 had travelled about 400 metres away from
Somerset station towards Orchard station, TO Hady (W4) encountered the same problem with the fault lights. He contacted the OCC immediately but there was no response from the OCC. T139 then gradually came to a stop about 50 metres from Orchard station. It was then that the OCC instructed him to try and move the train into Orchard station. TO Hady (W4) informed the OCC that the same four fault indicators were still illuminated and T139 could not move at all. He was then directed by the OCC to put T139 in RM mode and thereafter to try to drive the train into Orchard station. TO Hady
(W4) did as he was instructed but could not move T139 forward. Instead,
T139 rolled back as it was on a gradient at that time. When the train rolled backwards, he applied the brakes of the train immediately and the train came to a stop. The OCC then directed him to try and use the High Tractive Effort
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switch in order to move the train in RM mode towards Orchard station. TO
Hardy tried to do so but T139 was unable to move forward at all. The OCC then asked TO Hady (W4) to check the line voltage indicator. TO Hady (W4) checked and found that the line voltage indicator was lit up. He pressed the power reset button again but was still unable to get T139 moving.
156 The OCC then instructed TO Hady to make announcements to inform the passengers of a delay in train service. TO Hady (W4) was not told how regularly he should make the announcements. He then made the announcement accordingly through the train’s PA system about three times at intervals of a few minutes between each announcement. Thereafter, the OCC asked him to check the line voltage indicator again and TO Hady (W4) replied that there was line voltage as he could see that the green light was illuminated
The OCC then directed him to make further announcements with regard to the train delay and wait for assistance. TO Hady (W4) did as he was instructed.
Around 6.52 pm – OCC confronted with situation of two stalled strains
157 By this time, two trains had stalled in the tunnel. T134 had stalled in the tunnel between City Hall and Dhoby Ghaut stations and T139, which was ahead of T134, had stalled in the tunnel between Somerset and Orchard
Stations. There were no other trains between T134 and T139.
158 According to CC Moksin (W8), the breakdowns of T134 and T139 in the tunnel were affecting the smooth operation of the north-bound train services. There were two matters that had to be taken care of. First, there was a need to regulate the train services ahead of T139 along the north-bound track by turning around certain south-bound trains to service the north-
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bound train ahead of T139, and secondly, there was a need to get ready an assisting train should the need for a rescue operation arise.
159 With these considerations in mind, CC Moksin (W8) directed the TO of
T118, which was behind T134, to detrain all passengers and thereafter stand by at City Hall station. Next, he directed two south-bound trains to detrain at
Newton station, and to thereafter cross over to the north-bound tracks via the cross-over track between Newton and Orchard stations, before resuming north-bound passenger service from Newton station. Subsequently, he directed the third turnaround train to be the rescue train for T139. At some point in time during the management of the two defective trains, CC Moksin
(W8) noticed that the duty Manager of the OCC Lum Kok Soon (“MOCC
Lum”) (W9), was present at the OCC and that he was assisting him in disseminating the train disruption information.
Around 6.55 pm – T133 stalled at Braddell station; third train to stall in a row
160 The OCC received yet another report of a stalling train; this time it was from the TO operating T133 who reported that the train was unable to depart from Braddell station.
161 According to the testimony of TO Yassin (W2), who was operating
T133, the train had been having recurring problems of fault lights coming on in between stations and clearing upon the train arriving at each station. This problem persisted all the way from Orchard station to Toa Payoh station. TO
Yassin (W2) did not continue to report to the OCC this problem of fault indicators being repeatedly illuminated as he thought this was a normal phenomenon. He was new to the job and 15 December 2011 was his first day operating a train on his own. While T133 was between Toa Payoh and
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Braddell stations, he further noticed that the battery charge indicator had also lit up, and that the speed of T133 declined from 40 km/h to only 20 km/h.
Prior to arriving at Braddell station, on seeing that the train was not operating normally and that it was slowing down, he made four attempts to contact the
TSC over the train radio communication set but was unsuccessful. He tried to contact the OCC through the Emergency Channel, but there was also no answer. He then tried to call the OCC using the handheld portable radio set but realised that it was damaged and unusable. Eventually, after multiple tries, he managed to contact the OCC using his own mobile phone. He reported that various fault indicators had lit up and the line voltage light was off. By this time, T133 had arrived at Braddell station. TO Yassin (W2) then opened the train doors for passengers to alight from and board the train.
Shortly after, he tried to operate T133 to depart from Braddell station but discovered that the train could no longer move. He reported the matter to the
OCC, and was informed by the OCC that there was a track fault. He was also directed by the OCC to play the pre-recorded announcement message to inform all passengers that there would be a slight delay due to a track fault.
The doors of T133 were left open. About 15 minutes later, TO Yassin (W2) received the TSC’s instruction to detrain T133. TO Yassin (W2) then played another pre-recorded message through the PA system informing all passengers that T133 would be terminating its service at Braddell station and that they would have to alight from the train. He also made similar announcements over the PA system himself.
162 According to the testimony of CC Moksin (W8), he was informed by the OCC staff in charge of track power supply that there was no problem with the power supply to the system. CC Moksin (W8) felt perplexed as he could not fathom what could have caused three trains to stall concurrently in the
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absence of any power failure. As such, he instructed the personnel in charge of power supply to make arrangements for manpower to be sent to where the defective trains were to do the necessary checks. He also contacted the P-way maintenance staff and requested them to inspect the third rail. The P-way staff informed him that there was only one team available to be deployed at that time. He then requested that the said team of P-way staff be sent to the tunnel between City Hall and Dhoby Ghaut stations to do the necessary inspection.
163 The stalling of T133 at Braddell station meant that the trains operating along the north-bound track behind T133 were held up and could no longer continue with their north-bound passenger services. These trains were T128, which was at Toa Payoh station at that time, as well as two other turn-around south-bound trains between Newton station and Toa Payoh station.
164 According to CC Moksin (W8), the paramount task was to detrain the passengers so that they would not be stuck within these trains. He therefore instructed the TO operating T128 to detrain all passengers, and at the same time, to stand by to assist T133. CC Moksin (W8) then realised that by this time, the two trains behind T128 along the north-bound track had already caught up with T128 and were in the tunnel between Novena and Toa Payoh stations. As such, he instructed the TO operating T128 to move the train forward towards Braddell station in order to ease congestion of trains behind, and also to act as the rescue train for T133 once the need arose.
165 According to CC Moksin (W8), when he asked T128 to detrain at Toa
Payoh station, it had not stalled yet. But as its path was blocked by T133, the detrainment was necessary as it would not be able to continue with its service
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when it reached Braddell station. CC Moksin (W8) did not instruct T128 to be the rescue train eventually as the train itself had developed faults.
166 However, TO Zainal (W3) who was operating T128, gave a somewhat different account of what transpired. According to TO Zainal (W3), as T128 was approaching Toa Payoh station, he noticed that it could move only at a speed of between 30 and 40 km/h. Its normal speed should have been between 60 and 80 km/h. Upon arrival at Toa Payoh station, he proceeded to open the train doors. At this juncture, there was a power failure of the train and the emergency lights came on. He was not able to operate anything else in the train, including the train radio communication set. He also could not operate his portable radio set as the battery was flat. He checked the line voltage indicator and observed that it was still flickering and alternating between on and off. TO Zainal (W3) alighted from the TO cab and proceeded to the headwall unit which was in the tunnel of Toa Payoh station. He then called the OCC via an emergency phone system called the EPAX and reported that his train radio communication set was not working and only the emergency lights were on. He obtained approval from the TSC at the OCC to detrain the passengers of T128, but he was unable to make the necessary announcements to the passengers as the train announcement system was also not working. Nevertheless, two station staff assisted by walking through the train to ask passengers to alight. After all the passengers had alighted from
T128, TO Zainal (W3) observed that the ATP-code was still lit, which meant that his train was still cleared to proceed to the next destination. He called the
TSC again through the EPAX phone to seek further instructions. The same
TSC told him to continue operating T128, which was now re-designated as
T928, to Braddell station to assist another train which had stalled. He was surprised but had to follow the instructions given by the OCC.
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About 7.00 pm – Crowd swelled at Newton station following detrainments
167 CSO Noor Ashah Bte A Majed (“CSO Ashah”) (W22) testified that while she was at the Passenger Service Centre (PSC) alone at Newton station, she received a call from the OCC informing her that she was to conduct a train-to-platform detrainment on a south-bound train that was arriving at
Newton station. She then proceeded to the platform for the detrainment.
Along the way, she informed SM Toh Kang Tiong (“SM Toh”) (W21) through her handheld communication device and asked him to assist her in the detrainment as she was alone but SM Toh (W21) was engaged. The TO helped her to detrain the commuters. After all the passengers had been detrained,
CSO Ashah (W22) returned to the PSC, as it had been left empty.
168 Shortly after arriving at the PSC, CSO Ashah (W22) was directed by the
OCC to conduct a second detrainment. She ran down to the south-bound platform to conduct a second detrainment and this time round, SM Toh (W21) was available to help her.
169 As soon as she got back to the PSC, CSO Ashah (W22) received another call from the OCC to carry out a third detrainment and thereafter for SM Toh
(W21) to contact the CC of the OCC as there were instructions for him to perform a rescue task. She ran down again to the south-bound platform and informed SM Toh (W21) of the CC’s instructions. SM Toh (W21) helped her detrain the passengers. CSO Ashah (W22) returned to the PSC after conducting the third detrainment while SM Toh (W21) went into the empty train as he was proceeding to conduct the rescue.
170 At that time, there was a huge crowd standing around the PSC, enquiring about what had happened. CSO Ashah (W22) attended to the enquiries and processed passengers’ requests for fare refunds.
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171 According to the testimony of SM Toh (W21), the platform was quite crowded with at least 1,000 commuters after the first detrainment. He did not ask the commuters to leave the platform as he did not know what was happening. SM Toh (W21) subsequently received a second instruction from the OCC to detrain the next south-bound train coming to his station. As he was not aware of what was happening, he just followed the OCC’s instructions. As there were no instructions from the OCC to make announcements over the station’s PA system to inform commuters not to board the south-bound train, no announcements were made to do so. By that time, the platform was crowded. Everyone was asking SM Toh (W21) questions and wanted answers, but all SM Toh (W21) could say to them was to wait for the next train as he did not know what was happening. SM Toh
(W21) tried to contact the OCC but was told to “wait out”. This meant that they were very busy and were asking him to just wait for further instructions.
About two to three minutes later, SM Toh (W21) saw the lights of the third train, T112, entering the south-bound platform. At the same time, the OCC contacted him and told him to perform another detrainment of that train.
After detraining the commuters, the TO closed the train doors but the train did not leave the station.
About 7.04 pm – T112 directed to rescue T139
172 Shortly after T112 was detrained at Newton station, SM Toh (W21) was directed by the OCC to board the train and take control of it, i.e. the TO would operate the train under his command. Before boarding the train, SM
Toh (W21) told CSO Ashah (W22) to take control of Newton station.
173 The OCC instructed SM Toh (W21) to take the train to pass the cross- over to the north-bound track between Newton station and Orchard station.
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After that, he was to operate the train south-bound against the normal flow towards Orchard station. SM Toh (W21) did as he was told and instructed the
TO accordingly. As the train was travelling against the usual direction of movement, the speed was limited to 18 km/h and SM Toh and the TO had to keep a lookout for what was in front of them. The distance between Newton and Orchard was about 1 km. Due to the speed at which the train was travelling, it took about 6 minutes to arrive at Orchard station.
About 7.07 pm – T918 encountered sagging third rail in the tunnel between
City Hall station and Dhoby Ghaut station
174 Meanwhile, T918 (re-designated from T118) was performing a “line- clear” and making its way towards T134 as directed by CC Moksin (W8).
After the train had travelled for about 50 metres away from City Hall station,
TO Aw Thiam Huat (“TO Aw”) (W6) observed that the third trail ahead of him on his right appeared to be out of place. He stopped the train immediately. Upon further observation, he noticed that the third rail about 10 metres ahead of his train had sagged and appeared to be touching the track sleepers, although he could not confirm whether there was any actual contact between the third rail and the sleepers. He further observed that a segment of the third rail cover, of about 3 metres in length, was missing. Immediately, he activated the Emergency Channel of his train’s radio communication set which allowed him to communicate directly with the CC in the OCC. He reported to the CC that an estimated 6-metre segment of the third rail had collapsed. The CC directed him to stop his train and to wait for further instructions. About ten minutes later, various persons started arriving at the site to inspect the sagged portion of the third rail. These persons included P- way personnel, the SM of City Hall station and the Rail Service Manager.
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They had to board his train via the rear door before they could gain access to the tracks using the emergency detrainment ramp.
About 7.08 pm – OCC decided to perform train-to-track detrainment for T134
175 Given that the third rail in the tunnel between City Hall and Dhoby
Ghaut stations had sagged, CC Moksin (W8) knew that it would not be possible for T918 to proceed to where T134 was. It would also be impossible for any rescue train to proceed to where T134 was via the cross-over track between Orchard and Newton stations because T139 had stalled along the north-bound track between Orchard and Somerset stations and would be an obstacle to any train approaching T134 from the north along the north-bound track. CC Moksin (W8) came to the conclusion that a train-to-track detrainment for T134 was unavoidable. He proceeded to inform MOCC Lum
(W9) of the situation and he agreed that a train-to-track detrainment for T134 was inevitable. CC Moksin (W8) then instructed the personnel in the OCC in charge of power supply to turn off the power supply to the third rail at that segment of the track. Thereafter, MOCC Lum (W9) took over the coordination of the train-to-track detrainment of T134 while CC Moksin (W8) returned to making arrangements for the rescue of T139.
About 7.10 pm – Detrainment of T134
176 Around this time, the TO Alwi (W5) received instruction from the TSC to prepare for the train-to-track detrainment of the passengers. The TSC further informed TO Alwi (W5) that the SM for Dhoby Ghaut station would be performing the necessary precautionary measures on his behalf. These involved ascertaining whether there was any electrical current running through the third rail by using a volt tester. Thereafter, Short Circuiting
Devices (SCDs) would be installed on the third rail. TO Alwi (W5) waited
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inside the train while these measures were being carried out. He also informed the passengers through the PA system to prepare to walk along the track towards Dhoby Ghaut station, and to be calm and walk towards the front of the train where he was.
177 When the TSC informed him that it was safe to go on to the track, TO
Alwi (W5) opened the emergency detrainment hatch at the front. He could see the SM with a small torchlight standing on the track near Dhoby Ghaut station. He could also see the lights of Dhoby Ghaut station. Although there were yellow lights on the side of the tunnel, they were very dim. In fact, it was so dark within the tunnel that a person would have to walk very cautiously on the track in order not to trip.
178 TO Alwi (W5) waited for the SM to walk over to him to assist in the detrainment process. Once the SM arrived at T134, TO Alwi (W5) positioned himself on the track at the end of the detrainment ramp and ushered the passengers slowly one by one onto the track. While doing so, he kept apologising for the breakdown of the train and also reminded the passengers to walk cautiously. TO Alwi (W5) estimated that there were more than 1,000 passengers on the train. Halfway through the process, SCDF officers also arrived at his train with stretchers and breathing apparatus to assist in the detrainment of passengers. The SCDF officers entered his train using the detrainment ramp and came out shortly after with a female passenger on the stretcher. That was when he realised that someone had fainted in the train.
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179 The detrainment process took nearly an hour to complete. It was about
8.05 pm by the time the last commuter from train T134 arrived at Dhoby
Ghaut station.81
180 The COI also heard the testimony of a passenger who fainted in T134.
She is Ms Ang Lai Guat, Charlene (“Ms Ang”)(W33). According to Ms Ang
(W33), the train was very crowded and there were many people standing.
After the train stalled, it got very stuffy and she could not feel any fresh air entering the train. She told a Malay passenger seated beside her that she could not breathe properly and the passenger managed to find a sweet for her.
However, the difficulty in breathing was worsening and two passengers started fanning her using pieces of paper. She passed out subsequently and regained consciousness only in the Accident and Emergency Department of
Singapore General Hospital.
181 According to Ms Ang (W33), after the train first came to an abrupt stop, the passengers became increasingly frustrated and there were children crying. She also saw passengers sitting on the floor of the carriage despite the crowded condition as they were probably tired from standing for an extended period. Generally, the passengers were calm but uncomfortable as they did not know how long they would be trapped in the train.
About 7.16 pm – SCDF received “995” call of a passenger fainting inside a train
182 SCDF received a “995” call from a member of the public. According to
Staff Sergeant Mohamed Nizar Bin Mohamed Marican (“SSG Nizar”) (W106), a Supervisor at the SCDF Operations Centre, the text of the message as recorded was “One pax fainted inside the train” between Somerset and
81 Annex E to ES1 at pages 49 and 50 80
Orchard stations. SSG Nizar (W106) directed an ambulance to be despatched and as a precautionary measure, he also despatched the Fire Brigade to
Orchard station.
About 7.18 pm – T928 stalled while on way to rescue T133
183 After T928 departed from Toa Payoh station and headed towards
Braddell station to rescue T133, the train stalled while it was inside the tunnel between Toa Payoh and Braddell stations. TO Zainal (W3) experienced a blackout in the first three cars of the train and reported the matter to the OCC.
He was told to remain where he was and to await further instructions.
About 7.23 pm – RIMP activated
184 CC Moksin (W8) received a call from SMRT’s Vice President Rail
Operations Lui Wai Meng (“VPRO Lui”) (W114) who directed that the RIMP be activated. According to the testimony of CC Moksin (W8), when the RIMP was activated, key personnel would report to their respective duty posts to assist in managing the situation and the recovery of service. SMRT Chief
Engineer Tay Ko San (“CE Tay”) (W83) 82 would report to the OCC to oversee the operation of service recovery and SMRT Senior Vice President of
Engineering and Projects Vincent Tan (“SVP Tan”) (W84) would also report to the OCC for the service recovery.
185 According to MOCC Lum (W9), the RIMP is designed to manage crowds which would build up at the various affected MRT stations, and also the recovery of stalled trains. The activation serves to provide the OCC with the necessary manpower numbers to cope with the entire operation.
82 Mr Tay Ko San was Senior Manager Control Operations (“SMCO”) at the time of the incidents on 15 and 17 December 2011. 81
About 7.31 pm – T112 hauled T139 to Orchard station for detrainment
186 As T112 passed Orchard station, SM Toh (W21) saw through the glass doors that it was as packed as Newton station. SM Toh (W21) finally saw the stalled T139 about 100 to 150 metres after he passed Orchard station. He proceeded to couple T112 with T139 and was then instructed by the OCC to pull T139 to be in line with Orchard station so that the train could detrain. It was at that point that SM Toh (W21) knew that the train had passengers on board. SM Toh (W21) and the TO went to the TO cab at the opposite end of the train and began to haul T139 to Orchard station. At the start, it was difficult because of the weight of the two trains but slowly, they managed to inch forward and pull the train to be aligned with Orchard station.
187 According to TO Hady (W4), T139 had stalled for about 45 minutes when he saw T112 coming towards him from Orchard station. It was only then that the OCC contacted him and informed that the approaching train would couple with his train in order to haul it to the next station. Prior to that,
TO Hady (W4) had sought to contact the OCC but there was no reply.
According to TO Hady (W4), passengers onboard the train started pressing the ECB after T139 had stalled for about 15 minutes. They asked whether the train was going to move. They also complained that it was very warm. TO
Hady (W4) advised these passengers to be patient. At that time, the lights and the air-conditioner inside the TO cab were still in working order because he could see that the line voltage indicator was lit. For security reasons, he did not open the door between the TO cab and the passenger cabin. He did not physically enter the passenger cabin to check if the lights and air-conditioner were still operating. They were louvers on the door through which he could have observed the conditions within the passenger cabins but he did not do so. This was because he had observed that the line voltage indicator in the
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driver’s cabin was still illuminated in green, which indicated that there was electrical power. Based on his knowledge and the training that he had received, the operation of the lights and air-conditioner would not be affected so long as there was still traction power channeled to the train.
188 When T112 managed to successfully haul T139 to Orchard station, TO
Hady (W4) got out of his cabin and informed the SM of Orchard station to manually open the platform screen doors.
189 According to 15 December 2011 afternoon shift Orchard SM
Kamalludin Bin Rabu (“SM Kamalludin”) (W19), the detrainment process took about 30 minutes as he chose to manually open all the train doors one- by-one as he felt he could better control the passengers’ disembarkation and to observe whether anyone may be in need of medical attention. This was also to prevent a possible stampede if everyone rushed to the opened alternate exits given their state of frustration. He entered the train via the TO cab door and proceeded to assist the TO to isolate and open the door which was right behind the console cab to allow the passengers to detrain. Once he entered the carriage, he observed that the passengers were rather agitated and there were many rude remarks and some vulgarities uttered to the TO and himself. Some of the passengers also blocked their path and demanded to know what would happen to their interrupted journeys and demanded refunds of their fares.
During the detrainment process, he heard repeated service disruption announcements by CSL Gowri informing passengers that due to a train fault, there would not be any north-bound services.
190 After the detrainment was completed, SM Kamalludin (W19) and TO
Hady (W4) saw a smashed window in one of the carriages. There was a fire- extinguisher on the floor with the glass fragments. However, there were no
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blood stains around. Neither did they notice any injured passengers during the detrainment process.
191 When SM Kamalludin (W19) returned to the concourse level, he saw that it was quite chaotic. There were about 100 passengers in the paid area and most of them appeared to be seeking refunds at the PSC. Beyond the paid area, the concourse was extremely packed. People were standing shoulder-to- shoulder. SM Kamalludin (W19) estimated that there were about 7,000 passengers in the concourse areas, both paid and free.
192 SM Kamalludin (W19) could only see two of his CSLs in the PSC. CSL
Gowri was still making public announcements to inform the passengers that due to a train fault, there would be no services to the north-bound direction while CSL Faezan was handling the queues of passengers seeking refunds. By this time, around eight or nine police officers had also arrived and they were trying to control the agitated crowd.
193 SM Kamalludin (W19) entered the PSC and instructed CSL Gowri to set up the service disruption signages at the designated areas while he took over making announcements. CSL Gowri returned ten minutes later looking pale, and told him that she was almost assaulted by a man in the crowd. SM
Kamalludin (W19) stepped out to respond to him. He was making various demands of SM Kamalludin (W19), including wanting him to arrange and pay for a cab for him to his intended destination. SM Kamalludin (W19) managed to get one of the police officers to engage with the man and then requested another police officer to advise the passengers that SMRT would be providing refunds to them and that they could approach any counter at any
MRT station within 14 days for their refunds.
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194 According to SSG Nizar (W106) of the SCDF, a female passenger was conveyed by ambulance to the Singapore General Hospital from Orchard station. The Fire Brigade officers, who had been activated to Orchard station, assisted the ambulance crew in carrying the female passenger from the station platform to the ambulance.
About 7.55pm – LTA activated Public Transport Crisis Management Team
(PT-CMT)
195 LTA Deputy Chief Executive Lim Bok Ngam (“DCE Lim”) activated the PT-CMT upon the advice of Deputy Group Director of Vehicle and Transit
Licensing Yeo Teck Guan (“DGD Yeo”) (W104). LTA officers were recalled to assist in monitoring SMRT’s recovery efforts and the bus bridging services. Enforcement officers and CISCO wardens were deployed to facilitate the movement of bridging and regular buses. Additional “green time” to facilitate bus movement was accorded to these vehicles. LTA officers were also sent to affected stations to monitor the crowd situation and the site of the sagged third rail to report on the recovery efforts. LTA also requested SBST to help manage the crowds at SMRT-NEL interchange stations.
About 7.56 pm – First bridging bus arrived at Bishan station
196 SMRT Deputy Director of Station Operations Teo Wee Kiat (“DDSO
Teo”) (W81), who was one of the key personnel activated under the RIMP, was involved in liaising with the Bus Operations Control Centre (BOCC). The
BOCC was instructed to send buses to the affected stations in order to provide a bridging service in respect of the affected stations on the NSL. According to
DDSO Teo (W81), the first wave of buses consisted of about 40 buses. The first bus arrived at around 7.56 pm at Bishan station and the first bus at City Hall station arrived around 8 pm.
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About 8.30 pm – Partial resumption of train service
197 According to CC Moksin (W8), south-bound passenger service up to
Raffles Place station was resumed so that trains arriving at Raffles Place station could cross over to the west-bound track, proceed to Jurong East station, before crossing back to the south-bound track. This allowed for partial resumption of passenger services.
About 11.40 pm – Full resumption of train service
198 According to CC Moksin (W8), after the respective on-site teams reported that the third rail had been fixed, the OCC started the train rescue operations after the requisite line-clear had been conducted. There were no more passengers onboard the trains. The defective trains were successfully rescued and full passenger service resumed at about 11.40 pm that night.
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CHAPTER 7
INCIDENT ON 17 DECEMBER 2011
Summary of events
199 Shortly after the commencement of revenue service on the morning of
17 December 2011, a number of trains encountered intermittent loss of line voltage on the NSL, similar to the events of 15 December 2011. Some trains were able to continue operating normally until they returned to the depot later in the day, where they were found to have damaged CCD components.
However, four trains were immobilized at various locations along the north- bound and south-bound tracks on the NSL. Another train was pre-emptively detrained after it was found to be operating with only emergency lighting and ventilation in three of its cars.
200 The first train to stall was T137 which lost power at around 6.44 am while travelling south-bound between Dhoby Ghaut station and City Hall station. This was followed by T113 which was unable to proceed forward after being released from a “hold” at 7.03 am between Orchard and Somerset stations south-bound. Next, T132 stalled after losing traction power at 7.03 am between Somerset and Dhoby Ghaut stations south-bound while performing a line-clear. T136 was detrained and taken out of passenger service at 7.06 am at Ang Mo Kio station’s north-bound platform after the TO was informed that only the emergency cabin lights were on in the train’s first three carriages.
Later in the morning at 8.38 am, T123 was also detrained and withdrawn from service at the north-bound platform of Bishan station after the TO reported that the train had lost propulsion power and the train’s fault lights had lit up, like the trains that had stalled earlier.
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201 Except for those on T113, which was immobilized in the south-bound tunnel between Orchard and Somerset stations, and T132, passengers on the other three trains were detrained directly onto station platforms. In the case of
T137, passengers detrained via the TO’s cabin as the train had “under-run” the platform at City Hall station, such that only the door to the TO’s cabin was aligned with the station’s platform screen doors. As for T132, at the point that it stalled, there were no passengers in the train as the TO had already detrained all passengers at Somerset station as instructed by the OCC, in preparation to conduct a line-clear.
202 The sequence and locations of the breakdowns are tabulated as shown in Figure 43:
Train Time Location where train stalled/was withdrawn from service T137 6.44 am City Hall station T113 7.03 am South -bound tunnel between Orchard and Somerset stations T132 7.04 am Dhoby Ghaut station T136 7.06 am Ang Mo Kio station (detrained and withdrawn from service pre-emptively) T123 8.38 am Bishan station
Figure 43: Sequence and locations of breakdowns
203 The passengers of T113 had to detrain onto the track. Fortunately, however, they did not have to wait in the stalled train for long. Detrainment commenced within 14 minutes of the train stalling and was completed half an hour after the train was immobilized.
204 The RIMP was activated at 7.12 am. All south-bound trains were instructed to turnaround at Newton station (and for a time Toa Payoh station) or hold at stations. Bus bridging service commenced at 7.30 am when the first
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bus arrived at Newton station. Starting at 8.29 am, alternate trains operating on the EWL were also diverted to crossover onto the NSL to partially reinstate north-bound service between Marina Bay and Newton stations, which had also been disrupted as south-bound trains were unable to turnaround at
Marina Bay station.
205 At about 8.40 am, a team of P-way maintenance personnel found a 20- metre section of sagged third rail approximately 100 metres north of the tailwall of the south-bound track at Orchard station. The sag was at a track section with a tight left hand curve with a 300 metre radius. The third rail was observed to be almost touching the track bed. A “split end” was found at the upper part of the fishplate joint between the two third rails segments.
However, SMRT assessed that there was no safety and operational risk in temporarily restoring the third rail to allow train service to resume, as long as a speed limit was imposed on passing trains. Restoration and regauging of the third rail therefore commenced at 8.50 am and was completed at 9.25 am. The cracked third rail was replaced after the end of revenue service on 17
December 2011.
206 South-bound service resumed at 1.19 pm after the immobilized trains had been hauled off the tracks. Normal service resumed at 1.53 pm. An estimated 94,000 passengers were affected by the 7-hour long disruption.
Compared to the one on 15 December 2011, the disruption on 17 December
2011 affected a smaller number of commuters as it occurred on a Saturday morning.
Chronology of events
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207 A chronology of events on 17 December 2011 prepared by CID is presented at Annex L. A separate account prepared by the SMRT IIT is presented at Annex M.
Witnesses’ accounts
208 A summary of witnesses’ accounts related to the incident is provided below in chronological sequence.
Around 6.28 am – T136 experienced jerk and air-conditioning fault light illuminated before reaching south-bound platform of Orchard station
209 When his train was around 300 metres from the south-bound tailwall of Orchard station, the TO of T136 Lim Han Ping James (“TO Lim”) (W31) felt it “jerk” forward slightly and saw that the train’s master fault light had illuminated. Upon checking the fault panel, he saw that the air-conditioning fault light had also lit up.
Around 6.29 am – Fault lights extinguished when T136 arrived at Orchard station
210 When T136 arrived at Orchard station, TO Lim (W31) saw that the master and air-conditioning fault lights had extinguished. Based on this, as well as the illumination of the fault lights being a common occurrence in his experience, he did not report the matter to the OCC.
Around 6.30 am – CC (Trains) informed of faults reported by T127; TO of T137 instructed to carry out line-clear; fault lights on T136 continued to illuminate each time the train left a station and extinguish when reaching a station
211 CC (Trains) Quah Siew Ghee (“CC Quah”) (W38) was overseeing the
NSEWL OCC when he was informed by a TSC that the TO of south-bound
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T127 had reported some faults with the train. CC Quah (W38) testified that since the train was still able to move, he instructed the TSC to direct the TO of
T127 to continue operating the train southward, and to instruct the TO of the train behind T127 to conduct a line-clear.
212 The train directly behind T127 was T137, operated by TO Mohamed
Redzuan Shah (“TO Redzuan”) (W32), which was en route to Newton station on the south-bound track. TO Redzuan (W32) affirmed that he was instructed by the OCC to conduct a line-clear to look out for any abnormalities or foreign objects although no reason was given for the instruction. There was also no communication between the OCC and other TOs that suggested that there was any problem ahead.
213 Meanwhile, T136 departed Orchard station. Subsequently, at Somerset,
Dhoby Ghaut, Raffles Place and Marina Bay stations, TO Lim (W31) noticed that the master and air-conditioner fault lights lit up each time the train left a station and extinguished whenever it entered a station. At City Hall station, the two fault lights remained illuminated while the train was at the platform.
214 According to TO Lim (W31), he did not assess that T136 could be encountering a repeat of the 15 December disruptions as the faults did not appear to be permanent and the train appeared to function as normal.
Furthermore, he had not been briefed in detail on the 15 December incident and its causes. Therefore, he did not report the intermittent illumination of the fault lights to the OCC. However, to ensure that T136 was not malfunctioning, he checked the fault panel in each carriage when “changing ends” at Marina
Bay station. He saw that none of the individual carriages’ air-conditioning fault lights were on; the lights in the carriages also appeared to be working well. He thus proceeded to operate T136 north-bound.
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Around 6.35 am – Fault lights on T137 lit up after leaving Newton station
215 T137 arrived at Newton station. Up to this point, TO Redzuan (W32) had not encountered any abnormalities, but shortly after it left Newton station, the train’s master, air-conditioning, compressor (local), compressor
(train) and converter fault indicators lit up. Apart from this, he did not encounter any other abnormalities such as jerking, excessive rocking or unusual sounds or odours. The train was also able to accelerate normally, leading him to conclude that the train was still drawing line voltage from the third rail, although he did not notice whether the line voltage indictor was actually lit.
216 TO Redzuan (W32) did not attempt to perform any defect rectification procedures as he did not think there was much that he could do with multiple fault lights illuminated. However, he reported the illumination of the fault lights to the OCC which advised him to continue operating the train with caution. He then put the train in CM mode to carry out a line-clear as instructed earlier.
217 Since this was not a “standard” line-clear using an empty train, which would have to be conducted at below 35 km/h, TO Redzuan (W32) operated the train at around 60 km/h, slightly below the maximum speed permitted by the ATP system. He assessed the track to be normal without any abnormalities or foreign objects on the track or third rail, although he was only able to see the running rail, sleepers and third rail about 30 to 40 metres ahead due to the dim conditions in the tunnel.
Around 6.37 am – T137’s fault lights extinguished upon reaching Orchard station
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218 T137 arrived at Orchard station. Once the train stopped, TO Redzuan
(W32) saw from the reflection in his windshield that the fault indicators were no longer lit. Finding this strange, he reported it to the OCC which instructed him to continue monitoring the situation and updating the OCC while proceeding cautiously.
Around 6.38 am – T137’s fault lights lit up again upon leaving Orchard station
219 When T137 departed Orchard station, the fault indicators illuminated again. There were no other abnormalities such as excessive rocking or unusual sounds or smells. Furthermore, the train was able to accelerate normally. TO Redzuan (W32) reported the situation to the OCC which again advised him to continue operating the train with caution. He also attempted to reset the air-conditioning system but the fault indicators remained illuminated. He then continued to conduct the line-clear. He observed the track between Orchard and Somerset stations to be normal, without any abnormalities and foreign objects on the track.
Around 6.39 am – Fault lights on T137 extinguished upon reaching Somerset and illuminated after leaving the station
220 Again, the fault indicators ceased to be illuminated when T137 arrived at Somerset station and lit up when the train left the station. As before, TO
Redzuan (W32) notified the OCC and was instructed to proceed with caution.
Approximately 200 metres past the station, the fault lights came back on but when TO Redzuan (W32) attempted to inform the OCC again, his train radio communication set experienced a signal disruption and he did not receive any response from the OCC. In the meantime, he continued to perform the line-
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clear and observed the track between Somerset and Dhoby Ghaut stations to be normal.
Around 6.40 am – First detrainment at Marina Bay station
221 Night shift Marina Bay SM Mustamam Bin Salleh (“SM Mustamam”)
(W14) was instructed by the OCC to detrain a train arriving at the station. No other information was provided, but based on his experience, SM Mustamam
(W14) assessed that the incoming train could be “defective”. Once the train reached the platform, its doors opened normally and he detrained the approximately 100 passengers on board. He did so alone as the other Marina
Bay station staff had not reported for work yet. Subsequently, after returning to the PSC, SM Mustamam (W14) saw from the signal panel that the train was stationary at the station’s overrun track.
Around 6.41 am – T137 reached Dhoby Ghaut station; TO reported faults to
OCC via EPAX
222 T137 arrived at Dhoby Ghaut station. Once again, the fault lights went off. Feeling uneasy with the repeated illumination of the fault indicators, TO
Redzuan (W32) disembarked from the train to contact the OCC via the EPAX phone at the headwall of Dhoby Ghaut station. TO Redzuan (W32) testified that he used the EPAX phone as he felt that it would allow to speak to OCC staff “more directly”. He asked the TSC if T137 should continue operating passenger service and was again directed to continue operating the train to
City Hall station cautiously.
223 TO Redzuan (W32) testified that at this point, he was “rather frustrated” with the OCC’s instructions to continue operating the train.
However, he did not question or decline to comply since the train was
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operating otherwise-normally and he did not know whether there might be
“testing” being conducted on the third rail.
Around 6.42 am – T137 departed Dhoby Ghaut station; CC (Trains) directed south-bound trains to turnaround at Newton station or hold at stations
224 Train T137 departed Dhoby Ghaut station. The fault lights illuminated when the train left the station. TO Redzuan (W32) continued to operate the train toward City Hall station in CM mode. Upon reaching an upslope, he shifted the train’s MCH into “P4” mode to increase the train’s traction power in order to climb the upslope, before shifting it back into “coast” mode. He did not observe any abnormality on the train’s movement or the track.
225 In the OCC, CC Quah (W38) was informed of the illumination of fault lights in T137. Even though he had not been formally briefed on the suspected causes of the 15 December disruption at that point, CC Quah (W38) assessed that this could be a precursor to a repeat of that incident. In order to avoid trains stalling between stations, he immediately instructed his TSCs to direct south-bound trains north of Newton station to turn around at Newton station, the southernmost station before the suspected “problem stretch” at which trains could turn around using a crossover track. 83 He also told the TSCs to instruct all trains between Orchard and Marina Bay stations to stay put at their respective stations until further instructions were given.
226 CC Quah (W38) testified that he did not inform the SM of Newton station that trains would be turning around there because he was preoccupied with monitoring the overall situation on the NSL. He also expected that one of
83 CC Quah (W38) testified that he suspected a problem with the south-bound track south of Newton as T137 had not encountered any faults before reaching Newton. 95
the other OCC staff would have informed the Newton SM once he had given the turnaround instruction.
Around 6.44am – T137 stalled at City Hall
227 When T137 was about 200 metres away from City Hall station, TO
Redzuan (W32) applied the brakes to slow the train so that the train doors would be aligned with those of the station platform. However, while the train was pulling into the station, he realized that the train was moving too slowly for its doors to be aligned with those of the station. He tried to increase the train’s speed by shifting the MCH from “coast” into “P1” and then “P2” but sensed that the train had no traction power. TO Redzuan (W32) instinctively turned to check the fault panel behind his seat and saw that the line voltage indicator was no longer lit, indicating that the train was no longer receiving traction power from the third rail.
228 TO Redzuan (W32) immediately stopped applying the brakes to allow
T137 to coast as far into City Hall station as possible. The train came to a halt shortly afterward and was unable to move any further. None of the train’s passenger carriage doors were aligned with the platform screen doors.
Fortunately, however, the “B” side TO cab door was aligned with the first platform screen door.
229 TO Redzuan (W32) reported the situation to the OCC which directed him to “isolate” the train doors to allow them to be opened manually and to detrain the passengers through the TO cab door. When he opened the partition door separating the TO cab and the passenger cabin, he realized that only the emergency lights and ventilation system were on in the passenger cabin, indicating that the train was operating on backup power. However, as there were not many passengers on board, the train did not appear to be
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stuffy. TO Redzuan (W32) made announcements to the passengers using the train’s PA system to inform them of service delays and that they would have to detrain onto the station platform.
230 At around the same time, having received an alarm and seen from the
CCTV that a train had stopped at the platform without opening its doors, City
Hall night shift SM Mustadza Bin Nasar Bin Ahmadtalib (“SM Mustadza”)
(W15) proceeded to the platform. 84
Around 6.45 am – T132 TO instructed to detrain to platform at Somerset station
231 T132, the train behind T137, was travelling between Orchard and
Somerset stations on its first south-bound run for the day when TO See Boon
Siong (“TO See”) (W36) received an instruction from the OCC to detrain all passengers at Somerset station. Prior to this, he had not encountered any abnormalities with the train or tracks. TO See (W36) testified that as he was not given any further information, he only announced that the train was experiencing technical problems and requested all passengers to disembark at
Somerset station.
Around 6.46 am – T132 arrived at Somerset station; SM instructed to detrain it
232 T132 arrived at Somerset station. Night shift Somerset SM R
Kamaruzzaman (“SM Kamaruzzaman”) (W18) testified that he saw the train
84 SM Mustadza (W15) testified that he first received an alarm indicating that a train had stopped at the south-bound platform without opening its doors. He then saw from the CCTV that both the train and platform screen doors were closed. After monitoring the train for about 15 seconds, SM Mustadza (W15) activated the “train hold” button to prevent the train from moving off without allowing its passengers to alight. However, the train doors remained closed, and it was then that he decided to proceed to the platform to investigate. 97
when he was at the south-bound platform to check that the tunnel lights were switched on, as the OCC had instructed him to do.
233 SM Kamaruzzaman (W18) then returned to the PSC which was unmanned since no other station staff had officially reported for duty at that point. Upon returning to the PSC, he was instructed by the OCC to detrain the train at the platform, without any other information given.
Around 6.47 am – Fault lights illuminate again on T136 during north-bound run
234 Upon T136’s arrival at the north-bound platform of City Hall station,
TO Lim (W31) observed that the air-conditioner fault indicator had illuminated again. Prior to this, no fault lights had lit up during the train’s journey from Marina Bay station. However, he did not report the situation to the OCC.
Around 6.48 am – Sluggish acceleration of T136; T132 detrained to platform at Somerset station
235 As T136 departed City Hall station, TO Lim (W31) found the train to accelerate more sluggishly than normal, although the train was eventually able to reach the maximum speed imposed by the Auto-Train-Control (ATC) system. At the same time, the OCC informed all TOs on the NSL over radio that there was a problem with the south-bound track and directed TOs of south-bound trains to inform their passengers of possible delays. As TO Lim
(W31) was operating T136 north-bound at that point, he did not make any announcements.
236 The intermittent illumination of T136’s air-conditioning fault indicator and the sluggish acceleration persisted until the train arrived at Ang Mo Kio
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station. TO Lim (W31) did not recall the other fault lights for the compressor
(local), compressor (train) and converter illuminating at any point.
Throughout its north-bound journey up to Ang Mo Kio station, he did not report the abnormal behaviour of his train to the OCC.
237 Meanwhile, assisted by a CSL, SM Kamaruzzaman (W18) detrained about 300 passengers from T132 onto Somerset station’s south-bound platform within two minutes while TO See (W36) remained in his cabin to make announcements. Upon completion of the detrainment, TO See (W36) closed the train doors and walked through the passenger carriages to ensure that there were no passengers on board.
238 At around the same time, night shift Orchard SM Wong Nian Sam
(W20) heard the OCC asking an unknown TO over the radio to confirm that there was no line voltage. 85 As there were no instructions to him, he did not act on this, but he suspected something was amiss when he noticed shortly afterward that a train was stationary at the south-bound platform of Somerset station for more than two minutes, much longer than the usual 30 seconds.
Around 6.49 am – T113 put on automatic hold at Newton station
239 T113 arrived at the south-bound platform of Newton station on its first south-bound run of the day. Up to this point, TO Masrudin Bin Mat Salim
(“TO Masrudin”) (W35) had neither encountered any abnormalities while operating the train nor been informed of any indications of trouble from the
OCC. However, once the train doors opened, TO Masrudin (W35) observed that the red “on-hold” ATP code light was lit, indicating that the train would
85 SM Wong Nian Sam (W20) was only able to receive transmissions from the OCC to TOs but not those from TOs back to the OCC. 99
not be allowed to move until there was a sufficient distance between T113 and the train ahead.
240 TO Masrudin (W35) testified that he found it “unusual” that the on- hold light was lit while the doors were still open. He waited for about one minute before reporting the matter to the OCC per SMRT’s SOP, and was then informed that a train ahead was experiencing faults. On the OCC’s instruction, TO Masrudin (W35) played the pre-recorded train-delay message over the train’s PA system at intervals of about 20 seconds.
Around 6.50 am – Zone 11 SOM pre-emptively mobilized SMs in case of prolonged disruption
241 SMRT Zone 11 Station Operations Manager (SOM) Lim Sing Long
(“SOM Lim”) (W54) was notified by SM Mustadza (W15) of the stalling of
T137. Suspecting a recurrence of the 15 December incidents, SOM Lim (W54) requested the night shift SMs at seven other stations not to report off-duty and to stand by for further instructions. He also headed immediately to City
Hall station, even though he had not yet been instructed to do so by his supervisor, then-NSEWL Manager Station Operations Ow Huay Ping (“MSO
Ow”).
242 At the same time, 17 December morning shift CC (Trains) Frankie Lee
(“CC Lee”) (W39) reported for duty and learned of the ongoing problems encountered by various trains.
Around 6.51 am – T137 detrained to platform; T113 departs Newton station
243 SM Mustadza (W15) was instructed by the OCC to detrain T137. He opened the platform screen door which was aligned with the train’s TO cabin door. With the assistance of TO Redzuan (W32) and another member of the
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station staff, he directed the approximately 400 passengers to detrain onto the station platform.
244 At the same time, TO Masrudin (W35) received ATP code clearance to operate T113 southward. En route to Orchard station, he did not encounter any abnormalities such as illumination of fault lights, excessive rocking or unusual sounds or smells. He also did not receive any communications over the train’s radio set.
Around 6.52 am – T113 held in tunnel before reaching Orchard station
245 As T113 approached Orchard station, it decelerated automatically and coasted to a stop approximately 100 metres from the station. TO Masrudin
(W35) saw the red tail-lights of another train at the south-bound platform of
Orchard station. He waited three or four minutes before receiving ATP clearance to move forward. In the meantime, he played the pre-recorded train-fault message over the PA system at regular intervals. There was no communication between him and the OCC during this time.
246 T113 subsequently moved into Orchard station automatically, after the train in front of it left the station and T113 was given ATP code clearance to enter the station. However, when the train doors opened, the red “on-hold” indicator lit again. As he did at Newton station, TO Masrudin (W35) waited about one minute before contacting the OCC, which confirmed that the train was indeed on-hold and instructed him to play the pre-recorded train-fault message in the train.
Around 7.00 am – First train detrained to platform at Newton station; P-way staff activated to prepare to inspect track between Newton and Orchard stations
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247 Night shift Newton SM Sundaraj S/O Ramasamy (“SM Sundaraj”)
(W48) was instructed by the OCC to detrain a train at the south-bound platform of his station as there was a “service disruption”. He proceeded to do so, assisted by morning shift SM Nur Hafizah Bte Amir (“SM Hafizah”)
(W49) and a CSO.
248 At around the same time, SMRT P-way Day Support Team Assistant
Engineer Ibrahim Bin Ismail (“AE Ibrahim”) (W65) was at home on his off- day when he was informed by NSL Line Manager Yan Thiam Hock of the faults experienced by trains after passing Newton station and requested to report back to work. AE Ibrahim (W65) then arranged with Technical Officer
Adam Bin Ismail (“Technical Officer Adam”) (W64) to meet at Bishan station before proceeding to Newton station. However, as the location of the third rail problem was not yet known, he and Technical Officer Adam (W64), were subsequently redirected to stand by at Raffles Place station instead. Upon arriving at Raffles Place station, he was informed that the incident site had been identified as a section of the south-bound track just north of Orchard station. He thus proceeded to Orchard station and activated the P-way maintenance staff who had been on standby at Marina Bay station to also head there.
Around 7.01 am – T113 proceeded towards Somerset station
249 T113 departed Orchard station and proceeded toward Somerset station after receiving ATP code clearance. When CC Quah (W38) discovered that the train had been released from hold, he instructed a TSC to direct TO Masrudin
(W35) to coast the train all the way to Somerset station.86 However, T113
86 CC Quah (W38) testified that since he had instructed his staff in the OCC to hold south- bound trains at stations, T113 should not have been allowed to leave Orchard. However, he did not know who had released the train. 102
decelerated automatically as it approached the station since another train was still at the south-bound platform. Just as T113 was about to reach a complete halt, the train in front moved off.
Around 7.02 am – Completion of first detrainment at Newton station
250 SM Sundaraj (W48), SM Hafizah (W49) and a CSO completed detrainment of the train at the south-bound platform of Newton station. SM
Hafizah (W49) testified that as the station staff were not informed that subsequent south-bound trains would also detrain at Newton station, she advised passengers from this train to wait for the next one. However, she was told shortly afterward that the next train would also be detraining at Newton station.
Around 7.03 am – T113 lost line voltage and rolled backwards twice shortly before Somerset station; T132 also lost traction power between Somerset and
Dhoby Ghaut stations
251 T113 stopped approximately 100 metres away before Somerset station, but instead of remaining stationary, it immediately started to roll backwards.
TO Masrudin (W35) immediately depressed the emergency brakes and the train stopped after rolling backwards for about half a metre. He then reset the train system and received ATP-code clearance to proceed into Somerset station but when he released the emergency brakes, the train rolled backwards again. He immediately depressed the emergency brakes again.
252 Not understanding why this had happened, TO Masrudin (W35) instinctively reset the train’s Safety Interlock Relay and again received ATP- code clearance to operate the train forward. Sensing that something was
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amiss, he also checked the fault panel behind his seat and discovered that the line voltage indicator was no longer lit. 87
253 TO Masrudin (W35) reported T113’s loss of traction power and that it had rolled backward twice to the OCC. He was instructed to await further instructions and to make train-delay announcements again. While waiting, he noticed that all of the train’s fault lights, including the master fault indicator, remained unlit. He also saw, by looking through the louvers in the partition door to his TO cabin, that the lights in the passenger carriages were working normally but was unable to tell if the air-conditioning system was still working.
254 Meanwhile, TO See (W36) operated T132 southward from Somerset station to conduct a line-clear as instructed by the OCC. While doing so, he noticed from the train’s TIMS panel that the train was not receiving any traction power. However, the train was able to coast to Dhoby Ghaut station.
Prior to this, he had not received any fault indications in the train.
Around 7.04 am – T132 stopped and shut down at Dhoby Ghaut station; CC
(Trains) obtained approval for train-to-track detrainment of T113 and activation of RIMP
255 T132 came to a stop at Dhoby Ghaut station. TO See (W36) reported to the OCC that the train was not receiving any traction power and was instructed to shut down the train’s power system. He then waited in the train for further instructions, but did not receive any instructions or information from the OCC until a rescue train arrived around five and a half hours later.
87 TO Masrudin (W35) testified that he had not noticed when the indicator stopped being illuminated as it was less obvious when indicator lights ceased to be illuminated, compared to when they lit up. Furthermore, the green light from the line voltage indicator is faint compared to those of the orange fault indicators. 104
256 Meanwhile, upon being informed that T113 had stalled, CC Quah
(W38) concluded that he was facing a repeat of the 15 December incident.
Deciding that he would not be able to isolate the train faults, he informed
SMRT Chief Engineer Tay Ko San (“CE Tay”) (W83) of the situation by telephone. CC Quah (W38) told CE Tay (W83) of his intention to instruct a train-to-track detrainment of T113, as opposed to a push-out by another train lest the rescue train also be immobilized, and his view that the RIMP should be activated. CE Tay (W83) concurred with CC Quah (W38) but requested that he seek approval from SMRT Vice President Rail Operations Lui Wai
Meng (“VPRO Lui”) (W114). 88
257 CC Quah (W38) then called VPRO Lui (W114) to brief him on the situation. After speaking to SMRT Senior Vice President Engineering and
Projects Vincent Tan (“SVP Tan”) (W84) who agreed that the service disruption was likely to last more than an hour as it did on 15 December 2011,
VPRO Lui (W114) activated the RIMP and gave CC Quah (W38) his consent for the train-to-track detrainment of T113. He then called other SMRT staff to notify them of the disruptions before proceeding to the OCC.
Around 7.05 am – Detrainment of T137 completed; additional trains detrained at Newton station; DDSO activated bus bridging services and assistance of other SOMs to assist at affected stations
258 Detrainment of T137 concluded 14 minutes after it started. The detrainment was completed in an orderly manner. After the detrainment, TO
88 CC Quah (W38) testified that although SMRT’s SOP specified that approval for RIMP activation should be sought from SVP (Engineering and Projects) Vincent Tan (W84) as the RIMP Officer-in-charge (OIC), he called CE Tay (W83) first as he was “the most experienced”. He then called VPRO Lui, the alternate RIMP OIC, as advised by CE Tay (W83). In his testimony, CE Tay (W83) said that he requested CC Quah to contact VPRO Lui (W114) rather than SVP Tan (W84) as he thought that SVP Tan (W84) was on leave. 105
Redzuan (W32) was instructed by the OCC to operate certain sealed switches in the TO cabin to try to power up the train. However, even with the assistance of night shift SMRT Rail Services Manager Chin Boon Leong who happened to be at City Hall station at the time, he was not able to restart the train. TO Redzuan (W32) was then directed by the OCC to stand by for a rescue train to haul T137 away.
259 Subsequently, various SMRT maintenance and management personnel also arrived at the scene to inspect T137’s CCD shoes. TO Redzuan (W32) stood at the station headwall and observed them working. He testified that he saw the maintenance staff place about four or five damaged CCD shoes in the train, although he did not see where they were removed from or how they had been removed. Some of the CCD shoes were “rather badly damaged” with extensive “pitting” on their top surfaces. After the maintenance staff completed their work, TO Redzuan (W32) walked through the train and manually closed the train doors.
260 Meanwhile, a second south-bound train arrived at Newton station and was detrained by SM Sundaraj (W48) and SM Hafizah (W49). More south- bound trains arrived and detrained at Newton station subsequently; SM
Sundaraj (W48) and SM Hafizah (W49) testified that they detrained approximately ten trains at two to five-minute intervals although they had not been told why the trains were being detrained or that Newton station was being used as a turnaround station for south-bound trains. 89 SM Sundaraj
(W48) recalled that the first few trains had about 1,000 passengers each while the rest had fewer passengers. However, assisted by frequent announcements from the PSC that south-bound service had been suspended, the SMs were
89 SM Sundaraj (W48) further testified that none of the Newton station staff were informed of the activation of the RIMP at any time on 17 December 2011. 106
able to get passengers to leave the station upon disembarkation and proceed to the bus bridging point, such that the platform did not get overcrowded.
261 Around the same time, after being informed by VPRO Lui (W114) of the disruptions, SMRT Deputy Director Station Operations Teo Wee Kiat
(“DDSO Teo”) (W81) called SMRT Manager BOCC Joseph Ho (“MBOCC
Joseph Ho”) to activate bus bridging services. He then phoned MSO Ow to prepare a plan for the deployment of NSEWL SOMs to the affected stations.
While MSO Ow subsequently informed the NSEWL SOMs of their deployments, DDSO Teo (W81) contacted the Circle Line SOMs and instruct them to handle the CCL-NSL interchange stations which were expected to experience increased passenger volumes. He then proceeded to the OCC from which he oversaw the bus bridging services, as well as the deployment of
SOMs and Customer Service Teams (CSTs) to the affected stations.
Around 7.06 am – T136 detrained at Ang Mo Kio station and found to have lost line voltage
262 Upon the arrival of T136 at Ang Mo Kio station, TO Lim (W31) was asked by two station staff why the train was operating in “off-service” mode, i.e. with only partial lighting. Surprised by this and thinking that he may inadvertently have switched the train to partial lighting, he immediately pushed the “auxiliary-on” button to switch on full cabin lighting and air- conditioning. However, he realized later that the train was already in “on- service” mode, i.e. that the train should have been operating with full lighting and air-conditioning as long as it was drawing power from the third rail.
263 TO Lim (W31) then opened the partition door and saw that the front three passenger carriages only had emergency lighting while the lights in the rear three carriages were working normally. He also observed that the
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emergency ventilation system was operational but there was no air- conditioning. Not having encountered similar situations previously, he called the OCC using the EPAX phone at the headwall. He was directed to detrain all passengers and await further instructions.
264 After receiving these instructions, TO Lim (W31) made a PA announcement to inform all passengers that they would need to disembark from the train. Shortly afterward, two Ang Mo Kio station staff arrived to oversee the detrainment and ensure that no passengers remained on the train.
TO Lim (W31) remained in the TO’s cabin to make additional announcements and prepared to close the train doors upon the completion of detrainment in order to prevent passengers from boarding the train. The detrainment process took less than one minute.
265 After one of the station staff signalled that all passengers had detrained, TO Lim (W31) closed the train doors. He then noticed that T136’s line voltage indicator was not illuminated. He reported this to the OCC through the EPAX system and was told to await further instructions.
Around 7.07 am – Entrances to Marina Bay station closed
266 After receiving an SMS on his duty handphone informing that there was no service in both directions between Marina Bay and Newton or Bishan stations, SM Mustamam (W14) instructed the Marina Bay station staff to put up signs and make announcements to advise them to leave the station. After all passengers had exited the station, he closed the ground-level entrance to the station and deployed a staff member to assist passengers. SM Mustamam
(W14) testified that he closed the station without being instructed by the OCC so that passengers would not enter the station, only to find that there were no trains at the platform.
108
Around 7.08 am – Orchard station closed by SM
267 SM Wong Nian Sam (W20) received a UMS message that there was no traction current on the north-bound track. However, after learning from SMs at Newton and other stations further north that there were no south-bound trains at those stations, he concluded that there would not be any service at
Orchard station in either direction for an unknown duration. 90 He thus decided to close the station, even though he had not been instructed by the
OCC to do so.
268 Following the task list in the Train Service Disruption File, he deployed morning shift SM Ron Teo (“SM Teo”) (W47) and the other station staff to ask all passengers to leave the station, shut down the ticket machines and escalators, close all fare gates and put up signs and make periodic announcements about the station closure. Some of the doors to the station were also closed but left unlocked to allow passengers to exit or access buildings linked to the station.
Around 7.09 am – LTA officers notified of service disruption
269 LTA’s DDTR Soo (W82) received an SMS from the LTA LTOC that the
SMRT OCC had reported that there was no train service between Marina Bay and Newton stations and that all south-bound NSL trains were turning around at Newton station.
Around 7.11 am – T113 TO told by OCC to prepare for train-to-track detrainment
90 SM Wong Nian Sam (W20) testified that after he was informed that there was no traction current on the north-bound track, he asked the OCC if there was still south-bound service and was told that there was still “staggered” south-bound service. However, he decided to contact other stations to ascertain if this was indeed the situation. 109
270 TO Masrudin (W35) was informed by the OCC that there were problems with the third rail and instructed to prepare for a train-to-track detrainment, in which he would be assisted by the staff of Somerset station.
He thus made an announcement to inform passengers on T113 of a track fault and that they would soon have to detrain onto the track.
Around 7.12 am – SMRT staff informed of RIMP activation; Somerset SM prepared for train-to-track detrainment; various SMs and CSTs activated to assist at affected stations
271 The OCC sent out a message informing SMRT staff of the activation of the RIMP.
272 Although he was supposed to hand over duties to CC Lee (W39) by
7.15 am, CC Quah (W38) agreed to continue managing the disruption since he was more familiar with the ongoing situation. He directed OCC staff to switch off third rail power supply for the entire stretch of track between Orchard and
Marina Bay stations.
273 CC Quah (W38) also instructed SM Kamaruzzaman (W18) to prepare for the detrainment of T113. SM Kamaruzzaman (W18) thus proceeded to switch on the track protection key switch, install SCDs and deploy CSL Kek
Ze Rong to the buffer door at the south-bound tailwall to receive passengers from the track. After these preparations were completed, SM Kamaruzzaman
(W18) obtained the OCC’s permission to proceed to T113.
274 In the meantime, CC Lee (W39), working together with the morning shift CC (Area) Ng Seow Hock (“CC Ng”) and TSC (Liaison), notified station staff and SMRT personnel of the RIMP activation through the Urgent Message
System (UMS) and Group Dissemination System (GDS). He also directed the
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TSC (Liaison) to broadcast a pre-recorded PA announcement to all stations to inform commuters of the disruption of service in both directions between
Marina Bay and Newton stations.
275 Upon receiving the RIMP activation message and also being informed by SM Mustadza (W15) of the situation there, SOM Lim (W54) requested 16
December night shift Kallang SM Siti Ilyana Bte Mohamad (“SM Siti”) (W41),
Lavender SM Geof Chia (“SM Chia”) (W42), Aljunied SM S Indirakumar (“SM
Indirakumar”) (W43) and Bugis SM Abdul Shamir Bin Abdul Sawal (“SM
Shamir”) (W44) to report to City Hall to assist with the service disruption. He also requested Jufri Bin Arshad (“SM Jufri”) (W13), the night shift SM at
Raffles Place, and SM Mustamam (W14) not to report off-duty, and for
Customer Service Team (CST) leader Eng Wee Jin (“CSTL Eng”) (W55) to activate his team members to report to City Hall station.
276 Similarly, then-Zone 6 SOM Ramli Bin Rahmat (“SOM Ramli”) (W56) contacted CST Leader Philip Tay (“CSTL Tay”) (W57) to activate his team to
Dhoby Ghaut station.91 On the instruction of MSO Ow, then-Zone 9 and 10
SOM Tan Peng Foong (“SOM Tan”) (W58) also deployed the Zone 10 CST to
Dhoby Ghaut station and the Zone 9 team to Somerset station, while then-
Zone 12 SOM Chia Pen Chuen (“SOM Chia”) (W59) activated his CST to
Orchard station.92
91 Zone 6 comprises Dhoby Ghaut, Somerset and Newton stations. Although SOM Ramli (W56) was himself activated to Dhoby Ghaut station, he also called the station staff at Orchard and Somerset stations who informed him that the situations there were under control, although detrainments were taking place at both stations. Apart from his CST, CSTL Tay (W57) testified that another team led by a CSTL Shah was also deployed to Dhoby Ghaut station. It is not known however who this second team was activated by. 92 Zone 10 comprises Buona Vista, Commonwealth and Queenstown stations while Zone 9 comprises Redhill, Tiong Bahru, Outram Park and Tanjong Pagar stations. At the time of the incidents, SOM Tan (W58) was overseeing Zone 10 as an interim covering arrangement. 111
277 At the same time, shortly after being notified of the activation of the
RIMP, SMRT Director Train Operations Shahrin Bin Abdol Salam (“DTO
Shahrin”) (W80) was instructed by VPRO Lui (W114) to proceed to stations affected by the disruptions to monitor developments and manage the buildup of crowds. DTO Shahrin (W80) testified that although he is required under the
RIMP to report to the OCC to head the Train Operations Team, he complied with VPRO Lui (W114)’s instruction as he was confident that CE Tay (W83) would be able to command the Train Operations Team as his alternate. 93 He therefore proceeded to Ang Mo Kio station, at which trains might be turned around.
278 Meanwhile, SMRT VP Maintenance Ng Tek Poo (“VPM Ng Tek Poo”)
(W113) instructed SMRT Deputy Director Rolling Stock and Tracks Ng Wai Yi
(“DDRS&T Ng Wai Yi”) (W111) to proceed to the incident site.
Around 7.17 am – Detrainment of T113 commenced
279 SM Kamaruzzaman (W18) arrived at T113. By this time, TO Masrudin
(W35) had lowered the emergency detrainment ramp, opened the TO cabin partition door and made an announcement to request all passengers to move forward to detrain. During the detrainment, TO Masrudin (W35) remained in the TO cab to control the flow of passengers disembarking from the train and make announcements while SM Kamaruzzaman (W18) stood at the foot of the detrainment ramp to assist passengers, lending his shoulder to those requiring support and carrying out a head count, as instructed by CC Quah
(W38). Morning shift City Hall SM Wong Weng Tuck (W78), who happened
93 VPRO Lui (W114) also testified that he instructed DTO Shahrin (W80) to proceed to the affected stations as he intended to head the Train Operations team under the RIMP Command and Control structure himself. 112
to be on T113 on his way to work, also stepped forward to assist in the detrainment by shining a torchlight on the ramp to guide passengers.
280 TO Masrudin (W35) testified that while the detrainment was taking place, the lights in T113’s passenger carriages were still fully lit and the air- conditioning fault indicator was not illuminated, suggesting that the air- conditioner was still functioning. However, the tunnel was rather dark even though the tunnel lights and train headlights were on. In his testimony, SM
Wong Weng Tuck (W78) also affirmed that the lights and air-conditioning were on during the detrainment.
Around 7.20 am – EWL SMs arrived at City Hall to assist passengers; CST arrived at Bishan station
281 Upon their arrival at City Hall station between 7.20 am and 7.35 am,
SM Siti (W41), SM Chia (W42), SM Indirakumar (W43) and SM Shamir (W44) stationed themselves at the concourse and north-bound platform to inform passengers that north-bound service had been disrupted and that they would need to find alternative means of transport. SMs Siti (W41), Chia (W42) and
Shamir (W44) testified that there were “not many” passengers at the platform and that while some were “unhappy,” the SMs were able to get them to leave the platform without having to use loudhailers or signs. SM Indirakumar
(W43) testified that there was a small crowd at the free area of the concourse, at which he stationed himself to provide passengers with information on alternative transport arrangements, using a bus route handout given to him by the City Hall CSLs. He recalled that other station staff also distributed these handouts to passengers. These SMs assisted passengers at City Hall station until between 10 am and 11 am, when they were released from duty by SOM Lim (W54).
113
282 Over at Bishan station, a CST led by Roland Neo arrived and was deployed by morning shift SM Jamaludin Bin Mohamad Amin (“SM
Jamaludin”) (W24) to handle passenger queries. However, the team left after about 45 minutes as it was redeployed to Toa Payoh station. SM Jamaludin
(W24) testified that at its peak, the crowd at Bishan station was about 300 persons, but the station staff were able to manage the situation.
Around 7.21 am – LTA management informed of disruptions
283 The LTOC notified LTA management of the disruptions by SMS.
Around 7.25 am – Morning shift MOCC reported for duty at OCC
284 SMRT’s 17 December duty MOCC Tan Juke Boon (“MOCC Tan”)
(W40) reported for work. Upon being briefed by CC Quah (W38) on the situation, MOCC Tan (W40) advised CC Quah (W38) to resume partial north- bound service by diverting alternate east-bound trains onto the NSL. He then oversaw information dissemination to commuters in stations and trains, station staff, TOs and SMRT management, assisted by CC Lee (W39), CC Ng and the TSC (Liaison), until the full resumption of service.
Around 7.27 am – LTOC informed of suspension of service between Marina
Bay and Newton stations
285 CC Lee (W39) informed the LTOC that there was no service between
Marina Bay and Newton stations and that south-bound trains were turning around at Newton station.
Around 7.30 am – SOM, CST and recovery teams arrived at Orchard station; first south-bound bridging bus arrived at Newton station; partial resumption of north-bound service approved
114
286 SOM Chia (W59) and the Zone 12 CST arrived at Orchard station around the same time that the closure of the station was completed. The recovery teams which had been activated earlier also arrived at Orchard station to inspect the south-bound track between Newton and Orchard stations. Meanwhile, SMRT Manager for Track Renewal Lim Sime Simm
(“MTR Lim”) (W66) arrived at Newton station after having been activated by
SMRT P-way Branch Manager Zulkifli Bin Alias.
287 At roughly the same time, the first bridging bus arrived at Newton station to operate a shuttle service to Raffles Place station. DDSO Teo (W81) testified that he was notified by the BOCC approximately ten minutes before the arrival of each first bridging bus and again when the bus arrived at its first stop.
288 Upon arriving at the OCC, SVP Tan (W84) was briefed by CE Tay
(W83) on the situation and approved the proposals to resume train service, for example, by diverting EWL trains to operate north-bound on the NSL.
Around 7.33 am – Detrainment of T113 completed; first north-bound bridging bus arrived at Raffles Place station
289 Detrainment of T113 was completed. About 500 passengers detrained in an orderly manner, with none of them experiencing any difficulty despite an approximately half-metre gap between the end of the detrainment ramp and the trackbed. While there were a few elderly passengers and passengers with mobility difficulties on board, they were able to make their way safely to
Somerset station, assisted off the train by SM Kamaruzzaman (W18) and guided along the tracks by fellow passengers.
115
290 After walking through the train to ascertain that no passengers were left behind, TO Masrudin (W35) notified SM Kamaruzzaman (W18) who conducted a line-clear of the track while returning to the station with the last passenger to detrain. TO Masrudin (W35) then waited on board T113 for further instructions.
291 Some time later, various SMRT personnel arrived to inspect the train.
After obtaining CC Lee (W39)’s approval to do so, morning shift Somerset SM
Chan Keng Ping (“SM Chan”) (W46) activated the Special Key Protection
Switch and installed SCDs to facilitate track access. SM Chan (W46) testified that as he remained at the platform, he was not able to observe what was done to the train. Likewise, as TO Masrudin (W35) was inside one of the train carriages, he did not observe the inspection and only saw a damaged CCD shoe with a twisted metal piece being placed in the train. TO Masrudin (W35) testified that he did not know how the damage was sustained or how the
CCD shoe was removed. Subsequently, TO Masrudin (W35) shut down the train as instructed by the OCC to conserve backup power, in case the train was to move or be hauled away later.
292 Upon arriving at the OCC some time after the completion of the detrainment of T113, CE Tay (W83) oversaw the operations of the OCC, including the recovery of stalled trains and the maintenance of train services on unaffected sections of the network.
293 The first bridging bus operating northward to Newton station arrived at Raffles Place station.
Around 7.40 am – Brake air pressure in T136 decreased; first bridging bus arrived at Marina Bay station
116
294 VPM Ng Tek Poo (W113) arrived at Somerset station and proceeded to walk along the south-bound track between Somerset and Orchard stations to check for damage to the third rail. He testified that when he arrived at
Somerset station, DDRS&T Ng was already examining the stalled train at the station (T113).
295 Meanwhile, TO Lim (W31) noticed from the console in T136’s TO cabin that the air pressure in the train’s main cylinder, which should have been between 8 bar and 11 bar, had decreased to 7 bar, such that it would not be possible to release the train’s brakes. He informed the OCC, which informed him to await further instructions.
296 At Marina Bay station, the southern end of the NSL, the first bridging bus arrived to transport passengers to City Hall station.
Around 7.45 am – SMs and CST arrived at Raffles Place station
297 The first member of the CST activated to Raffles Place station arrived at the station to assist with crowd management. 94 SM Jufri (W13) also saw some
SMs from other stations, who had been requested by SOM Lim (W54) to assist at Raffles Place station.95
Around 7.49 am – LTA PT-CMT activated
298 LTA’s Public Transport Crisis Management Team (PT-CMT) was activated by Deputy Chief Executive Lim Bok Ngam. 96 Various LTA officers
94 SM Jufri (W13) testified that although there were three crowd control contingency plans for Raffles Place station, none of these plans were implemented during the 17 December disruption as the crowd size was deemed to be “manageable”. 95 SM Jufri (W13) testified that he only found out that the RIMP had been activated at around 7.30 am, when he was informed by Zone 12 SOM Anthony Chang who had been activated to assist at Raffles Place station. 96 The PT-CMT is typically activated by LTA’s Chief Executive, but he was overseas at the time of the incident. 117
subsequently reported back to the LTOC. DDTR Soo (W82) monitored the recovery process, checking periodically with SMRT Director Strategic
Planning Lui Weng Chee by phone about the status of fault rectification and service recovery.
Around 7.50 am – SCDF Operations Centre informed by OCC that no assistance was required; DTO arrived at Ang Mo Kio station to monitor station situation
299 The SCDF Operations Centre received a message from SPF informing them of a train fault from Orchard station to Marina Bay station. Upon calling the OCC, however, SCDF staff were told that no assistance was required and that the OCC would contact SCDF if any assistance was needed subsequently.
300 Upon arriving at Ang Mo Kio station, DTO Shahrin (W80) found that the passenger volumes were normal and did not warrant special attention.
With the concurrence of VPRO Lui (W114), he proceeded southward to
Bishan station, which was similarly “under control”, and subsequently Toa
Payoh station.
301 When he arrived at Toa Payoh station, DTO Shahrin (W80) saw that a crowd had built up at the station and hence proceeded to take charge of crowd management. He stationed the 20 to 30 CST members at the station at five to eight metre intervals within and outside the station to answer passenger queries, make announcements regarding alternative transportation arrangements and direct passengers to the bus bridging point. He also enlisted the assistance of three police officers to manage the crowd at the bus bridging point. Then-SMRT CEO Saw Phaik Hwa (W87), who was visiting
Toa Payoh and other stations to monitor the situation, also assisted in advising passengers on alternative transportation options.
118
302 Subsequently, DTO Shahrin (W80) proceeded to Newton station where he instructed a few CST members and station staff to ensure that the queue at the bus bridging point was orderly. He stayed at the station until the recovery of train service was completed.
Around 8.00 am – T123 held at Yio Chu Kang station
303 T123, operated by TO Mazli Bin Abdul Nasir (“TO Mazli”) (W34), arrived at Yio Chu Kang station on its second south-bound run of the morning. 97 At this point, T123’s red “on-hold” indicator illuminated and TO
Mazli (W34) was informed by the OCC that a train ahead was experiencing some problems. As instructed by the OCC, he announced to the passengers that the train would be slightly delayed. About two minutes later, he was given permission to operate the train toward the next station.
304 Over at the OCC, with the detrainment of T113 safely completed, CC
Quah (W38) handed over his CC duties to CC Lee (W39).
305 At Newton, MTR Lim (W66) was informed by station staff to proceed to the tracks to check for abnormalities. Accompanied by two SMRT Day
Support maintenance officers, he walked along the south-bound track towards Orchard station while inspecting the third rail and running rail. Near the south-bound tailwall at Orchard station, he saw numerous SMRT management staff and officers gathered. He also observed some third rail covers on the trackbed although he could not recall whether there was any damage to them.
97 T123 commenced revenue service at Bishan station on the morning of 17 December 2011, traveling south-bound to Marina Bay where it turned around to operate up to Yishun. The train then turned around again to operate southward to Marina Bay. TO Mazli (W34) testified that he did not encounter any abnormalities or the illumination of fault lights during the train’s first south-bound and north-bound runs. 119
About 8.02 am – All TOs instructed to operate in CM mode with a maximum speed of 40 km/h
306 Upon T123’s arrival at Ang Mo Kio station, TO Mazli (W34) was again instructed by the OCC to announce a delay as the train ahead of T123 was still experiencing problems. While making the announcement, the train’s red “on- hold” indicator illuminated again. Shortly afterward, while T123 was still on hold at Ang Mo Kio station, the OCC made an announcement to “all trains” through the radio set, directing all TOs to operate in CM mode at 40 km/h and to look out for any irregularities on the tracks.
307 Soon after this announcement, TO Mazli (W34) saw that T123’s “on- hold” light was extinguished. He thus proceeded to operate T123 southward in CM mode at a speed not exceeding 40 km/h in compliance with the OCC’s instructions, even though the train had received an ATP speed-code which indicated that he could have operated the train at a higher speed.
308 TO Mazli (W34) operated T123 on to Bishan and Braddell stations without experiencing any problems. However, upon arriving at Braddell station, he was instructed by the OCC to detrain all passengers at the next station, Toa Payoh.
Around 8.20 am – South-bound turnaround station changed from Newton to
Toa Payoh station; inspection of south-bound track between Newton and
Orchard stations commenced
309 Inspection of the south-bound track between Newton and Orchard stations commenced after power supply to the track was switched off. The turnaround station for south-bound trains was also switched from Newton to
Toa Payoh, partly as a safety precaution to facilitate the inspection and also
120
because Toa Payoh station, which was linked to a bus interchange, was assessed to be better-equipped to deal with a large crowd. CC Lee (W39) testified that he could not recall whether the change of turnaround station was announced by the OCC via the GDS or UMS but CE Tay (W83) testified that OCC staff telephoned the staff of the affected stations to inform them of the change.
310 At around the same time, SOM Chia (W59) visited the bus stops in front of Tang Plaza and behind Wisma Atria to check on the crowd situations.
While SOM Chia (W59) did not see any bridging bus arrive at either bus stop, he was “not worried” as there were no crowds. SOM Chia (W59) also testified that Zone 12 CST Leader Ricky Tay reported throughout the morning that bridging buses were arriving frequently and there was no crowd buildup at the Tang Plaza bus stop.
Around 8.22 am – Bus bridging services extended northward to Toa Payoh station
311 DDSO Teo (W81) requested MBOCC Joseph Ho to extend the bus bridging service between Raffles Place and Newton stations northward to Toa
Payoh station. He testified that each time bus bridging services were extended, the SOMs of the affected stations were notified by the OCC and updates were also indicated on stations’ Rail Travel Information System
(RATIS) screens.
Around 8.29 am – North-bound service partially resumed
312 Upon the completion of line-clears by two empty trains along the north-bound track, CE Tay (W83) directed CC Lee (W39) to resume partial north-bound service between Raffles Place and Jurong East stations using
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east-bound trains which crossed over onto the NSL at Raffles Place station.
These trains operated via the middle track at Ang Mo Kio station as the north- bound track was obstructed by T136.
313 Once notified of this, SOM Chia (W59) instructed SM Teo (W47) to reopen Orchard station for north-bound service, but to inform passengers through signs and frequent announcements that south-bound service remained suspended. SM Wong Nian Sam (W20) testified that the trains were however running at irregular intervals and that there were few passengers on board, with less than ten passengers disembarking from each train at Orchard station.
Around 8.30 am – CST arrived at Newton station; rolling stock staff arrived to inspect T137
314 A CST arrived at Newton station and stationed itself at the bus bridging point. SM Sundaraj (W48) testified that prior to the arrival of the
CST, the situation at the bus bridging point was “chaotic” with many passengers approaching him for information and directions.
315 At around the same time, a team from SMRT’s rolling stock department arrived at City Hall station to inspect T137. They concluded that the immobilisation of the train had to do with its CCD shoes which would need to be knocked away or removed before the train could be moved. They proceeded to do so some time between 9 and 10 am.
Around 8.33 am – T113’s CCD shoes lowered
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316 VPRO Lui (W114) left the OCC for Somerset station.98 There, he saw that the recovery team was in the process of lowering T113’s CCD shoes, which were “badly damaged and bent”, from contact with the third rail. A while later, he proceeded to Orchard, hoping to establish the cause of the sag.
317 While VPRO Lui (W114) was not able to do so by visually inspecting the third rail, he observed that the third rail cover was “badly scratched” and some portions of the cover had been dislodged. He also saw a claw that had dropped onto the track but appeared to be in good condition. However, he did not notice any broken pieces of mirror that could have come from the
MFV.
318 VPRO Lui (W114) then proceeded to Bishan station where he assessed that the crowd flow was normal and there was no build-up of passengers.
From Bishan station, he proceeded to Newton station, where he saw a larger crowd than at Bishan station, although the crowd was lined up in an orderly manner along the covered linkway leading to the station entrance. He thus called the OCC and advised the staff there to turn south-bound trains around at Toa Payoh station instead of Newton station.
Around 8.34 am – T123 detrained at Toa Payoh station
319 T123 arrived at Toa Payoh station. TO Mazli (W34) requested all passengers to alight as the train would terminate at Toa Payoh station. The station staff helped to detrain passengers while TO Mazli (W34) remained by the TO cab partition door. Once the station staff signalled that detrainment was completed, he closed the train doors and walked through the train to
98 VPRO Lui (W114) arrived at the OCC at 7.50 am. However, as SVP Tan (W84) was already at the OCC overseeing the implementation of the RIMP, EVP (Trains) Khoo Hean Siang (W115) directed him to proceed to the stations at which trains had stalled to monitor the situation on the ground. 123
ensure that there were no passengers left on board. He was then instructed by the OCC to “change ends”, open the train doors and recommence revenue service in the north-bound direction.
Around 8.35 am – T123 departed Toa Payoh station north-bound
320 After passengers boarded T123 from the south-bound platform and he had been assured by the OCC that it was safe to do so, TO Mazli (W34) operated the train northward for approximately 100 metres on the south- bound track to cross over to the north-bound track. He then operated the train northward to Braddell station in CM mode at 40 km/h as instructed by the
OCC. The train arrived at Braddell station around one minute later.
Around 8.38 am – T123 detrained at Bishan station after line voltage light found to be flickering and fault lights illuminated
321 T123 departed Braddell station to proceed northward to Bishan station.
When the train was about 100 metres away from Bishan station, TO Mazli
(W34) heard a “flickering” sound in the TO cabin. He found that the master and other fault indicators were not lit but the line voltage indicator behind him was flickering. Up to this point, he had not encountered any abnormalities such as the illumination of fault lights, unusual train vibration or track problems.
322 Once the train doors opened at Bishan station, TO Mazli (W34) informed the OCC by radio of the “flickering” line voltage indicator. 99 Upon checking the fault indicator panel again, he saw that the converter, compressor (local), compressor (train) and air-conditioning fault indicators, as
99 TO Mazli (W34) testified that he did not immediately report the flickering sounds and line voltage indicator to the OCC since he had to concentrate on stopping the train safely at Bishan station. 124
well as the master fault light, were now all illuminated and that the line voltage indicator was no longer lit. He also realized that the train could not move.
323 Upon conveying this to the OCC, TO Mazli (W34) was instructed to detrain all passengers immediately. This being an emergency detrainment, he made announcements advising all passengers to disembark and opened the
TO cabin door to supervise the detrainment without waiting for the station staff to arrive at the platform.
324 A few station staff arrived to assist with the detrainment subsequently.
After the detrainment of an estimated 500 to 600 passengers was completed,
TO Mazli (W34) closed the doors of T123 and walked through the train to ensure that there were no passengers on board. He then notified the OCC which instructed him to await the arrival of a rescue train. He testified that he could not recall whether the lights and air-conditioning in the train were functioning during the detrainment.
Around 8.40 am – Third rail found sagging on south-bound track just north of
Orchard station; LTA contacted both public bus operators
325 An SMRT P-way maintenance team found that a 20 metre-long segment of third rail was sagging at about 100 metres north of the south- bound tailwall at Orchard station, with a “split end” on the upper part of the fishplate joint between two segments of third rail. DDRS&T Ng Wai Yi
(W111) testified that when he reached the incident site subsequently, he saw dropped claws, scratch marks on the third rail and debris including fallen spacer blocks and damaged third rail covers around south-bound chainage
63950. However, he did not see any broken pieces of the mirror from SMRT’s
MFV. VPM Ng Tek Poo (W113) too testified that he did not see any mirror
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fragments among the debris. At that stage, he was not aware of the MFV’s mirror crack incident.
326 Shortly after arriving at the LTOC and being updated on the details of the situation, LTA Deputy Director Bus and Vocational Licensing Josephine
Tan (“DDBVL Tan”) (W88), the LTA Key Contact Officer for bus service issues during major incidents, contacted Mr Dave Ong of SMRT Buses and Mr
Ngoh Peng Guan of SBST Buses. Both informed her that they were operating basic bus services along the affected rail corridor at weekday peak-hour frequencies. DDBVL Tan (W88) asked Mr Ong and Mr Ngoh to inform her if
LTA’s assistance was needed to facilitate the smooth operation of the basic bus services and bus bridging services.
Around 8.50 am – Restoration of sagged third rail commenced
327 After examining the sagged third rail, VPM Ng Tek Poo (W113) noticed that the “split end” was on the upper part of the fishplate joint and the bottom of the two third rail segments were in alignment. He assessed that it was safe to temporarily restore the third rail, pending replacement after revenue service that night. For safety reasons, he told the OCC to impose a speed limit on this section of the track.
328 Under the supervision of AE Ibrahim (W65) and Technical Officer
Adam (W64), SMRT’s North Zone P-way maintenance team mounted the sagged third rail back onto the support brackets. The three third rail claws that had dropped onto the trackbed were also reinstated. 100 They then secured the claws using cable ties. Debris such as dislodged CCD shoes, damaged
100 AE Ibrahim (W65) testified that he was not aware that there was a crack at the fishplate joint. 126
third rail covers and dislodged spacer blocks were also cleared before a line- clear of a 50 metre-long stretch of track was conducted.
329 While the third rail restoration work was ongoing, SMRT P-way
Maintenance Assistant Engineer Hashmy Bin Ridzuan (“AE Hashmy”)
(W74)’s patrol team arrived at Orchard station.101 At the work site, he saw that there were scratch marks on the third rail cover with about 10 to 15 metres of third rail exposed but he was unable to tell if they were fresh scratches.
Someone asked for the third rail further north from the incident site to be checked. He and one of his staff walked along the track towards Newton station. They did not find any other third rail cover scratch marks but they placed about four fallen insulator covers back onto the third rail. After walking about 500 metres, they returned to Orchard station as they were informed that third rail power was about to be switched on.
Between 9.00 am and 9.30 am – Novena SM unable to get through to OCC
330 As the crowd at Novena station was building up, morning shift SM
Alan Fong (“SM Fong”) (W50) attempted to call the OCC on the EPAX phone three or four times to find out the cause of the expected duration of the disruption but his calls were not answered.
Around 9.00 am – T123 pushed to Ang Mo Kio; LTA PT-CMT meeting convened
331 As directed by CC Lee (W39), a train detrained at Braddell station. It was then deployed as a rescue train to push T123 from Bishan station to the
101 AE Hashmy (W74)’s team was initially activated to Marina Bay. Upon reporting there around 7.20 am, they were initially told to stand by. At around 8.00 am, they were instructed by East Zone line manager Jeremy Goh to proceed to Orchard. 127
north-bound platform at Ang Mo Kio station. This was done to allow other north-bound trains to maintain service.
332 TO Mazli (W34) then remained on standby at the crew room of Ang
Mo Kio station until about 3 or 4 pm. During this time, he went up to the platform several times, when he saw two or three SMRT maintenance staff checking the interior of T123. He testified that he did not know what the maintenance staff were doing and that he did not notice anyone on the trackside of T123.
333 Meanwhile, a PT-CMT meeting chaired by LTA Deputy Chief
Executive Lim Bok Ngam was convened.
334 LTA DDBVL Tan (W88) decided to activate second team to man LTA’s
Public Transport Specialist Cell in the event that the disruption turned out to be a prolonged one. Concurrently, she continued to monitor the CCTVs in the
LTOC, alerting the bus operators when buses were seen to be overcrowded and deploying LTA enforcement officers to take action against illegally- parked vehicles at bus bridging points such as those at Toa Payoh and
Novena stations.
Around 9.10 am
335 SMRT Senior Fellow (Rolling Stock System) Ng Peng Hoe (W79) testified that when he arrived at Newton, he saw only a few passengers and that “a lot of” buses were picking up passengers there. He also saw SMRT personnel carrying out recovery work on the track although he did not go down to the track himself.
Around 9.18 am – Bus bridging services extended to Ang Mo Kio station and commenced between Marina Bay and Raffles Place stations
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336 Bus bridging services to/from Raffles Place station were extended northward to Ang Mo Kio station as DDSO Teo (W81) assessed that the recovery of stalled trains could affect stations as far north as Ang Mo Kio. 2- way bus bridging service also commenced between Marina Bay and Raffles
Place stations.
Around 9.25 am – Sagged third rail restored and regauged
337 After the sagged third rail was restored and regauged by the SMRT P- way recovery team, a “megger test” was conducted to ensure that there was no leakage of electrical current from the third rail to the running rails. The recovery team also checked that the power cables supplying electricity to the third rail were not damaged. Shortly afterward, after verifying that there was no one on the track, CC Lee (W39) instructed south-bound trains to turnaround at Newton station again. 102 MOCC Tan (W40), CC Ng and a TSC notified trains and the station staff of Toa Payoh, Novena and Newton stations of the change.
Around 10.00 am – Line-clear conducted between Dhoby Ghaut and City Hall stations
338 SMRT Rolling Stock and P-way maintenance staff arrived at Dhoby
Ghaut and City Hall stations to conduct a line-clear on the south-bound track in preparation for the arrival of a rescue train for T137. 103 This was completed
102 MOCC Tan (W40) testified that the Toa Payoh SM had earlier requested the OCC not to turn any more trains around there, but the OCC staff decided to continue doing so since they assessed from the CCTV system that the situation at the station was still manageable. Some SMs such as Bishan SM Siak Weng Hong (W28) and Ang Mo Kio SM Shaik Khan Bin Hamid (W29) testified that there were further changes of the turnaround station between Toa Payoh and Newton subsequently, causing some confusion to passengers and station staff. 103 One of the teams conducting the line-clear was led by SMRT Engineering Trains Branch Line Manager Matthias Loke (W73), who had initially been activated to stand by at Newton station at about 7.00 am, before being redirected to Dhoby Ghaut station. 129
around 11.00 am with no abnormalities found. The OCC then switched track power back on.
Around 10.40 am – T136 TO instructed to examine CCD shoes; second LTA
PT-CMT meeting held
339 TO Lim (W31) received a call from the OCC on his mobile phone. He was instructed to go down to the track to examine the CCD shoes of T136. He testified that at this stage he might have put the train in “Auxiliary-off” mode in order to conserve the train’s backup power supply. It is not known which
OCC officer instructed TO Lim (W31) to examine T136’s CCD shoes. CC Quah
(W38) testified that he did not give any such instruction.
340 Upon inspecting the train exterior, TO Lim (W31) found that three of the twelve CCD shoes on the left side of the train (when facing forward in the north-bound direction of travel) had been twisted inwards. He was unable to examine the CCD shoes on the right side of the train as his view was obstructed by the platform.
341 TO Lim (W31) informed the OCC of his findings and reported again that he was unable to move T136. He was instructed to wait for a rescue train that would be arriving from Bishan Depot.
342 At this time, a second LTA PT-CMT meeting was held. LTA DDTR Soo
(W82) informed the meeting that SMRT had found the 20 metre-long section of sagging third rail. LTA DCE instructed LTA’s Rail Projects and Engineering staff to proceed to the incident site to help SMRT diagnose the problem.
Around 11.06 am – Bus bridging services to/from Marina Bay station extended to City Hall station
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343 Two-way bus bridging services to/from Marina Bay station were extended to City Hall station.
About 11.15 am – LTA officers arrived at OCC
344 LTA DDTR Soo (W82), Deputy Director Design Development Sy Hong
Soon (“DDDD Sy”) (W116) and another LTA officer arrived at the OCC to obtain updates on the situation from SMRT and feed them to the LTOC.
Around 11.24 am – Unsuccessful attempt to haul T113
345 A rescue train arrived to try to haul T113 away but the rescue operation was aborted as the rescue train had suffered a propulsion fault.
Around 11.26 am – T136 hauled away from Ang Mo Kio station
346 An unnumbered rescue train arrived from Bishan Depot to push T136 to a location between Ang Mo Kio and Yio Chu Kang stations. TO Lim (W31) was then informed by the OCC that SMRT maintenance staff and LTA officers would be inspecting the train. Soon after, two SMRT staff and a team of LTA officers commenced an inspection of the CCD shoes. TO Lim (W31) testified that he did not see or hear any knocking of the CCD shoes. He later saw the group having a discussion outside the train but could not hear the discussion.
At about 1.00 pm, the train was hauled back to Bishan Depot where TO Lim
(W31) saw many SMRT maintenance and LTA staff inspecting trains that had returned to the depot. He did not seek to find out what they were doing.
Around 11.38 am – T137 hauled to Ulu Pandan Depot
347 A rescue train coupled with T137 and hauled it to Ulu Pandan Depot via the west-bound track of the EWL.
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Around 12.13 pm – T132 hauled to Marina Bay station
348 A rescue train arrived to couple with T132 and haul it to Marina Bay station. At this point, TO See (W36) was not aware of the train’s CCD shoes being damaged. He was also not around when SMRT maintenance staff inspected the train subsequently.
Around 12.46 pm – VPRO returned to the OCC
349 VPRO Lui (W114) left Newton station for the OCC after the crowd at the station returned to more manageable levels following the change of the turnaround station back to Toa Payoh station.
Around 1.15 pm – T113 successfully hauled to Ang Mo Kio station
350 A second train arrived to rescue T113. The trains coupled successfully and T113 was hauled to the north-bound platform of Ang Mo Kio station.
Around 1.19 pm – South-bound service resumed
351 South-bound service resumed.
Around 1.53 pm – Resumption of normal service
352 Normal passenger service resumed on the NSL after approval was given by CE Tay (W83). However, SM Wong Nian Sam (W20) closed Orchard station again shortly after reopening it fully as train frequencies were initially irregular, which he assessed would frustrate passengers.
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