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.