Update on investigations by SMRT into fatal accident on 22 March 2016

1. SMRT has completed its investigations into the fatal accident near Pasir Ris MRT Station on 22 March 2016, following a review by an Accident Review Panel. The report has been submitted to the Ministry of Manpower, Singapore Police Force and Land Transport Authority to assist with their statutory investigations. 

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

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

4. On the day of the accident, a joint engineering team comprising six Signal staff (including four trainees) [1] and nine Permanent Way staff (including two trainees) were tasked to examine a signaling condition monitoring device along the tracks near Pasir Ris MRT Station. The device had earlier registered a warning of a possible fault that could affect train service [2]. The engineering team made their way to the device in single file along the maintenance walkway. As they approached the device, the Signal team, led by the supervisor, stepped onto the track before protection measures were implemented. The supervisor narrowly avoided being hit by the oncoming train, but Nasrulhudin and Muhammad Asyraf, who were second and third in line, were unable to react in time.

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

6. The Accident Review Panel determined that this vital safety protection measure was not applied and that the effectiveness of such protection before entry into the work site was not ensured as required under existing procedure, directly causing the accident. There were also other factors identified as areas for improvement, namely track access management controls, communication protocols and track vigilance by various parties.

7. The Accident Review Panel has concluded that while existing safety protection mechanisms are adequate, and current operating procedures continue to be relevant and applicable, these can be improved for greater clarity and ease of ground implementation.

8. SMRT deeply regrets that the failure to apply a vital safety procedure led to the tragic accident on 22 March 2016. SMRT Trains has taken immediate steps to ensure stricter enforcement of procedures, strengthened system ownership and control across levels and work teams, and tightened supervision within teams to prevent a recurrence. 

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


[1] The trainees were attached to the work teams, as part of their ground orientation, to observe fault rectification works.

[2] Engineering staff are authorised for track access to investigate faults, on average, about two to three times a day on the North-South and East-West Lines.


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