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COI findings in detail: Safety breaches and panic led to Aloysius Pang’s death

SINGAPORE — As the gun barrel inside the howitzer was about to be lowered, one of the two servicemen in the cabin along with the late actor Aloysius Pang had told Pang to move closer to him or to a safe position.

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SINGAPORE — As the gun barrel inside the howitzer was about to be lowered, one of the two servicemen in the cabin along with the late actor Aloysius Pang had told Pang to move closer to him or to a safe position.

Pang, who held the rank of Corporal First Class (National Service), replied in Mandarin that “it was fine and that the gun barrel would not hit him”, said Defence Minister Ng Eng Hen.

But it did, and as the barrel hit 28-year-old Pang, the serviceman who had warned him earlier tried to push the gun barrel with his hands, while the other tried to stop the barrel’s movement through the main control screen.

On Monday (May 6), Dr Ng presented the findings of a Committee of Inquiry (COI) in Parliament, where he laid out the sequence of events leading up to Pang’s tragic death. 

The two servicemen should have activated the emergency stop buttons, he said. Instead, they “panicked and acted irrationally”, based on the findings of the COI looking into Pang’s death.

Four days after the accident on Jan 19 and after undergoing three surgeries, Pang died on Jan 23 from severe sepsis, a serious complication of an infection arising from his severe chest and abdominal injuries. 

Corporal First Class (National Service) Aloysius Pang was caught between the flick rammer and the slew ring when the gun barrel was lowered. Photo: Nadarajan Rajendran/TODAY

“It is sad but undeniable that the direct causes determined by the COI that resulted in the death of Corporal First Class (National Service) Pang was preventable had there been compliance to safety rules,” said Dr Ng.

“It was not for lack of knowledge of these rules or inexperience of personnel working on the howitzer gun.”

In its findings, the COI ruled that Pang’s death was a result of safety breaches committed by all three men. The incident was set off by the lowering of the gun barrel “without ensuring that everyone was in their safe positions”.

There was no evidence of foul play or that the incident was caused by any deliberate acts, the COI added.


As part of his reservist training, which was already into its seventh cycle, Pang travelled to Waiouru Military Training Area in New Zealand on Jan 5 for Exercise Thunder Warrior, which was a live firing exercise. Pang was an armament technician from the 268th Battalion Singapore Artillery.

On Jan 19, the gun detachment commander — a third sergeant who was also on reservist training — called on Pang to help diagnose a fault in the gun of the self-propelled howitzer used in the exercise. It had to be rectified in order for live firing to resume.

But as Pang could not resolve the issue, another technician — a regular serviceman — was dispatched to help out. The two of them, together with the gun commander, were the only persons in the howitzer.

By protocol, before rectifying the fault, the gun barrel has to be in a locked position. This means lowering the barrel first.

The individuals also have to be in three safe positions: The gun commander manning the control system should be in an elevated chair on the left side of the barrel; Pang should be standing behind him, while the other technician should be standing on an elevated platform on the right side of the barrel.


Seeing that Pang was not in a designated safe position, the other technician told him to move either closer to him or to be in a safe position.

At the time, Pang was standing near the technician removing the screws from the ammo handling system box as part of the process to rectify the fault. However, Pang said he was fine and the barrel would not hit him.

The COI findings stated that, before lowering the barrel, the gun commander checked if the path was clear and he saw Pang standing near the barrel.

But since the barrel was in the highest elevated position, the gun commander “wrongly assumed” that Pang could move away given that it would take some time for the barrel to be lowered to its standby position.

The Singapore Armed Forces (SAF) previously said that it takes an average of nine to 10 seconds for the gun barrel to be lowered.

Citing the COI’s findings, Dr Ng told the House that the gun commander proceeded to shout “standby, clear away” before activating the control to move the gun. This was heard by the other technician as well as personnel standing outside the gun.

With his back facing the barrel, Pang “initially made no attempt to move away”.

The gun commander later noticed that Pang “was making some evasive movements as the barrel was moving closer to him”. Shocked that Pang was still in the barrel’s path, the other technician “tried to use his hand to push against the barrel to stop the movement”.

In a moment of panic, the gun commander tried in vain to stop the barrel’s movement through the control system.

The accident, which took place at around 2.05pm Singapore time (7pm New Zealand time), saw Pang pinned between the end of the gun barrel and the cabin wall of the vehicle.

He was attended to by an onsite medic before being evacuated 10 minutes later to the battalian casualty station. After he was stabilised, he was sent to Waiouru Base Medical Centre at 2.50pm.

Two hours later at 4.50pm, he was evacuated by a helicopter to Waikato Hospital — a tertiary hospital and regional trauma centre — where he underwent an operation at about 11pm. Pang had two more surgeries on Jan 21 and Jan 22 before his condition deteriorated. He died at 7.45pm on Jan 23.


The COI said that there was “non-compliance with the standard operating procedures and safety breaches”.

Pang was standing in the path of the moving barrel and was not in a safe position before the gun barrel was moved. This, despite being warned that the barrel would be lowered, the COI said.

And even though the other technician knew the barrel would be moved, he did not ensure that Pang moved to a safe position. Similarly, the gun commander proceeded to move the gun barrel despite knowing that Pang was not in a safe spot.

The COI pointed out that there was a “lack of coordinated safety control procedure between the gun crew and the maintenance crew”.

“There was a lack of clarity on who should be in the gun, the command and control, and whether there was a need for acknowledgement before the gun barrel is moved,” it said.

This responsibility lies with the gun commander as stated in the howitzer’s operator manual. “However, this does not absolve the person activating the gun barrel movement (if it is not the gun commander) of his responsibility to ensure that everyone is in a safe position before moving the gun barrel,” the COI said.

There were other lapses found: The maintenance work started before the gun barrel was in a locked position. The gun commander and the other technician miscalculated the time it took for the barrel to hit Pang and “acted irrationally” instead of pressing the emergency stop buttons to halt the barrel’s movement.


In its report, the COI said that before the exercise began, the howitzers’ guns were certified fit for firing in Singapore and later in New Zealand. TODAY understands there have been no incidents involving the howitzer in the last 15 years.

“It has been established that there was no mechanical fault with the gun that had directly caused the accident,” the COI said.

In Parliament, Dr Ng also spoke about how Pang's peers noted that he “had a positive work attitude and was very helpful to others when it came to work”.

Beginning his full-time national service in October 2008, Pang had attended several courses and training, graduating with an overall A-grade from the armament basic technician training.

“He was also professional when executing his tasks and was seen by his superiors as someone who would not cut safety corners when working,” Dr Ng said.

“Nevertheless, the COI found that the incident was due to lapses of all the servicemen who were in the gun at the time of the incident.”

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