Key Recommendations of the Board of Inquiry on the Death of SCDF Full-Time National Serviceman Corporal Kok Yuen Chin

1.     Following the death of Singapore Civil Defence Force (SCDF) Full-Time National Serviceman Corporal (CPL) Kok Yuen Chin on 13 May 2018, the Minister for Home Affairs, Mr K Shanmugam, convened a Board of Inquiry (“Board”) on 22 May 2018 for the following purposes (“Inquiry”):

(a)     inquire into the circumstances of the incident on 13 May 2018 in which CPL Kok passed away (i.e. what happened prior to the incident, how his death occurred, as well as SCDF’s response to the incident);

(b)     inquire into the existing measures to educate SCDF servicemen and prevent the conduct of any unauthorised activities disclosed; and

(c)     arising from (a) and (b) above, recommend improvements to regulations, rules, systems, infrastructure, programmes, processes, and any other possible actions SCDF could take, to prevent the recurrence of similar incidents.

2.     This Inquiry is separate from the investigations undertaken by the Singapore Police Force, from which five SCDF officers have been charged in Court. The Inquiry is also separate from any subsequent disciplinary proceedings that may be undertaken by SCDF.

3.     In the course of its Inquiry, the Board had interviewed and obtained statements from over 50 SCDF personnel, including SCDF senior management, visited Tuas View Fire Station where the incident took place and reviewed evidence relevant to the incident.

4.     Board subsequently submitted its report to Minister Shanmugam on 28 August 2018, and he has accepted its recommendations in full. Minister Shanmugam said: “I thank the Board for their efforts over the past few months. The recommendations will help the SCDF eradicate unauthorised activities, such as ragging. The conduct of the officers involved was unacceptable. Those who were assessed to be criminally culpable have been charged and will answer for their actions in Court. The others will be investigated for departmental disciplinary actions. We will do whatever we can to ensure that no more officers come to harm because of such activities. CPL Kok’s death was a most tragic loss, both for his family and SCDF. Our thoughts continue to be with his family, and we will support and assist them in any way we can.”

5.     The Ministry of Home Affairs and SCDF also thank the Board for its work and recommendations. SCDF has since studied the Board’s recommendations and will be implementing the necessary follow-up actions. The Board’s key findings and recommendations have been shared with CPL Kok’s family. A summary of these findings and recommendations are set out in the Annex .

ANNEX

Summary of the Board of Inquiry’s Report on the Death of SCDF Full-Time National Serviceman Corporal Kok Yuen Chin

1.     Following the death of Singapore Civil Defence Force (SCDF) Full-Time National Serviceman Corporal (CPL) Kok Yuen Chin on 13 May 2018, the Board of Inquiry (“Board”) was convened to:

(a)     inquire into the circumstances of the incident on 13 May 2018 in which CPL Kok passed away (i.e. what happened prior to the incident, how his death occurred, as well as SCDF’s response to the incident);

(b)     inquire into the existing measures to educate SCDF servicemen and prevent the conduct of any unauthorised activities disclosed; and

(c)     arising from (a) and (b) above, recommend improvements to regulations, rules, systems, infrastructure, programmes, processes, and any other possible actions SCDF could take, to prevent the recurrence of similar incidents.

Method of Inquiry

2.     The Board had interviewed and obtained statements from over 50 persons, including SCDF servicemen from Tuas View Fire Station (TVFS) and SCDF senior management. The Board also made a site visit to TVFS and reviewed evidence relevant to the incident.

Key Facts

3.     TVFS has three Rotas ^[1] . CPL Kok was part of Rota 3, comprising 23 personnel. Rota 3 had commenced their 24-hour duty tour at 8.00am on 13 May 2018. This was CPL Kok’s last duty tour before his Operationally Ready Date (ORD) on 16 May 2018.

Events Leading Up to the Incident on 13 May 2018: Celebration at the Watch Room (8.40pm to about 9.04pm)

4.     Between 8.40pm and 9.04pm, the Rota 3 personnel on duty held a celebration at the station’s watch room to mark CPL Kok’s impending ORD. A plaque and cake were presented to CPL Kok by the Rota as part of the celebration.

The Incident (9.04pm to 9.07pm)

5.     After the celebration, CPL Kok was carried by certain members of his Rota to the pump well, where he sat on the edge. At 9.07pm, one of the officers went behind him to push him into the well ^[2] as kolam .

Rescue (9.07pm to 9.43pm)

6.     CPL Kok did not re-surface after being pushed into the pump well. The first serviceman jumped into the well eight seconds after CPL Kok was pushed into it, in an attempt to rescue CPL Kok. Other servicemen jumped in thereafter as well, but to no avail. The servicemen then used a fire engine suction pump to pump water out of the pump well and those jumping in then used breathing apparatus in order to dive deeper into the well. One of the servicemen subsequently located CPL Kok within the well. The servicemen then worked together to use ropes to pull CPL Kok out. CPL Kok was extracted from the pump well at 9.43pm, about 36 minutes after he had fallen in.

Medical Response (9.43pm to 11.02pm)

7.     Paramedics who attended to the incident tried unsuccessfully to resuscitate CPL Kok after he was extracted at 9.43pm, before conveying him to Ng Teng Fong General Hospital, reaching there at 10.13pm. CPL Kok was pronounced dead at 11.02pm. An autopsy found the cause of death to be drowning.

Key Findings and Recommendations

8.     The Board found that the events on the night of 13 May 2018 started off as a celebratory activity that subsequently went tragically wrong. This celebration was an initiative by the TVFS Rota 3 personnel to mark CPL Kok’s ORD and was paid for by the Rota 3 servicemen themselves. The key factors that led to the incident, and the Board’s recommendations to prevent unauthorised activities are summarised below.

Building an Anti-Ragging Culture within SCDF

9.     The Board found that the SCDF had clear anti-ragging policies and frameworks. There were anti-ragging briefing sessions for all servicemen at the point of enlistment and during training. These messages were further reinforced through regular interviews and informal sessions with NSFs by commanders. Posters were also displayed at fire stations to remind servicemen of SCDF’s anti-ragging policy.

10.     The Board noted that the incident took place in spite of these measures. To strengthen the anti-ragging ethos within SCDF, the Board recommended that SCDF further review their anti-ragging measures, particularly in terms of helping servicemen to better internalise their anti-ragging policy. The Board also recommended that SCDF look into having more hands-on instructional methods to teach servicemen on how to identify and stop ragging, and equip servicemen with a standard set of response lines to help them say “No” to ragging.

11.     The Board found that SCDF had clear disciplinary and whistle-blowing policies. It recommended that these policies be further enhanced to give greater assurance to victims and observers that their interests will be protected. The Board also recommended that SCDF expand the number of channels through which servicemen can report ragging incidents.

12.     The Board noted SCDF’s zero tolerance policy towards all forms of unauthorised activities, including ragging. The Board recommended that SCDF ensure that its commanders are trained to help them pre-empt ragging amongst officers under their charge. Officers who do not hold command positions but are senior in terms of rank or length of service should also be further trained to reinforce an anti-ragging culture within their own circles of influence.

13.     In addition, the Board recommended that SCDF review how they recognise positive behaviours demonstrated by officers who show care for fellow colleagues. This could help to strengthen SCDF’s anti-ragging ethos.

Decommissioning of P ump W ells L ocated at F ire S tations

14.     During its discussions with SCDF, the Board found that pump well testing and training can be centralised at the Civil Defence Academy (CDA), without compromising SCDF’s operational effectiveness. It is therefore not necessary for each fire station to have its own pump well. The Board therefore recommended that the fire station pump wells be decommissioned, to remove the risk of unauthorised access. For the pump wells at CDA, the Board has suggested that SCDF take additional measures to restrict access and ensure their safe usage.

Other R ecommendations

15.     The Board also made additional recommendations, including enhancing CCTV coverage in vulnerable areas within SCDF areas , and strengthening training on risk management and workplace safety.

[1] A Rota, used in the fire station context, describes a team comprising fire and rescue specialists and paramedics who are on standby duty to provide emergency services.

[2] Some servicemen interviewed by the Board said that the unauthorised activity known as kolam (the Malay term for a pool of water), in which a serviceman enters the pump well, is sometimes conducted to mark a serviceman joining or leaving the fire station.