Zit Seng's Blog

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Reminder To SMRT: Claw At Root Cause

SMRT’s investigation of the fatal accident on 22nd March has concluded that failure to follow key safety procedures led to the deaths of two SMRT employees. I think most of us have pretty much reached that conclusion ourselves, as soon as sufficient details of the accident had been made known, over a month ago. Thank you for stating the obvious.

SMRT Train

According to SMRT (via Yahoo News): “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.”

The independent panel appointed by SMRT to review the accident determined that this vital safety protection measure was not applied. While there were other factors, this is the one that is blamed for directly causing the accident.

The panel appointed by SMRT is supposedly independent, but I’m not so sure how independent they are. That panel apparently comprises members of the SMRT Board Risk Committee, the exact numbers unknown, and three independent experts. I wonder, isn’t the purpose of typical risk committees to look out for risk exposures and to minimise their impact to the organisation? I sense a conflict of purpose here. This independent panel would likely want SMRT to be blame-free in the outcome.

SMRT’s independent panel just reported the obvious and left it at that. Safety protocol was not followed. Is that all there is to it?

Were there other safety protocols and safety mechanisms in place? If so, why did they not work? If not, how is it that human lives could be allowed to hinge on that one safety protocol to be applied properly?

Either way, there is something manifestly wrong with SMRT. As SMRT reported, other factors that played a part in the accident included track access management controls, communication protocols, and track vigilance. I believe, any one of these safety measures could have prevent the incident. The logical reason why the accident could have occured was the complete breakdown at all levels of their safety measures.

Clearly, there must be a systemic problem in SMRT. You can’t just lay blame on the people downstream.

SMRT says they’ve taken steps to ensure stricter enforcement of procedures. Why weren’t there strict enforcement before? They will also strengthen system ownership. Does that mean system ownership was vague, or perhaps not present at all?

More importantly, was management aware of these lapses and gaps? If so, why did they not do anything? If not, then what were they doing?

Don’t just blame the peons. With problems like this, the root cause is usually somewhere else. It sounds to me like safety isn’t even something they care very much about.

Our previous Transport Minister spoke about wanting to claw back commuter confidence in the public transport system. I don’t think he managed to claw back anything. That job falls on Mr Khaw Boon Wan now. Before clawing back commuter confidence, we need to claw at the root cause of this accident.

If two people died because of just one safety slip up, SMRT should just step aside and let someone else more capable take over and run the train system.

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