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Ministerial Statement on the Government's Response to Report of COI into the 15 and 17 December 2011 MRT Disruption

10 Jul 2012 In Parliament

Please click here to view the Key Points of the Ministerial Statement.

1.     Mr Speaker, Sir, in January, I delivered a ministerial statement in this House on the service disruptions that took place on the North-South MRT Line on 15 and 17 December 2011. More than 200,000 commuters were affected and the severity of the incidents was unprecedented.
2.     A Committee of Inquiry (COI) was convened on 29 December, led by Chief District Judge Tan Siong Thye, with two other members, Professor Lim Mong King and Mr Soh Wai Wah. It was tasked to investigate the cause of the disruptions, as well as other factors that might have contributed to them. Based on the findings, the Committee would make recommendations to minimise the recurrence of similar incidents, and improve the management of such incidents.
A thorough inquiry and a comprehensive report
3.     The COI's report resulting from the inquiry was submitted to my Ministry on 3 July 2012. The report is comprehensive, detailing the Committees findings and recommendations. These will be invaluable to ongoing efforts to improve the reliability of our public transport system.
4.     I want to put on record my deep appreciation for the Committees hard work. The inquiry was demanding and challenging, given the technical nature of the issues. Prior to the start of public hearings, the Committee had to expend time and effort to equip itself with contextual and technical information in preparation for the inquiry. The public hearings started on 16 April, and lasted six weeks, concluding on 25 May. During this time, a total of 116 witnesses were called to the stand.
5.     Apart from the Committee members, I must also thank the team that supported the Committee, including but not limited to its secretariat, resource persons, officers from the Attorney-Generals Chambers, and investigators from the Criminal Investigation Department and the Air Accident Investigation Bureau. I also thank witnesses who testified at the inquiry, including expert witnesses, LTA and SMRT senior management and staff, and members of the public. Without them, the inquiry would not have been successfully completed.
Government accepts the COI's findings and recommendations
6.     I will first summarise the COI's key findings and recommendations, and then provide the Governments response. I will update Members on the measures that we have already taken, and further measures we will take, to improve MRT reliability and incident management. While the COI found shortcomings in SMRT, LTA too fell short. I will also speak about the improvements that LTA must make, particularly with regard to how it regulates the public transport operators.
7.     Let me say here before I proceed further, that my Ministry accepts the findings and recommendations of the COI.
Events on 15 and 17 December 2011
8.     As the media has reported extensively on the findings of the COI, I will not dwell on them.
9.     The COI assessed that the immediate cause of the stalling of the trains in both incidents was damage to their Current Collector Device (CCD) shoes, due to contact with a sagging third rail. The third rail, or power rail, runs along the MRT tracks and supplies electrical current to the running trains, which draw this power through CCD shoes mounted on the trains. During both incidents, sections of the third rail were found to have sagged and multiple claws dislodged. These claws are a key component of Third Rail Support Assemblies (TRSAs), which hold the third rail above the track.
10.   The incident on 15 December was initiated by a defective fastener on one of the TRSAs. This caused the claw of that TRSA to dislodge and the third rail to sag. Although trains continued to pass the sag, it rendered the two adjacent TRSAs more vulnerable to vibration. Over time, these two TRSAs, which insulators were coincidentally also defective, failed gradually. By the evening of 15 Dec, the third rail sag had gone beyond the tolerance limit of the trains CCD shoes, damaging the CCD shoes on trains passing the incident site. Some trains stalled after passing the site as they were no longer able to draw sufficient power from the third rail. At the incident site, multiple trains impacting the sagging third rail eventually caused three more claws to dislodge, such that a stretch of the third rail came to rest on the track-bed. This segment of the track then became impassable to all trains.
11.   The COI attributes the incident on 17 Dec 2011 to one, or possibly more, rogue train(s) that suffered CCD shoe damage when they passed the 15 Dec incident site as the third rail was progressively sagging. The damaged CCD shoes of the rogue trains destabilised the third rail system at other locations along the North-South Line on 16 Dec, causing one third rail claw on the south-bound track between Newton and Orchard stations to dislodge and the third rail to sag. On 17 Dec morning, Train 119 made unusually forceful contact with the third rail at the incident site, causing an adjacent claw to also dislodge. With two adjacent claws dislodged, the third rail sagged further and caused damage to the CCD shoes of Train 119 and the trains that passed after it. Some of these trains subsequently stalled as they were no longer able to draw sufficient power.
12.   On incident management, the COI recognised the complex challenges that SMRT and LTA faced on the two days, given the trying and unprecedented circumstances. While commuter safety was not compromised, there were lapses and gaps in the management of the incidents. Individual SMRT staff generally did their best, but the overall incident response was skewed towards train safety and operational considerations, resulting in insufficient attention to the well-being of passengers in stalled trains and stations.
13.   The COI's key conclusion is that the incidents were preventable, had adequate maintenance measures and checks been carried out. The COI found shortcomings in SMRT's maintenance work culture, and in its overall maintenance and monitoring regime. In particular, the COI agrees with the expert witnesses that the material defects in the fastener and insulators likely took time to develop before the 15 Dec incident. However, they were regrettably not identified and remedied by SMRT's maintenance efforts. After the 15 Dec incident, SMRT's checks, including the checks done after 16 Dec MRT operations, failed to detect the damaged CCD shoes on the rogue trains and the third rail sag. This allowed the 17 Dec incident to take place.
Measures to improve MRT reliability
14.   Sir, let me now bring the House through the COI's key recommendations to improve MRT reliability. Let me assure Members that we will follow through on all the recommendations. SMRT and LTA have already implemented or decided to implement many of the recommendations, while some others require further feasibility study. SMRT has given its initial response last week on how it is already improving its maintenance and monitoring regime and work processes. LTA, as the MRT regulator, will provide its detailed response later today.
15.   The COI has made a number of recommendations specifically on the third rail system as this was the source of the problem for the Dec 2011 disruptions. We need to avoid a situation where we have two or more adjacent claw drops, as the third rail will then sag beyond the tolerance limit of the CCD shoes. This means we must identify third rail sags and fix the sags in a timely manner. In this regard, SMRT has accepted the COI's recommendation to enhance the maintenance regime for the third rail system. Full maintenance requirements in the original MRTC maintenance manual, which includes annual TRSA inspections, will be implemented. Non-destructive tests such as ultrasound scanning have already been carried out at vulnerable stretches of the third rail, to pick out cracks on third rail joints. LTA and SMRT are reviewing the upgrading of SMRT's current Multi-Function Vehicle (MFV). The review will be completed by August 2012, at which point SMRT will call for tender to upgrade the MFV. A new MFV will be acquired on top of this current MFV. In the meantime, the Circle Lines (CCL) MFV has been redeployed to the North-South and East-West Lines (NSEWL).
16.   SMRT will explore capabilities to detect third rail sags via the installation of sensors on selected trains. Installation and testing are expected to begin by the end of this month. In addition, SMRT will study a camera-based system so that the third rail can be monitored on a real-time basis. As an interim measure, SMRT will implement stainless steel capping on TRSAs with cable ties at higher-risk areas such as high speed ramps of tight turn-outs. This will further reduce the likelihood of claw dislodgements.
17.   The COI has also recommended that the design of the TRSAs be reviewed. The TRSAs that we have in the older parts of the NSEWL are over 20 years old. There are now better and more robust designs which have more effective locking features. SMRT will undertake a change-out programme for the older TRSAs on the NSEWL. Fifth generation claws will be installed at Floating Slab Track (FST) sections, where several of the dislodged claws were found in December. Installation will begin by the end of this month, and be completed by August. Thereafter, current speed restrictions that were imposed upon these sections will be lifted progressively. In addition, SMRT and LTA will continue to study plans to replace TRSAs for the rest of the network, and make a final recommendation on the type of TRSA that will be used by the end of the year.
18.   Specific train components also contributed to the December incidents, in particular, severe vibrations caused by wheel defects. SMRT will monitor the condition of train wheels through the use of a Wheel Impact Loading Detection (WILD) system which automatically picks up wheel defects. This system is already in place on the Circle Line today, and will be implemented for the NSEWL by December. In addition, SMRT will procure additional wheel lathes for wheel re-profiling to rectify wheel defects. To monitor all this, LTA will require the MRT operators to introduce formal processes to track indicators and analyse faults, including the number of trains in queue for wheel profile works. LTA and SMRT will also study the COI's recommendations to improve the maintenance regime for CCD shoes, and to explore means to detect defective CCDs.
19.   Beyond recommendations for specific components, the COI has emphasised the need for SMRT to strive for maintenance excellence. SMRT has assured me that it will improve its maintenance and monitoring regime. I understand that it is already taking steps to enhance its engineering and maintenance capabilities and resources, and that it has put in place a more robust maintenance regime overall.
The regulators role must evolve
20.   Sir, it is the responsibility of LTA as the regulator to hold the operator accountable for delivering a reliable system for commuters. LTA fell short in this regard. It must do better. LTA must re-look how it can better fulfil its duties as the regulator. It must work with and supervise more closely the operator, and strengthen its regulatory framework.
21.   Today, the oldest parts of the NSEWL have been in operation for some 25 years. Given these ageing assets and the added strain of increased ridership, the quality and robustness of the maintenance regime, especially preventive maintenance, become even more critical. Rather than relying on a corrective approach to rectify problems, we must adopt a systems approach towards maintenance to pre-emptively identify potential areas of concern.
22.   The operator and regulator will therefore need to work even closer than before, on key preventive maintenance and upgrading plans, starting with the NSEWL, but eventually extending this same approach to all other lines as they too will age.
23.   Earlier this year, I directed both LTA and SMRT to set up a Joint Team, comprising engineering and maintenance experts from both sides, to look into reducing disruptions and enhancing the reliability of the NSEWL.
24.   The Joint Team has briefed me twice on its findings and recommendations. They plan to reduce the number of train service withdrawals by 30% by 2013, by adopting a systems-based preventive maintenance approach, and tackling key areas like the pneumatic compressors, propulsion systems, and brake control units of different generations of trains. The Joint Team has also identified additional areas of improvement, including systematic upgrading and replacement of infrastructure and operating assets. This illustrates LTA's evolving role. While LTA in the past would have largely left it to the operator to decide on what components to change-out as part of mid-life upgrading of the trains, LTA will henceforth jointly work with the operator on critical aspects of such upgrading programmes.
25.   I expect LTA and SMRT to continue this new Joint Team approach in studying and implementing the COI's recommendations.
A stronger regulatory framework
26.   Sir, apart from working closer with the operators, the LTA will also strengthen its regulatory framework. LTA's regulatory approach in the past has been outcome-based, with selective intervention on safety-critical aspects. Going forward, LTA's regulatory framework will be enhanced to be more prescriptive, and to also exercise greater oversight on areas that affect reliability and commuter comfort.
27.   To exercise closer and more effective oversight over train operators maintenance and operations, LTA will require operators to track certain indicators so that early detection of problems and timely preventive actions can take place. This includes indicators such as the Mean Time between Failure (MTBF) of train propulsion and braking systems, incidents of dropped claws and misaligned third rails, and the number of trains in queue for wheel re-profiling works. These will give the regulator a better sense of the operator's maintenance efforts. In addition, the operators will be required to submit to LTA, trend analysis and improvements plans with specific timelines to arrest and reverse faults.
28.   The COI has also recommended that LTA impose a requirement on SMRT to conduct a Maintenance Management System audit, to identify areas of possible improvement in their maintenance regime. I fully agree with this recommendation. LTA will require SMRT to engage independent experts to audit their maintenance processes every three years. I have also asked SMRT and LTA to work with and consult their counterparts overseas who have to operate and regulate older MRT systems, to see what preventive measures we should put in place, and what useful lessons we can learn, to cope with an ageing rail system.
29.   New Operating Performance Standards (OPS) will be introduced to better reflect commuter's experience. In particular, more stringent standards will be set on the frequency and number of delays. LTA will also review the penalty framework, which includes the maximum fine payable by the operators for regulatory breaches, so that penalties can be more commensurate with the severity of incidents and their impact on commuters.
Measures to improve incident management
30.   For incident management, the COI has called for greater clarity in the roles of stakeholders, and for improved coordination between stakeholders; improvements to various aspects of the incident management plan with an emphasis on the well-being of passengers; and ensuring incident management readiness. LTA and SMRT have taken steps to address the gaps and lapses that were identified with regard to incident management, even prior to the release of the COI report. I am confident that parties are better equipped today than they were a year ago to handle similar incidents.
31.   LTA has taken the lead to better integrate stakeholders land transport emergency plans to ensure that there is clarity in roles. Since the December incidents, LTA has worked with the operators to harmonise their incident classification levels to be consistent with LTA's. This ensures that appropriate support from all parties is rendered in accordance with incident severity. LTA will continue to review and refine these plans, and robustly test these against realistic exercises and challenging scenarios.
32.   We have taken measures to improve the incident management plan with an emphasis on passenger well-being. When I addressed this House in January, LTA and the operators were already looking into the improvement of contingency plans for train service disruptions particularly with regard to bus bridging services and the improvement of communication to in-train commuters and the public. Since then, LTA has worked with the PTOs to provide regular bus services free of charge at designated points nearest to affected stations in the event of an extended MRT service disruption, to improve signage at the stations, and to develop more robust and comprehensive station-level plans to deal with incidents.
33.   In addition, the pre-mature failure of batteries during the December incidents caused great discomfort to commuters. In response to the COI's recommendation to improve back-up power, SMRT has committed to instituting more battery checks, while a detailed study will be carried out to look into the feasibility of extending the current duration of back-up power from 45 minutes to 60 minutes.
34.   As regulator, LTA issued to the PTOs early this year a Code of Practice (COP) on incident management. The new COP sets more prescriptive standards for compliance on key aspects of incident management such as incident reporting by operators to LTA and other authorities, information management via regular and comprehensive announcements, detrainment of passengers from stalled trains, and bus bridging services. The introduction of a COP relating specifically to incident management signals its importance, and will raise standards of incident management. Beyond the COP, the rail operators will be required to seek approval from LTA for their Rail Incident Management Plan (RIMP).
The COI has met its objectives
35.   Sir, the COI was set up to look into the causes of the December disruptions and to make recommendations to minimise the recurrence of such incidents, as well as how future incidents should be managed. The COI has delivered on their Terms of Reference, and done so in a manner which is open, transparent, and fair in allowing for due process. This also means that it is to be expected that the parties involved will hire good lawyers and credible experts as part of the inquiry process. More importantly, I believe the COI has taken an objective, fact-based and thorough approach in its inquiry, with a clear emphasis on being constructive and forward-looking. MOT is satisfied that the Committee has met its objectives and our expectations.
36.   In particular, the COI has enabled us to get to the root of what happened on 15 and 17 December as best as we can, given that unfortunately some of the information was not preserved or available by the time the Committee started its work. We will have to implement more effective forensic investigation procedures as recommended by the COI, so that we can learn useful lessons whenever we have significant incidents and disruptions. Nonetheless, as a result of the COI's thorough and systematic work, we now know much more about the vulnerabilities of our NSEWL, and can take appropriate preventive and remedial measures.
37.   It is not the purpose of the COI to determine accountability and penalties to be imposed for the incidents. LTA, as the regulator, will separately complete its investigation into the December incidents. The findings of fact within the COI report will provide useful input to LTA's investigation, and I understand that LTA will announce the outcome of its investigation shortly, including penalties.
38.   Sir, let me conclude.
39.   SMRT's maintenance regime had shortcomings, but we too both MOT, as the supervising Ministry, and LTA, as the regulator have to shoulder our share of the responsibility. We could have done more, and could have done better. The December incidents were a painful lesson, but we can and will learn from them. We will improve our ability to address new challenges that arise with an expanded public transport network. I give the House my assurance that we will spare no effort to improve.
40.   The COI itself may have drawn to a close, but it marks the start of the next phase for all of us. We know that we must work hard to restore confidence in the MRT system. We will put in place measures to address specific problems that have been identified to improve the reliability of our system. We will move towards a more holistic and robust framework for maintenance issues, and we will strengthen today's regulatory framework so that the operator is held more accountable.
41.   The Government is responsible for delivering a quality public transport system to Singaporeans. We take this responsibility seriously, and will deliver.