Report Cap7 Safety2

Safety
CHAPTER 7 - SAFETY
1. Safety and the safety culture in the Circle Line project for C824 fell short. There
were many safety mistakes and errors. Errors were made from inception of
design to construction of the C824 project. These led to under-design of the
temporary retaining wall system, poor quality during construction, ineffective
engineering control and judgment, and critically, an unresponsive safety
management. There was lack of a safety culture, prevailing particularly of the
Main Contractor. The safety policies, if any, were unclear. This chapter sets out
the safety errors, organisational failures and the recommendations on safety.
2. Safety is freedom from unacceptable risk of harm. Safety culture is the product
of individual and group values, attitudes, competencies and patterns of
behaviour that determine the commitment to, and the style and proficiency of,
an organisation’s approach to health and safety.1
3. There are sound economic, health and ethical reasons for reducing work related
accidents. An effective safety management system not only minimizes risk to
employees and others, it also promotes business efficiency, reduces costs and
enhances the image of the business as a caring and responsible organisation.
Such a system improves business performance and makes good business
sense. Safety is achieved within a sound legislative framework. The goal
setting legislation being proposed by the Ministry of Manpower, which would
require organisations to manage their activities in order to anticipate and
prevent circumstances that might result in occupational injury or ill health, is an
important and significant step forward.
4. Human factors including the culture, attitudes and beliefs within organisations
can make or break the effectiveness of any safety management system. Safety,
in essence, is dependent on ‘human factors’. These factors were present in the
Circle Line project. Safety of the Circle Line project was heavily dependent on
systems of management and work. People had to make complex judgments in
many differing types of work, often under difficult site conditions.
1
See BS 8800:2004, Occupational Health and Safety Management Systems – Guide.
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5. But human beings are prone to making unintentional errors and intentionally
violating works systems. These errors and violations are human failures.
Although properly designed machines have distinct advantages over people,
machines cannot carry out critical safety tasks. This is because safety
measures involve both a product and a process. Simply implementing them is
not enough. They have to be watched, worried about, tuned and adjusted.
Reliance is placed on human beings for solving complex safety problems.
Therefore if projects such as the Circle Line project are to be undertaken safely,
it is essential that those managing the process understand how human failure
happens, what can be done to prevent it, how it can be detected and corrected
and how to recover. Indeed failure to consider the issue is human error.2
6. Human error is not confined to operators, but can occur throughout an

organisation. There is a need to guard against an overly simplistic analysis of
incidents, as this can lead to the search for ‘scapegoats’ at the operator level.
High level errors can play a major part in creating the circumstances where
others make errors at the work place.3
7. The collapses of the temporary wall elements in C824 could have been
prevented but for a cultural mind-set that focused attention on the apparent
economies and the need to meet construction schedules rather than the
particular risks. From the early stages of the project through to final collapse,
there were failures to appreciate that serious errors were made and the
necessary level of care was lacking. Warnings of the approaching collapse were
present from well before the incident but these were not recognised.
8. Even as the Inquiry proceeded midway, after hearing 103 out of 155 witnesses
at that stage, the Committee was concerned that the 20th April final collapse
exhibited hallmarks of an organisational accident. There are two kinds of
accidents: those that happen to individuals and those that happen to
organisations. Organisational accidents are rare, but often catastrophic, events
that are unacceptable in terms of their human, environmental and commercial
costs. A confluence of factors led to the position where systems used by the
LTA and NLCJV failed and a major accident adversely affecting the safety of a
2
See Safety of New Austrian Tunnelling Method (NATM) Tunnels Report at p.36.
3
Ibid.
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large number of people occurred. There were undoubtedly human errors, but
these were merely a consequence of foreseeable organisational failures. The
collapse was rooted, among others, in failures in ‘defensive’ systems that did
not adequately deal with hazard identification, risk avoidance and reduction, and
the control of remaining residual risks.
9. Completely aware that the hearing had not been completed, the Committee
nevertheless issued an Interim Report on 2 September 2004. It was to flag the
systemic organisational shortcomings in the execution of C824 of the Circle Line
Project and that such shortcomings do not adversely affect the ongoing deep
excavation projects under the purview of the Land Transport Authority.
10. The Government accepted the broad thrust of the recommendations made in
the Interim Report. Such recommendations comprised both short term actions
and long term changes. The Interim Report and the Government’s Response
crystallized the subsequent direction of the Inquiry on the matters concerned in
the Interim Report.
11. In short, the accident on the 20 April 2004 was rooted in history. It was a history
of safety errors and organisational failures. Organisational failures are the
manifestation of a lack of safety culture. The principal safety errors and
organisational failures in C824 are highlighted below.
7.1 SAFETY ERROR IN INSTRUMENTATION AND MONITORING
12. In C824, the original design level stipulated at Type M3 was 145 mm. On 23
February 2004, a reading of 159 mm was recorded from inclinometer I-65. The
works were at the stage where the 6th level struts were being installed.
Following a back-analysis the design level was revised to 253 mm. On 30
March 2004, a reading of 302 mm was recorded from inclinometer I-104 while
excavation was progressing to the 9th level. Following a second back analysis,
the design level was revised to 359 mm.
13. A clear trend showing an ever increasing level in the wall deflections at Type M3
can be deciphered. Special attention should have therefore been placed on the
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inclinometers I-65 and I-104. These were the two instruments which could best
monitor the movements of the diaphragm wall.
14. Yet, no readings on 18 and 19 April 2004 for I-104 were taken. These readings
were extremely crucial readings which would have reflected the alarming rate of
movement of the diaphragm wall, which moved a total of about 90mm in the
short period from 17 April to 20 April 2004.
15. All the relevant persons involved in analyzing the instrumentation readings knew
that the readings for I-104 had to be taken on a daily basis but did not
appreciate the significance and context of taking inclinometer readings.
16. The implication of the reading on 17 April 2004 at 349.81 mm was not
recognised. The 17 April 2004 reading showed an increase of over 20 mm from
the reading taken just two days before on 15 April 2004, which was at 325.2
mm. Although 349.81 mm was still below the revised design level of 359mm,
alarm bells must ring for the need to analyse the rate of movement as well. This
is particularly so when the 359 mm was decided after two unmeritorious
revisions from the original design level of 145 mm.
17. There was no credible explanation why the crucial readings on 18 and 19 April
2004 were not taken by Balasubramani, the direct person in charge of
instrumentation from L&M. When informed by his worker that the reading for I-
104 was not taken as it was covered with soil, it did not occur to him to
personally go down to the location of I-104 to verify and resolve this situation.
This is commonsensical. Instead, he was merely content to inform Ahilan from
NLCJV about this. When the situation remained unchanged on the 19 April
2004, Balasubramani once again did nothing more than to relay the information
to Ahilan. According to Balasubramani, “I did not take up on the matter, because
I thought since I already told the main contractor, it should be alright.”
18. Ahilan, in turn, was also merely content to relay the information to Kasukawa
without giving instructions of any sort to Balasubramani to ensure that the
readings were taken as per the Schedule. According to Ahilan, he felt that the
responsibility of ensuring that the readings were taken belonged to Kasukawa
and not himself. However, Kasukawa, the person who drew up the
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instrumentation Schedule, testified that he had “reminded Suresh, L&M and

Ahilan on many, many occasions to take the readings”.
19. The key players passed responsibility from one to another. On 20 April 2004,
Suresh Kumar and Andy Wong proceeded to the location of I-104 and they
discovered that it was no more than a small heap of soil which covered I-104
and it took only 5-10 minutes to clear it. If not for this serious safety error, the
situation was farcical. This shows a lack of culture in which safety is paramount.
20. The situation also shows a habit of thought. Earlier readings for I-104 were not
taken from 10 - 25 March, 12 - 14 April as well as 16 April 2004. Considering
the original design level had been revised at the end of February 2004, greater
circumspection, attention and caution should have been given in respect of I-
104 and I-65.
21. The excuses for the missing readings offered were inane. Kasukawa, who was
specifically deployed by NLCJV to the C824 site with the “main duty to check
the monitoring results with the designer’s point of view…” conceded that he was
“not happy” with the reasons given as to why the readings for I-104 were not
taken. In general, Kasukawa testified that “the instrumentation reading was not
done as I requested.” Kasukawa himself was not faultless.
22. When piezometer GW(V)24 malfunctioned in February 2004, there was no

request for a replacement made by NLCJV. While it is acknowledged that there
were numerous monitoring instruments deployed at the worksite, sound and
proper engineering judgment must be exercised by the senior personnel
involved in respect of issues such as the replacement of damaged monitoring
equipment. In the present case, GW(V)24 was installed within the excavated
area below final level of the excavation at a depth of about 38m and was a
crucial instrument, especially in monitoring against the possibility of a base
hydraulic uplift. As such, it should have been replaced expeditiously and all the
more so as an “observational approach” (with its implied emphasis on
monitoring) in lieu of a design review had been purportedly adopted by NLCJV
as of October 2003.
23. Other obvious shortcomings were the lack of training and experience of the
workers involved in taking the readings for instrumentation. William Chee,
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Project Manager (Instrumentation) from L&M, testified that he was given only
general workers who were attached to and supervised by other workers who
were more experienced than them. There was no formal training or courses
available for the workers to undergo training.
24. To reiterate what the COI has stated at paragraph 29 of its Interim Report:
(a) Instrument-based performance monitoring systems must be effective,

adequately resourced and maintained;
(b) There is a need to integrate information from the various instruments

and to relate the crucial information to what is happening on the
worksite, as well as the quality of each of the elements in the
construction.
25. Management systems and resources capable of collecting, inputting, processing

and interpreting the large amounts of instrumentation data were required. The
evidence showed that this capacity fell short.
26. The absence of such fundamental requirements in C824 gave rise to a critical
safety lapse in C824. Monitoring is vital to determine the behaviour of the
diaphragm wall. Unsatisfactory trends must not only be identified sufficiently
early, but doggedly monitored and the subsequent risks appreciated to enable
corrective steps to be taken. A regular supply of accurate and up-to-date
monitoring information is essential. Its correct and timely interpretation,
including comparisons between predicted and actual design values and the
trend line from the history of the movements of the temporary walls, is critical to
safety.
27. The LTA has, since the Interim Report, taken definitive steps to improve its
monitoring regime. The Committee was informed by Mr Rajan Krishnan, the
Engineer of C824, that the LTA no longer permits sub-contractors to engage
instrumentation contractors and has taken upon itself to engage such
instrumentation contractors to ensure better and close supervision of
instrumentation.
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7.2 CHAIN OF COMMAND AND LACK OF CLARITY AND INEFFECTIVE

COMMUNICATION
28. Increased complexity in an organisation, compounded by interfaces with others,

can lead to problems in identifying and correcting errors. Opaque systems that
cannot readily be understood further complicate issues. Inadequacies in
training and communication, and poor division of responsibilities increase the
opportunities for error.4
29. Communication problems fall into three categories:
(a) System failures in which the necessary channels of communication do

not exist, or are not functioning, or are not regularly used;
(b) Message failures in which the channels exist but the necessary
information is not transmitted; and
(c) Reception failures in which the channels exist, the right message is sent,
but it is either misinterpreted by the recipient or arrives too late.
30. The issue of the chain of command and communication, both inter-party and
intra-party, became evident in the course of the Inquiry. As will be seen, C824
was characterised by a lack of clarity in the chain of command and ineffective
communication which led to a host of safety issues. This was a common
problem shared by the LTA, NLCJV and the sub-contractors.
Problems in Chain of Command between Main Contractor and Sub-contractor
31. A salient example can be seen in the events on the 20 April 2004, the day of the
accident. Kori’s Site Engineer, Lee Yeng Tat, was ostensibly in charge of all the
Kori workers and foremen at C824. Directly under his command was foreman
Ramadoss. That morning, Lee Yeng Tat felt that the situation was dangerous
and both he and Ramadoss objected to the request from Liew Teck Boon of
4
The Report on the Safety of New Austrian Tunnelling Method (NATM) Tunnels at p. 35 para 152.
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NLCJV for the Kori workers to install C-channel stiffener plates and struts at the
10th level. However, when Ramadoss later agreed, albeit reluctantly, to the
request for Kori workers to pour concrete on the walers at the 9th level as part
of the proposed remedial works, Lee Yeng Tat did not raise any objection,
although he stated that his view was that he was not agreeable.
Q. Judging from your evidence, Mr Lee, at this point in time, were you
agreeable to help TB Liew to pour concrete on all the walers on the 9th
level?
A. Are you referring to that morning?
Q. No, at the point when Ramadoss agreed to try to help.

A. My view was that I was not agreeable, but I did not raise my objection
either.
This is a classic example of a category (a) communication problem above.
32. Lee Yeng Tat raised his concerns with his superior, Hooi Yu Koh, but was told
to “leave the matter to Nishimatsu…because they have a very experienced
contingency plan.” The evidence also suggested that Lee Yeng Tat did not
know that his own foreman, Heng Yeow Pheow and about 8 Kori workers were
doing remedial works at the base of the excavation at the Type M3 area that
afternoon. This is a category (b) communication failure. According to Lee Yeng
Tat, Heng Yeow Pheow might have been helping out because he was a “close
friend” of Liew Teck Boon.
33. Hooi Yu Koh, Kori’s Project Director, testified he had the “final say” in safety
matters. Here again, we see a category (b) communication failure. Hooi said
that he was unaware that his men were engaged in remedial works on that day
and conceded that that the system of work which he had put in place had failed
and that there was a break in the chain of command, as can be seen in the
following evidence:
Q. Mr Hooi, were you not aware subsequently that many of your workers
were down below on the 9th and 10th level casting, infilling the walers
beams with concrete?
A. No, I was not told at all.
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Q. You were not told at all?

A. No.
Q. Why is this so? You said that you had a very clear system of work?
A. Right after lunchtime when they started the work, I already started
meetings in 823. During those meetings I did not receive any call, no.
Q. So, Mr Hooi, are you saying that neither Mr Lee nor Mr Ramadoss or
any of your foremen informed you that they will be carrying out these
remedial works which you say you would have objected to had your men
been tasked to do?
A. None of them informed me.
Q. None of them informed you?
THE CHAIRMAN: Your system failed?

A. On that day, yes.
THE CHAIRMAN: You failed your system?

A. Yes.
Problems in the LTA Chain of Command
34. The LTA had separate design and construction teams in their hierarchy. As the
teams performed different but complementary roles and functions, a clear chain
of command was required in order to give clarity of direction as the construction
progressed. It is imperative for the teams to understand not only their respective
roles and functions, but also the importance of working in tandem, so that
problems that surface in the course of construction could be properly resolved.
35. The evidence at the Inquiry reveals that synergy and proper communication
between the teams were sorely lacking with the result that the ability of the
relevant personnel when called upon to make timely and sound engineering
judgment was adversely affected.
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36. The duties of the Design Team of LTA included, inter alia, design review,
instrumentation monitoring and verifying the back analysis put forth by NLCJV.
Implied and inherent in these duties must be the power of the Design Team to
recommend stop work, especially in a situation where the instrumentation
readings show design levels being exceeded or the back analysis put forth is
found to be unsatisfactory. The Design Team could make this recommendation
to the QP (ST), who was also the Project Director, the Engineer or the
Engineer’s Delegate, all of whom were vested with the power to order a
suspension of works.
37. Yet, it is evident that the Design Team did not view the critical task of
recommending the suspension or stoppage of work as a matter within their
purview. Instead, the Design Team appeared to be content to rely on a
contractual clause stating that work should be stopped when design levels were
reached as well as the project team for work to be stopped. The following
excerpt from the testimony of Shirley Sivakumaran best illustrates this point :
Q: In the event that the design team is of the view that work has to be
stopped just for a moment on these two factors, how would you go
through this process to ensure that work is stopped ?
A: We do not really—because we would expect the project staff—that if the
contractor does not voluntarily stop, we would have thought the project
staff would have enforce a condition, Your Honour.
38. In essence, even when the Design Team was doing critical work such as
assessing the back analysis, which was done and submitted to LTA when there
were excessive wall deflections, there was no procedure in place where the
Design Team actually knew if work on the site had been stopped. This is clearly
a category (a) communication failure.
39. This situation is clearly unsatisfactory and in effect, relegates the assessment of
the back analysis to a potentially meaningless exercise, for workers would have
been exposed to the risk and dangers at the site which a proper back analysis is
supposed to negate.
40. In respect of the QP (ST), to whom they provided support, the Design Team
appeared to be unaware that they could recommend stop work in appropriate
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circumstances, such as when inclinometers readings exceeded deign levels.

Shirley Sivakumaran testified that this route of stopping work through the
QP(ST) was there, but it remained unexplored. Here again, we see a glaring
category (b) communication failure. The following evidence is relevant:
Q. Since you agreed with me that there was no process in which the design
team actually checked that the work was stopped, when you were doing
your back analysis, surely this is not satisfactory?
A. Yes, I would think so, your Honour.
Q. Quite apart from just relying on a contractual term which says work
should be stopped, was there any understanding that you could stop the
work through your recommendation to, for example, the QP, whom the
design team provides support? Could you have done that?
A. Yes. I could talk to my Design Manager and he could talk to the Project
Manager, I think.
Q. That was one option in which work could have been stopped?
A. Yes. Normally when I come to know of excavations, I keep my Design
Manager also in the loop, your Honour.
Q. By "Design Manager", do you mean Mr Joshua Ong?

A. Yes, your Honour.
Q. Was it the understanding or the mindset of the design team that, for
example, if the instrumentation readings showed a very dangerous level,
you would tell Mr Joshua Ong, so that he would in turn tell the QP to
stop work; was there such thinking?
A. I do not think so, your Honour.
Q. If there was no such thinking, in that scenario where you found the
instruments showing very dangerous levels, what would you do?
A. That is what, I mean. I sent the e-mail on the 5th, if you are referring to
the second back analysis, your Honour. But now I think we have looked
at the procedures in LTA, yes. I would agree with you that we need to
also take part in this process, your Honour.
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Q. It would appear that even for a person of your rank and experience, you
did not fully appreciate the option of stopping work from a safety
perspective through the option of using the QP?
A. Yes. But I did not think it was not safe, your Honour, at that time.
Q. Sorry, you did not?

A. I did not think it was unsafe, your Honour.
Q. Ms Shirley, I am exploring with you the system in place. It appears that

even if you thought it was unsafe, and I gave you the example of the
inclinometers, if you would not go by the route that I have described to
tell your Design Manager and in turn the QP to stop work?
A. Yes, the route was there, yes, your Honour.
Q. But it was unexplored at that point in time?

41. Further, Shirley Sivakumaran was also of the view that it was the Construction
Team who had the safety overrides. However, there were situations where the
Construction Team appeared to be relying on the Design Team to give the ‘go-
ahead’ for works to continue. An example of this will be the email by Siew Yau
Kok, Senior Engineer of LTA, in respect of excessive wall movement at the
Type K area.
42. The Design Team of LTA was not informed of :
(a) The permit to excavate to the next level introduced by the construction
team in July 2003;
(b) The Design Change Notification (DCN) concerning the change from
plate stiffener to C Channel.
43. The above, in particular the DCN, are clearly matters which should have been
brought to the attention of the Design Team.
44. To sum up, Shirley Sivakumaran, testified that there was “no real clarity” in the
relationship between the Construction and Design teams of LTA. The
Construction team would seek the advice of the Design Team “optionally” on an
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“ad hoc basis”. There was no formalised system or procedure in place in which
the Design and Construction teams of LTA operated, especially in regard to the
critical issue of who should order stop work. This is symptomatic of a category
(a) communication failure.
Problems in the NLCJV Chain of Command
45. Problems between the Design and Construction teams of NLCJV were also
evident as work progressed on C824. This was most evident in the situation
where walers on site started to buckle.
46. Chikushi testified that he was the one who links the Design and Project Teams,
but it was usually the Construction Manager (Liew Teck Boon) and Deputy
Project Manager (Shimizu), who would inform him on what was happening on
site. He testified that “without instructions from Design Team, Construction
Team cannot do anything”. In similar vein, Liew Teck Boon, faced with high
inclinometer readings, stated that he had to trust his Design Team, and the
Construction Team just followed the design given for construction.
47. When asked if NLCJV’s Design Team had been consulted on the contingency
plans in respect of waler buckling, Liew Teck Boon, who was at the upper
hierarchy of the chain of command as a Construction Manager, said he was
“unsure”. One would have expected a person of his capacity, as a person who
would be expected to exercise sound engineering judgment, to be more
proactive, especially for a matter as serious as contingency measures adopted
in the face of waler bucking.
48. In the light of the supposed trust and dependency placed by the Construction
Team on the Design Team, one would have expected a timely report of critical
events, such as the buckling and deformations of construction works, by the
Construction Team to the Design Team for appropriate advice.
49. However, Shimada testified that he was never informed by either Shimizu or
Chikushi on the deformation of waler beam at 7th level S125 (south side) as
depicted at the photograph shown in Figure 5.8. Shimada testified that he only
got to know of this event after the collapse and was of the view that the site
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people i.e. Construction Team, should have reported this to the Design Team.
Similarly, Shimada testified other instances of similar buckling were not reported
back to him by the Construction Team. There was clearly a category (b)
communication failure.
50. Also noteworthy is the fact that an officer as important as Shun Suguwara, who
was appointed Project Director and Senior General Manager for C824 on 15
October 2003 claimed not to know of the problems at the Type M3 area.
Similarly there were numerous site events, such as the buckling of stiffener
plates at S125 (south) as shown in E93 which, according to Paul Broome,
should have been brought to the attention of himself and of the Design Team.
This, “unfortunately” was not the case.
51. The problems in the chain of command and ineffective communication,

especially that of the relay and communication of important events on site, is
perhaps best summed up by Shimada :
“… What I can say is as designers, we could not investigate because

there was no information that came to us. But I do not know whether in
the construction side they have done anything.”
52. Lessons have to be drawn from the examples cited above. The chain of
command has to be well established and communication must be effective.
Only then will the inevitable problems which arise as construction progresses
are effectively and efficiently relayed up to the relevant personnel such as the
Directors, Managers and Engineers in charge of design and construction. Only
then can such relevant personnel take ownership of problems, exercise sound
and timely engineering judgment towards the resolution of such problems. Only
then will such engineering judgment be correctly and properly carried out as
effective remedial works by the workers on site.
7.3 NO STOP WORK ORDER
53. Stop work order is an essential and critical element that must exist as a viable
safety measure in the construction process.
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54. Clause 47.1 of the Contract 824 provides for the Engineer and the Engineer’s
Delegate to suspend or stop work by way of a written order. Where the
suspension of work is necessitated to ensure the safety of the works, Clause
47.1(c) specifically exempts the Contractor from being paid Loss and Expenses
incurred. On a broader level, both Mr. Chua Chong Kheng and Guy Taylor,
Senior Project Manager as well as Engineer’s Delegate for C824, testified that
each and every one of the LTA officers can order stop work for reasons of
safety with full support of the management.
55. Condition 8 of the Conditions of Permit issued by the Building Control Authority
under section 7(2) of the Building Control Act imposes on the QP(ST) the
responsibility of exercising due diligence and reasonable care in monitoring the
excavation or tunneling works, assess the readings and when the critical level is
reached, instructs the builder to take corrective action. Similarly, under
Condition 5, the PE is to certify and endorse on the plans that he would be
responsible for the design and supervision of the construction of the temporary
works. Both the QP(ST) and the PE are reposed with the power to issue stop
work.
56. In addition, contractual clauses such as clause 6.1.4.3 provide, inter alia, the
Contractor should, in the event any instrument reaches or is expected to reach
the allowable levels, inform the Engineer, make the affected work safe and
cease work until remedial measures are submitted, accepted by the Engineer
and implemented.
57. The problems encountered during the C824 project cannot be described as
rare, localised or minor. Serious problems were encountered from August 2003
to April 2004 in Launch Shaft 2, Type K, Type M2 and Type M3 itself. The
serious problems are well documented and include the following :
(a) In August 2003, excessive ground settlement at the cricket field next to
Launch Shaft 2 (Type W2a and Type Y walls) resulted in a crack of
about 150m long in the field. The measured wall deflection was
exceeded the trigger level and was close to design level. The concrete
corbel connecting diagonal strut S530 to the south side diaphragm wall
was crushed and there was settlement of the road;
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(b) In December 2003, excessive wall deflections were recorded at Type K

and a cracking of the corbel for diagonal struts were observed;
(c) In January 2004, excessive wall deflections recorded at Type M2 with

design level exceeded;
(d) In February 2004, excessive wall deflections recorded at Type M3 with

design level exceeded;
(e) In March – April 2004, excessive ground settlement led to cracking of

shop houses in adjacent area;
(f) In March 2004, excessive wall deflections were recorded again at Type
K, exceeding the revised design level;
(g) On 1 April 2004, excessive wall deflections were recorded again at Type
M3, exceeding the revised design level;
(h) There were about 10 reported buckling of walers in the entire C824
construction site; and
(i) On 17-19 April 2004, leakages in diaphragm wall at Type K resulted in

significant inflow of water and soil into the excavation.
58. In light of the above well documented problems, serious consideration should
have been given to the option of stopping work across the entire C824 site
pending a full review of the design of the entire strutting system. Shimada
admitted that a design review should be done even when one waler buckles and
he conceded that NLCJV did not do a thorough investigation on the waler
buckling until the DCN was proposed. The following exchange is instructive:
ASSOC. PROF. TEH: So do you agree with us that 10 upon 3,000 or even 2
upon 3,000 -- 10 incidents out of 3,000 struts or 2 incidents out of 3,000 struts is
not the issue. If there is a single incident, that requires your full attention in
doing a proper review?
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A. If there is any web buckling or stiffener buckling, if these buckling are

informed, of course we will conduct investigation and we will investigate
on the location of the buckling, horizontal positions, depths, strut load,
and so on, by using the monitoring data and looking at the site condition.
But we did not -- I did not perceive this as the situation which needs the
review of the design calculation itself. I did not feel such urgency for this
case, your Honour.
ASSOC. PROF. TEH: Let us stick to the principle. Do you agree that even if
one waler buckles, you need to do a review?
59. From the evidence adduced before the Committee, an order for stop work can
be classified into two categories; firstly, a stoppage at a localised area and
secondly; a stoppage across a large part of the Works. In respect of the former,
any staff of the LTA can stop work for safety reasons. In respect of the latter, a
formal Engineer’s Instruction can be issued to the Contractor to stop work up to
the extent of the entire project.
60. The serious problems encountered in the course of the Project which have been
highlighted above fall into the latter category. Guy Taylor, was of the view that
“Stopping work is a major issue…It is not confined to one person’s
responsibility.”
61. There is no issue that the consideration and decision to stop should be a joint
collective effort by the relevant engineers and managers in any project, who
should be reposed of the ability to make sound engineering judgments and
recommendation in appropriate circumstances to the persons whom the power
to issue stop work is vested. However, the responsibility of ensuring that there is
a proper reporting system in place which allows the necessary information to
reach the top of the hierarchy so that the critical issue of stop work can be
assessed, and if necessary, issued, lies on the persons vested with this power
to stop work.
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62. In the present case, the lack of information appears to be one reason why the
Ng Seng Yoong, the QP(ST) did not stop work. This has been extensively
discussed in the context of his liability under the Building Control Act.
63. The Temporary Works Professional Engineer, Paul Broome, testified before the
Committee that he “still would not have stopped work in the Type M3 area at
that time”. In his view, close monitoring and block excavation were intended
contingency measures at the M3 area. In respect of block excavation, PB
conceded that it was “not necessarily good practice” that an entire area the size
of 8 strut bays (S333-S 340, 10th level) were left unstrutted on 19 April 2004.
But he claimed that safety considerations were complied with by the close
monitoring of the strutting system. However, there were numerous occasions
when inclinometer readings were not taken for the Type M3 area; critically on 18
and 19 April 2004. Monitoring was poor and woeful, and did not even come
near to qualifying as “close monitoring”.
64. Hence, the basis and justification for work not to be stopped at Type M3 was
flawed. Conditions set upon which the continuation of work is contingent upon
must be strictly and rigidly adhered to and their implementation monitored by
the relevant personnel at the top of the hierarchy. When the need arises, such
conditions should be reassessed by such personnel, jointly and collectively
where necessary.
65. In this regard, Mr. Rajan Krishnan testified that there was currently “no formal
structure” or “established forum” for the PE and QP to meet. It is left to the QP
to hold his own meetings. This is an example of a shortcoming that must be
addressed for future projects.
66. It is not disputed by any party that safety is paramount. This was an often heard
expression in the course of this Inquiry. And implied in the very notion of safety
is that works must be stopped based on sound engineering judgment in
appropriate and necessary circumstances. It must be emphasised that the
relevant personnel at the top end of the chain of command must regard the stop
work order as an exercisable and realistic option and must ensure that a proper
chain of command and reporting structure exist to facilitate a proper flow of
information from the site. Failing this, the power to stop work will be nothing
more than empty words existing only on paper.
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7.4 SAFETY ERROR IN BACK ANALYSES
67. The back analysis has far reaching safety implications. It is the means by which
the safety of works could be assessed upon the breach of trigger or design
levels for instrumentation readings. It is inextricably linked to whether work on
site continues or not. As a prediction of future expected forces and movement
of the diaphragm walls, it is also crucial for an accurate assessment of the
continued safety and stability of the temporary works.
68. The integrity of a back analysis is critical to safety, and is dependent on the
basic assumptions that it would be done properly, honestly and in good faith.
As soon as the back analysis departs from its basic objective of safety
assessment and degenerates into a curve fitting exercise for the purpose of
justifying the continuation of work, it would have transformed from a benign tool
to a treacherous contrivance.
69. The Committee has elsewhere in the Report commented extensively on the
various back analyses in C824. There is no necessity to traverse the same
ground, save as to point out that the curve fitting exercise of BA2-Type M3 had
led to a continuation of work on site which ultimately resulted in the catastrophic
collapse of the temporary works which killed four people, injured three others
and subjected countless others to risk of lives and personal injuries. BA2-Type
M3 was not only a dangerous tool, but a lethal one as such. It was the
penultimate safety error in C824.
7.5 SAFETY ERROR IN DUAL APPOINTMENTS
70. The independence of the QP (ST) is essential to avoid situations of conflict of

interest so that building works can be constructed with proper and impartial
supervision. The regulatory philosophy recognizes the importance of the
independence of the QP (ST). This may be seen in the 2003 amendment to the
Building Control Act, which came into effect on 1 January 2004. The
amendment provided that the QP (ST) cannot be a partner, officer or employee
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of the builder or any of the builder’s associates in projects that require checks
by accredited checkers.
71. While the amendment seeks to ensure that the QP (ST) is independent of the
builder, there is no corresponding provision to ensure that the QP (ST) is
independent of the client. Yet, as the experience in C824 shows, the practice of
appointing the QP (ST) from within the ranks of the client may put the QP (ST)
in a position of conflict and dangerously erode the effectiveness of the check-
and-balance role the QP (ST). It is a safety lapse.
72. Ng Seng Yong was both the QP (ST) and Project Director in C824. It was his
duty as the Project Director to ensure that the project was completed on time
and within budget. A delay in the completion of the contract would create
scheduling problems for the LTA and for him personally. Apart from cost
implication, there was also the need to meet the expectations of the public. The
following evidence is apposite:
Q. When we talk about delay, the impact of delay, there would be several
forms of impact. I will name two of them. One possibly could be the
issue of cost, extra expense would be incurred if there is any delay;
would I be right?
A. That is right. Yes.
Q. The other would be of course the expectations of the public. Certain

announcements had been made as to when the project was expected to
be completed, so any delay would have a public interest factor; would I
be correct?
A. That is right.
Q. Would I also be correct to say that LTA being a public body, the interests
of the public would be one major concern when you implement the
projects?
A. That is correct. Public is always our – we always put emphasis on the
public, yes.
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Q. Would it also be fair to say that therefore it really would be important to

you to ensure that the project was completed in time and delivered to the
public as promised?
A. Yes.
73. Understandably, the responsibility falling on NSY’s shoulders, as the LTA

Project Director for C824, was enormous. The Project Director was always
faced with considerations of speed and cost. These considerations, however,
could conflict with considerations for safety. Although the Project Director was
also concerned with safety management as part of his overall responsibility, it
would be dangerous to equate this with the mental framework of the QP (ST),
whose paramount consideration should always be safety. Rules of conflict of
interest exist because of the recognition of human fallibility. The conflicting
interests and obligations arising from such dual appointment would make it
difficult for any appointment holder to discharge his duties effectively. This is
amply illustrated in the following incidents.
74. In a letter dated 20 October 2003 written by NSY in his capacity as the QP (ST)
to the BCU following the incident at Launch Shaft 2, he sought to assure the
BCU that there was no problem with the temporary works at the Nicoll Highway
Station when he knew in fact that there were concerns with the design and
adequacy of the temporary works at the Nicoll Highway Station and other areas
of the project. NSY wanted to assure the BCU that there would be no problem
going forward with the remaining major excavation at the Nicoll Highway
Station. He admitted, in his oral evidence, that he was concerned that the BCU
might ask him to stop work on site if he had been open with them:
Q. Why did you not say in your letter of 20th October that there was an
incident, we have checked the area is safe, but going forward for the
NCH Station is major, we are asking them to review and we will report to
you further after that?
A. It could have been that way.
Q. I beg your pardon? What do you mean by that?

A. It could have been that way, if we to write to BCU to say that we are also
reviewing the other part of the Nicoll Highway.
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Q. But it was not that way, as reflected in this letter?

A. That is right, yes.
Q. May I suggest to you that perhaps one of your concerns at that point in
time was that as you had been open with the BCU about your concerns,
they may have asked you to stop work on site.
A. Yes.
75. This startling admission revealed NSY’s state of mind when he wrote the letter:
Although he was reporting to the BCU in his capacity as the QP (ST), it would
seem that he was actually operating within the mental framework of his
alternate role of Project Director.
76. In another instance in February 2004, there were internal meetings within the
LTA to assess the impact of all the CCL1 and CCL2 civil contract delays on
contract C830. ‘Hot spots’ were identified for individual contracts and were
presented to the senior management during these meetings. The areas
identified as ‘hot spots’ meant that there was lack of progress. For C824, the
probable delay in the handing over the TSA (temporary staging area), the
completion of the cut-and-cover tunnels to Nicoll Highway Station and the Nicoll
Highway Station were identified as hot spots. As a result, the progress of these
areas became a matter of great concern for the C824 project team led by NSY.
The minutes of a management meeting of 27 February 2004 showed NSY to
have told his project team as follows:
“PD pointed out that the progress at C&C2 area was critical and it might
affect the handing over of that area to C830. C824 had informed that
one of the constraints was to excavate the site in ‘blocks’ in order to
maintain the required excavation profile. PD requested the C824 project
team to review the excavation profile so that the excavation works could
be expedited.”
77. NSY was aware at that time that the block excavation was one of the
contingency measures that NLCJV had proposed and agreed to by the design
management team. The block excavation was a safety measure against over
excavation. Despite knowing that, NSY wanted the project team to consider
reducing the number of excavation blocks to expedite. The reduction of the
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Safety
number of excavation blocks would mean that a larger, longer area would be
excavated before the struts were put in.
78. Pursuant to NSY’s direction, the project team suggested to NLCJV to revise and
reduce the number of excavation blocks to expedite the excavation works.
NLCJV however was not prepared to reduce the excavation blocks, preferring
instead to monitor and observe the current excavation before making any
revision.
79. Although NSY explained in his oral evidence that he was not asking NLCJV to
reduce the blocks blindly, the fact remains that he was greatly concerned with
the progress of the works and was contemplating a reduction in the number of
excavation blocks, even though block excavation was a safety measure. This
incident highlighted yet again the danger of conflict of interest, where
operational considerations weighing in the mind of the Project Director could
insidiously affect his judgment as the QP (ST).
80. The importance of the independence of the QP (ST) cannot be

overemphasised. It must be safeguarded if the institution is to remain robust,
effective and vigilant.
81. It would be advisable for the LTA to consider appointing an independent QP

(ST) from outside the organisation, even though this is not strictly required
under the current regulatory regime. There is also a need for the LTA to review
its current practice of dual appointment to identify potential areas of conflict of
interest and to take such measures as to avoid or reduce the conflict. The
practice of appointing the same person as the Project Director and the QP (ST)
for the same project, as happened in C824, should be strongly discouraged, as
this would give rise to a serious safety lapse.
7.6 FURTHER UNSAFE ACTS, UNSAFE CONDITIONS AND UNSAFE

ATTITUDES
82. Accidents are often the direct results of unsafe acts, unsafe conditions and
unsafe attitudes. Some examples in C824 are given below:
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(a) Failure of QP(ST) and PE to discharge their duties properly.
(b) No interaction between the QP (ST) and PE.
(c) Failure of NLCJV to carry out a proper investigation of the cause of the
buckling of walers.
(d) Lack of urgency, safety instinct and plain indifference on the part of
some officers of the LTA and NLCJV. Examples:
(i) Wong Hon Peng (‘WHP’), as LTA’s Project Manager for C824,
was the highest ranking officer on site for the LTA. As the Project
Manager, he was responsible for both the safety and quality of
the works on site. The evidence however suggests that he was
prepared to compromise safety to avoid any costs implications to
LTA. This is clear from the chain of emails concerning the
proposal for a temporary decking over the M3 area to facilitate
C830 coming onto the site to start work. WHP was prepared to
over-ride Shirely Sivakumaran’s safety concerns if such concerns
would result in claims to the LTA. He admitted at the Inquiry that
he had a callous and irresponsible attitude, as can be seen here:
Q. Shirley is raising a very serious concern about safety, is she

not?
A. Yes, I agree.
Q. Your response to this very serious concern about safety is

the adequacy of the Dwall, design of the steel and
protection to 66 kV is C824's problem. That is what you
say, is it not, in your reply, Mr. Wong?
A. Yes.
Q. Mr Wong, would you not agree that the attitude you

expressed in this e-mail, where you say the adequacy of
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the Dwall is C824's problem, and you tell Shirley not to

impose a constraint arising from her safety concerns, is an
utterly callous and irresponsible attitude?
A. Yes, I agree.
(ii) WHP knew about the serious problems on site. He had been
warned of the excessive deflections at M3 and that the retaining
wall was at the limit of its capacity. Yet he was prepared to allow
work to continue, as clearly seen here:
Q. On 16th April, you receive an e-mail where you are told the
capacity of the M3 Dwall is at its limit. You know,
obviously, that it cannot exceed that capacity without there
being a collapse. You must have taken this very seriously;
is that right?
A. I should have taken it very seriously.
Q. But you did not, did you?

A. (Pause.) Why you say I did not take it seriously?
Q. What did you do after you saw this? Did you give
instructions to your project team to stop the excavation at
M3?
A. No.
Q. Did you raise it with Mr Ng Seng Yong?

A. No.
Q. Did you raise it with anybody?

A. No.
Q. Now do you agree that you did not take it seriously, even
though you should have done so?
A. It was oversight. I was preoccupied with some other things.
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Q. It was an oversight. That is the best you can do, Mr Wong.

An oversight, and four days later you have a collapse in
which people died. Right, Mr Wong?
A. The responsibility of the collapse also lies with the contractor.
Q. That is actually very revealing, Mr Wong, very revealing

indeed. And it comes back to the middle portion of this e-
mail. For you, it really does not matter what has happened,
as long as the contractor has endorsed, and particularly the
PE has endorsed; is that right?
A. The PE has the primary responsibility to ensure the safety
of the --
Q. Based on your evidence, Mr Wong, only the PE has the

responsibility?
A. We are guided by the PE, this endorsement.
Q. So even if the LTA believes that the capacity of the Dwall is

at its limit, as long as the PE is okay to proceed, just
proceed; that is your attitude? Yes, Mr Wong? That is your
attitude? You revealed it just now.
A. You can say that.
Q. With that, the LTA expects the PE to hang, and the LTA to
have no responsibility, with that kind of attitude; is that
right?
A. The PE has the primary responsibility.
(iii) NSY, the QP (ST), wrote to the BCU on 20 October 2003 to re-
assure the BCU about the temporary works design when clearly
there were serious concerns about Method A at that point in time.
According to NSY, he had consulted WHP on the letter before
sending it out to the BCU. WHP admitted at the Inquiry that it
would be dishonest to withhold the information from the BCU but
claimed he could not recall whether NSY had consulted him.
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(iv) The LTA Design Team’s request to purchase a copy of the Plaxis
software (which cost $5,000) was rejected, even though this
would have enabled the design team to conduct more thorough
design checks. In an email titled “Re : A Humble Request”, LTA
Design Manager Joshua Ong states:
“The use of Plaxis needs to be better understood

so that it can be more effectively used in the
future. I’m still trying to beg or borrow Plaxis to
facilitate our study… On this account, I appeal to
you to reconsider the decision on the purchase of
Plaxis.”
According to the evidence of Joshua Ong,
“For me, since October 03, I was anxious to get someone

in-house to run the Plaxis based on the total stress
parameters. Unfortunately, the waiting period to use the
only copy of the software in the Engineering Division was
too long. A request to purchase a new copy was also not
acceded to. When I was eventually loaned a copy in early
January 2004 for a limited time, I could not find a full time
engineer to help me run the analysis. Hence, in between
meetings and off office time, I personally tried an analysis
using total stress parameters. However, with my limited
knowledge on the use of the software and limited time
available, I was only able to get a brief grasp of output
results at some stages of the excavation.”
(v) LTA had a system to monitor the instrumentation readings and

the system relied on Michael Eng. It is clear that Michael was
very inexperienced and overwhelmed with work. He was so busy
with his other responsibilities that he did not realise that
instrumentation readings were not taken during a two-week
period from 10-25 March 2004.
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(vi) The conduct of NLCJV’s officers, in particular, Shun Sugawara,

Paul Broome and Kazuo Shimada, has been extensively
discussed in the preceding chapter on Criminal Liability in this
Report.
(e) Over excavation and deviation from block excavation practice.
(f) Insufficient gangway and stairways, as can be seen in the following

evidence:
Evidence of Construction worker Ganapathi Gurunatha
Q. So you would have to alternate between C-channels and support

beams in making your escape?
A. Yes. I can continuously use the support beam, but it will take
more time because I have to go up and down the beam.
Q. But there was no continuous gangway of sorts that would allow

you to run horizontally across the area?
A. No.
THE CHAIRMAN: How long did it take you to escape?

A. About 10 minutes.
Evidence of Kori Site Manager Lee Yeng Tat
THE CHAIRMAN: Did you insist, for example, that they provide
gangways to lower levels for your workers?
A. No.
THE CHAIRMAN: Why is that?

A. Because the workers were at the excavation, the lowest level,
excavation area, the lowest level. So they would go directly to
the staircase area.
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THE CHAIRMAN: Even when the thing collapses, when the thing falls
on them?
A. Yes.
THE CHAIRMAN: Do you know how your workers escaped from the
tunnel pit?
A. They were doing works at the 9th level. There was no access
route at the 9th level, from what I know.
THE CHAIRMAN: So you are saying that there is no need for

gangways?
A. There is a need.
THE CHAIRMAN: Then why was it not installed?

A. Because of the urgent nature of the works.
(g) Lack of emergency preparedness. A number of workers on site were

not familiar with emergency evacuation procedures. Examples:
Evidence of Construction worker Liu Erxiao
Q. Nobody approached you? Do I take it that nobody approached

you, nobody forewarned you about something happening at the
site?
A. That is so.
Q. Following from what you say, nobody told you to evacuate?

A. No.
Q. Did you see any safety officers -- by the way, do you know who
the safety officer is at the site?
A. The person who was wearing blue helmet was the safety officer.
Q. Did you see him at the site on the day in question?

A. I saw him in the morning.
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Q. What time?
A. Some time between 9 am and 10 am.
Q. Has the safety officer ever briefed you about evacuation from the
site in the event of an accident?
A. Yes.
THE CHAIRMAN: Do you remember the details?
A. No.
THE CHAIRMAN: You do not remember the details about how to

behave, what to do in the event of an accident?
A. No.
Evidence of Safety Officer Roslee Bin Sutrisno
THE CHAIRMAN: Now that the accident has happened, what are some
of your own thoughts about how we can improve the situation better?
A. Is it respective to the public, your Honour?
THE CHAIRMAN: Whether it is for the work site or for the public, you
must draw from lessons from this accident, right?
THE CHAIRMAN: What have you learnt as a safety officer?

A. As a safety officer, the lesson that I -- with reference to at the
collapse area and our own workers, we will improve on our
frequency of our evacuation exercise. That is one way that we
believe will help to improve the awareness of the workers in the
event of an emergency. And the next thing, what I will suggest is
that we will improve -- also increase the number of accesses,
improve on our access, which I feel -- and we will have to study.
(h) Emergency siren was blocked by hoarding. Again, the evidence was as
follows:
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Evidence of Site Supervisor Ramadoss
THE CHAIRMAN: Did you not have an opportunity to press the horn?
A. There was no button to press at the place where I was, sir.
THE CHAIRMAN: No, did you have an opportunity to do that, to press

the horn? You were already on the surface.
A. I did not get the opportunity to do so, sir.
THE CHAIRMAN: Why?

A. At one part, it had collapsed and the other part, there was some
restriction because there were hoardings done, sir, to divert
grout. That is closer to the Nicoll Highway, sir.
THE CHAIRMAN: You mean the horn was behind the hoarding?
A. That is correct, sir.
Evidence of Safety Officer Roslee Sutrisno
THE CHAIRMAN: What other things can we establish?

A. The other thing that we can improve is that all this while, we are
depending our sirens, on the electrical type of sirens, so we
might consider to use a mechanical type which are other means
other than depend on electrical; in the event of any power failure,
we will still be able to activate our alarm. That is another
consideration that we would like to consider, your Honour.
(j) No Safety Plan in place relative to the public, as conveyed by the Safety Officer
as follows:
THE CHAIRMAN: Mr Roslee, tell me whether there is any safety plan in

place relative to the public.
A. Relative to the public, your Honour? No, your Honour.
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THE CHAIRMAN: You were not required or that was not necessary?
A. From my best knowledge, not required from – not necessary,
your Honour, because for the public safety, near our work site,
we display a direction sign board, a warning sign board to warn
them about our work and what is the activity that we carry out,
whether there is any vehicle movement.
….
THE CHAIRMAN: In the event there was a collapse, who actually
stopped the traffic?
A. In the event of the collapse, when we -- when we arrived to the
scene, all the vehicles were already stopped.
THE CHAIRMAN: By whom? Do you know?

A. So from what I know from my site people, some of whom are near at
the scene, tried to assist and stop the vehicles.
THE CHAIRMAN: It was not any one of your safety officers?
A. No, at that moment, most of us are not near the locations, as I

was at the office and my safety supervisor, Mr Neo, was also at
the Nicoll Highway Stations. When we arrived to the scenes,
most other vehicles were already stopped at the middle of the
Nicoll Highway.
(j) Lack of awareness of the Safety Department. Again we quote the

evidence of the Safety Officer:
THE CHAIRMAN: Your safety officer is always on site?

THE CHAIRMAN: On 20th April?

THE CHAIRMAN: In the afternoon, about 1 o'clock onwards?

A. Yes. My safety supervisor, they are on site from 1 o'clock.
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THE CHAIRMAN: There were no anxieties about what was happening

on the work site from that time onwards?
A. No, your Honour.
THE CHAIRMAN: At 2 o'clock?

A. No, your Honour.
THE CHAIRMAN: 3 o'clock?

A. No.
THE CHAIRMAN: When it collapsed?

7.7 SITE PROBLEMS
83. Apart from the safety errors in C824, there were also a number of site problems
from March 2003 to April 2004.
(1) Table 7.1 - Excavation works at CC1 that resulted in the tilting of Ophir Flyover
Date Area Description
10 March 2003 Type B Tilltmeter reading exceeded design level
12 March 2003 Type B : Tilltmeter reading creeping towards trigger level. Ophir
flyover tilting towards the excavation.
Ophir
Flyover According to Paul Broome – Type B had exceeded
Abutment design level during excavation
(2) Table 7.2 - Excavation at CC1 that resulted in deflection of the Type C wall beyond
design value
30 July 2003 Type C I-2 reached design level
BLS I-79 hit trigger level
I-2 and I-55 reached design level
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Safety
(3) Table 7.3 - Settlement and Wall Deflection at Boulevard Siding / Launching Shaft 2
(Type W and Y areas)
5 August 2003 Launch Ground settlement

Shaft 2
(near
Kallang
Cricket field
areas)
5 August 2003 Boulevard Collapse of the fill and some significant deflection of the
Siding diaphragm wall
5 August 2003 Cricket field Crack of about 20mm wide and 150m long observed on
the field
11 Feb 2004 Launch Movement of bored piles near south wall about 900mm &
Shaft 2 300mm
14 Apr 2004 Cricket A crack was found at the Cricket Field, measuring 45m x
Field 10mm
15 Apr 2004 Type W1b Inclinometer reading increased to about 500 mm
16 Apr 2004 Type W1b Distressed strut, S509 had buckled with a sharp sound
(4) Table 7.4 - Excavation at CC1 that resulted in deflection of the Type C wall beyond
design value
3 July 2003 Type C I-53 exceeded trigger level on 3 July 2003

A waler at the 4th level was found distorted on site
30 Aug 2003 Type C I-53 had reached design level of 87mm on 30 Aug 2003
20 Sep 2003 Type C Cracks to diaphragm wall
24 Sep 2003 Between Base heave at utility gap

Type - B
and C
End Sep 2003 CC1 Strut S90 exceeded design level
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Safety
(5) Table 7.5 - Excavation at Nicoll Highway Station that resulted in Settlement at
Driveway at Furniture Mall
6 Dec 2003 Furniture Settlement at driveway of Furniture Mall. Settlement

Mall drive- was 45mm and excavation was at 3rd level.
way
End Dec 2003 Furniture Complaint on sinking driveway

Mall drive-
way
(6) Table 7.6 - Numerous Complaints from residents about cracks in their buildings
along Beach Road and Arab Street
Dec 2003 The Plaza Cracks observed at Merlin Health Center & Singsation
KTV Lounge
(Block E)
7 Jan 2004 The Plaza Report of damage to Merlin Health Centre and
Singsation KTV Lounge
(Block E)
28 Jan 2004 The Plaza Management Committee for The Plaza wrote to LTA
reporting rapid development of cracks to the building
(Block E)
6 Mar 2004 The Plaza Tenants in Block E including UOB reported of damage
to their unit (in Block E)
(Block E)
9 March 2004 Shop Extensive cracking of up to 4mm wide while some units
Houses at were found to have some serious cracking
Bussorah
Settlement of the shop houses
street and
Arab street
5 Apr 2004 243-249 Cracks on wall, column along the façade, staircases
Beach Rd; and internal
7A, 11A Haji
Lane;
11A, 12, 23
& 23A
Bussorah
Street
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Safety
(7) Table 7.7 - Cracks at the joint of XOB and CC2 (Type K)
12 July 2003 Cross-over Soil slided into excavation and pushed king post and
box “thung” sound was heard from S262.
Kingpost was slightly bent
12 July 2003 Type – I, J Slope failure
26 Dec 2003 Type K I-63 hit trigger level
7 Jan 2004 Type K I-63 exceeded design level
30 Jan 2004 Type K Gap in diaphragm wall
Early Feb 2004 Type K Gap reopen in diaphragm wall
9 Feb 2004 Type K & M2 Exceeded design levels
11 Feb 2004 Type K & L Gap between Type K & L
11 Feb 2004 Type K & L & Exceeded design and trigger level
LS2
(8) Table 7.8 - Deflections of Type M2 Wall exceeded the Design Level
31 Dec 2003 Type M2 I-102 exceeded design level at 4th level of excavation
Mid Jan 2004 Type M2 I-102 exceeded design level at 4th level of excavation by
20%
9 Feb 2004 Type K & M2 Exceeded design levels
(9) Table 7.9 - Deflections of Type M3 Wall exceeded the Design Level
23 Feb 2004 Type M3 I-65 exceeded design level
Mid March 2004 Type D1 Buckling of Struts at 7th Level at NCH Station
Between 10-25 Type M3 I-104 breached revised design level (252mm)

March 2004
With a factor of 0.85, I-104 breached 1st revised design
level on 30 Mar 2004
19 Apr 2004 Type M3 66kV was settling
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Safety
(10) Table 7.10 - Several Complaints received from residents of Golden Mile Towers
over settlement issues
March 2004 Golden Mile Settlement of 11mm at columns in basement of Golden

Tower Mile Tower
(11) Table 7.11 - Deflections of the Diaphragm Wall in the Type D1a area
26 Feb 2004 Type D1 Three inclinometer readings triggered
20 Mar 2004 I-88 on south 447mm lateral movement

station
(12) Table 7.12 - Water Seepage at Type I Diaphragm Wall
19 Apr 2004 Type I Water and fine white sand seepage through joints
between diaphragm wall panels 107 and 108. Leakage
was near formation level.
84. These problems show the need for a safety information system that collects,
intelligently and reasonably analyses and disseminates information from
incidents and near-misses as well as from regular production checks on the
systems vital signs which impact safety. All of these activities can be said to
make up an informed culture. An informed culture in a real sense is a safety
culture. The above incidents show that an informed culture was lacking.
7.8 THE 20 APRIL 2004 INCIDENT
85. The ingrained lack of safety sensitivity and culture of the main contractor and its
sub-contractors was manifested with dire consequences on the day of the
collapse, 20 April 2004. We have meticulously set out the 20 April 2004
incident in this Report. The lack of safety culture and the resultant safety errors
were evident in the following manner:
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Safety
(a) Construction and design defects resulted in the buckling of several strut
walers
(b) There were no contingency and residual risks plans. Residual risks
necessitate pre-planned emergency procedures to ensure that the
workers in the excavation area on that day were protected.
(c) There was a continuation of a bureaucratic safety culture by NLCJV.
(d) Judgment errors by the key operators including supervising engineers.
(e) The operators took personal injury risks. In construction, personal injury
risk is always high.
(f) There were already manifestly ominous signs in the earlier part of the 20
April 2004.
(g) There were pressures to carry on with the construction without sensitive
regard for defensive precautionary measures.
(h) There was no demonstrable high level consciousness or commitment to

safety by the senior and key operators that day, including consultation
on safety.
(i) The measures taken for the buckled strut walers were only reactive.
The remedial measures were performed at some speed with no idea of
their effectiveness and likely consequences. Pre-requisites for adequate
safety control are: (a) a sensitive multichannel feedback system, and (b)
the ability to respond rapidly and effectively to actual or anticipated
changes in the safety realm. This was not present on the day.
(j) The progressive buckling accompanied by the “thung” sounds clearly

signaled a system under great distress. It showed a complex safety and
remedial task was required, which required a high level of
comprehension and skill. This appreciation was not present.
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Safety
(k) There was inadequate appreciation of the likelihood of total collapse.
(l) There was also limited appreciation of what level of residual risk was
considered tolerable.
(m) There was inadequate appreciation of the following safety defences by

the key engineers and operators in that:
- They had no understanding and awareness of the local hazards
- There was no guidance on how to operate safely
- There were inadequate alarms and warnings of imminent danger
- They did not interpose safety barriers between the visible

hazards and the safe state of works
- There were no means of escape and rescue should the remedial

works fail
(n) There was confusion on the ground arising as to whose responsibility it

was to carry out the remedial works
(o) Controls were implemented but ineffective
(p) Failures of reactive monitoring to learn from near misses that would
have revealed ineffective controls
(q) No sensitivity analysis to enable the relative importance of differing risks

to be judged
(r) Inability to turn the risk assessment into effective risk control and risk
management measures
(s) Failure to consider how to discover emerging trends and ensure that
recovery through remedial action can be taken within the time available
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Safety
7.9 CONCLUSION AND RECOMMENDATIONS
86. The real question is not what safety costs us, but what it saves. The Safety
Recommendations have been expressed by public and private practitioners in
this area. The COI sets this out. These views accord with the view of the COI.
87. In a Ministerial Statement made on 10 March 2005, the Honourable Minister for
Manpower, Dr Ng Eng Hen said:
“To achieve higher safety standards will require a change of mindsets of

all stakeholders to be intolerant of safety lapses. Accidents can only be
prevented if all individuals have embedded deep within them a safety
culture.”
“Government cannot improve safety standards alone. We have to

involve all stakeholders and adopt new principles to accelerate change.
We need an overhaul of our present system to ingrain good safety habits
in all individuals at the workplace – from top management to the last
worker.”
88. Simply moving in the direction of greater safety is not difficult. The challenge lies
in sustaining these improvements. To hold such a position against the strong
countervailing currents requires a steadfast resolve and commitment by all
concerned. As Dr Ng has rightly pointed out,
“…industry itself must be required to take greater ownership of safety

outcomes. They must self-regulate to reduce the loss of life and injury to
workers under their charge.”
89. The Honourable Minister for National Development, Mr Mah Bow Tan, at the
parliamentary sitting on 19 May 2004, said:
“Let me assure this House that we will do whatever is necessary to

enhance construction safety to prevent mishaps and loss of lives. We
will strengthen the existing regulatory framework where it is found
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Safety
wanting. But let me emphasize that a strong regulatory framework alone

is not enough. I agree that construction safety is a responsibility of all
parties and stakeholders involved – Government, developers,
professionals, contractors, sub-contractors, and workers.”
90. Emphasing the importance for all parties to have prime regard to safety, Mr Mah
said:
“The public has placed significant trust and confidence on building

professionals to ensure safe construction practice. Good ethical
practices and high moral standards should prevail over commercial
interest. Architects, engineers and contractors must perform their
professional and contractual duties with due care and diligence, with
prime regard to safety. If they do not, they must face the full force of the
law.”
91. The importance of safety was also emphasized by the Honourable Minister for
Transport, Mr Yeo Cheow Tong, at the 24th May 2004 30th International
Tunneling Association General Assembly, as follows:
“…while we can step up our safety measures and increase the number
of checks, when an incident of such a magnitude like Nicoll Highway
occurs, it is not just physical infrastructure that needs to be reinstated,
but also public confidence in excavation works. I can assure you that in
Singapore, we will spare no effort to restore this public confidence, as
well as to continue to explore new and efficient, yet safe ways to carry
out our excavation works.”
92. Mr Yeo Guat Kwang, Member of Parliament for Aljunied GRC and Director,
NTUC, at the 10 March 2005 parliamentary sitting spoke of the labour
movement’s call for more stringent safety measures:
“The labour movement has always been advocating for a better and safe
workplace for all. As union leaders, we strongly support and welcome
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Safety
the MOM’s proposed new framework. For those in the last one or two
decades, we have put in all efforts to try to make incremental
improvement in occupational health and safety in Singapore. It is time
for us to improve further and do more to ensure that we all enjoy a safe
workplace. If errant employers continue to risk the lives of workers by
ignoring our repeated calls for more stringent safety measures, then
MOM has to seriously consider what we need to do more to ensure that
the employers carry out their duty.”
93. Understandably, the media which followed the Inquiry closely was also
concerned with safety. This is how Lianhe Zaobao expressed its concern on 13
April 2005 in its recommendation to the COI:
“Though it is only natural for defending parties to want to exonerate

themselves as much as possible from any liabilities, a general
impression shared by journalists was that none of the parties involved in
the Nicoll Highway collapse were forthcoming enough to accept any part
of the responsibility for what happened on April 20 2004.
Safety appears to be the furthest thing from their minds. What had
transpired during the inquiry had been a startling catalogue of errors,
embarrassing accounts of incompetence, complacency and possible
negligence.
Very often, we see banners and boards put up at construction sites,

reminding workers the importance of safety. It makes one wonder: was
there ever a safety culture within the involved parties in the first place?
When expressed principles do not correspond with the observed actions,
are the claims of “safety first” by different witnesses just cosmetic
claims?
Further issues can be derived from above. Was the checking system
(between parties and within it) sufficiently robust? If it was robustly
designed, does it have any implementation or enforcement problems?
Were the job scopes of various project personnel realistically and clearly
defined?
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Safety
Ultimately, regardless of the answers to all the above questions, it is

obvious that the onus is on every individual. It has to do with their
professional competence, their sense of responsibility and their moral
courage to point out what is wrong.
The mistakes committed that caused Nicoll Highway to collapse should

not be allowed to happen again.”
94. The entirety of Berita Harian recommendations was on safety, as follows:
“All temporary construction works, should be classified as permanent

works thus requiring the same building standards as their permanent
cousins. This is to ensure that adequate safety measures and tolerance
levels are adhered to.
Government agencies should not consider a good tender as being the

least costly. They should also consider the safety factor of the
construction process to be used.
Government agencies should also understand that to ensure safety,

construction work must not be rushed along, thus a guideline that sets
out a realistic construction time-table, which takes into account safety
checks and procedures should be drafted by the relevant authorities.
There must be different levels of monitoring of construction works, which

includes the owner of the project.”
95. The Straits Times dedicated its 15 September 2004 Editorial to “Timely call on
Safety”. It reiterated in another Editorial on 17 March 2005 with “Safety as an
instinct”. In its 14 April 2005 recommendation to the COI, the tenor of the
Straits Times’ view was to balance safety goals and production goals. The
assumption of safety must underlie the following comments:
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Safety
“But it seems so clear to many readers who called in since the tragedy
that there is surely a need to look beyond the physical causes or at least
to see if there are any.”
“At the worksite, is there any room for price or deadline adjustments?
Are workers and supervisors given ample opportunity to be well-rested?
Is there a guideline on overtime, even if it is voluntary? How about
access to counseling for stressed out personnel”
“Changing or unforeseen site conditions may be another huge spanner

in the works that can upset earlier cost analyses. Obviously, if a main
contractor, sub-contractor or consultant has little room for manoeuvre
when cost and other conditions vary, the consequence can be much
more dire than popping floor tiles or leaky bathroom ceilings.”
96. NTUC made several specific and pointed recommendations5 which we agree.
These are:
1) Review training and education framework

We believe that high standard of occupational health and safety will be
achieved with appropriate arrangement to facilitate active worker
involvement.
There is need to equip workers with the relevant information and

knowledge to encourage greater worker involvement in identifying and
tackling work-related health and safety problems. The people best
placed to make workplaces safe from hazard and harm are the workers
and managerial who work in them. They do this best with greater
willingness to share concerns about potential problems.
A review of the training and education framework by the MOM in

consultation with employers and unions would ensure that workers have
full knowledge of the hazards at work and the safe way of carrying out
5
NTUC’s response dated 20 April 2005 from Mr Yeo Guat Kwang, Director of Quality Worklife.
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Safety
their duties, particularly in specialised works such as deep excavation

works.
2) Empowerment of workers
In general, employees do not talk about their safety and health problem
with their employer if they are potentially worked threatening. After
equipping workers with the skills and knowledge to identify and prevent
hazards at the workplace, they should be empowered to be able to
request for relevant expertise to remove or eliminate the hazards at
work.
We suggest that a dedicated national hotline be set up to encourage

greater participation of workers in highlighting OSH concerns.
3) Strengthen accountabilities of all stakeholders

In the existing Safety Management System, the OHS professionals were
supposed to ensure that work should not continue until risks have been
reduced. The project owner as well as the contractor must have
ownership of this responsibility as well. We suggest greater emphasis
be placed to strengthen the commitment, culture, competence, co-
ordination and consultation in safety management plans and
performance by top management and specialist personnel.
We suggest that accountabilities of all parties who create the risks be

clearly established and tougher penalties be imposed on those
responsible for safety infringements. This would drive home the
message that safety must be the responsibility of everyone in the whole
value chain.
A safety culture should never take second place in the minds of

employers and workers. Employers and management staff at all levels
must show concern, and have the interests of our workers at heart.
The main responsibility for a safe working environment lies with the
employer. The employer’s financial consideration should not influence
the acceptable safety standard of the working environment. We would
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Safety
like to call for the government to increase maximum penalties for health
and safety offences against errant employers.
4) Enhance Regulatory Enforcement

We wish to see enforcement improved and be more proactive. MOM
Inspectorate should look deeper into the work systems and be prepared
to work closely with management and union to identify potential hazards,
so as to develop responsive action plans to eliminate risk occurrences at
work.
97. In a site visit to ExxonMobil Chemicals (Singapore Chemical Plant), the COI
learnt about their safety philosophy and principles. The COI was also briefed on
ExxonMobil’s commitment to continuous improvement in their safety
performance to achieve their goal of “Nobody Gets Hurt”. The COI also had a
discussion with the senior officials of the ExxonMobil Singapore Employees
Union. Safety is a Key Performance Indicator (KPI) in their management and
employee performance assessment and reward. This has been an accepted
culture in ExxonMobil. The COI noticed that both management and the trade
union officials were enthusiastic with the use of this KPI. As a management
tool, safety as a KPI is not commonly practised in the construction industry. The
COI is of the view that such a KPI culture should be introduced in the
construction industry particularly in deep excavation projects.
98. Other stakeholders as listed below and experts appointed by the parties have
given useful suggestions on safety which are in the Appendix A-17.
1) Association of Consulting Engineers Singapore (ACES)

2) Berita Harian / Berita Minggu
3) General Insurance Association of Singapore (GIAS)
4) Housing & Development Board (HDB)
5) Institution of Engineers Singapore (IES)
6) Jurong Town Corporation (JTC)
7) Lianhe Zaobao
8) Nanyang Technological University (NTU)
9) National Trade Union Congress ( NTUC)
10) Professional Engineers Board Singapore (PEB)
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Safety
11) Singapore Civil Defence Force (SCDF)

12) Singapore Contractors Association Ltd (SCAL)
13) Singapore Institution of Safety Officers (SISO)
14) Singapore Institute of Surveyors and Valuers (SISV)
15) Singapore Productivity and Standards Board (SPRING)
16) The Straits Times
17) Tunneling and Underground Construction Society, Singapore (TUCSS)
99. All these demonstrate that the stakeholders and public bodies are, rightly,
intolerant of safety errors and the need for a strong safety culture.
100. The Government, in its response to the COI’s Interim Report, assured the public
that immediate actions have been taken to address safety risks in on-going
construction sites. A MND-MOM Joint Construction Safety Review Committee
has been set up to review practices along the entire value chain of the
construction industry that could impact safety in construction projects.
101. In summary, the main safety lessons and recommendations (which

include the COI’s Interim Report and the Government’s Response to the
COI’s Interim Report) are as follows:
(1) Temporary works were not given the same respect as permanent works.
The Government, in its Response to the COI’s Interim Report, agreed
that the structural safety of temporary works is as important as that of
permanent works and should be designed according to established
codes and checked by competent persons.
(2) There must be a strong safety and safety culture in all construction
projects. The Government’s Response to the COI’s Interim Report
agreed that safety systems and a pervasive culture of safety
consciousness that permeates every level from developers down to least
skilled worker must be in place. In this regard, MOM will be introducing
the Workplace Safety and Health Act to address safety and health
issues through the life-cycle of a building including the design,
construction and even maintenance of the building. The implementation
of the proposed legislation would augment the safety management
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Safety
systems and enhance the overall management of safety and health in

the construction worksites.
(3) Safety policies must be clear and unambiguous. As disclosed in the

Government’s Response to the COI’s Interim Report, MOM had
conducted inspection of the deep excavation sites under LTA. MOM’s
inspections revealed that while emergency evacuation plans were
established and drills conducted by site personnel, clear guidelines on
what type of situations call for an immediate evacuation from the
worksite had not been established. MOM has addressed this. LTA has
also taken the initiative to require its contractors to provide better access
and evacuation facilities at a number of sites.
(4) Safety culture is concerned with individual and group values, attitudes,
competencies and patterns of behavior that determine the commitment
to and the style and proficiency of an organisation’s approach to health
and safety.
(5) There must be an effective safety management system to minimise risk

to employees and others. Such a system needs to be within a sound
legislative framework which the MOM is proposing. In such a safety
management system there is a need to consider human factors,
including the culture, attitude and belief within the project organisation.
Those managing the safety process must understand how human failure
happens, what can be done to prevent it, how it can be detected and
corrected and how to recover.
(6) Safety measures need to be continuously watched, worried about, tuned

and adjusted. The cultural mindset must focus on particular risk relative
to apparent economy and the need to meet construction schedules.
(7) There is a need to guard against an overly simplistic analysis of

incidents and blame only operators. High level errors can play a major
part in creating the circumstances where others make errors at the
workplace.
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Safety
(8) An effective safety management system must recognise two kinds of

accidents: those that happen to individuals and those that happen to
organisations. Organisations must then have defensive systems that
adequately deal with hazard identification, risk avoidance and reduction,
and the control of remaining residual risk.
(9) Instrument based performance monitoring system must be effective,

adequately resourced and maintained. There is a need to integrate
information from the various instruments and to relate the crucial
information to what is happening on the worksite, as well as the quality
of each of the elements in the construction. Management system and
resource must be capable of collecting, inputting, processing and
interpreting the large amount of instrumentation data.
We note from the Government’s Response to the COI’s Interim Report

that the LTA has re-examined its project management and process and
has set up a risk register for all sites, covering safety, design and
construction matters. Site staff are now required to immediately report
instrumentation readings which are above the trigger values to a
committee comprising senior and project staff for review and follow-up
action.
We also note that LTA will also directly handle the appointment of
specialist instrumentation contractors for its projects instead of leaving
this to the contractor so as to have better control over the overall
process and the monitoring of construction works. LTA has also
instituted quality control of the instrumentation sub-contractors for its on-
going projects. This requires contractors to have a quality plan in
relation to their scope of works, manpower qualifications, training, as
well as instruments and calibration.
(10) Unsatisfactory trends must not only be identified sufficiently early, but
doggedly monitored and the subsequent risks appreciated to enable
corrective steps to be taken. A regular supply of accurate and up-to-
date monitoring information is essential. Its correct and timely
interpretation, including comparisons between predicted and actual
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Safety
design values and the trend line from the history of the movements of
the temporary walls, is critical to safety.
(11) The chain of command within the project organisation must be well
established and communication must be effective. There must be
ownership of problems, exercise of sound and timely engineering
judgment toward the resolution of problems. Only then will such
engineering judgment be effectively carried out. There must be a proper
chain of command and reporting structure to facilitate the proper flow of
information from the site. The Government, in its Response to the COI’s
Interim Report, agreed that there should be greater clarity in the working
relationships between the various project parties in complex projects.
MND/BCA will look into the issue together with MOM.
(12) Stop work order is an essential and critical element as a viable safety
measure in the construction process. Stop work order must be an
exercisable and realistic option.
(13) The integrity of a back analysis is critical to safety, and is dependent on

the basic assumptions that it would be done properly, honestly and in
good faith. As soon as the back analysis departs from its basic objective
of safety assessment and degenerates into a curve fitting exercise for
the purpose of justifying the continuation of work, it would have been
transformed from a benign tool to a treacherous contrivance.
(14) The independence of the QP (ST) is essential to avoid situations of

conflict of interest so that building works can be constructed with proper
and impartial supervision. In this regard, it would be advisable for the
LTA to consider appointing an independent QP (ST) from outside the
organisation. There is also a need for the LTA to review its current
practice of dual appointments to identify potential areas of conflict of
interest and to take such measures as to avoid or reduce the conflict.
The practice of appointing the same person as the Project Director and
the QP (ST) for the same project, as happened in C824, should be
strongly discouraged. We note from the Government’s Response to the
COI’s Interim Report that the LTA is engaging independent consultant
engineers to carry out checks on the design of temporary works for all
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Safety
their projects. These engineers will ensure that all procedures and
checks have been carried out, and that works are constructed according
to design. BCA is also exploring various options to strengthen the
regulatory framework for temporary works pertaining to deep excavation.
(15) The QP (ST) must have sufficient time to carry out his checks seriously
and thoroughly. The criticality of the role of the QP (ST) must be
recognized and implemented. The check-and-balance role of the QP
(ST) must not be forsaken for cost consideration and reduced to a mere
perfunctory function.
(16) Accidents are often the direct result of unsafe acts, unsafe conditions
and unsafe attitudes.
(17) It is important to have a safety information system that collects;

intelligently and reasonably analyses; and disseminates information from
incidents and near-misses.
(19) In a deep excavation works, it is useful to evaluate the project on the

basis of its risk profile.
(20) The three principles to ingrain safety awareness are:
• To reduce risk at source by requiring all stakeholders to minimise or

eliminate risks which they create. This requires assessment to
identify the source of risks at the work place, the action to reduce
these risks and the parties responsible for doing so.
• Industry itself must be required to take greater ownership of safety

outcomes. They must self regulate to reduce the loss of lives and
injuries to workers under their charge.
• Accidents can be prevented through higher penalties for poor safety

management.
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Safety
(21) Safety must be achieved within a sound legislative framework. An

effective goal setting legislative framework (currently being proposed by
MOM) is a step in the right direction. Such legislation should require
project owners and builders to manage their activities and anticipate and
prevent circumstances that might result in unsafe worksites practices,
injuries or ill health.
(22) Good ethical practices and high moral standards should prevail over
commercial interests. Accordingly, architects, engineers and contractors
must perform their professional and contractual duties with due care and
diligence with prime regard to safety.
(23) There is always a continuing need for public confidence in safety in deep
excavation works.
(24) The safety training and educational framework should be reviewed6 to

equip management and workers with relevant information and
knowledge of work hazards and safe work practices, in particular for
specialised works such as deep excavation works and to empower
workers to ‘whistle blow’ on unsafe workplace practices, as well as to
remove or eliminate work hazards. Safety should be incorporated as a
Key Performance Indicator (‘KPI’) in both management and workers’
performance assessment and reward.
(25) It is essential that we get enough of our local workers, particularly in

deep excavation works, to develop core skills. These workers can then
be supplemented with foreign workers.
6
See written recommendation dated 20 April 2005 by Mr Yeo Guat Kwang, Director of Quality Worklife,
NTUC.
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Safety

6. Human error is not confined to operators, but can occur throughout an

7.1 SAFETY ERROR IN INSTRUMENTATION AND MONITORING

instrumentation Schedule, testified that he had “reminded Suresh, L&M and

22. When piezometer GW(V)24 malfunctioned in February 2004, there was no

(a) Instrument-based performance monitoring systems must be effective,

(b) There is a need to integrate information from the various instruments

25. Management systems and resources capable of collecting, inputting, processing

7.2 CHAIN OF COMMAND AND LACK OF CLARITY AND INEFFECTIVE

28. Increased complexity in an organisation, compounded by interfaces with others,

29. Communication problems fall into three categories:

(a) System failures in which the necessary channels of communication do

Problems in Chain of Command between Main Contractor and Sub-contractor

Q. No, at the point when Ramadoss agreed to try to help.

This is a classic example of a category (a) communication problem above.

Q. You were not told at all?

Q. None of them informed you?

THE CHAIRMAN: Your system failed?

THE CHAIRMAN: You failed your system?

Problems in the LTA Chain of Command

circumstances, such as when inclinometers readings exceeded deign levels.

Q. By "Design Manager", do you mean Mr Joshua Ong?

Q. Sorry, you did not?

Q. Ms Shirley, I am exploring with you the system in place. It appears that

Q. But it was unexplored at that point in time?

42. The Design Team of LTA was not informed of :

Problems in the NLCJV Chain of Command

51. The problems in the chain of command and ineffective communication,

“… What I can say is as designers, we could not investigate because

7.3 NO STOP WORK ORDER

(b) In December 2003, excessive wall deflections were recorded at Type K

(c) In January 2004, excessive wall deflections recorded at Type M2 with

(d) In February 2004, excessive wall deflections recorded at Type M3 with

(e) In March – April 2004, excessive ground settlement led to cracking of

(i) On 17-19 April 2004, leakages in diaphragm wall at Type K resulted in

A. If there is any web buckling or stiffener buckling, if these buckling are

A. Yes, your Honour.

7.4 SAFETY ERROR IN BACK ANALYSES

7.5 SAFETY ERROR IN DUAL APPOINTMENTS

70. The independence of the QP (ST) is essential to avoid situations of conflict of

Q. The other would be of course the expectations of the public. Certain

Q. Would it also be fair to say that therefore it really would be important to

73. Understandably, the responsibility falling on NSY’s shoulders, as the LTA

Q. I beg your pardon? What do you mean by that?

Q. But it was not that way, as reflected in this letter?

80. The importance of the independence of the QP (ST) cannot be

81. It would be advisable for the LTA to consider appointing an independent QP

7.6 FURTHER UNSAFE ACTS, UNSAFE CONDITIONS AND UNSAFE

(a) Failure of QP(ST) and PE to discharge their duties properly.

(b) No interaction between the QP (ST) and PE.

Q. Shirley is raising a very serious concern about safety, is she

Q. Your response to this very serious concern about safety is

Q. Mr Wong, would you not agree that the attitude you

the Dwall is C824's problem, and you tell Shirley not to

Q. But you did not, did you?

Q. Did you raise it with Mr Ng Seng Yong?

Q. Did you raise it with anybody?

Q. It was an oversight. That is the best you can do, Mr Wong.

Q. That is actually very revealing, Mr Wong, very revealing

Q. Based on your evidence, Mr Wong, only the PE has the

Q. So even if the LTA believes that the capacity of the Dwall is

“The use of Plaxis needs to be better understood

According to the evidence of Joshua Ong,