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SINGAPORE: A coroner ruled that the death of an SMRT technical officer, who died after being struck by a rod that was thrown from a machine at Bishan Depot, was a disgrace.
Coroner Christopher Goh noted the steps that SMRT has taken since then to prevent future recurrences, and said such a scenario had not been anticipated before.
Muhammad Afiq Senawi, 30, was operating a hydraulic press machine in the rolling stock workshop, where the trains and their components are maintained, when the incident occurred on March 23 last year.
He was assigned to the station with a co-worker and they took turns operating the machine while the other person acted as an assistant.
Afiq’s friend went first without problems, and when Mr. Afiq pressed the piston of the machine, his friend asked him to stop when he noticed that the device was moving very slowly.
He thought something was stuck or had gone wrong, and Mr. Afiq agreed, lifting the piston slowly. His friend looked away and heard the piston working, followed by a loud “thump”.
Mr. Afiq was seen falling backwards and lying on his back in front of the machine, gasping for air. A hole had been created in a fence gate that was intended to keep people away from the machine, and a spacer rod that was initially inside the machine had been ejected.
Afiq was seen with blood coming out of his mouth and was taken to hospital, where doctors said a 5 kg object had flown in his face. The forensic court later heard that the spacer rod weighed 2.86 kg.
He died later that day from injuries to his face and chest. No foul play was found in his death.
OFFICIAL MOM TESTIFIES
An official from the Ministry of Manpower (MOM) testified that the machine was manufactured in 2015 and has a power of 100 tons, which is equivalent to a production of about 400 bars of maximum pressure.
When asked to quantify it, he said it was very difficult to make a comparison and said that it is basically “very high pressure.”
The hydraulic press machine was surrounded at the front by a metal fence made of wire mesh that was intended to prevent anyone from interfering with the machine’s operating area and to contain any components that could be thrown out.
MOM investigations revealed that when Afiq placed a component in the machine and operated the piston, he and his friend had forgotten to remove the old component that was still in the cavity. Due to the pressure build-up, the spacer rod was ejected.
The MOM officer said that both Mr. Afiq and his partner had been properly trained to operate the machine, but that certain details of the operating processes were not in the work instructions.
In particular, there were no instructions to make sure the cavity was empty before proceeding to the next step. While risk assessments had found that components could fly away, with fences as the solution, SMRT did not anticipate that the spacebar would be a strong projectile.
No such incidents had occurred in the more than two decades since the work processes were implemented in the 1980s, he said.
After the incident, MOM issued a work stoppage order and required SMRT to conduct a reassessment of the risks involved in the processes. The trucking company devised numerous steps to improve related service processes.
The machine has been completely redesigned, added the MOM official. Simpler names were given to the parts of the machine, while a locking interface for the piston and center bore was introduced. The bottom of the machine now has windows so operators can make sure it is empty before continuing.
There are now pressure valve regulators on the machines to allow only the proper pressure to be applied, he added.
The metal fence has also been redesigned and now covers both the front and rear of the machine, and a professional engineer was hired to examine the stiffness of the fence and its ability to withstand a certain force.
The coroner said that while SMRT had security measures in place, such a scenario did not appear to be foreseen. He said the company “on its merit” has taken steps to ensure such incidents are avoided in the future.
