|
Press
Releases
17
May 2005
GOVERNMENT
RESPONSE TO THE FINAL REPORT OF THE COMMITTEE OF INQUIRY INTO
THE NICOLL HIGHWAY COLLAPSE
The
final report of the Committee of Inquiry into the collapse
of Nicoll Highway was submitted on 11th May 2005. The Government
thanks Senior District Judge Richard Magnus, Dr Teh Cee Ing
and Er Lau Joo Ming for their conscientious efforts in unravelling
the complex chain of events that led to this accident. Faced
with the monumental task of piecing together information from
193 [1]
witnesses and volumes of documents, they performed their duty
with professionalism and dedication, and elucidated clearly
the crucial errors and persons responsible for the collapse
of Nicoll Highway.
2
The Report lays bare a string of lamentable errors relating
to design, construction, monitoring and supervision, regulatory
weakness and the lack of defensive systems and emergency planning.
The COI also highlights human and organisational failures
which contributed to the collapse. In the COI’s words:
“Warnings of the approaching collapse were present from
an early stage but these were not taken seriously.”
[2] It concludes that “the death of four
persons was the direct result of the collapse” [3]
and that “[t]he Nicoll Highway collapse could have been
prevented.” [4]
[1]
173 witnesses of fact and 20 experts.
[2]
COI Report, Executive Summary, page vi (4th paragraph)
[3]
COI Report, page 202 para 83.
[4]
COI Report, executive summary, page vii (4th paragraph).
3
The Government accepts in full the findings and recommendations
of the COI. The Report has concluded that Nishimatsu Construction
Co. Ltd breached its statutory duties under the Factories
Act to ensure that places of work be of sound construction
and properly maintained, and as far as reasonably practicable,
made safe for any persons working there. It has also found
that these contraventions were facilitated by the neglect
of three of its officers - the project director, project co-ordinator
and design manager. In relation to the project co-ordinator
and design manager, the COI has noted alternative contraventions
under s 304A of the Penal Code, for causing death by a rash
or negligent act. In addition, the COI has found that the
Qualified Person appointed by LTA under the Building Control
Act to supervise the building works breached his statutory
duties of due diligence and reasonable care in monitoring
the excavation works, assessing the readings and instructing
the builder to take corrective action. Such failures are completely
unacceptable. The Report has been submitted to the Attorney-General
to consider if criminal proceedings ought to be instituted.
The Ministries will also examine if more severe penalties
are warranted for companies and persons who have wantonly
flouted safety laws that are meant to protect workers and
prevent destruction to property.
4
Immediately after the Nicoll Highway collapse and following
the Interim Report, the various agencies had acted to ensure
the safety of other Circle Line and deep excavation projects.
But beyond this, the Government decided to review the construction
safety regulatory framework, and also address the systemic
weaknesses identified in the COI Interim Report. In May 2004,
a Joint MND-MOM Review Committee (JRC) was convened to examine
safety standards in the construction industry. The Report
of the JRC, which also covers the recommendations of the COI
Final Report, was released today.
5 The JRC reviewed the entire life-cycle of a construction
project from design through procurement to construction, and
proposed fundamental changes to improve safety systems. These
include centralising building control functions at the Building
and Construction Authority to preserve the integrity of the
system and maintain public accountability; strengthening disciplinary
actions against professionals; incorporating safety records
in tenders for public sector projects; tightening regulation
for deep excavation projects and temporary works; and requiring
licensing for specialist contractors. The Government recognises
that incremental changes will not result in a quantum improvement
of safety standards, and so has decided to implement these
comprehensive reforms involving multiple Ministries.
6
Earlier this year, MOM had also announced a major reform of
its occupational safety and health framework to raise safety
standards and embed a safety culture at the workplace. By
the end of this year, MOM will pass a new Workplace Safety
and Health Act which will mandate risk assessments for workplaces,
raise safety training requirements for workers and enhance
accountability and penalties for poor safety management. Ministers
for National Development and Transport will also subsequently
highlight measures their respective agencies will take. The
Annex summarises the key
weaknesses identified by the COI and the corresponding measures
to address them.
7
The combined efforts of Ministries must ultimately increase
safety awareness and inculcate safe practices to reduce injuries
and lives lost due to workplace accidents. However, all stakeholders
must take ownership to improve safety outcomes. Employers
must invest time and resources to build a safety culture within
their companies. The Government will reward employers who
achieve high standards, and penalise those with poor safety
records. Professional associations and industry partners must
maintain standards and uphold the integrity of their members.
Workers should not be allowed to perform tasks until they
possess the competency and awareness to do them safely. Training
and accreditation will be stepped-up, so that workers are
better able to appreciate risks and alert the relevant authorities
of unsafe work practices. Regulatory agencies within Government
must work in a concerted manner to reduce injuries and fatalities.
We must engage all stakeholders effectively if we are to achieve
the safety targets.
8
Some changes can be made quickly. But changing mindsets to
internalise safety into our daily work habits will require
continuing efforts, even after the memory of the Nicoll Highway
collapse has faded. Every individual involved in the work
process from regulator, builder, professional, manager to
the last worker has to accept responsibility for the work
environment, for his own safety and health, and for those
under his charge. The Government is confident that if we each
do our part to maintain safety standards, we will make Singapore
one of the safest places in the world to work.
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Annex
Summary
of COI Recommendations and Corresponding Measures
| COI
Recommendation |
Corresponding
Measures |
|
(1)
Effective Risk Management
(Executive
Summary pg xiv and xv)
(a)
Accidents must be prevented through effective risk management.
The potential for major accidents whether due to the
construction process or deficiencies in design must
be recognised and expeditiously controlled.
(b)
It is inappropriate to leave the control of risk wholly
to contractors.
(c)
Risk assessment should also consider major hazard events,
which could affect the public and not simply risks to
individuals at work. Identified risks can be communicated
to others by preparing and making available the risk
register.The owner, builder and operators must honour
and respect their own risk analysis, assessment, and
reports.
(d)
New and unfamiliar technologies require particular review,
as do major projects with the potential to cause significant
harm to workers or the public. |
Reform
of OSH framework
Contractors
will be required to have a comprehensive safety and
health plan for every worksite, which includes a structured
risk assessment, names of persons responsible for safety
for each aspect of work, and contingency planning. The
risk assessment must also address the potential risk/impact
of the work to members of public. There must be emphasis
on translation of the plan into ground action.
Developers
as a key stakeholder will in future also be required
to ensure that the designers they appoint also assess
and address any major design risks.
MND-MOM
JRC
Requirement
for OSH management certification (OHSAS18001 standards)
will be extended from tier ‘A’ contractors
only to all contractors in BCA’s Contractors Registry
System. OHSAS18001 provides a framework for risk identification,
avoidance, mitigation, monitoring and control. It will
also require the collation of safety information for
the purpose of preventing potential accidents.
LTA
LTA
has set up comprehensive risk registers for each site.
The risk register identifies the hazards/risks involved
in each construction activity with associated risk index
and describes the risk mitigation measures to be undertaken
to bring the residual risks to an acceptable level.
The risk register, as a live document, is monitored
and updated at weekly risk assessment meetings at the
project/site level with the contractor. Risk owners,
from contractor to LTA, are tasked to implement the
mitigation measures, monitor and close-out the risks
accordingly. A non-conformance procedure and ‘defects’
register system have also been set up. The procedure
requires the project team to monitor, track and close
out works that are not in compliance with the specification
and the design drawings for the temporary works. Work
will not be allowed to proceed unless the safety critical
non-conformances have been closed out.
At
the macro level, the Project Directors/Senior Project
Managers and the Design Managers will apprise senior
management on a weekly basis of any safety concerns
arising from the instrumentation readings either breaching
or likely to breach the predetermined instrumentation
review levels. Senior management may direct that additional
mitigation measures be implemented where necessary. |
(2)
Managing Uncertainties and Quality
(Executive
Summary, pg xvi)
(a)
There is a need for a high quality management, which
recognises the presence of uncertainties and fosters
a generative culture where responsibilities are shared,
mistakes are quickly learned and conflicts are well
managed. Roles and responsibilities must be clearly
established.
(b)
Owner’s and builder’s management must seek
a balance between production pressures and quality and
safety goals.
(c)
There must be honest and regular consultations between
the owners and the builder, the QP(ST) and the PE, and
the owner’s and the builder’s designers.
(d)
An effective management is one, which demonstrates the
effective commitment from the senior management level
and involves everyone at work including their safety
representatives. |
Reform
of OSH framework
Duties
will be prescribed for all stakeholders (e.g. owners,
employers, designers, suppliers) in the proposed Workplace
Safety and Health Act to strengthen accountability.
Contractors’
safety and health plans must consider the flow of safety
information among parties. Their risk assessments must
clearly set out the triggers for stopping work.
MND-MOM
JRC
Safety
considerations must be integrated into the established
planning and coordinating processes at the worksite.
This could be done through the Site Safety Coordinating
Committee or other existing Committees.
Contractors
to adopt a ‘Permit to Work’ system for identified
classes of hazardous work. This ensures a systematic
assessment of safe work environment and conditions is
undertaken prior to execution, which clarifies and removes
any uncertainties.
Tougher
penalties for professionals (PEs and architects) who
do not perform their duties with due diligence. The
maximum period of suspension for moderate contraventions
should be raised from 1 to 2 years. The period before
a registered professional can apply for reinstatement
to the register after being struck off should be raised
from 2 to 3 years. The PEB and BOA shall also be given
flexibility to impose a combination of disciplinary
actions, rather than be restricted to only one action.
LTA
On
each contract/project there are weekly design review
and instrumentation and monitoring meetings. The procedure
has now been standardised at all the sites where Project
Managers, Design Managers, and the contractors’
design / geotechnical staff as well as the PE(TW) and
QP(S) are required to attend the meetings. Issues related
to design and construction matters are discussed and
work will not be allowed to proceed till all parties
are satisfied on safety and quality.
Design
and quality shortcomings as well as instrumentation
breaches of alert and work suspension levels are to
be immediately reported to higher management.
LTA
has in place a formal Corporate Safety Organisation.
LTA will reinforce the safety message through its Corporate
Safety Committee (CSC) chaired by its Chief Executive
and comprising senior management, who are responsible
for setting and driving Corporate safety policies. Safety
implementation monitoring and control are undertaken
by the Project Safety Committees chaired by the respective
Project Directors. (See attached chart) LTA has also
developed safety management processes to ensure the
"Safe to Build" and "Safe to Use"
aspects of our projects. |
(3)
Management and Monitoring of Geotechnical Instrumentation
and Data
(Executive
Summary, pg xvi)
(a)
There should be appropriate instruments deployed. There
should be proper use and management of the collated
data. The monitoring system must determine the qualitative
and the quantitative data sufficient to meet all design
and construction needs. In particular, monitoring during
construction must be meticulously undertaken with an
eye to safety. |
MND-MOM
JRC
Licensing will be introduced for specialist contractors
engaged in critical geotechnical work such as soil investigation
and instrumentation.
PE
(Geotec) will be responsible for instrumentation and
monitoring for TERS in deep excavations, including data
interpretation and specification of review trigger levels.
AC
(Geotec) will have to conduct field reviews and site
inspections, including review of data interpretation
and trigger levels.
It
will be mandatory for PE (Geotec) and contractor’s
Technical Controller to stop works when the relevant
trigger levels are exceeded.
Critical
information, which has impact on safety, could be disseminated
through the proposed Site Safety Coordinating Committee
or other existing Committees.
LTA
For
new projects, LTA will be engaging specialist instrumentation
contractors to carry out the instrumentation and monitoring
works.
For
ongoing projects, where there are existing contracts,
LTA has instituted quality control of the instrumentation
contractors. |
(4)
Robustness of Design
(Executive
Summary, pg xvii)
(a)
A robust design is essential. This robustness is provided
by identifying the hazards and checking that the proposed
design can adequately withstand them. The design should
also have sufficient redundancy to prevent a catastrophic
collapse in the event of a failure of any particular
element.
(b)
The design must have built-in factors to cater for material
deficiencies and construction imperfections. |
MND-MOM
JRC
A
technical committee has been set up under SPRING Singapore
to develop a code for deep excavation works in Singapore.
The code will cover the design issues highlighted by
the COI (i.e. design robustness and redundancy, design
review, time sensitivity, and guidelines and procedures
for multi-prop level retaining wall).
PE
(Geotec) and AC (Geotec) will be required to comply
with requirements of SPRING’s excavation code.
Pending the finalisation of this code, BCA has issued
an advisory note covering these guidelines.
Construction
of all temporary structures will have to be supervised
and certified by a PE before being subjected to its
intended loading. The PE for the permanent works should
be consulted where appropriate. |
|
(5)
Design Review and Independent Check
(Executive
Summary, pg xvii)
(a)
A design review must be carried out where there is structural
distress or when instrumentation readings show deviation
or aberrations. This requires a planned program at the
inception of the project.
(b)
Independent checks should be undertaken in all temporary
works for deep excavation as is the current practice
for permanent works.
|
MND-MOM
JRC
AC
(Geotec) will be required to undertake independent review
of design.
AC
(Geotec) has to meet prescribed requirements in terms
of qualifications and experience in geotechnical works.
AC
(Geotec) has to be appointed independently by the owner
and not the contractor, as with the AC in permanent
works.
LTA
LTA
has engaged external independent consultants/ QP(Supervision)
to check the design of temporary works prepared by the
contractor.
To
ensure the independence of the PE(Temporary Works),
LTA will require that the PE(Temporary Works) engaged
by the contractor shall not be an employee of the contractor
or have financial interest in the firm.
|
(6)
Numerical Modelling in Geotechnical Design
(Executive
Summary, pg xvii)
(a)
Numerical analysis should supplement and not supplant
sound engineering judgement and practice.
(b)
Those who perform geotechnical numerical analysis must
have a fundamental knowledge of soil mechanics and a
clear understanding of numerical modelling. |
MND-MOM
JRC
SPRING’s
Excavation Code will also address the use of numerical
modelling.
Design
and supervision of TERS will have to be done by PE (Geotec)
and AC (Geotec). These are persons who will have specialist
knowledge and experience of geotechnical engineering.
Courses
will be developed and incorporated as part of the requirements
under the existing Continuing Professional Development
(CPD) Programme for PEs. The PEB will work with BCA,
MOM and industry to accredit these courses. The PEs
will be required by the relevant authorities to show
proof that they have attended accredited courses on
the critical design codes and software, which they have
used in their submissions to authorities for approval.
LTA
Training
for staff to increase their professional and job competencies
will be stepped up. Engineers will be sent for specialised
training to develop core & functional competencies.
Internal sharing sessions are regularly conducted. LTA
has been working in partnership with ACES for technical
talks to be given to our staff and industry professionals,
including joint conferences. |
(7)
Jet Grout Piling (JGP)
(Executive
Summary, pg xviii)
(a)
There must be a rigorous review to secure a rational
understanding of the behaviour of JGP with respect to
its function in the designated structure, ground conditions,
the construction process and other known experience.
(b)
It would be useful to tap into the available body of
knowledge such as in the learned journals, codes of
practice and published guides. |
MND-MOM
JRC
SPRING’s
Excavation Code will also cover the use of JGP in deep
excavations.Pending finalisation of the code, BCA has
issued an advisory note recommending that JGP be restricted
to ground strengthening/soil improvement works, but
not used as a compressive strutting system in TERS.
This is in view of the uncertainties involved.
LTA
LTA
has reviewed its specifications and tightened the requirements
on quality control during production of the JGP and
in the verification of the quality of the JGP by rigorous
testing in accordance with BS EN 12716:2001. |
(8)
Codes and Specifications
(Executive
Summary, pg xviii)
(a)
Relevant Codes for deep excavation and strutting system
should be developed. Specifications to improve the performance
of the design and construction process should be specific. |
MND-MOM
JRC
SPRING’s
Excavation Code being developed will address this issue. |
(9)
Stop Work
(Executive
Summary, pg xx)
(a)
Stop work order must be an exercisable and realistic
option.(Executive Summary, pg xiv)
(b)
Workers should be empowered to ‘whistle blow’
on unsafe workplace practices, as well as remove or
eliminate work hazards. |
Reform
of OSH framework
Powers
of safety officers will be enhanced.
MOM
will provide a hotline for workers to call if they think
that their work conditions are unsafe and warrants a
stop work.
MOM
will conduct an outreach programme to educate workers
on their basic rights, including their right to a safe
working environment.
LTA
LTA
has issued a checklist to its staff to provide greater
clarity on when the stop-work orders should be issued
i.e. where there is serious concern about unsafe practices,
for example:
- Major works carried out without approved Method Statements;
- Breaches of instrumentation review limits;
- No clearance to proceed to next stage of work. |
(10)
Emergency Preparedness
(Executive
Summary, pg xviii)
(a)
Worksites should develop a contingency plan to address
all safety related emergencies. The plan should address
the various scenarios that could occur and spell out
the procedure to evacuate all affected workers. The
plan must be communicated to all staff. |
MOM
The
requirement for emergency plans already exists under
the Factories Act. Such plans should be frequently reviewed
to account for changes in the worksite. The shortcoming
lies in the activation of these plans when the situation
requires. MOM will work with SCDF and other relevant
agencies to strengthen this.
LTA
Better
access and evacuation facilities are provided at LTA
worksites.There are now regular drills in which workers
have to evacuate a site in less than 10 minutes. |
(11)
Competence of Professionals, Contractors and Sub-contractors
(Executive
Summary, pg xviii)
(a)
Personnel engaged in specialist functions need to have
the minimum knowledge, qualification, and experience.
Further, as part of their professionalism, specialist
sub-contractors must go beyond mere contractual compliance
and alert the employer of any deficiency in design,
drawing and method of construction which impacts safety.
(Executive
Summary, pg xiv)
(b)
There is a need to nurture and sustain a core group
of technically skilled and competent local workers. |
MND-MOM
JRC
Require
specialised PE (Geotec) and AC (Geotec) in design and
supervision of TERS in deeper excavations.
General
building contractors and critical specialist contractors
to be licensed.
Specification
of number, qualifications and experience of supervision
teams for structural works.
All
supervisors to attend mandatory safety training.
Contractors
must engage an accredited inspection firm to survey
the fabrication process for welded steel structures
The
feasibility of a Tradesmen Registration Scheme is being
explored. |
(12)
Contract and Tender Evaluation System
(Executive
Summary, pg xix)
A
strict weightage system should form part of the contract
and tender evaluation system. The weightage system should
include non-technical and non-commercial attributes
such as safety records and culture of the bidder, and
its core or corporate competency.
Such
a weightage system should apply even if the tenderer
is a joint venture or a consortium. |
MND-MOM
JRC
Use
of current price and quality (including safety) attributes
in tender evaluations will be formalised for public
sector projects through the Price-Quality Method (PQM).
This is recommended as the preferred method of procurement
for public works.
LTA
For
all its major projects, LTA adopts a prequalification
process to evaluate, assess and pre-qualify potential
bidders based on their technical competencies shown
in past projects and their safety performance track
record. A more structured safety dimension will be added
for future tender evaluation in line with the proposed
Price Quality Method (PQM). |
(13)
Safety Culture
(Executive
Summary, pg xxi)
(a)
There must be a continuous and demonstrable commitment
by management and workers, accompanied with a frank
and honest consultative approach, to ensuring safety
and health, from inception of design to execution of
the project. |
Reform
of OSH framework
Drive
change in safety culture through prescribed duties for
all stakeholders and requirement for comprehensive safety
and health plans and risk assessments.
Enforcement
will focus on systemic and cultural issues, rather than
physical lapses only.
MND-MOM
JRC
Extension
of requirement for OSH management certification from
tier ‘A’ contractors only to all contractors
in BCA’s Contractors Registry System.
LTA
LTA
will reinforce the “Safety First” culture.
It has implemented the Occupational Safety and Health
Management (OSHM) framework for its major projects since
July 2001. This requires that hazard identification
and risk assessment be carried out from the concept
design, detailed design to the construction stages of
the project life cycle.
LTA
also actively promotes safety for our staff as well
as contractors' staff, in the form of safety training,
workshops, as well as the Annual Safety Award Convention
(ASAC) to give recognition to parties who excel in safety
performance.
To
encourage and reward safety excellence, LTA has implemented
a performance scheme for new civil works contracts.
Contractors with good safety performance will be rewarded
an additional 0.5% of the contract sum, up to a maximum
of $1 million. Conversely, contractors with poor safety
performance may have a deduction of up to one-third
of the 1.5% of the contract value set aside, also subject
to a cap of $1 million. LTA will review this cap with
the view to raising it so as to further incentivise
safety at worksites. |
(14)
Chain of Command
(Executive
Summary, pg xii)
(a)
The chain of command has to be well established and
communication must be effective. |
Reform
of OSH framework
Duties
will be prescribed for all stakeholders (e.g. owners,
employers, designers, suppliers) in the proposed Workplace
Safety and Health Act to strengthen accountability.
This
will translate to clarity in the chain of command.
LTA
Weekly
design review and instrumentation and monitoring meetings
are held. These meetings are attended by the PE(TW),
QP(S) as well as the LTA and the Contractor’s
project and design staff. All areas of concern are elevated
to higher management of LTA. |
(15)
Independence of QP
(Executive
Summary, pg xii)
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 LTA to consider
appointing an independent QP(ST) from outside the organisation.
|
MND-MOM
JRC
Currently,
the BC Act prohibits the QP (Supervision) from being
associated with the builder or contractor, but not the
client or developer. The relationships between the QP
and the developer/client, as well as various parties
such as project managers, will be reviewed and addressed
(where necessary) by BCA in consultation with industry.
This is to uphold the independence of the QP (Supervision).
LTA
LTA
is phasing in the complete segregation of the QP(S)
role from that of the Project Director’s role
for all projects. It will expedite the process of engaging
external QPs for all its other major contracts and bring
about the necessary changes to the project management
structure by the end of July 2005. |
(16)
Building Control Functions
(Volume
1, pg 338)
The
Committee is reminded that the MND-MOM review on construction
safety will also review the delegation of building control
functions by BCA to the BCUs and to see how this relationship
can be improved. |
MND-MOM
JRC
Building
control functions should be centralised at BCA to remove
any doubts that BCU staff will undertake their work
with impartiality and independence. This will also maintain
public accountability and confidence in the regulatory
framework. |

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Last updated on 18 May 2006
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