A VITAL safety protection measure - where the speed limit on the affected track sector is set to 0 km/h before a work team is allowed on it, so that no train can enter on automated mode - was not applied on March 22, 2016, "directly causing" the accident that killed two SMRT staff.
In a press release on Monday morning, SMRT said it has completed its investigations into the fatal accident, following a review by an Accident Review Panel. The panel comprised members of the SMRT Board Risk Committee and three independent experts: one each from Keppel Corporation and Transport for London (which runs the London Underground), and a third who was formerly with Hong Kong's Mass Transit Railway Corporation.
Said SMRT: "Before a work team is allowed onto the track, protection measures must be applied. This includes code setting the speed limit on the affected track sector to 0 km/h so that no train can enter on automated mode, and deploying watchmen to look out for approaching trains and provide early warning to the work team.
"The Accident Review Panel determined that this vital safety protection measure was not applied and that the effectiveness of such protection before entry into the work site was not ensured as required under existing procedure, directly causing the accident. There were also other factors identified as areas for improvement, namely track access management controls, communication protocols and track vigilance by various parties.
"The Accident Review Panel has concluded that while existing safety protection mechanisms are adequate, and current operating procedures continue to be relevant and applicable, these can be improved for greater clarity and ease of ground implementation."
SMRT added that it has taken immediate steps to ensure stricter enforcement of procedures, strengthened system ownership and control across levels and work teams, and tightened supervision within teams to prevent a recurrence.
The report has been submitted to the Ministry of Manpower, Singapore Police Force and Land Transport Authority to assist with their statutory investigations.