This article, as well as the reply from MHA, appeared in TODAY quite some time back. Sze Yong had helped prepare it for posting here, but I've only just gotten around to publishing it. It should be read in light of my speech on security lapses and my OPQ on the sudden deaths of NSmen.
Where do we go from here?
Weekend • June 21, 2008
LAST Sunday night, Channel NewsAsia launched a fortnightly news show called Talking Point. The producers were kind enough to invite me to be a guest.
The show discussed last week’s incidents at two key Government ministries: The tragic deaths of two Singapore Armed Forces (SAF) servicemen during training and the escape of two men from the Subordinate Courts lock-up for a short while before being caught. We focused on three aspects: the flow of information, reactions of Singaporeans and complacency.
The police released the news of the escape nearly 12 hours after the incident. But the information in a press statement, released just past midnight, was very detailed. It went into some length about what really happened in the holding cell on June 11.
As for the reactions of the public, there was general agreement that there was great concern, mainly because the escape had happened barely four months after Mas Selamat’s break-out from the Internal Security Department detention centre at Whitley Road.
On the part of the Ministry of Defence (MINDEF), it had reacted quickly by not just telling Singaporeans about the deaths, but also acting swiftly in calling for an unprecedented three-day suspension of all training activities.
Still, it was the issue of complacency that occupied much attention during the show. Simply put, the question was: Had the Mas Selamat lesson been absorbed across the Home Team? In particular, has the rank-and-file on the ground sufficiently internalised the importance of their work?
A series of human errors was blamed for Mas Selamat’s escape. The latest case has also been blamed on human error, and Minister for Law and Second Minister for Home Affairs K Shanmugam told Singaporeans last Saturday that the risk of human risk cannot be completely eliminated.
But that is precisely why well-designed systems are so crucial: they should mitigate, or even prevent, human risk, if possible. The Subordinate Courts’ security system was audited in March and April. There will be another review to minimise the level of human error, and to strategically reconsider the flow of accused persons through the building.
This, then, raises the question of whether the earlier review had covered those aspects.
Ever since 911, Singaporeans have been reminded to be ever-vigilant; that we need to win every battle but the terrorists only need to win once. I believe that, if (touch wood) there is ever a successful terror attack due to human error, Singaporeans will wonder what is happening to our systems and our guardians of security.
When Parliament debated the findings of the Committee of Inquiry on Mas Selamat’s escape, Deputy Prime Minister and Minister for Home Affairs Wong Kan Seng rightly pointed out that “it would be stretching the argument too far” to say that “the whole Ministry and all the Home Team departments are complacent”.
But clearly, complacency existed at Whitley Road, as well as in the Subordinate Courts, at least up until last Wednesday.
In Mas Selamat’s case, the Government’s approach to accountability for errors was to discipline those who were personally responsible, as well as those with direct management over, or statutory responsibility for, the area in question. What the Ministry of Home Affairs needs to ask itself is, moving forward, whether this approach is sufficient to prevent another disaster.
In the same week, two SAF Servicemen died in as many days, while undergoing training. The SAF then suspended physical and endurance training across the military for three days. This suspension ended on Saturday, with the SAF determining that proper procedures are in place and being followed.
Some would wonder about the need for the unprecedented suspension. Was it an attempt to reassure Singaporeans that MINDEF takes these deaths very seriously? Was it to avoid the unthinkable tragedy of yet another training death?
Since the incident, some doctors in private practice have proposed more comprehensive screening of enlistees for heart conditions. A cardiologist has estimated that it would cost about $3 million to screen 10,000 recruits using treadmill tests and echocardiograms, or $5.7 million a year assuming an annual cohort of 19,000 recruits.
Other doctors have rejected such a step as unnecessary, citing high cost and the impossibility of completely eliminating such deaths. In other words, it is not cost-effective. Implicit in such a view is the belief that human life can be adequately quantified in monetary terms.
Sudden cardiac deaths are not new to the SAF, and yet no additional tests were introduced besides resting ECGs for all pre-enlistees in 2000. At the very minimum, MINDEF should conduct a trial project to ascertain whether the additional tests are indeed effective in detecting conditions that existing tests do not. If so, then there is a very valid question as to whether we should introduce the additional testing.
National Service is compulsory. It seems to me that if we as a society demand that all male Singaporeans perform NS, then the least we can do is to ensure that they are thoroughly screened for such potential heart conditions that are known to result in death, regardless of cost.
The writer is a Nominated Member of Parliament and corporate counsel,commenting in his personal capacity. He expresses his condolences to the families of the late 2LT Clifton Lam Jia Hao and REC Andrew Cheah Wei Siong.
The best of systems are not immune to human failures
Friday • June 27, 2008
Letter from TOH YONG CHUAN
Director (Corporate Relations)
Ministry of Home Affairs
I REFER to the commentary “Where do we go from here?” (June 21) by Mr Siew Kum Hong.
The incident at the Subordinate Court happened, as Mr Siew rightly pointed out, due to “human error”. Investigation of the incident indicated that the systems and established procedures were sound. But a few of the frontline officers concerned did not observe the procedures.
The security systems and procedures at the Subordinate Court were reviewed, tested and where applicable, upgraded. However, ultimately there is no human operator system that is not susceptible to human failure. This and the fact that the failures were individual human lapses do not diminish the seriousness of its occurrence and its consequences. However, it is misconceived to generalise that these human failures are reflective of systemic failure when the findings of the investigation, which explored this direction as well, do not support such a conclusion.
Mr Siew asserts that well-designed systems should mitigate, or even prevent, human risk, if possible. Indeed, sound systems lower the risk of failure and all security planners should pursue this end as far as is practicable.
However, all systems are inherently dated insofar as they are based on what its planner or designer knows at that point in time. And all systems have to be operated by individuals, who will have to be empowered to exercise judgment in some situations. Ironically, systems which minimise human judgment and discretion may appear hyper-efficient. But in fact, they face the serious risk of being blind-sided by a changing complex reality.
The ability of an operational system to adjust and overcome glitches and surprises beyond its designed parameters resides ultimately in the human operator. The key is to empower our officers and entrust them to do the right thing at the right time. This comes with some risk of occasional poor judgment. To mitigate this risk and the consequence of error, a key factor we seek to develop is the team’s ability to recover and respond when a lapse occurs.
In the incident at the Subordinate Court, the contingency response was swift and the recovery operations executed professionally. The two offenders were quickly detected and apprehended. The people and the recovery processes worked well.
It is noteworthy, that while SC/Cpl Donnie Lim should not have opened the cell door when giving water to the persons in custody, he also responded professionally and with personal courage. Notwithstanding the pain and injury of the assault he suffered, he picked himself up quickly, ran after the two escapees at the risk of further assault and raised the alert quickly.
The fact is that the human being remains both our weakest and strongest link in the frontline of any security system.
We must always guard against complacency even though we know there will never be zero failure on a permanent basis. To the best of our knowledge, no country or organisation has succeeded in achieving zero failure. Occasional individual lapses and failures will happen from time to time. The key is whether we will learn from such mistakes when they occur and evaluate if they are symptomatic of any deeper problem. We believe we will.
To generalise that the entire Home Team, which consists of many departments with different operational functions, is malfunctioning because of these incidents of specific individual failures does injustice to the commitment and effort of the thousands of regulars, NSmen and volunteers of the Home Team, in keeping Singapore safe and secure.
The low crime, drug abuse and recidivism rates that Singapore enjoy, are among the lowest in the world in comparison with similar foreign jurisdictions with their proportionately larger staffing ratios. This is not the product of work by thousands of men and women officers who are “switched off” or complacent.