A 44-year-old Malaysian was suffocated in an oxygen-deprived underwater chamber used to defuse animals before being slaughtered in a pig factory.
Mr. Hoe Chee Meng, a maintenance technician at a swine factory and native pork distributor in Primary Industries, commuted to Singapore every day for work.
A coroner determined that the fatality was a result of a work-related incident, which had, regrettably, have prevented Mr. Hoe from breaking the law governing entering and working in a restricted area.
WHAT HAPPENED
On Jul 18 last month, the carbon dioxide gem, which was part of the machine located at the company’s factory wall, broke down.
The device included a “ferris vehicle” system where animals in copper bars, known as gondolas, were lowered into an underground room filled with carbon monoxide.
The room was about 2.3m by 3m, and was around 3.8m serious. To help gondolas to spin in and out, the chamber’s leading was not completely enclosed.
The atmospheric carbon monoxide level in the room was monitored by a gas detection behind the driver’s work area, and the coroner’s findings stated that the supply to the chamber was controlled by a hand valve.
A hole in front of the technology, where a sign warned about the chamber’s confined space, allowed access to the underground chamber.
There was a security barrier switch on the back of the hole cover to prevent the machine from operating when the cover was empty, and the cover was secured with two bolts.
However, at the time of the accident, the safety interlock switch had reportedly been damaged, with the replacement in the midst of being connected and tested.
A man could enter the manhole by using a fixed vertical ladder and a safety cage that was installed at the opening.
According to investigations, the machinery lost power and broke down on the morning of Jul 18, 2023. The maintenance team immediately began fixing issues and continued to work until 5 p.m. when their shift was finished.
Four additional maintenance technicians started the work the following morning, and the team began opening the manhole cover around 11.30am, with the suspicion that the machinery malfunction could be brought on by faulty electrical wiring in the manhole cover safety interlock switch.
While one of the workers, Mr Kathiravan Narajan, was dismantling a bracket that secured the machinery door bearing, the bracket slipped and fell into the underground chamber.
Mr. Kathiravan promised to enter the room to retrieve the dropped bracket, but was instructed against doing so.
He made the decision to enter a surgical suite and apply a respirator that partially covered his face; this was not appropriate medical protection for entering oxygen-deficient confined spaces.
However, Mr Kathiravan felt overwhelmed just 32 seconds in and was helped out by his colleagues.
When Mr. Martin Ng Soo Leong, the maintenance and nbsp assistant manager, learned of this incident, he criticized Mr. Kathiravan for entering the chamber unintentionally and instructed the team to create a replacement bracket rather than attempt to retrieve the fallen one.
The workers were unable to locate a spare bracket, so they considered contacting Mr. Hoe because he had worked in machine maintenance for many years.
MR. HOE CALLED IN
Mr. Kathiravan spoke with Mr. Hoe, who was stationed at a different location and had not been a part of troubleshooting.
Mr. Hoe was aware that there was n’t a spare bracket nearby. Instead, he went to the machine, wanting to enter the manhole to retrieve the bracket.
Mr. Hoe informed Mr. Ng that he would enter the chamber to retrieve the dropped bracket when he received an N95 mask from the maintenance workshop at around 3.10pm.
Later, Mr. Ng claimed that Mr. Hoe had claimed that he had previously alleged that he had attempted to enter the manhole without issue and that he had done it numerous times before.
Mr Ng also said he asked Mr Hoe:” What if you die inside”?
He said Mr Hoe replied:” Die then die lor”.
Mr. Ng said he was unaware whether Mr. Hoe was making fun of people but that the company’s management had instructed him to behave more cunningly around employees, so he “unknowingly” followed Mr. Hoe to the manhole.
Mr. Hoe entered the chamber by putting on the mask. He began shivering. About 30 seconds after entering, he tried to climb back up the ladder to exit, but collapsed and fell back into the chamber, losing consciousness.
In an effort to wake up Mr. Hoe, Mr. Ng instructed the other workers to call for assistance and provide him with water.
Additionally, he hired workers to set up air blowers to circulate air in the room.
Soon after arriving at the scene, the Singapore Civil Defence Force extricated Mr. Hoe. He was taken to Ng Teng Fong General Hospital where he was declared dead the next day and unconscious.
The death was not the result of a purely natural disease process, but rather was suffocation in an oxygen-deprived environment.
The court was told that it was highly likely that Mr. Hoe entered the manhole with a significantly lower oxygen level, and that he died. He lost consciousness and collapsed.
The family lived in Johor Bahru, and Mr. Hoe and his wife, Madam How, had three children.
Mdm How claimed that her husband had only recently spoken to her about work matters since he began working for the company.
She raised questions in the inquiry, asking why her husband had not clearly stated his intention to work inside the manhole.
INVESTIGATIONS
According to investigations conducted by the Manpower Ministry, Mr. Hoe did not put in excessive hours in the workplace and was likely a result of work fatigue.
A gas sample at the bottom of the chamber, which MOM re-created to simulate gas measurement, revealed the lowest concentration of oxygen, confirming that residual carbon dioxide had settled closer to the chamber because it was heavier than atmospheric air.
The oxygen level at the bottom of the chamber near Mr Hoe’s breathing zone was 13.5 per cent, which was not within the safe range of 19.5 to 23.5 per cent oxygen as stipulated in the Workplace Safety and Health ( WSH) ( Confined Spaces ) Regulations.
A person exposed to an environment with an oxygen concentration between 12 and 14 percent would experience rapid pulse and breathing difficulties, according to the WSH Council’s technical advisory on working safely in confined spaces.
No harmful gases were found in the chamber despite the fact that toxic gases like carbon monoxide, hydrogen sulphide, and methane had been tested for.
After the accident, MOM conducted an inspection at the company and issued a stop-work order after observing non-compliance.
After the company implemented control measures to stop such an accident from occurring again in October 2023, the order was lifted.
These include developing a safe work environment, establishing lock-out policies and a key control system to restrict access to confined spaces, educating staff members on the risks of entering confined spaces, and reviewing risk assessment and safe work practices for repair and maintenance work.
At the time of the coroner’s inquiry, MOM was contemplating taking enforcement action against the parties involved.
The workers were aware of this because the manhole, which was a defined confined space, were a known confined space, according to Coroner Wong Li Tein’s findings.
This was partly due to the company’s use of external contractors to perform work involving confined spaces since 2019 and also because safety measures had to be implemented to enter it.
The coroner determined that Mr. Hoe was knowledgeable about working in tight spaces and was aware of what security measures needed to be in place prior to any entry.
This was not his first time making attempts to repair construction in a tight space.
He was told by his colleagues not to do it before entering the manhole, and he even received a warning that Mr. Kathiravan had earlier attempted to do it and was overpowered by the gas in the chamber, according to Coroner Wong.
She expressed her condolences to Mr. Hoe’s family for their loss and concluded that there was no foul play in the death.