[2026] SGDC 255

[1] The accused company, PSA Corporation Limited (“PSA”) claimed trial to the following charge :

[2] At the close of the trial, PSA was found guilty and convicted of the proceeded charge. PSA was sentenced to a fine of $225,000. The fine has been paid.

[3] Being dissatisfied, PSA has appealed against its conviction and sentence. The Prosecution has filed a cross appeal on the sentence imposed.

[4] I now set out my reasons below.

Statement of Agreed Facts:

[5] The accused company is PSA Corporation Limited (UEN: 199706229Z) (“PSA”). PSA is a port operator and provides container handling and terminal-related logistics services to terminals including the Keppel Terminal, Singapore 089055 (“Keppel Terminal”), which was a workplace within the meaning of the Workplace Safety and Health Act (Chapter 354A, Rev Ed 2009).

[6] At the material time, Technical Specialists were employed by PSA under the Keppel Terminal Engineering Department (Yard Crane Section) (“KTED”), which is a maintenance department. Technical Specialists (“TSs”) were split into Groups A, B and C respectively (“Group A, B, C” respectively). The main work scope of Technical Specialists was to carry out:

(a) maintenance works at the servicing yard located within the Keppel Terminal;

(b) preventive maintenance works involving scheduled checks on cranes used at the Keppel Terminal to ensure that the machinery remained in safe working condition; and

(c) corrective maintenance and troubleshooting works involving checks on cranes pursuant to issues reported by other employees such as crane operators.

[7] When a crane is reported with an issue, a Service Recovery team, which operates 24 hours every day, would respond onsite and attempt to rectify it. If the Service Recovery team is unable to rectify the issue onsite, they would send the crane to the servicing yard for further checks and repairs, and list it as a work order for the maintenance department. Whilst onsite, the Service Recovery team may also call the maintenance department directly to report the issue and request for further assistance.

[8] At the start of every day, the work order list would be generated from the system, showing the issues reported by the Service Recovery team. Work relating to the resolution of such specific issues would be classified as corrective maintenance and troubleshooting work, which includes, issues relating to abnormal noises heard from the gearbox of a crane as reported by the Service Recovery team.

[9] The relevant parties and their respective roles at the material time have been set out in the following table:

[10] At the material time, the line of reporting within the maintenance department is set out as follows:

(a) Technical Specialists report to an in-charge of their respective Group (Technical Specialists in Group B report to Khairun); and

(b) The Principal Service Engineer (i.e. Seow Cheong) oversees the Technical Specialists and Service Engineers in Group B.

[11] The Deceased worked as a Technical Specialist for PSA since 1 September 2008.

[12] On 19 September 2017, the Service Recovery team was informed that noises were detected from a Mitsui Paceco MP91 model Rubber Tyred Gantry crane KTT140 (the “Mitsui RTG crane”). The onsite service team identified noises from the gearbox but was unable to identify the root cause to resolve it onsite. The Mitsui RTG crane was then brought to Block J11 Yard Crane Servicing Bay for checks.

[13] On 20 September 2017, at around 8am, a toolbox briefing was conducted (SSE Chin Chen Hong and another colleague conducted the toolbox briefing that day). After the toolbox briefing, Khairun informed the Deceased and Iqbal that they were assigned to run checks on the Mitsui RTG crane. It was also highlighted to the Deceased and Iqbal that the noise was coming from the gearbox, and they were asked to confirm it.

[14] Upon arriving at the Mitsui RTG crane at about 8.50am, the Deceased and Iqbal first proceeded up the trolley platform and conducted a visual check of the hoist system, which included the motor housing, rope drum and gearbox. The Deceased removed the bolts of the inspection cover (closest to the main hoist rope drum) of the main hoist gearbox to check for any damaged gears, while Iqbal checked the Main Hoist Motor Housing. No abnormality was observed from these initial visual checks.

[15] Following the visual check, at around 9.30am, the Deceased and Iqbal proceeded to the operator cabin. They performed hoisting and lowering of the crane spreader, to determine the source of the noises from the Mitsui RTG crane. Both the Deceased and Iqbal confirmed the presence of abnormal noises consistent with a faulty Main Hoist gearbox. The Deceased told Iqbal to remain in the operator’s cabin while he proceeded back up to the trolley platform for another inspection of the hoist system. Between 9.49am to 9.55am, the Deceased, through a walkie talkie, instructed Iqbal to operate KTT140 and perform movements at the Deceased’s directions at varying speeds, while the Deceased observed the gearbox and hoist system while trying to identify the cause of the abnormal noise.

[16] At around 9.56am, Iqbal asked the Deceased, via the walkie-talkie, if he needed the spreader hoisted. The Deceased told Iqbal, “Ok hoist up”, and Iqbal proceeded to hoist the spreader until it almost reached the top. At that moment, Iqbal saw a black object drop from the trolley platform, which was located just above the operator’s cabin. Sensing something was amiss, Iqbal immediately stopped the crane operation and powered off the crane. Iqbal then tried to contact the Deceased via the walkie-talkie but there was no response from the Deceased. Iqbal proceeded to climb up to the trolley platform to check on the Deceased.

[17] Upon reaching the trolley platform, Iqbal saw the Deceased lodged between the rope drum and a platform located next to the motor housing where the gearbox was located. The Deceased was lying in a horizontal position, with his head towards the direction of the gearbox. He was motionless and did not respond to Iqbal’s calls. Iqbal immediately called Khairun and informed him about the accident.

[18] At about the same time, Lee Yoon Ming, (“Lee”) a process maintenance & construction worker from Akoh Welfit Engineering Pte Ltd, was working within the same service yard on another RTG crane KTT230, which was adjacent to the incident crane KTT140. After hearing a loud scream coming from the direction of KTT140, Lee turned and saw a leg moving up and down on top of the rope drum at the trolley platform area. At that point, Lee saw Iqbal making his way up to the trolley platform area and shouted to Iqbal that someone fell and required help.

[19] PSA’s Emergency Response Team (“ERT”) was activated, and they arrived the accident scene at around 10.11am. The ERT assessed the accident scene and called the Singapore Civil Defence Force (“SCDF”) for assistance as the extrication of the Deceased from the rope drum was complicated. SCDF arrived at the scene at around 10.36am and extricated the Deceased from the rope drum and brought him down to ground level using a boom lift. The Deceased was pronounced dead at the scene by attending SCDF paramedics at 11.02am.

[20] The autopsy report revealed that the condition leading to the death was “Multiple Injuries”, consistent with that of being crushed between the rope drum and the trolley platform. Toxicology report of blood and urine samples taken from the Deceased did not reveal the presence of any drugs or substances that could have impaired his judgement.

[21] As part of the inspection process for Mitsui RTG cranes, the maintenance department from KTED will carry out the servicing and repair works after faults were reported by PSA personnel operating these Mitsui RTG cranes.

[22] Abnormal sounds for gearbox are usually attributed to damaged bearings or poor conditions of the gears such as pitting or broken teeth. The corrective maintenance process for Mitsui RTG crane gearbox faults include, in the following order:

(a) Visual Inspection: The maintenance team assesses the trolley platform for a visual inspection of the gearbox to look for pitting or broken teeth.

(b) Functional Test, which comprises hoisting and lowering the crane’s spreader: This would be carried out by Technical Specialists to operate the machinery to ascertain if abnormal noises are present. A functional test can take place, (i) even if the Visual Inspection does not reveal any fault, or (ii) to verify any issue detected during the Visual Inspection.

[23] During the Functional Test, the Mitsui RTG crane’s spreader will be hoisted and lowered to various positions at varying speed. One of the Technical Specialists will attempt to ascertain the source of the abnormal noise. The aforementioned Technical Specialist will be coordinating the hoisting and lowering of the spreader using a 2-way radio communication with the other Technical Specialist, who will be stationed in the operator cabin and operating the crane.

[24] PSA has a statutory duty as an employer under s 12(1) of the WSHA to take, so far as is reasonably practicable, such measures as are necessary to ensure the safety and health of its employees at work.

[25] PSA had established Risk Assessments (“RA”) for (a) “Preventive Maintenance Functional Test of RTG Cranes” for the review period of 30 June 2015 to 29 June 2018; (b) “Corrective Maintenance for the Replacement/repair of Main Hoist System Components and Accessories” for the review period of 30 April 2015 to 29 April 2018; and (c) “Corrective Maintenance for the Replacement/repair of Trolley System Components and Accessories” for the review period of 30 June 2015 to 29 June 2018. These RAs were collectively used for the Mitsui RTG Cranes as well as the Samsung and Doosan RTG crane models that are maintained by PSA personnel from KTED.

[26] It is not in dispute that at the material time the deceased and Iqbal (PW1) were the only two TSs working under KTED, a maintenance department responsible for carrying out maintenance work, who were specifically tasked to ascertain the root cause to the abnormal noises, which were earlier identified by the onsite service recovery team (“SRT”) to be coming from the gearbox in the MH reducer housing of The Mitsui RTG crane that was brought to Block J11 Yard Crane Servicing Bay for checks.

[27] Abnormal sounds for gearbox are usually attributed to damaged bearings or poor conditions of the gears such as pitting or broken teeth. The corrective maintenance process for RTG crane gearbox faults include both a visual inspection, as well as a functional test. A functional test can take place even if the visual inspection does not reveal any fault.

[28] During the functional test, one of the TSs (the deceased in the present case) will attempt to ascertain the source of the abnormal noise. rather than simply confirm the fact that there were abnormal noises present as SRT had already identified abnormal noises coming specifically from the gearbox in the MH reducer housing but had been unable to identify the root cause to resolve it onsite.

[29] It is undisputed that in the process of the functional test, the RTG crane’s spreader would be hoisted and lowered to various positions at varying speeds, with one TS (Iqbal or PW1) positioned in the operator cabin, and another TS (the Deceased) coordinating the hoisting and lowering of the spreader through a two-way radio communication at the trolley platform level.

[30] The positioning of Iqbal in the operator cabin is not in dispute. However, the main dispute between the Prosecution and the Defence lies on the position where the Deceased ought to be positioned at the trolley platform level while coordinating the hoisting and lowering of the spreader and at the same time also having to ascertain the source, or root cause, of the abnormal noises which the SRT had previously determined to be coming from the gearbox in the MH reducer housing.

[31] The Prosecution relied on the above Statement of Agreed Facts (“ASOF”) and the Prosecution Witnesses’ testimonies to establish the two particulars stated in the charge against PSA, namely (a) PSA’s failure to implement control measures to prevent its employees from being exposed to rotating parts during maintenance work, and (b) the safe work procedures (“SWP”) for maintenance work on the Mitsui RTG crane were inadequately implemented and that the failures by PSA in (a) and (b) caused the death of the Deceased.

[32] The salient parts of the Prosecution Witnesses’ testimonies pertaining to the charge against PSA are outlined below.

[33] The Prosecution led evidence to show that PSA failed to effectively implement control measures to prevent its employees from being exposed to rotating parts during maintenance work due mainly to the lack of clarity and specificity in the risk assessment (“RA”) or safe work procedures (“SWP”) for the Mitsui RTG crane which should be distinct and separate from those developed for the Samsung or Doosan RTG cranes.

[34] According to PW1, the corrective maintenance work performed on a Mitsui RTG crane was more challenging than the other crane models due to its layout. As compared to other crane models such as Samsung or Doosan RTG cranes, TSs working on Mitsui RTG cranes faced space constraints when performing visual checks of the gearbox in the MH reducer housing as it was cramped and difficult to move around.

[35] This has resulted in TSs having no choice but to stand at the small black platform (near to where Deceased’s body was discovered) as identified by the PWs to inspect gears which exposed them to rotating parts.

[36] PW1 testified that the RTG crane could operate at a maximum speed of five knots, and TSs would need to stand clear of the black platform at that speed. Notwithstanding this danger, PW1 confirmed that there was no other way for the TS to conduct their checks apart from standing on the small black platform (“black platform”), identified by PW1 in Photograph 22 and marked by PW2 Muhammad Syafiq Bin Mohamed Samsudin (“PW2”) with a blue circle in Photograph 19 of P11. As part of inspecting the gears, TSs would need to see whether the gear was properly engaged during rotation. The dimensions of the black platform was measured about nine inches at its width, and the gap to the MH drum to be about three to four inches.

[37] PW1 testified that the SWP and P4 provided no guidance on safe positioning during gear inspections. He adopted unsafe practices that were inherited from senior workers as there was no documented SWP addressing the practical reality of where workers needed to stand for such inspections.

[38] PW1 further testified that he had consistently engaged in this unsafe practice throughout his employment with PSA, from sometime in 2013 until the fatal incident in 2017.

[39] PW1 further informed that despite the safety concerns associated with performing a close visual inspection of the gears in the MH reducer housing, during the functional test, which was part of the maintenance works, he had to carry on as it will affect his appraisal if they did not do so. The concern of an adverse impact on appraisal was also mentioned by PW2.

[40] In cross- examination, PW1 admitted that he had not personally stood at the black platform during the FT or witnessed any other TS doing as such.

[41] PW2 testified that the TSs’ practice of standing on the black platform was due to necessity rather than adherence to any documented procedures. According to him, there was simply no clear documentation by PSA providing guidance on where to safely position oneself during the visual inspection of the gears in the MH reducer housing, as follows: (a) the RAs (P1, P2 and P3) failed to address the specific hazards of checking abnormal noises from the MH reducer housing of a Mitsui RTG crane; (b) the SWP (P4) lacked clear guidance on the procedure to conduct visual inspection of the gears in the MH reducer housing of a Mitsui RTG crane; and (c) PSA’s TSs relied on on-the-job training from seniors.

[42] PW2 testified that that there was no other platform or place to step on to inspect the gears, as the black platform was the nearest and best place to step and check. PW2 further testified that it required three people to perform the task safely but they were often made to do it with two people.

[43] PW2 was of the view that P4 addressed only preventive maintenance works, not corrective maintenance works. PW2 further stated that there were no procedures for troubleshooting abnormal noises, nor could he find any guidance in either the RAs (P1 to P3) or P4 regarding the checking of abnormal noises from the MH reducer housing. Therefore, it was necessary for him to rely solely on on-the-job training from seniors.

[44] During cross examination, PW2 agreed with the Defence that the SWP and P4 prescribed sequential steps for functional tests, and that P4 contained clear safety control measures including four key cautions :

[45] PW2 also admitted under cross-examination that standing in the black platform to inspect the gears would be in breach of the SWP but he qualified it by mentioning the breach would occur in the context of two persons performing the FT on the RTGC crane.

[46] However, during PW2’s re-examination, he elaborated that TSs could not determine if the MH reducer needed to be brought down to the ground level without first inspecting its gears within. This process would take at least a day to bring down MH reducer to the ground level, and this was not possible as operations needed quick confirmation if the Mitsui RTG crane could be used. PW3 Khairulanwar estimated that to arrange for the MH reducer to be brought down would take about two to three days.

[47] PW3 Khairulanwar Bin Rohaimi (“PW3”), another TS, testified that there was effectively no possible place to stand as the black platform was the only place that he could stand to conduct the necessary gear inspections in the MH reducer housing.

[48] PW3 was of the view that the position at the black platform was "not 100% safe". PW3 added that there was a "chance of falling into the drum" because they were "working on rotating part". PW3 concluded that there was no safe alternative position, and stated, "there isn't any possible way to stand".

[49] During PW3’s cross-examination, he clarified that his evidence in EIC in relation to standing at the black platform was given in the context of the visual inspection defined in ASOF at [18(a)] and acknowledged that close-up gear inspection was not documented in P4 or included as part of work activity to be performed during a functional test.

[50] Although PW3 agreed under cross-examination by the Defence that close-up gear inspection ought to be done when functional test stops, he explained during his re-examination that the functional test and gear inspection were interconnected. PW3 stated that he had to check gears during a functional test to confirm the source of abnormal noise. PW3 also explained that there were instances where TSs could not wait for the MH reducer to be brought to the ground level as the operations needed the crane urgently.

[51] PW3's re-examination further revealed there were two types of function tests required: (a) First function test at full speed to detect noise; and (b) Second function test at 1 knot to inspect gears.

[52] According to PW3, the second function test was necessary to "double confirm" the source of abnormal noise before reporting to a supervisor. PW3 explained that he could not report to a supervisor without completing both functional tests.

[53] From PW3's testimony, when reviewing the RAs, P1 to P3, he confirmed that there was no control measures identified for the works in relation to the checking of abnormal noises from the MH reducer housing.

[54] PW3 also testified that he could not find steps for checking abnormal noises in P4. He stated that there was no documented guidance on where to stand: "they never say, like, where to stand all". Consequently, PW3 relied on his Machine In-Charge's (“Machine IC”) verbal instructions: "I just follow my IC. He ask me where to stand, I---I stand".

[55] The evidence from PW4 Khairun, in his position as a supervisor, was consistent with the testimonies of the TSs (PW1, PW2 and PW3) regarding the absence of documented guidance on safe positioning during gear inspection : (a) The RAs did not comprehensively address the specific task of checking abnormal noises; and (b) Supervision was occasional rather than systematic.

[56] The evidence from PW5 Lee, being PSA’s Principal Service Engineer, was the most senior ranking PSA officer amongst the Prosecution witnesses, confirmed the evidence supporting the fact that the TSs were effectively left on their own to devise methods to visually inspect the gears during a functional test. PW5 testified that: (a) there was no written documentation regarding the specific procedure for checking abnormal noises; (b) workers learned through on-the-job training rather than documented procedures to learn specifically on conducting maintenance work on a specific model of RTG cranes; (c) the visual inspection requirements in the SWP contained no guidance on how to safely position oneself while inspecting internal components on RTG cranes; and (d) the safety documents provided general safety measures rather than specific guidance for this particular task of checking on abnormal noises coming from the MH reducer housing of an RTG crane.

[57] PW5 testified that P4 did not contain the procedure governing inspection of gears in the context of checking abnormal noises of a Mitsui RTG crane. When given an opportunity to review P4, he was unable to recall if the procedures he described existed in any written document from PSA.

[58] The Prosecution submitted from the evidence adduced at the close of the Prosecution’s case that it was established that PSA failed to: (a) properly document SWP; (b) provide clear guidance on critical safety controls such as safe positioning on the trolley platform; (c) implement proper safety control measures for the work activity of ascertaining abnormal noises from the MH reducer of an RTG crane; and (d) establish proper supervision protocols.

[59] The Prosecution submitted that when the defence was called, PSA has failed to discharge its burden under section 47 of the WSHA from the evidence adduced by the Defence witnesses.

[60] The main crux of the defence case is that the Prosecution’s case rests on a false premise: that determining abnormal noise from the MH Reducer required a close visual inspection of the gears during a functional test while the crane was in motion. The Defence contended that this premise is not supported by P1 to P4, the Prosecution’s own witnesses, objective facts or practical reality.

[61] The Defence further contended that there was no need for a “close up” visual inspection of the gears in the MH reducer housing and in any case, such “close-up” visual inspection was not part of a functional test. During cross-examination, PW2 acknowledged that close-up visual inspection of gears was neither prescribed in P4 nor part of the functional test. Furthermore, PW2 stated that such inspections should only be done when the crane was in "control off" mode.

[62] It is not in dispute at the material time that the maintenance department at the Keppel Terminal Engineering Department (Yard Crane Section) (“KTED”) worked on 3 models of Rubber Tyred Gantry (“RTG”) cranes, i.e. the Mitsui, Samsung and Doosan RTG crane models.

[63] It is not in dispute that a functional test is performed on the RTG crane models in the course of all types of maintenance works, namely : (a) Preventive Maintenance (“PM”); (b) Troubleshooting, and (c) Corrective Maintenance (“CM”).

[64] The purpose of a functional test i.e. to check that the relevant components (including mechanical and electrical aspects) on a crane are functioning well under operating conditions, which is required across all three stages of maintenance works. Across PM, troubleshooting and CM works, the main objective of the three stages of maintenance works is to conduct checks on the working conditions of all components on the cranes.

[65] As part of conducting checks on the components, one primary purpose of the functional test entails “operat[ing] the machinery to ascertain if abnormal noises are present and the source of such abnormal noises.”

[66] It is also not disputed that a functional test necessarily entails the movement of component parts of the crane. Where a functional test is conducted on the main hoist reducer, it would involve hoisting and lowering of the spreader; and rotation of the wire rope drum.

[67] It is not disputed that the applicable safety documents governing crane maintenance works for the KTED at the material time were P1 to P4.

[68] According to the Defence, P1 and P4 comprise the risk assessment (“RA”) and safe work procedure (“SWP”) for the work activity to conduct a “PM functional test of RTG cranes”. P1 sets out the different tasks, from start to end, that would be carried out to complete the stated work activity, namely performing a PM functional test on the RTG crane.

[69] According to the Defence, P4 sets out in detail the sequential steps to be complied with when conducting a PM functional test.

[70] P2 and P3 are the RAs that govern CM works on a RTG crane. P2 applies to the replacement or repair of the main hoist (“MH”) system components and P3 applies to the replacement or repair of faulty accessories and trolley system components and accessories. A functional test is performed as part of CM at the end of the repair and replacement of the faulty MH / trolley component. The purpose of conducting a functional test at that stage is to test if the MH / trolley system is in good working condition again after the faulty component part is repaired or replaced.

[71] In relation to Particular 1 of the charge against PSA, the Defence submitted that PW2 to PW5 have shown that there was an effective implementation of control measures to prevent PSA employees from being exposed to rotating parts. Specifically on the undisputed facts of this case, the only exposed rotating part is the main wire rope drum.

[72] The Defence submitted that at the material time, the control measures had been set out in P1, P2 and P4. The PSA employees were trained in and knew how to implement the control measures set out in the documents. The Defence further submitted that PW2, PW3, PW4 and PW5 have all agreed under cross examination that to confirm the source of abnormal noises, no close visual inspection of the gears is required during a functional test where the wire rope drum is rotating. The control measures implemented had thus been reasonably practicable to eliminate the risk of exposure to rotating parts.

[73] The Defence sought to cast doubt on PW1’s evidence that there can be a close visual inspection of the gears during a functional test as manifestly unreliable and inherently incredible.

[74] In relation to Particular 2 of the charge against PSA, the Defence submitted that the Prosecution witnesses, PW1 to PW5 have agreed that the safe work procedures for the MP91 Cranes maintenance works are the same as the safe work procedures for all other RTG crane models. The different layout of the cranes does not render the control measures set out in P1, P2 and P4 ineffective to implement.

[75] When the defence was called, essentially the Defence witnesses DW1 Chee, DW2 Ng, DW3 Ang Chew Peng (“DW3”), and DW4 Tan Qian Rong Phinehas (“DW4”) while acknowledging that the layout and orientation in terms of where the MH reducer was found on the trolley platform to be different for the Mitsui RTG crane as compared to either the Samsung or Doosan RTG cranes nevertheless maintained that there was no need for a separate and specific RA and SWP for the Mitshui RTG crane.

[76] As a preliminary point the Defence contended that there was no conclusive evidence that the Deceased was positioned at the black platform at the material time. Even if he was found by this court to be at the black platform trying to ascertain the source of the abnormal from the MH Reducer through a close visual inspection of the gears from the opened inspection cover during a FT, the Defence submitted that the Deceased had acted in breach of the RA and SWP by putting himself exposed to the rotating parts and hence, not exercising caution of the moving parts. As there were gaps in the Prosecution’s case, the Defence submitted that the Prosecution has not proved its case beyond reasonable doubt.

[77] The key issues to be decided by this court are (a) whether the Deceased was in fact positioned at the black platform at the trolley platform level while coordinating the hoisting and lowering of the spreader and at the same time conducting a close-up inspection of the gearbox to ascertain the source, or root cause, of the abnormal noises which the SRT had previously determined to be coming from the gearbox in the MH reducer housing; and (b) whether in doing so at (a), the Deceased were in clear breach of the PSA’s PAs and SWPs which resulted in his death.

[78] The Defence raised a preliminary issue that since PW1 was at the cabin level while the Deceased was at the trolley platform level there was no conclusive evidence that Deceased was conducting the close-up inspection at the black platform area at the material time as Deceased is no longer around to give evidence and there is no eyewitness to testify where deceased was positioned prior to him being caught by the rotating drum.

[79] The Defence further pointed out at the ASOF outlined at [18] above that Lee who was working within the same service yard on another RTG crane KTT230, which was adjacent to the incident crane KTT140 and after hearing a loud scream coming from the direction of KTT140, Lee turned and saw a leg moving up and down on top of the rope drum at the trolley platform area. At that point, Lee saw Iqbal making his way up to the trolley platform area and shouted to Iqbal that someone fell and required help. Lee could not be called to give evidence in court and all we have is the ASOF regarding Lee’s evidence.

[80] It is clear to this court that from the ASOF, Lee did not see where Deceased was positioned before he heard the loud scream and his attendance in court would not provide much assistance in ascertaining the prior position of the Deceased before Lee saw a leg moving up and down of the rope drum.

[81] Having considered the ASOF at [14] to [16] above and heard the evidence adduced by the Prosecution, in particular the evidence of PW1 which was corroborated by the other PWs, this court is of the view that the irresistible inference to draw from the understanding between Deceased and PW1, given the circumstances of this case at the material time, was that the Deceased was to be positioned at the black platform area to conduct a close-up inspection of the gearbox to ascertain the cause of the abnormal noise from the gearbox while giving instructions to PW1 on the hoising and lowering of the Mitsui RTG crane.

[82] From the position where the Deceased’s body was discovered which was near the black platform area, and the evidence from PW1 that there were no other alternative place for the Deceased to position himself to get a clear close-up view of the gearbox through the opened inspection cover besides the black platform area, this court is of the view that Deceased must have positioned himself at the black platform area when he gave instruction to PW1 to raise the hoist for 24 seconds just before the accident occurred.

[83] Notwithstanding, that PW1 has never performed the role of the Machine I/C and that he has never positioned himself at the black platform area to conduct close-up inspection of the gearbox, he was candid in his evidence that he has learned from the Deceased and others on the job training, that there was no other better alternative other than the black platform position to conduct a close-up inspection of the gearbox for the Mitsui RTG crane despite its risk of the Deceased being exposed to the moving part of the rope drum. In my view there are no cogent reasons for PW1 to fabricate such evidence against PSA.

[84] I agreed with the Prosecution that there is a lack of clarity and specificity in the RAs (P1 to P3) and the SWP, in particular P4, from the evidence adduced by the PWs that there was no clear documentation by PSA providing guidance on where to safely position oneself during the visual inspection of the gears in the MH reducer housing.

[85] From the evidence adduced, it is clear that black platform area present at the Mitsui RTG crane was unique to Mitsui crane and absent in the other crane models and due to the space constraints faced by the TSs when conducting visual checks of the gearbox in the Mitsui reducer housing, the TSs ended up having to prioritise “efficiency” over “safety” concerns to stand at the black platform area to perform the visual checks on the gearbox.

[86] I agreed with the Prosecution that any risk assessment (“RA”) or safe work procedures (“SWP”) for the Mitsui RTG crane should be distinct and separate from those developed for the Samsung or Doosan RTG cranes. The Prosecution relied on the High Court’s decisions which has consistently emphasised the inadequacy of general RAs.

[87] I agreed with the Prosecution’s submission that a specific assessment of the risks involved in performing maintenance works on a Mitsui RTG crane would be required, such as when considering the risks arising from the work activity of ascertaining the source of abnormal noises from the MH reducer housing, and the corresponding control measures to be implemented to address the risks. This would ensure that the TSs were aware of the specific risks of performing maintenance works on a Mitsui RTG crane due to the unique orientation.

[88] Hence, I agreed with the Prosecution that a clear and specific SWP would have to be developed for the maintenance works involving Mitsui RTG cranes as distinct from the other crane models, so that the TSs are aware of the safe steps to deploy, such as where to correctly position themselves, so as to safely perform checks on the gears within the MH reducer housing during a functional test.

[89] The inadequacies of the RAs and SWP especially P4 have led to an unsatisfactory disconnect and mismatch on the evidence between the PWs and DWs on this issue of clarity and specificity of the RAs and SWP in relation to the assigned task given to the deceased and PW1 on the fateful day in the following areas:

(a) the failure to identify the black platform area at the Mitsui RTG crane trolley platform which could be used by the TSs to perform visual checks on the gearbox as a potential hazard as this black platform area was absent in the other crane models;

(b) the failure to provide a suitable platform similar to the post-incident platform installation provided by PSA to obviate the need for the TSs to use the black platform area in the Mitusi RTG crane to perform the assigned task by the Deceased;

(c) the failure to provide a specific RA and SWP in respect of the Mitsui RTG crane for a safe close-up inspection of the gearbox by Deceased at the trolley height level during a FT after the Deceased had removed the inspection cover to ascertain the cause of the abnormal noise;

(d) the claim by the Defence that the inspection covers must not be left opened or close-up inspection of the gearbox must only be done when the crane control is at power-off was clearly not complied with by Deceased and PW1 in performing their assigned task and there was no evidence of serious oil spillage as seen from the photographs taken of the scene after the incident;

(e) take reliance of a general document in P4 with its four general cautions in applying to a specific task assigned to the Deceased and PW1 has inevitably led to differences in the interpretations of the P4 by all the witnesses;

(f) the discretion given to the TSs and their supervisors to deploy either a three-man or a two-man team to perform the assigned task by the Deceased and PW1 which clearly compromised safety when a two-man team was deployed in the present case;

(g) lack of clarity why there was a need to ascertain the cause of the abnormal noise emanating from the gear box at trolley height level or a second confirmation by the Deceased and PW1 instead of the decision by the management of bringing the hoist down to ground level for repair immediately after the SRT had confirmed that there was noise coming from the gearbox which led to differences in views that it will take days to mobilise and repair the damaged gears and the view by DW4 that PSA has surplus cranes and operation would not be compromised;

[90] It should be borne in mind that none of the DWs had personally performed a FT to determine the source of abnormal noise coming from a Mitsui RTG crane and therefore clearly not in a position to comment on how SWP and P4 in particular should apply in the context of the assigned task given to the Deceased and PW1.

[91] In my view the Deceased acted reasonably when he was performing an assigned task given to him by positioning himself at the black platform area to ascertain the cause of the abnormal noise of the gearbox even though he was aware of the attendant risk of the moving parts as according to PW1, Deceased had asked for a three-man team and raised safety concerns before but these were however not documented but it nevertheless showed the mental state of the Deceased who was trying his best to help PSA in performing his work.

[92] In my view the Deceased had not breached any RA or SWP as there was a lack of a specific RA and SWP in relation to the assigned task given to the Deceased and PW1 for a Mitsui RTG crane and there was no clear prohibition even in P4 as it merely stated “to exercise caution” of moving parts and not worded as an absolute prohibition and which also explained why the black platform area was not barricaded.

[93] The onus is on PSA, the employer to take reasonably practicable measures that are necessary to ensure the safety and health of their employees at work to prevent their employees from being exposed to rotating parts on the crane during maintenance work and to implement safe work procedures for the Mitsui Paceco MP91 cranes maintenance works, and there is clear and incontrovertible evidence against PSA that they have failed to do so on the two particulars mentioned in the charge.

[94] In my view, PSA has failed to discharged its burden under section 47 of the WSHA and there are no merits raised by the PSA in its defence. Accordingly, I convicted PSA on the charge. It is also clear from the evidence that PSA’s failures caused the death of the Deceased.

[95] The parties referred to the two-step sentencing framework as developed in the recent High Court decision in Public Prosecutor v Manta Equipment (S) Pte Ltd [2022] SGHC 157 (“Manta”) , and submitted for a fine in the range of $300,000 to $350,000. This is based on Prosecution’s assessment of PSA’s culpability falling within the low end of the high range and harm in the highest end of the high range. This would yield an indicative starting range of between $300,000 to $500,000.

[96] The Prosecution submitted that actual harm caused was death and should fall at the top end of the high range according to the Manta framework. The Prosecution also assessed the potential harm to be high as TSs were exposed to powerful rope drums rotating at varying speeds up to five knots, creating exposure to rotating parts that materialised in the Deceased's death.

[97] The Prosecution further submitted that the nature of the risks which TSs were exposed to was not theoretical but proven by the actual harm that materialised. TSs were forced by necessity to improvise under dangerous conditions, including leaning against motor housing, removing safety harnesses, and relying on informal communication to watch for rotating parts. According to the Prosecution, these desperate measures highlight the extreme seriousness of the harm risked when proper safety measures were absent. These were the very safety measures PSA was under a duty to ensure as an employer under the WSHA.

[98] The likelihood of harm arising was not merely possible but inevitable given PSA's systemic failures. PSA's own post-incident study, conducted only after the Deceased’s death, confirmed that the dangerous black platform was the "best location" to access essential inspection covers on the Mitsui crane.

[99] According to the Prosecution, the number of people exposed to this deadly risk was significant and extended over a decade as many TSs in Group B were regularly forced to use the same dangerous positioning as testified by PW1, PW2, and PW3 that the unsafe practice was a standard procedure which revealed a systemic exposure across the maintenance department, with TSs forced to rely on informal, unsafe practices passed down by seniors due to the absence of proper and safe guidance from their employer PSA.

[100] The assessment of culpability requires consideration of the number of breaches or failures, the nature of the breaches, the seriousness of breaches, whether the breaches were systemic or isolated, and whether the breaches were intentional, rash or negligent. PSA's conduct demonstrated high culpability across all these areas according to the Prosecution.

[101] The Prosecution submitted that PSA has committed two serious, interconnected breaches as shown in the two particulars of the charge endangering the lives of their employees.

[102] PSA has adopted a generic approach in their RAs and SWP ignoring the specific hazards created by the Mitsui crane unique layout and orientation.

[103] PSA’s failures directly exposed their TSs to rotating machine parts with no safe alternatives provided. PSA's post-incident conduct revealed the seriousness of their pre-incident failures as PSA was able to install proper safety measures within days of the fatality, proving that safe alternatives were always available but deliberately not implemented. DW2 Ng admitted that a study on safe positioning was only conducted after the deceased's death, demonstrating PSA's reactive rather than proactive approach to safety of its employees.

[104] The Prosecution further submitted that PSA's breaches were clearly systemic, spanning over a decade of corporate negligence where supervision was occasional and safety committee meetings failing to identify obvious dangers that its TSs faced over many years.

[105] According to the Prosecution, PSA's reactive safety culture represented a systemic failure to fulfil the proactive employer duties required under the WSHA. PSA waited for feedback rather than identifying risks, with DW2 Ng testifying there was "no trigger" to study safe positioning until someone died. This approach breached the fundamental principle that employers must proactively identify and eliminate workplace dangers before harm occurs.

[107] According to the Prosecution, after the accident, instead of conducting a thorough investigation to identify and address systemic failures, PSA prioritised the rapid resumption of operations by conducting a rushed 4.5-hour investigation rather than examine the fundamental safety deficiencies that had persisted for years.

[108] The Prosecution further submitted that the installation of proper safety measures after the incident, shows that PSA possessed the knowledge and capability to prevent such tragedies but chose not to act until compelled by the ultimate consequence of their negligence.

[109] The Prosecution submitted that PSA’s culpability should be pegged at low end of high due to the following: (a) unconscionable victim-blaming and lack of remorse by shifting the blame onto the Deceased who cannot defend himself and who has an exemplary safety record with PSA and was actively involved in PSA’s safety committee; (b) systemic nature of failures spanning over a decade; (c) the fundamental breach of employer’s duties; (d) the prioritisation of commercial interests over employees’ safety; (e) failure to focus sufficiently on safety concerns at the workplace; and (f) failing to act expediently to improve workplace safety post fatal accident.

[110] While causation is not an element of the offence under section 12(1) of the WSHA, it remains relevant for sentencing purposes. The High Court in Koh Lian Kok v Public Prosecutor [2024] SGHC 132 established that for sentencing purposes, "all that is needed is to show some causative link between the breach and the harm" and that "the relevant test to make out a causative link under the WSHA is that the offending conduct had contributed to the harm in more than a minimal, negligible or trivial manner."

[111] The evidence adduced showed that there was a causal link between PSA’s failures and the Deceased’s death. The Prosecution submitted for an indicative sentencing range of between $300,000 to $500,000 under the sentencing benchmark as established by Manta at [28]. The Prosecution took the view that a starting point in the range of $300,000 to $350,000 was appropriate.

[112] The Prosecution submitted that PSA has demonstrated no genuine mitigating factors. PSA proceeded to a full trial and took no remedial steps until forced by the incident. There were no mitigating factors warranting a sentence reduction.

[113] In mitigation, the Defence referring to Manta submitted for a fine of S$70,000 to S$100,000.

[114] The Defence submitted that although the actual harm was high as death was caused but the potential harm fell under the low end of the ‘moderate” harm. The likelihood of the actual harm occurring in the present case was very low according to the Defence as it was not common for PSA’s TSs to perform the assigned task and the incident in question was not reasonably foreseeable by PSA due to its comprehensive RAs and SWP.

[115] The Defence also disagreed with the Prosecution’s characterisation that the number of people exposed to the risk was “significant and extended over a decade”, with multiple TSs exposed to the same risks.

[116] The Defence submitted that the relevant consideration for this court in sentencing should be focused on the number of people likely to be performing the same assigned task as the Deceased of ascertaining the source of abnormal noise form the MH reducer of a Mitsui RTG crane.

[117] In the present case whether it was a three-man or two-man team performing the FT there will at most be only one person standing at the trolley level which will be exposed to the rotating parts and such an assigned task rarely occurred in PSA.

[118] The Defence submitted that notwithstanding that the level of actual harm being pegged at high due to a single death that was caused, the level of potential harm falls within the low end of “moderate harm” such that final level of harm should be downgraded to fall within the high end of the “moderate” range.

[119] As for the level of culpability, the Defence submitted this is not a case where there was absence of RAs and SWP and submitted that notwithstanding its statutory duty as an employer under the WSHA to ensure the safety and health of its employees at work, there were proper systems and procedures in place to govern the conduct of work at the workplace to minimise risks and workers were properly trained to be familiar with the RAs and SWP and in the circumstances the PSA’s culpability should fall in the low end of the “low culpability”.

[120] With reference to Manta, the Defence submitted for an assessment of “moderate harm” and “low culpability” where the indicative sentence would be a fine between $75,000 to $150,000 and since the Defence submitted that the level of harm in the present case should be at the high end of “moderate” and the level of culpability should be at the low end of “low”, the indicative sentence would be a fine of between $100,000 and $130,000.

[121] In applying the second stage of the Manta framework, the Defence contended that PSA should not be penalised for exercising its right to claim trial and that the Prosecution should not have alleged that PSA engaged in victim-blaming as PSA was entitled to conduct its own independent inquiry following the incident.

[122] The Defence further clarified that it has taken no position on whether the Deceased had been acting ultra vires and where the Deceased had been standing just prior to the incident.

[123] The Defence submitted that PSA cooperated fully with MOM and PSA has good safety records and PSA has extended aid to Deceased’s family and PW1 and in view of the lack of aggravating offender-specific factors and the strong mitigating factors, there should be a downward calibration of the indicative starting sentence range to a global fine of between $75,000 to $100,000.

[124] In arriving at an appropriate sentence, this court is aware that both parties are in agreement in referring to Manta as the appropriate sentencing framework. What they defer is in the categorizing of the charge within the Manta framework in the two- stage process.

[125] This court is of the view that there is largely a mismatch of evidence adduced by the PWs and DWs which showed a disconnect between what was perceived by the management and the ground staff (TSs) which arose mainly due to the lack of clarity and precision in the RAs and SWP in relation to the specific assigned task given to the Deceased and PW1 for the Mitsui RTG crane which resulted in the unfortunate death of the Deceased who was doing his best given the constraints of the Mitsui RTG crane as compared to the other existing cranes.

[126] In my view, the level of harm in the present case falls within the “high” category as actual harm caused was death. I did not agree with the Defence that the risk and the likelihood of the actual harm occurring in the present case was very low as it was not common for PSA’s TSs to performed the assigned task and the incident in question was not reasonably foreseeable by PSA due to its comprehensive RAs and SWP.

[127] It is clear to this court that due to the unique configuration of the Mitsui RTG crane, the black platform area was clearly a potential hazard which was not identified by PSA due to its reliance on generic RAs and SWP that did not cater to the attendant risk associated with the assigned task at a Mitsui RTG crane. Hence, I did not accept the Defence’s contention that the harm should be calibrated downwards to ‘moderate”.

[128] As for the culpability factor, while I accept that this was not a case of absent RAs and SWP as PSA relied on generic documents which was clearly inadequate, PSA’s culpability should not fall at the low culpability as the post incident installation of the platform by PSA after the incident clearly shows that it was not difficult for PSA to erect the new platforms to obviate the need of the TSs standing at the black platform area to perform the assigned task at the Mitsui RTG crane.

[129] I am of the view that there is no conclusive evidence that suggested that PSA’s breaches and failures were systemic as put forward by the Prosecution especially in regard to the assigned task and I accept the Defence’s contention that the assigned task was not a common occurrence and both breaches in the charge related to the same assigned task. I am however, of the view that PSA’s culpability was at most at the highest end of the low category or the lowest end of the moderate culpability in the Manta framework.

[130] While I accepted that PSA had cooperated fully with the authorities and had a good health and safety record and that PSA was entitled to conduct their own internal independent inquiry and such conduct should not be viewed as a deliberate attempt to put the blame on the Deceased and since this is a claimed-trial case, I am of the view that there are no merits for any further adjustments to the indicative sentencing range.

[131] In my view, a fine of $225,000 is appropriate and fair given the circumstances of this case.

Mr Delvinder Singh and Ms Kimberly Boo (till 16 March 2026) for the Public Prosecutor;

Mr Yusfiyanto Bin Yatiman and Ms Josephine Chee and Ms Ng Pei Qi (M/s Rajah & Tann Singapore LLP) for the Accused.