He revealed that Pte Lee died of an allergic reaction in a training exercise after a platoon commander threw six smoke grenades, even though regulations specified no more than two grenades were to have been used.
He revealed that the cause of death was certified by the forensic pathologist of the Health Sciences Authority (HSA) to be due to an "acute allergic reaction to zinc chloride due to inhalation of zinc chloride fumes".
The COI believed that "if the Training Safety Regulations had been complied with, PTE Lee and his platoon mates would not have been subjected to smoke that was as dense as that during the incident".
In the case of 3SG Tan who died after a jeep he was in overturned, it was found that individual negligence and breaches of safety had contributed to 3SG Tan's death.
Firstly, the master sergeant had assigned an unlicensed driver to the vehicle, and the rear passengers including 3SG Tan did not wear a helmet or put on their seat belts.
Other incidents of unlicensed driving were also found at the Combat Intelligence School, where the accident happened.
A Commanding Officer and six other commanders have been redeployed to other assignments which do not require them to supervise soldiers for training or operations.
The Chief Military Prosecutor will determine if these personnel should be subjected to a General Court Martial (GCM).
Police investigations are also ongoing to determine if the personnel involved, including the unlicensed driver of the jeep, should be prosecuted in a Civil Court.
Dr Ng said the SAF and Mindef were "deeply sorry for the untimely and tragic loss of Pte Lee and 3SG Tan and the anguish and distress it has brought to their families".
He concluded: "These two deaths could have been avoided if safety instructions had been followed."
"The SAF will learn from the incidents, correct any inadequacies and punish those who disregarded safety regulations," he also said.
The Singapore Armed Forces (SAF) will strengthen training safety in the light of lapses leading to the deaths of two full-time national servicemen this year.
In both cases, the respective Committees of Inquiry (COIs) uncovered breaches of training safety regulations in the events leading to their deaths, Defence Minister Ng Eng Hen said in Parliament yesterday.
Private Dominique Sarron Lee, 21, died on April 17 after he experienced breathing difficulties during a training exercise at the Murai Urban Training Facility in Lim Chu Kang. On May 11, Third Sergeant (3SG) Tan Mou Sheng, 20, died after the jeep he was in overturned in the Marsiling training area.
"These two deaths could have been avoided if safety instructions had been followed," Dr Ng said.
Seven servicemen - including a training school's commanding officer - have been relieved of their duties over their involvement in the incidents. They have been redeployed to assignments where they will not supervise soldiers in training or operations, and may face general courts martial as well as prosecution in the civil courts, Dr Ng added.
He announced that the SAF will make "three key systemic changes" across the whole organisation: First, more safety officers will be deployed on the ground. Their primary role will be to ensure that safety measures are followed.
Second, an Army Safety Review Board chaired by a senior civil servant has been set up outside of the Ministry of Defence. It will review the army's overall safety structure, processes and culture.
Third, an SAF Inspectorate will be set up to oversee the entire SAF. It will promulgate best practices and ensure that safety-related policies are sound and up to date. The Inspectorate will report directly to the Chief of Defence Force.
Citing inquiry findings, Dr Ng said Pte Lee had an "acute allergic reaction" after inhaling fumes from zinc chloride, a primary component used in smoke grenades.
He said the zinc-chloride smoke grenades have been used by the SAF since the 1970s, and Pte Lee's death - due directly to zinc-chloride inhalation - was the first in SAF's records.
Dr Ng said SAF has suspended the use of all smoke grenades with zinc chloride in training, and is looking for alternatives.
In 3SG Tan's case, the COI found that the jeep driver, 3SG Cavin Tan, was not licensed to drive the vehicle. The deceased, along with another rear passenger, were not wearing helmets or lap belts at the time of the accident. SAF has since made it mandatory for drivers to display their licences on the dashboards of vehicles.
The Combat Intelligence School, where the deceased was an instructor, was found to have a weak safety culture, with previous cases of unlicensed driving. The school's vehicular-management system has been tightened and SAF has checked other units as well, he said.
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