A 54-year-old woman, Madam Chong Lee Wan, was killed when she tried stopping a runaway delivery van with her hands, only to be run over.
The State Coroner found her death to be a tragic misadventure and said that Madam Chong had not fully engaged the vehicle's handbrake when she parked on a downhill slope at Pearl Bank Apartments on Feb 11, 2017.
During the inquiry into her death on Friday (Aug 4), State Coroner Marvin Bay said that the van's gear was in neutral mode during the time of the incident, and it moved forward and ran over Chong.
He said: "Given this, the brakes were not in a position to effectively stop the van from rolling downwards... I would therefore attribute the inclination of the pick-up and drop-off area, as well as the inadequate engagement of the handbrake to be the prime contributing factors for the mishap.
"The actual movement of the van... was likely triggered by the closing of the driver's door, which caused the said vehicle to move forward and subsequently run over Madam Chong."
The tragedy had happened during a routine furniture delivery run for Cristar Furniture, a family business which Madam Chong was involved in, reported The Straits Times.
Madam Chong and her son, Mr Lim, arrived at the driveway of Pearl Bank Apartments in Pearl Bank, close to Chinatown, around 10.10am on the day of the incident.
Mr Lim said that he recalled hearing a click sound when his mother engaged the handbrake of the Opel Vivaro van.
According to Shin Min Daily News via Lianhe Zaobao, while Mr Lim went up to deliver a chair, Madam Chong waited near the vehicle.
When Mr Lim returned 10 minutes later, after making the delivery, the van was nowhere to be found.
Security personnel nearby told him that the Van had rolled downhill.
Mr Lim later found his mother lying on the sloped road, the van about 50m from where she had initially parked it.
Madam Chong was conveyed unconscious to the Singapore General Hospital (SGH) where she died about an hour later from multiple injuries.
Coroner Bay cited senior automotive engineer Tan Jiat Shee, who examined the van and found the handbrake at the first click position.
In the position, the handbrake would be ineffective, and the van's rear wheels would still be able to turn.
The coroner said that even at the second click position, the rear wheels of the vehicle can still be turned with enough force.
Only at the third click position is the rear wheels completely secured.
Coroner Bay said: "(Mr Tan) opined that the full application of the handbrake - at six clicks - should be applied when parking the vehicle."
He also reminded drivers to park their vehicles at designated parking areas which are level, firm, well-lit and clearly marked.
If drivers need to stop or park their vehicles on a slope, they should engage the gears if it is safe to do so, and use wheel chokes.
He concluded: "Drivers should ensure their vehicles are properly parked with the brakes engaged, engine turned off, starter keys removed and load or equipment lowered and secured."