This proposal assumes duty of care is a governance requirement, not merely goodwill. In complex systems, serious harm rarely follows a single “bad decision”; it results when multiple safeguards degrade simultaneously. This is the Swiss Cheese model: layers of defense exist (policy, design, supervision, training, audit, emergency readiness), each with known weaknesses (“holes”). Catastrophe occurs when the holes align.

Below are three Singapore-linked incidents in living memory that illustrate how lapses across multiple layers can converge into mass-casualty outcomes.

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Case 1 — Sentosa Cable Car disaster (1983): interface risk without unified risk ownership

Risk domain: public transport infrastructure crossing an active maritime corridor (system interface risk).

Core governance observation: where two regulated domains intersect (transport operations + maritime navigation), duty of care must be treated as shared risk ownership with clear “who controls what” accountability. Interface risks are predictable and therefore governable.

Typical layers that can fail in alignment (Swiss Cheese mapping):

1. Design / planning layer
   • Critical infrastructure sits above/adjacent to navigable waters, creating a foreseeable external-strike hazard requiring compensating controls.
2. Rules / access-control layer
   • Exclusion zones, towing permissions, routing constraints, and enforcement protocols are either insufficiently defined, inconsistently applied, or not treated as “critical controls”.
3. Real-time supervision layer
   • Situational awareness, watchkeeping, and escalation pathways fail to prevent a vessel from entering a hazard corridor.
4. Emergency-readiness layer
   • Even with competent response, immediate self-rescue is limited (people are suspended, frightened, injured, or isolated).

Impact on people caught in the aftermath (duty of care consequence):

• Survivors: acute shock and long-tail trauma (fear conditioning, intrusive memories).
• Families: uncertainty and complicated grief during recovery/rescue windows.
• Responders: mass-casualty exposure and moral distress.

Governance takeaway: treat interface corridors as single risk spaces with integrated controls, not “two adjacent jurisdictions”.

Case 2 — Hotel New World collapse (1986): weak verification culture and brittle approvals

Risk domain: structural safety (high consequence, low frequency) where failures are often silent until collapse.

Core governance observation: catastrophic built-environment failures are often “paper-safe but not structurally safe.” Duty of care requires independent verification that can stop work—not merely checklists.