Israel Police and Prisons Service commanders failed in their response to the
December 2010 Carmel fire, and did not cooperate or analyze data in real time to
prevent the loss of 44 lives, the state comptroller ruled in a report released
In a section on the conduct of police during the fire, the
State Comptroller’s Office found that “the main failure by police was the lack
of systematic gathering and analysis of information which could have shed light
on the fire and helped them locate dangers as well as safe areas where people
could be evacuated.”
The report said police did not set up adequate field
command centers and did not use the centers they did set up efficiently in order
to devise an accurate snapshot of the situation on the ground.
fire is best known for the deaths of 37 Prisons Service cadets and wardens who
burned alive after their bus was trapped by flames en route to evacuate
prisoners from Damon Prison near Kibbutz Beit Oren. The report finds that in the
hours leading up to the incident, police, who were in charge of operating
roadblocks in the fire zone, did not adequately examine the dangers of Highway
721, where the cadets lost their lives.
“Police commanders did not assess
in a comprehensive way the dangers posed by the fire on the roads leading to
Damon Prison, in particular Highway 721, dangers that increased as time passed.
Police commanders did not ask the control centers to examine the information
that was passed on to them from the field and didn’t use assessments supplied by
helicopters flying overhead, which could have been used to form a situational
assessment to use as a basis for decision making,” the report states.
report also finds that police commanders did not recommend to the Prisons
Service alternate routes to Damon, despite the recommendation of the Fire and
Rescue Services that the prisoners be evacuated eastward and that Highway 721 be
closed between the Oren junction and the Beit Oren junction.
hours after the fire broke out, police district commanders in the North and the
Coastal District did not coordinate or concentrate the different reports coming
in from officers in the field and helicopters overhead, which complicated
efforts to assess the dangers faced by the ascent to Damon Prison, according to
They did not adequately weigh the pros and cons of opening or
closing the road to traffic or to finding alternate paths. The districts’
command centers didn’t examine helicopter footage and did not request from the
Fire Service information or forecasts on the dangers of the flame, directions it
could spread, damage it could cause and the influence of the weather on the
flames even though this was necessary info.
The report singles out
Northern District Commander Maj.-Gen. Roni Atiya, then the commander of the
Coastal District who took control of the response in the early hours of the
fire. The report says Atiya did not adequately coordinate the reports coming in
from the field with the Prisons Service or the varying command centers. It also
claims the decision to make Atiya the Northern District commander in May 2011
should have been delayed while the report was still being compiled.
report made wide use of police recordings from the time of the fire to compile
its findings. According to the report, from the recordings they could hear
various police commanders in the field talking about the dangers the fire posed
to Highway 721.
However those reports were not translated by police
higher-ups into decision-making in the field, especially in regard to the police
manning checkpoints on Highway 721, who were never given orders to close off the
road to rescue services.
The report also finds that the Prisons Service
was not prepared for the task of evacuating a prison both in terms of command
The report says that the Prisons Service bears
responsibility for the carrying out of the evacuation of Damon Prison and
Prisons Service commanders did not update the command centers in real time about
the dangers posed by the fire on Highway 721.
In addition, the report
said, the Prisons Service did not coordinate with police in the early hours of
the fire leading up to the disaster and vice versa.
In regard to both the
Israel Police and the Prisons Service, the report states that commanders showed
“courage and a willingness to risk their lives in order to save lives and
In response to the report’s findings, police issued a
statement Tuesday saying that “the dedication and determination of Israeli
police officers during the blaze led to the evacuation without harm of hundreds
of prisoners at Damon prison, hundreds of traveling civilians, residents of Beit
Oren and patients at the Tirat Carmel Mental Health Center.”
statement also says that police formed their own exploratory committee to
examine the response to the fire in order to learn lessons from the event, most
of which police said they have implemented. They have also appointed a
high-ranking team of officers to examine and implement the lessons included in
the comptroller’s report, police said.
The Prisons Service sent out a
press release Wednesday that said that the organization understands the
importance of the report and “will use it as a tool for improving our
organizational readiness ahead of dealing with future challenges.”
statement also said that the Prisons Service has over the past year and a half
carried out a wide range of changes to improve their operational readiness,
including the formation of regional command centers, updating command protocol,
training for dealing with fires and improving communications equipment. They
have also launched a foundation to support families of those who fell in the
Carmel fire, according to the press release.
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