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 Wednesday.

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.

The Carmel 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.

The 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.

Also, for 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 the report.

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.

The 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 and organization.

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 property.”

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.”

The 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.”

The 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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