‘Not act of fate', Goa temple stampede that killed 6 result of lapses, ‘fractured accountability': Probe panel
A government-appointed committee that investigated the stampede at a temple in Goa on May 3 has concluded that the tragedy was 'entirely preventable' and stemmed from 'a combination of poor planning, lack of enforcement, ignored directives, and inadequate infrastructure'.
Six people were killed and at least 100 were injured in the stampede that took place during the annual festival attended by thousands of devotees at Lairai Devi temple in North Goa's Shirgao village in the early hours of May 3. The Jatra, held in honour of Goddess Lairai Devi, is attended by thousands of special devotees, called 'Dhonds', who come from across Goa and neighbouring states.
The committee report flagged institutional and procedural shortcomings by the organisers (the management committee of the Shree Lairai Saunsthan), the district administration, police and the local body (village panchayat). The 'absence of basic crowd control infrastructure, disregard for specific administrative instructions and failure to utilise modern surveillance tools' contributed to a critical breakdown in safety, the report said.
It said the stampede was 'not an inevitable act of fate' beyond human control, but a 'preventable tragedy resulting from systemic oversights and fractured accountability'. The committee found that the stampede was precipitated by a 'confluence of preventable lapses and oversights among key stakeholders'.
'The immediate trigger was overcrowding on the sloped pathway between Tali (the holy pond) and Homkhand (fire pit), compounded by the sudden surge and forward movement of a group of Dhonds, disregarding the protocol, which caused the fall of a person and a subsequent domino effect,' the report said.
'However, this critical incident was precipitated by a chain of preventable failures arising from inadequate crowd risk assessment, absence of unidirectional circulation planning, non-implementation of safety directives, ambiguity in sectoral responsibilities, failure to utilise surveillance tools, unregulated roadside vending and the lack of pre-emptive crowd behaviour management,' it said.
The report said the crowd was permitted to enter the sloped pathway from Tali in groups, 'which were subsequently channelled into a two-by-two queue formation after the end of the sloped gradient leading towards Homkhand. This arrangement resulted in a build-up of people on the sloped section, causing overcrowding in that area. The overcrowding, coupled with attempts by some groups of Dhonds to push forward through the crowd and their unruly behaviour, caused instability among devotees walking along the slope'.
As a consequence, a person fell face-first on the sloped section, triggering a chain reaction in which several people behind and around her lost their balance and fell over one another. 'Owing to the downward slope, limited visibility and the push of the crowd and unruly behaviour, the people approaching from behind were unaware of the fall and continued moving forward, leading to the stampede,' the report said.
The stampede 'could likely have been averted with proper planning, risk assessment, and the implementation of effective crowd management strategies', it said.
Releasing the report in a press conference on Tuesday, Goa Chief Minister Pramod Sawant said the tragic incident was an 'eye opener'.
'The fact-finding committee has pointed out shortcomings by several stakeholders — the temple committee, the district administration, district police, village panchayat and crowd behaviour, and it is everyone's collective responsibility. The police have filed a case against unknown people and that inquiry will continue. The government will take action based on the recommendations (of the committee) in the next few days,' he said.
Sawant said that to avoid such incidents in future, crowd management plans will be outlined in advance, in accordance with norms of the disaster management authority, for all religious festivals.
A statement from the office of the Chief Minister said show-cause notices have been issued to eight officers in connection with the inquiry. Notices were issued to former district magistrate, North Goa district; former SP, North Goa; former deputy collector and SDM, Bicholim; former DSP, Bicholim; former mamlatdar, Bicholim; former police inspector, Bicholim police station; former inspector, Mopa police station; and panchayat secretary, Shirgao.
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Indian Express
14-05-2025
- Indian Express
‘Not act of fate', Goa temple stampede that killed 6 result of lapses, ‘fractured accountability': Probe panel
A government-appointed committee that investigated the stampede at a temple in Goa on May 3 has concluded that the tragedy was 'entirely preventable' and stemmed from 'a combination of poor planning, lack of enforcement, ignored directives, and inadequate infrastructure'. Six people were killed and at least 100 were injured in the stampede that took place during the annual festival attended by thousands of devotees at Lairai Devi temple in North Goa's Shirgao village in the early hours of May 3. The Jatra, held in honour of Goddess Lairai Devi, is attended by thousands of special devotees, called 'Dhonds', who come from across Goa and neighbouring states. The committee report flagged institutional and procedural shortcomings by the organisers (the management committee of the Shree Lairai Saunsthan), the district administration, police and the local body (village panchayat). The 'absence of basic crowd control infrastructure, disregard for specific administrative instructions and failure to utilise modern surveillance tools' contributed to a critical breakdown in safety, the report said. It said the stampede was 'not an inevitable act of fate' beyond human control, but a 'preventable tragedy resulting from systemic oversights and fractured accountability'. The committee found that the stampede was precipitated by a 'confluence of preventable lapses and oversights among key stakeholders'. 'The immediate trigger was overcrowding on the sloped pathway between Tali (the holy pond) and Homkhand (fire pit), compounded by the sudden surge and forward movement of a group of Dhonds, disregarding the protocol, which caused the fall of a person and a subsequent domino effect,' the report said. 'However, this critical incident was precipitated by a chain of preventable failures arising from inadequate crowd risk assessment, absence of unidirectional circulation planning, non-implementation of safety directives, ambiguity in sectoral responsibilities, failure to utilise surveillance tools, unregulated roadside vending and the lack of pre-emptive crowd behaviour management,' it said. The report said the crowd was permitted to enter the sloped pathway from Tali in groups, 'which were subsequently channelled into a two-by-two queue formation after the end of the sloped gradient leading towards Homkhand. This arrangement resulted in a build-up of people on the sloped section, causing overcrowding in that area. The overcrowding, coupled with attempts by some groups of Dhonds to push forward through the crowd and their unruly behaviour, caused instability among devotees walking along the slope'. As a consequence, a person fell face-first on the sloped section, triggering a chain reaction in which several people behind and around her lost their balance and fell over one another. 'Owing to the downward slope, limited visibility and the push of the crowd and unruly behaviour, the people approaching from behind were unaware of the fall and continued moving forward, leading to the stampede,' the report said. The stampede 'could likely have been averted with proper planning, risk assessment, and the implementation of effective crowd management strategies', it said. Releasing the report in a press conference on Tuesday, Goa Chief Minister Pramod Sawant said the tragic incident was an 'eye opener'. 'The fact-finding committee has pointed out shortcomings by several stakeholders — the temple committee, the district administration, district police, village panchayat and crowd behaviour, and it is everyone's collective responsibility. The police have filed a case against unknown people and that inquiry will continue. The government will take action based on the recommendations (of the committee) in the next few days,' he said. Sawant said that to avoid such incidents in future, crowd management plans will be outlined in advance, in accordance with norms of the disaster management authority, for all religious festivals. A statement from the office of the Chief Minister said show-cause notices have been issued to eight officers in connection with the inquiry. Notices were issued to former district magistrate, North Goa district; former SP, North Goa; former deputy collector and SDM, Bicholim; former DSP, Bicholim; former mamlatdar, Bicholim; former police inspector, Bicholim police station; former inspector, Mopa police station; and panchayat secretary, Shirgao.
The Hindu
13-05-2025
- The Hindu
Goa stampede: Fact finding inquiry committee recommends dissolving the temple management committee
The Fact-Finding Inquiry Committee (FFIC), constituted to investigate the tragic Goa stampede that occurred early on the morning of May 3, 2025, during the Lairai Jatra festival in Shirgao, North Goa, recommended that the Goa government dissolve the Shree Lairai temple management committee. The report, made available on Tuesday (May 13, 2025), stated that the incident, which led to multiple deaths and injuries, was entirely preventable. 'The failure on the part of the organisers are concerned, inter alia, especially with respect to planning and safety, with not taking cognizance of some untoward incidents in the past, and more particularly with their wilful non-compliance with administrative safety directives; consequently, the Committee strongly recommends that the government should explore the possibility of dissolving the Temple Management Committee and appointing an Administrator, after following due process of law, if deemed appropriate,' the report stated. The Committee's investigation encompassed site visits, consultations with stakeholders, and a review of administrative records. 'The FFIC has concluded that the tragedy was entirely preventable and stemmed from a combination of poor planning, lack of enforcement, ignored directives, and inadequate infrastructure. The recommendations provided in this Report aim to ensure that such incidents do not occur in the future.' Based on field visits, interactions with eyewitnesses, injured victims, organisers, executive magistrates, police officials, and perusal of available records, the committee found that the stampede was precipitated by a confluence of preventable lapses and oversights among key stakeholders. The report stated, 'The Committee has found that the immediate cause of the stampede was overcrowding on the pathway from Tali to Homkhand, particularly at the upper end of the sloped section near the RBL Bank Branch, Shirgao, aggravated by the unruly behaviour of the Dhonds and lack of proper crowd control measures at that location. The crowd was permitted to enter the pathway from Tali in groups, which were subsequently channelled into a two-by-two queue formation beyond the sloped section leading towards Homkhand.' This arrangement resulted in a build-up of people on the sloped section, causing overcrowding in that area. The overcrowding, coupled with attempts by some groups of Dhonds to push forward through the crowd and their unruly behaviour, caused instability among devotees walking along the slope. As a result, it was given to understand that a person fell face-first on the sloped section, triggering a chain reaction in which several people behind and around her lost their balance and fell over each other. Owing to the downward slope, limited visibility, the push of the crowd, and unruly behaviour, people approaching from behind were unaware of the fall and continued moving forward, leading to the stampede, the report read. 'During the inquiry, some injured victims informed the Committee that a minor incident of a similar nature allegedly had occurred in the past, wherein, in one instance, one devotee's arm was critically injured on the day of the Homkhand,' the 26-page report said, adding that last year, a woman allegedly died due to suffocation at the sloped section of the pathway. 'However, the Committee did not find any record to substantiate such an incident. Notwithstanding the absence of official records, the Committee is of the view that key stakeholders, including the organisers, the district administration, and the district police, should have reviewed past occurrences and undertaken adequate precautionary measures to prevent such untoward incidents.' Several eyewitnesses and injured victims reported that some groups of Dhonds forcefully attempted to move from Tali towards Homkhand. 'The organisers were expected to carry out thorough capacity planning based on the location of key sites and the available access routes. Despite the existence of multiple alternative routes, the Committee found that the organisers failed to develop a multi-route circulation plan to avoid congestion along the primary pathway between Tali and Homkhand. No systematic assessment appears to have been undertaken using historical data, crowd arrival patterns, the festival's growing popularity, the year-by-year increase in the number of Dhonds, and the nature of the visitors, particularly for high-density events like the Homkhand ritual,' the report read. The committee stated it was imperative for organisers to conduct a comprehensive risk analysis and preparedness exercise and/or cooperate with authorities, incorporating their input in planning and execution. 'However, a review of the minutes of all pre-event meetings conducted by revenue and police officials revealed that the organisers did not provide critical information regarding the expected number of visitors, potential risks based on past incidents, or options for alternative circulation routes. On the contrary, the Committee found that the organisers appear to have disregarded specific instructions issued by the revenue and police authorities regarding crowd management, focusing instead solely on the conduct of religious activities,' the report said. The report further stated that the organisers neither demonstrated the intent nor undertook any concrete steps to prevent the proliferation of stalls, despite having been clearly informed by the police and revenue officials about the risks involved. 'The Committee found that the organisers were fully aware of this constraint and its potential consequences but wilfully failed to initiate preventive measures to mitigate the risk of an untoward incident.' The Committee observed that although permanent CCTV cameras had been installed within the temple precincts, the organisers did not extend surveillance to high-risk external areas. 'It is particularly concerning that no temporary CCTV cameras were arranged (on a rental basis or otherwise) at key locations such as Tali and the pathway leading to Homkhand, including the sloped section, which is well known for overcrowding and the haphazard movement of Dhonds.' 'This critical incident was precipitated by a chain of preventable failures arising from inadequate crowd risk assessment, absence of unidirectional circulation planning, non-implementation of safety directives, ambiguity in sectoral responsibilities, failure to utilise surveillance tools, unregulated roadside vending, and the lack of pre-emptive crowd behaviour management — all pointing to institutional and procedural shortcomings among the organisers, the district administration, the police, and the local body,' the committe observed. 'The Police arrangement order issued by the Superintendent of Police, North Goa District, dated April 29, 2025, refers to the installation of six watchtowers. However, during its interaction with the Police Inspector, Bicholim, the Committee learnt that the watchtower designated near the sloped section was not erected at all, and the two police constables assigned to that location were deployed at other points,' the report added. Although the Police had deployed a drone for surveillance purposes, the Committee found that it was not utilised during the aforementioned critical period. The reasons for this could not be established at this time, the committee stated. The State government has issued Show Cause Notices to eight former officials from North Goa District administration, the local police department, and Shirgao panchayat.
Indian Express
05-05-2025
- Indian Express
Before Goa stampede that killed 6, police suggestion on CCTVs, barricades fell on deaf ears
Days before six people were killed in Saturday's stampede during the annual Jatra at the Lairai Devi temple in Goa, police had issued instructions to the temple committee to install CCTV cameras at entry and exit points, make arrangements for queueing with proper barricading, and set up a public address system to avoid any untoward incident, The Indian Express has learnt. The committee said the CCTV cameras were not installed because there wasn't enough time, and that the barricades were not set up because on a previous occasion when they were in place, they had caused injuries to devotees. The instructions were issued during a meeting on April 30 attended by senior police and district administration officials. Those who attended the meeting included North SP Akshat Kaushal, Bicholim SDPO Jivba Dalvi, Bicholim police station inspector Dinesh D Gadekar, Bicholim Deputy Collector Bhimnath Khorjuvekar, Bicholim Mamlatdar Abhijeet Gaonkar, and Shree Lairai Devasthan president Shirgao Dinanath Gaonkar, as well as other members of the temple committee. According to the minutes of the meeting, police issued instructions to the temple committee members 'to tackle any eventuality and contingency'. The minutes said, 'Instructions were issued to the temple committee to install PA (public address) system near Lairai temple premises and homkhund (fire pit that is circled by devotees). The temple committee is also asked to install CCTV at all the entry and exit points, crowded areas, near the temple and homkhund, along with CCTV control room wherein adequate police staff would also be provided.' 'The temple committee is also requested to make necessary arrangements with regard to the maintenance of queue with proper barricading wherever required. The committee is also requested to assist police in crowd control and management during the festivity,' the minutes read. In another joint meeting on April 16, concerns were raised about crowd control at the temple site of Mahamaya temple, homkhund and the road approaching the temple. Temple committee president Dinanath Gaonkar said a meeting was held on April 16 in which discussions were held with various stakeholders and duties were assigned. 'Another meeting was scheduled for April 25, but it was postponed. On April 30, senior police officers came and gave (these) instructions. They said stringent action will be taken if instructions are not complied with. It takes at least 15-20 days to set up CCTVs. In two days, what can we do? Regarding the barricading (near the temple), we refused because on a previous occasion, when we had put barricades during the Jatra, some devotees had suffered injuries,' he said. Gaonkar said all the requisite precautions had been taken by the temple committee. 'There is no mistake on our part in this regard. We have given our statement to the fact-finding committee and it is for the committee to come to a conclusion on what led to the mishap,' he said. The Goa government on Saturday constituted a four-member fact-finding committee to investigate the incident. The government also transferred North Goa Collector Sneha Gitte, SP Akshat Kaushal, Deputy SP Jivba Dalvi, Deputy Collector Bhimnath Khorjuvekar, and Police Inspector Dinesh Gadekar. The stampede occurred between 2.45 am and 3 am, when a big crowd of devotees made their way through a steep and narrow stretch of road towards the temple. 'As the Dhonds (the devotees taking part in the Jatra) formed multiple queues, there was a lot of pushing and shoving in the crowd. One woman tripped, and due to the topography of the narrow road, several others fell, which may have led to the stampede. The fact-finding committee is recording statements of all the victims and officials and will soon submit a report,' a government official said. Eyewitnesses on Saturday said the stampede was caused by a scuffle among the unregulated crowd on the narrow stretch leading to the temple. The Jatra, held in honour of Goddess Lairai Devi, is attended by thousands of devotees called Dhonds. They come from across Goa and neighbouring states. In a fire-walking ritual at the Jatra, the Dhonds circle a fire pit and walk barefoot across burning embers — a spectacle that draws many spectators.
