The subject of the report details a long list of failures and shortcomings in the handling of the various involved parties over the years, and contains recommendations on a variety of issues, while examining the prolonged conduct that contributed to the disaster. However, the main public, media, and political attention after the publication of the committee’s conclusions naturally focused on the last part of the report, which dealt with the personal responsibility of those who were warned by it. Without diminishing the contribution of personal recommendations to the development of political culture and the concept of public responsibility, it must be understood that these are actually only the tip of the iceberg. In this short paper, we will attempt to shed light on those conclusions that have almost completely disappeared from the public discourse, those that dealt with the systemic and root failures that led to the disaster, focusing on the committee’s recommendations for the systemic changes required to prevent the recurrence of such incidents in the future.
From examining the committee’s structural recommendations, general conclusions can be drawn both about the dynamics that lead to disasters and about the culture of learning from past mistakes in Israel. These conclusions may also be relevant to the lessons learned from the October 7 disaster and can teach us about the effectiveness of a state commission of inquiry on the matter, if established. Thus, in these days when there are many calls to establish such a state commission of inquiry, it is important to look back, learn from past cases, and examine this investigative tool with a clear and critical perspective.

It is a tradition in Israel to count the Omer during the days between Passover and Shavuot. A significant portion of these days is characterized by various mourning customs that end on Lag BaOmer, i.e., the 33rd day of the Omer. According to the existing tradition, on this day, Rabbi Shimon Bar Yochai (hereafter: “the Rashbi”) passed away and revealed many secrets of the Torah to his students, and the deadly plague that killed 24,000 of Rabbi Akiva’s students ceased as a punishment for their lack of mutual respect. Therefore, this day is generally marked by celebrations and joy, manifested, among other things, in a pilgrimage to the tomb of the Rashbi in Meron.
During the Lag BaOmer pilgrimage in 2021, the joy at the tomb of the Rashbi was cut short by a severe disaster. Forty-five men, boys, and children who came to celebrate the pilgrimage were crushed in an overcrowded crowd until they lost their lives. Many others were injured physically and emotionally. This is the most significant civil disaster in the history of the State of Israel. Therefore, on June 20, 2021, the Israeli government decided to establish a State Commission of Inquiry to investigate the event and prevent the recurrence of similar events. Immediately after the establishment of the committee, materials were gathered from various sources, site tours were conducted at the tomb of the Rashbi in Meron, and testimonies were taken in two stages. The first stage involved broad and open testimony gathering, aimed at creating a comprehensive and complete picture. Based on these testimonies, warning letters were sent to 18 parties according to Section 15 of the State Commissions of Inquiry Law. Alongside this process, the committee was required to prepare two interim documents containing recommendations and submit them. The need for this arose from the unique nature of the issue: the fact that the disaster being investigated occurred during an event that takes place every year.

State commissions of inquiry are regulated by the State Commissions of Inquiry Law, 1968, which details the manner of appointing the commission and its powers, including the ability to summon witnesses, issue search warrants, gather materials, and prepare a report on the findings of the investigation into the event under review. One of the main goals of establishing a state commission is to restore public trust in the executive branch through an investigation of a significant event or disaster that is “of vital public importance that requires clarification,” and Section 19(a) of the State Commissions of Inquiry Law grants the commission discretion as to whether and how to publish its recommendations. In this context, it is common to divide the recommendations of a state commission of inquiry into two types: personal recommendations regarding those who have been found to have failed in their roles, and structural-operational recommendations. These latter recommendations typically aim to create or improve existing legal structures, address the operational failures of public bodies that led to the event under investigation, and offer deep solutions to prevent the recurrence of similar incidents in the future.

Despite the public prestige and the great trust that state commissions of inquiry generally receive, in practice, there is no legal requirement for the government to accept their conclusions, and it is ultimately up to the government’s discretion. Does this mean that the committee’s conclusions are merely suggestions that the government can ignore at will? Not necessarily. In the past, the Supreme Court has ruled that there is at least an obligation to address the recommendations of a state commission of inquiry, even if not to accept them, due to the independent nature of the commission. Practically, it appears that most of the personal recommendations regarding those in positions of authority were accepted by the government in some form, but when it comes to the structural recommendations, the picture is quite different. Only a few of these recommendations in previous cases have been adopted, and it can be said that much of the work invested by commissions has remained on paper. The reality that has developed in Israel regarding the recommendations of state commissions of inquiry tends to prioritize personal recommendations, partly because the “blame for the failure” perspective allows the public to move on with the feeling that the event has been dealt with and that those responsible have been held accountable. This perspective, however, is incomplete, as in the long term, the structural recommendations are what can shape better decision-making mechanisms and a corrected political culture that can prevent similar failures in the future.

As mentioned, much has been said about the personal conclusions of the report, so this section will primarily focus on the structural-operational conclusions. A careful reading of these reveals that the structural recommendations are divided into two main types: the first type focuses on aspects directly related to the Meron events and the management of the Rashbi tomb site during regular times and on Lag BaOmer. The second type of recommendations addresses what can be identified as a response to structural, root, and deep failures of the public service that could lead to the recurrence of similar incidents. These recommendations should be viewed in light of the systemic failures inherent in the Israeli reality to which they relate, as done in this paper, as only a thorough and wide-reaching response to these will help prevent the recurrence of similar events in the future.

During its work, the committee identified several severe structural failures that led to the Meron disaster. In the published report, the committee highlights systemic ambiguity regarding the different areas of responsibility concerning the Rashbi tomb in Meron, as well as the interfaces between all the parties and ministries involved in Lag BaOmer events. It was also noted that within the public system, there exists a mental rigidity and an adherence to existing policies that are not reassessed or challenged, even when circumstances and conditions change. This regrettable reality is not unique to Meron, and it seems to characterize the functioning of the public service in Israel quite accurately. In this context, four major failures requiring structural changes were identified, and the committee’s recommendations aimed at addressing them.

• The Need for a Clear and Appropriate Division between Public Systems and the Use of Existing Authority
  The public service provides answers to needs in a wide range of areas of life in the state. This broad role naturally involves conflicts and overlaps between different actors. This is particularly significant in the current public climate where government ministries are established and dissolved frequently, and responsibilities shift from ministry to ministry. This reality, in which there are many overlaps on the one hand and a lack of clearly defined boundaries on the other, creates a potential for oversight or partial treatment of core issues. The committee found that the lack of a clear division between the Ministry of Public Security, the Ministry of Religious Services, and other relevant parties, as well as the tendency to avoid using authority, undermines their ability to function properly and create necessary solutions when needed. In this context, the committee recommended a new model for responsibility distribution.

• The Need for the Use of Existing Authority and Increased Central Government Involvement in Planning and Enforcement
  In examining the involvement and oversight of central government authorities in matters of planning and enforcement, it was found that both the local planning committee and the enforcement authority for real estate have powers under the law to act against illegal construction and the removal of dangerous structures in the Meron area. However, these powers had not been used for many years. Therefore, the committee recommended that there should be central government involvement in this area in the absence of action by the local council.

• The Need for a Mechanism for Resolving and Managing Disputes
  The committee recommended that when there is a dispute between government ministries and bodies regarding responsibility or authority over the event, the conflict should be resolved within a fixed period of time. This model can be viewed as a prototype for future cases, with an emphasis on resolving disputes before they escalate into crises.

• Improved Management of Mass Gathering Events
  The committee’s final conclusion emphasized the need to ensure the safety and proper management of mass gathering events by the authorities. The establishment of professional teams for crowd control and the setting of appropriate legal standards for safety protocols are crucial to preventing future tragedies.