Interim Report-Ellispark Soccer Disaster

INTERIM REPORT

COMMISSION OF INQUIRY INTO THE ELLIS PARK

STADIUM SOCCER DISASTER OF 11 APRIL 2001

CHAIRPERSON: MR JUSTICE B M NGOEPE

JUDGE PRESIDENT: TRANSVAAL PROVINCIAL DIVISION OF THE

HIGH COURT OF SOUTH AFRICA

ADDITIONAL MEMBER: ADV I A M SEMENYA SC

INDEX

1. INTRODUCTION..................................................................................................................1

1.2 The Commission=s Terms of Reference ...............................................................1

2. THE NATURE AND STRUCTURE OF THIS REPORT .........................................................3

3. ACKNOWLEDGMENTS ........................................................................................................4

4. PROCESS AND PROCEDURE ..............................................................................................5

5. THE SUBJECT OF INQUIRY: THE 11

APRIL 2001 DISASTER AT ELLIS PARK

STADIUM .......................................................................................................................8

6. THE VENUE: ELLIS PARK STADIUM.................................................................................9

6.5 The Joint Operation Centre (JOC)........................................................................13

6.6 The Scaffolding: Erected specifically for the day in question............................14

6.7 The Railings............................................................................................................15

6.8 Suites and access thereto.....................................................................................16

7. THE ROLE PLAYERS AND THEIR RESPECTIVE AREAS OF RESPONSIBILITY ON 11

APRIL 2001........................................................................................................................16

7.1 Ellis Park Stadium Management. ........................................................................16

7.2 Kaizer Chiefs. ........................................................................................................17

7.3 Orlando Pirates. ...................................................................................................18

7.4 Contracted security companies. ..........................................................................18

7.4.1 Wolf security .............................................................................................18

7.4.2 Associated Prevention Services ..............................................................19

7.4.3 Stallion Events Management ...................................................................19

7.4.4 Diligence Services Holdings ......................................................................20

7.5 Soccer bodies. .......................................................................................................20

7.5.1 South African Football Association (SAFA). ............................................20

7.5.2. The National Soccer League (NSL). ..........................................................21

7.6 The South African Police Services (SAPS)............................................................21

7.7 The Johannesburg Metropolitan Council............................................................22

7.8 Soccer supporters.................................................................................................22

8. PRE-EVENT HISTORY: RELEVANT EXPERIENCES OF THE PAST...............................22

8.1 Kaizer Chiefs v Orlando Pirates : Orkney, 1991 .................................................23

8.2 Kaizer Chiefs v Orlando Pirates : Ellis Park Stadium,

10 October 1998...................................................................................................24

8.2.1 The Version of the South African Police Services ..................................24

8.2.2 Kaizer Chiefs Version.................................................................................27

8.2.3 The Version of the Premier Soccer League.............................................28

8.2.4 The version of Ellis Park Stadium Management .....................................29

8.3 Orlando Pirates v Kaizer Chiefs: First National Bank Stadium, 29 November

2000........................................................................................................................30

9. EVENTS PRIOR TO, AND PREPARATIONS FOR, THE 11

APRIL 2001 GAME ........33

9.1 Operational Meetings............................................................................................33

9.2. Classification of the game.....................................................................................42

9.3 The Mobile Screen..................................................................................................43

10. SOME OF THE MATERIAL EVENTS FOUND TO HAVE OCCURED ON THE DAY OF THE

MATCH................................................................................................................................48

10.1 Traffic congestion and the blockade of the stadium by abandoned vehicles..48

10.2 The sale of tickets for the game..........................................................................50

10.3 The announcement that tickets were sold out; and the re-action of the

crowd thereto........................................................................................................53

10.4 The Crush...............................................................................................................55

10.5 The use of teargas, or similar substance.............................................................59

10.6 Stoppage of the game ..........................................................................................66

10.7 The tragedy............................................................................................................66

11. FACTORS WHICH PRECEDED THE EVENT AND WHICH LED TO THE TRAGEDY, AND

MISMANAGEMENT............................................................................................................67

11.1 Poor Forecast of Match Attendance....................................................................67

11.2 Failure to learn from the lessons of the past......................................................69

11.3 Failure by the role players to clearly identify and designate areas of

responsibility. .......................................................................................................69

11.4 Absence of overall command of the Joint Operation Centre............................72

11.5 The inappropriate and untimely announcement that tickets were sold out...74

11.6 Failure to adhere to FIFA and SAFA guidelines..................................................75

11.7 Unbecoming spectator behaviour........................................................................76

11.8 Sale of tickets at the venue and unreserved seating.........................................78

11.9 The use of teargas or a similar substance...........................................................80

11.10 Corruption on the part of certain members of security personnel..................80

11.11 Dereliction of duty: ...............................................................................................81

11.12 Failure to use the big screen.................................................................................83

11.13 Inadequate public address system......................................................................85

11.14 Failure by the Public Order Police Unit to react timeously and effectively .......86

12. GENERAL REMARKS..........................................................................................................87

12.1 The attitude of certain members of Private Security Companies.....................87

12.2 Castle complimentary tickets................................................................................89

COMMISSION OF INQUIRY INTO THE ELLIS PARK STADIUM SOCCER

DISASTER OF 11 APRIL 2001

INTERIM REPORT

1. INTRODUCTION

1.1_ Mr President, on 20 April 2001, following injuries to scores of people and

the tragic loss of lives at a soccer match between Kaizer Chiefs Football

Club and Orlando Pirates Football Club at Ellis Park Stadium in

Johannesburg on 11 April 2001, you established a commission of inquiry

into the incident; you also appointed me to chair the commission. Adv I

A M Semenya SC, was subsequently appointed additional member.

1.2 The Commission=s Terms of Reference

The Commission=s terms of reference are published in Government

Gazette No 22246 of 20 April 2001, Regulation Gazette no 7053:

AA.The Commission shall inquire into, make findings and report on the

following matters:

1. The facts that led to the disaster on 11 April 2001 at Ellis Park

Stadium, in particular:

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1.1_ the events that took place on the day in question;

1.2_ factors which preceded the event and which led to the

tragedy; and

1.3_ whether there was any mismanagement on the part of

anybody.

2. The Commission shall report and make recommendations on how a

similar occurrence is to be prevented in future.

1. These terms of reference may be added to, varied or amended from

time to time.

2. The Commission shall commence with its duties forthwith.

3. The Commission shall have the power to publish interim reports

4. The Commission shall be subject to and be conducted in terms

of the provisions of the Commissions Act No 8 of 1947, as amended,

and the regulations published thereunder.@

2. THE NATURE AND STRUCTURE OF THIS REPORT

2.1 This is merely an interim report; secondly, it will not include

recommendations as to what steps should be taken to prevent a similar

tragedy from happening again. This particular aspect requires further

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research, consultations, comparative studies etc. In the meantime,

however, it has been decided to release an interim report given the

public=s anxiousness, particularly as to what led to the tragedy.

Thirdly, in order not to burden the report, no attempt will be made to

summarise the evidence, except where absolutely necessary.

Adv Semenya SC concurs with the report.

2.2 No Executive Summary has been prepared, it being hoped that the

detailed index will make the contents of the report readily accessible.

2.3 Apart from the Introduction, this report deals with the following:

2.3.1 Acknowledgments.

2.3.2 Process and Procedure.

2.3.3 The subject of the inquiry.

2.3.4 The Venue: Ellis Park Stadium.

2.3.5 The role players and their respective areas of responsibility on

11 April 2001.

2.3.6 Relevant experiences of the past.

2.3.7 Events prior to, and preparations for, the 11

April 2001 game.

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2.3.8 Some of the material events found to have occurred on the day

of the match.

2.3.9 Factors which preceded the event and which led to the

tragedy, and mismanagement.

2.3.10 A few general remarks

3. ACKNOWLEDGMENTS

We consulted with a number of people in the United Kingdom who are experts

on the safety and security of the game of soccer and its administration. We

also read some of the publications on the matter, including reports of two

commissions of inquiry into similar disasters in that country, namely, the Inquiry

by the RT Hon Lord Justice Taylor into the Hillsborough Stadium Disaster on 15

April 1989; and the Committee of Inquiry into Crowd Safety and Control at

Sports Grounds chaired by Mr Justice Popplewell. We were able to visit two

stadia in that country. We also had the benefit of a report by a commission of

inquiry, chaired by the late Rodger Sishi, into the Orkney soccer disaster which

occurred in 1991 when the same teams met. The list is not complete.

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4. PROCESS AND PROCEDURE

4.1 Following the publication of the Government Gazette constituting the

Commission, several interviews were held with the media for wider

publicity; the purpose was to invite members of the public and role

players to make inputs into the work of the Commission. Wide spread

publicity was given by the media to the processes of the Commission,

for which I express my appreciation.

4.2 Meetings were also held with the legal representatives of the role

players to arrange days for the hearing of oral evidence. Despite the

inevitable difficulties in reconciling the availability of the different

participants and the urgency with which the matter had to be

addressed, we were able to settle such dates. I record the

Commission=s indebtedness to the legal representatives in this respect.

A special word of thanks must also go to Adv Attwell and his team that

included Advocates Ledwaba and Gangadu. They did good work in

leading evidence on behalf of the Commission; the same must be said

about the police who were assigned to assist the Commission. Another

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word of thanks must go to the secretariate of the Commission.

4.3 The hearings commenced on 16 July 2001. There were, inevitably, a

few adjournments in between. In the end, evidence was heard over

a period of about 10 weeks. A total of 47 witnesses testified. Some

of them had to relive their traumatic experiences of the night in

question, as also to endure what was sometimes an inordinately long

cross-examination. I am grateful for their input; the same goes for the

relatives and friends of the victims who appeared before the

Commission.

4.4 In the course of the inquiry, it became necessary to conduct a formal

inspection in loco and to make various observations which turned out

to be highly enlightening. I express my appreciation to the assistance

given by the Ellis Park Stadium management in facilitating and

arranging the inspection in loco.

4.5 I record my thanks to Mr Trevor Phillips of the United Kingdom, the

former Chief Executive Officer of the Premier Soccer League, for making

time to come to South Africa specifically for the purpose of testifying

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before the Commission.

4.6 At the conclusion of the evidence, the legal representatives of the

various role players submitted written argument. They were also

invited to make oral submissions if so advised. Their arguments were

constructive, objective and of tremendous help to the Commission.

4.7 Given the nature of the mandate and the fact that this unfortunate

incident was a repeat of similar tragedies in other parts of the world,

we visited a few authorities in charge of football in the United Kingdom

to learn from their experiences. The co-operation, understanding,

assistance and compassion given by the people we met was invaluable.

Special thanks must also go to the then South African High

Commissioner in London, Ms Cheryl Caroulus and her staff; they

facilitated the Commission=s work in that country.

5. THE SUBJECT OF INQUIRY: THE 11

APRIL 2001 DISASTER AT ELLIS

PARK STADIUM

5.1 During the early evening of Wednesday 11 April 2001 a large crowd of

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people descended onto the Ellis Park Stadium, Johannesburg, to watch

a soccer match between Kaizer Chiefs Football Club (Kaizer Chiefs) and

Orlando Pirates Football Club (Orlando Pirates). The event was to turn

into the worst soccer disaster the country had known. A stampede

ensued. At the end of it all, 43 people had lost their lives and scores

had sustained injuries of varying degrees.

5.2 The game was a Premier Soccer League fixture. There had been two

previous unsuccessful attempts to schedule the match for earlier dates;

the problem was fixture congestion and the clash between national

call-ups of the teams= players and the league=s fixtures. The game

was very crucial as the outcome thereof had the potential to determine

the league=s championship of that particular season. The two teams

were themselves amongst potential champions. For this reason, there

was bound to be a large number of spectators; especially because the

two teams have the most supporters in South Africa and are both

based in Johannesburg.

5.3 The match was a so-called home fixture for Kaizer Chiefs which had Ellis

Park Stadium as its home ground. It is accepted practice in soccer that

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home fixtures offer an added advantage to the home team in certain

respects: for example, the team would hope to attract a larger number

of supporters at such a venue and would be much more familiar with

the pitch; on the other hand, such a team incurs certain security

responsibilities.

6. THE VENUE: ELLIS PARK STADIUM

What follows is a broad description of the Ellis Park Stadium, with reference to

some of its features relevant to this inquiry.

6.1 Ellis Park Stadium lies east of Johannesburg in the Doornfontein area.

It is one of the premium stadia in the country with a capacity of about

sixty thousand (60 000) spectators. Adjacent to it is the Johannesburg

Stadium, also a superb facility designed along the lines of leading

international venues. Ellis Park Stadium forms part of what is

otherwise known as the Ellis Park Sporting Precinct. The precinct is a

world-class sports, recreation and entertainment venue. It is located

within walking distance of Johannesburg Central Business District and

the densely populated neighbourhoods of Berea and Hillbrow. It is

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easily accessible by road and rail and offers some of the best sporting

facilities in the world. The precinct is bordered by Charlton Terrace in

the north, Bertrams Road in the east, Miller Street in the south and a

railway line and Siemert Road in the west. The areas immediately

adjacent to the precinct are affected by activities within it; in

particular, the businesses and industries between Miller Street and

Bezuidenhout Street, and the Egoli Triangle, to the south of the

precinct. Its facilities are centred around the African Plaza, a

landscaped pedestrian area and are surrounded by seven-and-a-half

hectares of open space. Designed to cater for up to 150 000 people at

any given time, the precinct (not the stadium) offers facilities for a very

wide cross-section of the community on a sustained basis.

6.2 The Ellis Park Stadium does not, however, have any formal parking for

spectators, except for some areas that are reserved for AVIP@ parking.

On event days, the streets surrounding the stadium are congested with

parked vehicles and most businesses and industries in the area hire out

their parking to spectators.

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6.3 Ellis Park Stadium has an outer perimeter fence that runs from the

middle of the northern stand next to the Upper Ross Street, around the

east side to South Park Street next to gates 7, 8 and 9. There are

other sections of the fence along Ove Street to Upper Railway Street

and certain sections of the perimeter along Staib and Currey Streets.

B The one entrance to the stadium lies on the south-west side of the

stadium, closest to gates 10, 11 and 12. It is at this point that a

fair amount of spectators including those who use the railway gain

access into the stadium.

B Lying to the north-east corner of the stadium is the main gate which

is closest to gates 4, 5 and 6. The majority of spectators use this

entrance to enter the stadium. The stadium management has

always been aware that this entry point normally gets congested

during matches that draw a large number of spectators; the same

applies, to a lesser extent, to the entry in the south-west side.

B Between the outer perimeter fence and the stadium proper(property

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otherwise belonging to the local Municipality) is a large area that

accommodates spectators en route to various gates at each corner

of the stadium.

6.4 The Commission has been told that Ellis Park Stadium is accredited by

FIFA, SAFA, SARFU and the IRB as a suitable test venue. It has a

Sony Jumbo Tron screen, an Advertisement Scroll, an Internal and

External Public Address System, a Medical Surgery Unit, a Media

Centre, an Individual Telephone Services for thirty-two media personnel

(accommodating fifty internally), a South African Police Services charge

office, a Joint Operation Centre, two spotter kiosks, thirty-four internal

food and refreshment kiosks, a ticket printing and issuing office and

eight change rooms. For night games it has a lighting lux level of one

thousand six hundred and four standby generators for emergency, and

additional electrical requirements. The stadium has electronic

evacuation roller shutter gates which can be controlled jointly and

individually by either an electronic switch, or manually.

6.5 The Joint Operation Centre (JOC)

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6.5.1 Ellis Park Stadium had a purpose built Joint Operation Centre

(JOC) situated on the northern stand of the stadium. The

room had a glass face giving a wide view around the stadium

save a small section underneath it and the top sides of the

northern side of the stadium on either side. Behind the JOC

was another room that was used to house additional

members of the joint operations team. The JOC was fitted

with a transmitter and a radio. Since the incident the JOC

has been moved to the southern side of the stadium, rebuilt,

refurbished and even better equipped.

6.5.2 Seated in the JOC on 11 April 2001 were: a representative of

Ellis Park Stadium who was manning additional radios for two

security companies, a representative of the Visible Policing

unit of the South African Police Services, representatives of

two security companies and a Premier Soccer League

representative (the latter is alleged to have been present for

only a very short period of time). There was also a

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representative of the Johannesburg Metropolitan Police.

6.6 The Scaffolding: Erected specifically for the day in question

The stadium management erected scaffolding for the day to create

additional channeling of spectators towards gates 4 and 5. It must be

said that the scaffolding was a potential safety hazard. Moreover, the

area where the scaffolding was erected serves, according to the

stadium design, as an exit point during evacuation. The video footage

of the emergency rescue operations shows an ambulance whose access

to the pitch could have been impeded by the scaffolding at the tunnel

entrance. To suggest that ambulances were not meant to come onto

the pitch does not excuse the creation of a potential hazard and

obstruction.

6.7 The Railings

There were some railings at each corner of the lower terraces of the

stadium. These were made of metal and were affixed to the concrete

stairs that run from the top of the gangway to the bottom section of the

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stadium. The stated purpose of the railings was to separate the

sections of the stadium as well as to offer support as a handrail. The

railings in the north-east corner were damaged when some of the

victims got trapped and crushed against them. The railings were

therefore a potential safety hazard.

6.8 Suites and access thereto

The stadium has several suites. The suite areas represent

approximately ten thousand (10,000) of the sixty thousand (60,000)

seats offered by the stadium.

Given the history of Ellis Park as a rugby stadium, the majority if not

nearly all of the privately owned suites belong to companies whose

main interest is rugby as opposed to soccer. In most instances where

soccer is staged at Ellis Park, many suites remain unoccupied with the

result that they are referred to as a Aring of shame@. This must be

because whereas a large number of soccer fans would be congested in

the open grand stands, these suite areas would remain unoccupied.

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7. THE ROLE PLAYERS AND THEIR RESPECTIVE AREAS OF RESPONSIBILITY

ON 11 APRIL 2001

7.1 Ellis Park Stadium Management.

Ellis Park Stadium Management had contracted several security

companies to offer specialised security services for that day; it also had

to provide its own security team,emergency medical services at the

stadium, and the room referred to above as the Joint Operation Centre

(JOC) in which parties charged with security would be represented; the

management was also tasked with the printing, issuing and distribution

of tickets and the co-ordination of the operational meetings. The above

were only some of the responsibilities of the Ellis Park Stadium

management in relation to that game.

7.2 Kaizer Chiefs.

The club used the stadium as its home ground. The relationship

between Kaizer Chiefs and Ellis Park is ad hoc; however, it is said to be

loosely governed by a document entitled AEllis Park Stadium

Promoter=s Guide@. There is a serious dispute between Kaizer Chiefs

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and Ellis Park Stadium management as to who was in overall charge of

security, each contending that it was the other. As will appear later,

this situation did have a negative effect on the maintenance of security

on the day in question.

7.3 Orlando Pirates.

It was the visiting team. The team carried no real security

responsibilities, besides providing a contingent of security personnel,

including the head of its own security, as a component of the Premier

Soccer League security team.

7.4 Contracted security companies.

They were Stallion Events Management (Pty) Limited (that subcontracts

Viper Reaction Unit), Diligence Services Holding (Pty) Limited, Wolf

Security Group (Pty) Limited, and Associated Prevention Services (Pty)

Ltd (APS) - a subsidiary of Associated Intelligence Network.

7.4.1 Wolf security

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It was to control access into the stadium proper and the

suites. It deployed two (2) special events managers and three

hundred and two (302) special events officers who would be

dressed in an identifiable outfit. Their function was to control

access into the stadium by tearing the tickets of the

spectators, and routing spectators through into the stadium.

The personnel were to man each turnstile on the outside and

the inside.

7.4.2 Associated Prevention Services

It deployed twelve (12) members who would look after the

AVIP@ areas; there was also a representative in the JOC. To

that number would be added sixty (60) reaction officers.

7.4.3 Stallion Events Management

It deployed one hundred and forty-five (145) control officers,

sixteen (16) armed guards, two (2) additional armed guards

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for the administration building and seventy (70) reaction unit

members in and around the stadium. The responsibility of this

company was to man the gates of the outer perimeter and the

parking area; it would also provide reaction units (Viper) that

would defuse small conflicts whenever they arose.

7.4.4 Diligence Services Holdings

It deployed eighteen (18) people in total whose responsibility

was to ensure the security of the field, tunnel, change rooms

and all the bars.

7.5 Soccer bodies.

7.5.1 South African Football Association (SAFA).

It is the national body in control of the game of soccer

throughout the country, both professional and amateur. It is

affiliated to the world body, FIFA.

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7.5.2. The National Soccer League (NSL)

It falls under the jurisdiction of SAFA, and runs professional

soccer in the country, including the Premier Soccer League

(PSL) whose fixture the game was. PSL was to provide one

hundred and fifty (150) security personnel whose responsibility

was to help at the outer perimeter, to assist with crowd

control as well as the channeling of spectators at ticket selling

points. Its security comprised a team from Kaizer Chiefs and

Orlando Pirates each. PSL contends that the security

personnel it deployed on the day was far in excess of two

hundred and fifty (250). It insists, however, that its security

personnel were merely to act as Amarshals@.

7.6 The South African Police Services (SAPS).

SAPS had to be present to ensure law and order in and around the

stadium and to prevent crime. The Public Order Policing unit was to

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maintain public order whenever it was threatened. The Visible Policing

unit (Vispol) were responsible for crime prevention and were in uniform.

There was also a mounted corps and a bomp disposal unit.

7.7 The Johannesburg Metropolitan Council.

The council was to provide its police to ensure a smooth flow of traffic,

including the prevention of obstructive and random parking of vehicles.

The council also had a disaster management unit, which was also

primed to deal with emergencies.

7.8 Soccer supporters.

This was a very important constituency and played a major role that

night. A huge crowd turned up, with people coming from different

parts of the country.

8. PRE-EVENT HISTORY: RELEVANT EXPERIENCES OF THE PAST

Many witnesses testified about their experiences during previous clashes

between the two teams.

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8.1 Kaizer Chiefs v Orlando Pirates : Orkney, 1991

Kaizer Chiefs played Orlando Pirates in a friendly match in 1991 at

Orkney. A stampede occurred in which forty one people were killed and

many injured. Following the disaster, the National Soccer League

instituted a commission of inquiry under the chairmanship of the late

Roger Sishi. The following were some of the recommendations by that

commission:

8.1.1 that stairways, access ways and landings should be kept clear

at all times to avoid impeding pedestrian movement;

8.1.2 that in view of the fanatical support that Kaizer Chiefs and

Orlando Pirates enjoy, it is essential to employ adequate

numbers of security personnel whenever the two teams play

against each other;

8.1.3 that security personnel should always be visible to the

spectators;

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8.1.4 that security personnel should always be positioned where

they can have a clear and unobstructed view of the

spectators and can monitor the latter=s behaviour.

8.2 Kaizer Chiefs v Orlando Pirates : Ellis Park Stadium,

10 October 1998

Problems occurred at this game and the police were forced to use

rubber bullets. The role players involved had different versions,

particularly as to what caused the rioting.

8.2.1 The Version of the South African Police Services

The records of the SAPS indicate that the game was marred

by various incidents of violence, including damage to property.

The match was played on a Saturday afternoon. Records also

indicate that whereas the capacity of the stadium was about

sixty thousand (60,000), an estimated ninety thousand

(90,000) spectators turned up. The SAPS points in a report

that among factors that led to the violence were the following:

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B The fact that the PSL security personnel allowed

spectators through the gates after corruptly receiving

monies from them, resulting in ticket-holding spectators

being unable to enter the stadium;

B more spectators were allowed into the stadium despite

the fact that the stadium was already full;

B thousands of complimentary tickets were used, thus

swelling the numbers far beyond the projections;

B the issuing of complimentary tickets was apparently

unsupervised;

B the aisles, gangways and passages were congested with

spectators making the management, policing and

evacuation of spectators difficult;

B spectators became unruly at 15:00, breaking down the

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perimeter fence and the entrance gates when access to

the stadium was being restricted;

B when the police attempted to drive the spectators away

from the perimeter fence they were pelted with bottles

and stones; in response, the police fired rubber bullets

and used shields and tonfas;

B the PSL security officials were untrained and were believed

to have been drawn generally from lay members of the

public and could therefore not manage a crisis situation;

PSL security officials were more interested in watching

the game than in attending to their responsibilities;

B soccer has a culture of selling tickets shortly before the

event resulting in the ticket selling points being unable to

cope with the pressure brought onto them.

8.2.2 Kaizer Chiefs Version

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Kaizer Chief=s account of events is that whereas the stadium

capacity was sixty thousand (60 000), comprising fifty

thousand (50 000) on the open stands and ten thousand (10

000) on the suites, approximately twenty thousand (20 000)

more spectators than the capacity of the stadium arrived at

the venue. The pre-event operational plans had emphasised

that the capacity of the stadium would not be exceeded and

Ahouse-full@ signs were posted at 15:00.

Thousands of spectators who had bought tickets earlier found

it difficult to get into the stadium as most of the gates were

closed; ticket and non-ticket holders blocked the AVIP@ gate

and vehicles could not access the stadium. In frustration,

spectators coming from the Ellis Park Station started stoning

AVIP@ cars; windows of the ticket selling cubicles were

damaged and the cubicles set alight; spectators broke down

the perimeter fences, and entry gates into the stadium were

damaged; the unoccupied suites were also damaged.

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8.2.3 The Version of the Premier Soccer League

There was massive damage to property during the event.

Spectators broke through the perimeter gates, set alight ticket

offices, broke stadium gates, barged into suite areas and in general

caused mayhem and chaos. A ticket pre-sale campaign during the

week preceding the event did not help as only thirteen thousand (13

0 00) tickets had been sold by the Friday before the match.

Compounding the problem was that most people who had bought

their tickets in advance arrived late at the stadium, as did those

without tickets.

The PSL also recorded that there were approximately a hundred

thousand (100,000) spectators on the day of the match, which

number was far in excess of the capacity of the stadium. There

were injuries, but no fatalities were reported.

8.2.4 The version of Ellis Park Stadium Management

The Ellis Park Stadium Management record of the events indicates

that whereas the capacity of the stadium was sixty thousand

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(60,000), comprising fifty thousand (50,000) seats and ten

thousand (10,000) seats in the suites, the attendance for the match

was between eighty thousand (80,000) and one hundred thousand

(100,000). Only fourteen thousand (14,000) tickets were sold

during the week prior to the match, with thirty-six thousand

(36,000) available for sale on the day of the match. When capacity

was reached, ticket sales were stopped and the supporters reacted

by storming and breaking through the perimeter gates, setting

alight ticket offices, ripping out stadium gates and barging into suite

areas; damage to the stadium was between two hundred thousand

rand (R200,000.00) and two hundred and fifty thousand rand

(R250,000.00)

Ellis Park blamed the situation on the poor quality of the services of

members of the PSL security; it was said that they were

inexperienced, and not able to cope with the intensity of such a

situation.

8.3 Orlando Pirates v Kaizer Chiefs: First National Bank Stadium,

29 November 2000

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Several witnesses before the Commission also testified about this

game. It was played on a Wednesday night on 29 November 2000 at

the First National Bank Stadium, Johannesburg; a massive stadium

popularly referred to as ASoccer City@. Evidence shows that the selling

of tickets started at 17:30. The sale was slow and only started picking

up at approximately 19:45 when a crowd of about fifteen thousand

(15,000) to twenty thousand (20,000) arrived. There were thirty-four

(34) cashiers.

The game started while a large number of spectators was still in the

process of buying tickets, causing enthusiastic spectators to climb the

perimeter fence in order to get into the stadium; others tore the fence

down. Some of the spectators who gained entry in this way had tickets

but were too impatient to get in through the turnstiles.

In his report on the incident to the Chairman of Orlando Pirates, the

head of the team=s security described the events of that day as follows

(taken verbatim from the report):

-31-

AThe game started to play 20:00. The spectators started to show up

at around 19:30 and during that thirty minutes before kick-off B twenty

thousand (20 000) spectators were seen outside the stadium trying to

enter through the turnstiles. The gates were turning very slowly

because of the counting. Three gates were forced open and we

managed to control it again. When I was busy at the stadium, Mr

Thidiela (the then head of the PSL security) approached me and said

that I must open all the emergency gates that the spectators must gain

free entry. I refused his request and after fifteen minutes Oupa, who

is second in charge of security, came to me and reported that there are

two gates being forced open by the spectators outside. Oupa was

supposed to handle this matter.

We have tried very hard to control the spectators who had arrived later

thirty to fifteen minutes to kick-off time. The emergency gates at FNB

stadium were not so strong and the spectators managed to push it open

but we tried very hard and closed the gate. Mr Chairman, I want you

to know that the night game between Pirates and Chiefs it is always the

case with spectators. Last year between the Chiefs and Pirates at Ellis

-32-

Park a similar scene happened that the spectator arrive thirty minutes

before kick-off. Even at the game between Chiefs and Sundowns at

Johannesburg stadium the same thing happened. Mr Chairman, I am

requesting you not to allow the big games to be played at night because

some were shot by the police, some injured, some died at Ellis Park

stadium.@

The witness continued (taken verbatim from the report):

AAs the security members, having analysed the situation regarding

night games, particularly involving Kaizer Chiefs on the 29 November

2000 and the Rothmans replay, it appears it will always be problematic

dealing with spectators when they arrive. Spectators= arrival and queue

to buy tickets started heavily from 17:15 on both occasions this is

mainly because some come from far away and could not make it earlier

as it was during the week and they had work commitments.

It is a known fact that games of this nature generate a lot of

spectator=s interest and it will be advisable to play on a weekend.@

-33-

9. EVENTS PRIOR TO, AND PREPARATIONS FOR, THE 11

APRIL 2001

GAME.

9.1 Operational Meetings.

9.1.1 On 27 March 2001 the following role players held a meeting in

preparation for the game: Ellis Park Stadium Management,

representatives of Kaizer Chiefs, PSL, South African Police

Services, Stallion, AIN, Diligence, Wolf, Metro Traffic

Management, Pick it Up Environmental and Johannesburg

Sport. The minutes reflect that the meeting dealt with issues

such as the number of security personnel required and

equipment to be deployed. Notable in the minutes is that the

Visible Policing unit would deploy a hundred and fifty (150)

members plus one (1) who was to sit in the Joint Operation

Centre. The Public Order Policing unit would deploy twenty

five (25) members and four razor wire vehicles. Kaizer Chiefs

(clearly reference to PSL security) was to deploy two

hundred and sixty (260) security personnel. The meeting also

-34-

discussed the possible use of a big screen.

The minutes of the meeting, as amplified by the transcript,

also indicate that there was consciousness on the part of the

role players present that gates 4, 5 and 6, which are situated

on the north-eastern side of the stadium where the main

entrance is, had always been a problematic area. The minutes

state in so many words that there are huge problems in

respect of those gates at big games. This is what appears in

the transcript:

AJVR: Mr Chairman can I just raise a few problems at the

risk of being a pain in the butt? We=re shooting

ourselves in the foot there at gates 4, 5 and 6 with

every big match. We know now what a trend is and

we still keep on doing what we were doing we

don=t have enough tickets booths. At every single

match there we need the police to come and help us

-35-

out because they break the gates down because

there are too many people and too little Y that the

one problem, the second problem is that Y. But the

bulk of our people come through that gate, the bulk

of the stadium comes through there and 12

(referring to the booths) is not enough. The

problem is really, soccer is Y. When we started

doing soccer the people used to come in at 08:00 in

the morning to come watch the game at 16:00 in

the afternoon. Now when a game is 20:00 at night

they arrive at 19:00. When we=ve got 20 000

arriving at 19:00 we just don=t have enough gates

to get them through as simple as that. And we are

all fine there is no shouting and screaming until the

main match starts when that whistle go they break

the gates down. I mean it happens to us every

match and we just ride it through and we are being

stupidY@

-36-

ACC: I do not think it=s the problem at the ticket offices as

such, but it=s the whole areas where they go in,

they go straight to gates 4, 5 and 6 and that=s the

problem@

AJVR: I have a different problem concerning those gates. If

you have a sound system that we use at gate 4 and

I put in one of my black guys, its superb. What we

do is, when the guys come in they just naturally, all

stream to gate 4. Once that gets too crowded we

close gate 4 and send them around to gate 3, 2, 4,

5 rather 5, 6 and 7. But to do that we need a good

sound system and that sound system is not good

enough. Is there anything you can do about that.

Bearing in mind by that the guys are coming in with

bugles and its mad house. But if you are really able

to talk to those guys we can actually channel them

it goes a lot faster and there is no injuries that the

one thing and so far we have been pretty lucky but

-37-

we are going to have some injuries at some stage.@

AGS: Ok so to recap there, what you are saying is not

necessarily a number of tickets being sold for a

period, its actually accessing the stadium through 4,

5 and 6.@

AJVR: The problem really starts with Arnie and them

because the amount of people that want to come

through at the same time when the match starts the

first big balls up is with them and I=m not saying

with them but once again there is too many guys

that want to get through the gate at rush. Up until

then they are pretty okay. Once they hear the

whistle and people start shouting they want

through. Then when they get through it=s a run to

get to our gate and that where the whole thing just

gets worse.@

-38-

AAW: Bearing in mind we=ve got YY when we open up

North Park Lane we got 22 lanes that will let people

through they=ve only got 3 to get into Y.so it is a

problem.@

AST: You actually need to physically close that gate

otherwise the guys will stand at gate 4 and they will

try to get into that gate 4.@

AGS: And now the question is should we not only open that

later so that the guys would normally all the way

through move around move around B so we just

open it up so that the sitting in that area only gets

filled in that last slot.@

Apart from the problems around gates 4, 5 and 6 the following matters

were also considered: that the Public Order Police unit would deploy

Nyala vehicles and also provide razor wire for deployment if necessary;

mounted police; the provision of additional ticket selling booths; the

-39-

erection of a big screen in the North Park Lane area; the pre-sale of

tickets through an expanded network; the installation of a public

address system outside the stadium.

9.1.2 On 3 April 2001 a second operational meeting was held. Once

more, there were representatives of the various role players,

with the notable exception of both PSL and Public Order

Policing representatives.

The minutes of that meeting reflect, amongst others, the

following: that the number of police members (Vispol) was

reduced from a hundred and fifty (150) to a hundred (100);

the public address system was to be upgraded to enable the

announcers to channel spectators through the correct gates;

Kaizer Chiefs was to arrange additional megaphones; the

possibility of utilising the big television screen at the

neighbouring Johannesburg Stadium in the event of massive

spectator overflow was to be discussed with the relevant

people; Mr C Coetzee (the Ellis Park head of security) was to

-40-

co-ordinate a meeting of all the role players to discuss specific

requirements of the Joint Operation Centre, as also to describe

the role of each participant.

9.1.3 The third and final operational meeting was held on 10 April

2001. The Visible Policing unit increased their number from

a hundred (100) to a hundred and twenty-five (125)

members. Public Order Policing increased their number from

twenty five (25) to fifty (50) with twenty (20) members on

standby. PSL security reduced their own number from two

hundred and sixty (260) to a hundred and fifty (150). The

management of traffic was to be the responsibility of the

Metropolitan Police who, according to the minutes of the

meeting, were to deploy forty-five (45) members, plus one

(1) in the Joint Operation Centre. Their skeleton staff was to

be on duty from 07:00, and the perimeter to the stadium was

to be closed at 14:00.

Also discussed were the following: once more, the use of a

-41-

sound system outside the stadium; a big screen at the

Johannesburg Stadium; the use of room N523 by official

spotters inside the stadium; that Kaizer Chiefs would have one

person in the Joint Operation Centre and another in the

spotters room with a radio. There was to take place a briefing

of PSL security on the afternoon of the day of the game; razor

wire would be brought; Stallion Security would bring an extra

reaction team for deployment inside the stadium; ticket selling

booths would be moved to outside of the perimeter fence; Mr

Coetzee, head of the Stadium=s security, would facilitate a

meeting where Joint Operation Centre requirements would be

discussed.

9.2. Classification of the game

The minutes (and transcripts) refer to the terms AA category@ and

(occasionally) Afull house@ apparently synonymously. In their ordinary

meanings, these would mean - in terms of Ellis Park Stadium - ? 60, 000

spectators. During evidence before the Commission, however,

witnesses referred to a further AA plus@ category, meaning a sixty

-42-

thousand (60,000) spectator game at Ellis Park Stadium: AA@ category

simpliciter now only referred to a crowd attendance of forty to forty five

thousand (40- 45,000) (i.e a number safely below an ordinarily

understood Afull house@ capacity), for which lower figure various of the

parties later at the Commission hearing claimed they had in fact

planned; this despite the fact that some witnesses acknowledged that

they expected a real full house.

According to SAFA guidelines, PSL was supposed to be in overall charge

of security at a game of this magnitude.

9.3 The Mobile Screen

9.3.1 The minutes of the operational meeting of 27 March 2001

reflect a discussion about the use of a big mobile screen that

could be situated at the North Park Lane. The minutes read:

AMD: Mr Chairman if I can recommend we have done it in

the past (addressing the situation of spectators who

-43-

come too late to buy their tickets) we put a big

screen outside in North Park Lane then the guys who

(are) late don=t get agitated they can watch the

game (if) they are a little bit late. It takes the

pressure off B they turn not to Y.@

AGS: I understand that is quite expensive.@

ARH: Ja, but it is crucial.@

AEC: Ja, we used that as a solution at Kings Park before

but it cost us a good forty or fifty grand.@

AJVR: I just have one problem with that big screen Mr

Chairman. I agree that while guys are buying the

tickets it=s great, but once he has bought his ticket

he doesn=t give a damn about the big screen and

that=s when our problem comes. Because the big

screen is right over there and he wants to get in

-44-

here.@

AAW: Mr Chair I would disagree with that because we work

North Park Lane and that thing since prior to us

having the big screen and do not understand

obviously its huge financial implication but prior to

that these guys used to come here and break down

the gates every game. As soon as that big screen

went up we never had that problem again.@

AST: I don=t have a problem with that but maybe we just

have to talk to Chiefs and then let=s go 50/50 on

the big screen otherwise we put in the big screen

and there goes our money for the night.@

9.3.2 During the discussions of the operational meeting of 3 April

2001 the meeting addressed the issue of a big screen in the

following terms:

-45-

ARH: For that game, will have more people for the crowd

management part of it. Particularly on the north

side, we can also adjust it depending on how the

ticket sale go and also the screen will help.@

AGS: So a lot will depend on the screen?@

ARH: Yes.@

9.3.3 In the discussions of the operational meeting of 10 April 2001

the meeting further addressed the issued of a big screen in

the following terms:

APN: Is the big screen going to be at the ticket sale offices

at North Park Lane?@

AGS: At this stage it=s not.@

AVC: Is there anything at the Johannesburg stadium?@

-46-

AGS: We had a meeting with them, he=s got to come back

to us if we can turn it on or not. The problem that

they have got is that they are setting up for Greace,

they=re putting the equipment in there and they

want it locked off. So that takes that big screen out

of it then. We=ve had quotes and need to talk

about it straight after this, but they tell me it=s an

expensive exercise.@

ANM: Mr Chairman have you been quoted for the big

screen? Is that what you said?@

AGS: Yes. I think the decision will be made straight after

this, as the cost decision. What we try to do to

relieve part of the pressure, by creating more

turnstiles or opening accesses. But we know that

that definitely helps us a lot. But it=s a financial

decision.@

APN: On the issue of the screen, Mr Chairman, what it

-47-

does is it relieves the pressure from the ticketing.

Traditionally they leave it the last minute, and when

we get a huge rush on the ticketing, and the screen

was over there so that the people, when the game

started, they can take their time and buy the tickets.

To relieve that pressure. Pressure on other two

gates, into the precinct and into the stadium that

remains constant. But we don=t have the screen

then we are going to need, Y. I think Thami=s

people will have to manage that, because we won=t

be able to unless we bring in additional.@

AGS: Well we=ve touched on the ticketing, maybe we can

talk about it further. But it is a point. It makes

sense to have the screen, but it will have a cost

implication for Kaizer Chiefs.@

9.3.4 It is clear from the aforegoing that at all the three operational

meetings, the possible use of a big screen was discussed;

despite this, in the end it was never used.

-48-

10. SOME OF THE MATERIAL EVENTS FOUND TO HAVE OCCURED ON THE

DAY OF THE MATCH

10.1 Traffic congestion and the blockade of the stadium by

abandoned vehicles

10.1.1 According to the evidence, by approximately 19:00 the roads

leading to the stadium were congested with vehicular traffic.

The lane designated for AVIP@ entrance was blocked.

Witnesses who used vehicular transport told of immense

difficulties in reaching the stadium; the result was late arrival

at the stadium. The Chief Executive Officer of the Premier

Soccer League, despite using the AVIP@ lane, took more than

an hour to reach the stadium, a distance that would have

ordinarily taken him a mere fifteen minutes.

10.1.2 Evidence also shows that due to crowd pressure at the AVIP@

gate, the security personnel in charge decided to close it;

this caused traffic congestion. Many cars were abandoned

randomly making access to the stadium impossible. Some

traffic officers were themselves unable to drive around the

-49-

stadium; it was also impossible to use tow-away trucks to

remove offending vehicles as the trucks were themselves

closed in.

10.1.3 The congestion on the access roads also hampered

emergency and medical services vehicles that were called in

to assist with rescue operations.

10.1.4 The Metropolitan Police tried to blame the congestion and the

blockade on the drivers who had illegally parked their motor

vehicles in the way. It was also suggested that even if a

large contingent of the Metropolitan Police had been

deployed, the situation would still have been un-controllable.

There is no explanation, however, why the problem was

allowed to occur in the first place.

10.2 The sale of tickets for the game

10.2.1 The number of spectators who turned up for the match of 11

April 2001 was later said to be in the order of some eighty

thousand (80,000). Approximately less than four thousand (4

-50-

000) tickets were pre-sold. The majority of the spectators

bought their tickets on the day of the game.

10.2.2 Ellis Park Stadium management contends that by midday of 11

April 2001 it had printed sixty-two thousand (62,000) tickets.

It had offered to Kaizer Chiefs two thousand five hundred

(2,500) tickets that were to be pre-sold at the Kaizer Chiefs

village. The reason for printing sixty two thousand (62,000)

tickets (more than the stadium capacity) was to ensure

supply to those ticket booths that would outsell others. It

was expected, the commission was told, that the tickets

actually sold would not be allowed to exceed the capacity of

the stadium.

10.2.3 According to the reconciliation, tickets printed and sold by the

stadium management is fifty seven thousand six hundred and

forty (57,640) and three thousand nine hundred and fourteen

(3 914) were returned as unsold.

-51-

10.2.4 What causes some concern about Ellis Park Stadium=s

contention regarding the printing and the selling of the tickets

is that whereas sixty two thousand (62,000) tickets were

printed, the evidence points to some fifty-two thousand five

hundred and twenty-six (52,526) tickets having been sold and

three thousand nine hundred and fourteen (3,914) returned.

The two positions are not reconcilable, leaving as they do

approximately four thousand (4 000) tickets unaccounted for.

10.2.5 Compounding the difficulties with Ellis Park Stadium=s

contention is evidence suggesting that at 17:00 on 11 April

2001 Kaizer Chiefs representatives requested the printing and

issuing of two thousand (2 000) additional tickets when

realising that the ticket booths were fast running out of

supply in the face of a large number of spectators. Kaizer

Chiefs say this request was met, despite the fact that Ellis

Park had in the past shown some reluctance to print

additional tickets under similar circumstances. There was a

second request for yet additional two thousand (2 000)

-52-

tickets thirty (30) minutes after the initial one, which was

also met. Therefore, approximately four thousand (4 000)

tickets were issued to the Kaizer Chiefs representative by

18:00 on the day. In this connection evidence by a

representative in the Joint Operation Centre was that they

heard some announcement over the Ellis Park Stadium radio

that the tickets had been sold out and that more tickets were

being printed. However, Ellis Park management argues that

4000 additional tickets could not have been printed within

such a short time because their ticket printing machines are

only capable of printing one thousand (1 000) tickets per

hour.

10.3 The announcement that tickets were sold out; and the re-

action of the crowd thereto.

10.3.1 According to evidence, at about 19:15 announcements were

made that the tickets had been sold out, and that the stadium

was full; spectators were urged to go back home. The

announcement was not heeded; the crowd on the south-

-53-

western side was then diverted to the northern side for the

tickets, causing the security to allow people into the inner

perimeter for this purpose. The result was that large

numbers of people moved to the northern side where they

would have to go through gates 4, 5 and 6 after buying their

tickets. A combination of these people with those who had

rushed in over the collapsed perimeter fence on the north,

created a wave of people the security personnel could not

stop. They all pressed towards the direction of the above

gates, particularly gate 4. Although Public Order Policing

deployed the razor wire between the collapsed perimeter

fence and the stadium in reaction, this was in some respect

too late as thousands of people had already forced their way

into the stadium. The entrance gates were ripped apart and

a large number of spectators, estimated in the thousands,

rushed into the stadium causing damage to, inter alia the

roller gates.

-54-

10.3.2 Amongst those who went through in such an unauthorised

manner were both valid ticket holders and non-ticket holders.

Probabilities are that some of the spectators who stormed

their way into the stadium did so when they realised that

their prospects of obtaining valid tickets were nil. It is, in this

respect, important to remember that among the supporters

of Kaizer Chiefs and Orlando Pirates were people who had

come from all over the country. The reaction of such people

ought to have been foreseeable; more so if they had expected

to find tickets at the stadium on the day of the match. A

crush was to follow.

10.4 The Crush

10.4.1 After control at the perimeter fence was lost between 19:15

and 20:10: the stadium was bursting at its seams; thousands

of spectators accessed the stadium without going through the

control points, as the gates including the roller shutter doors

had been broken. With a large number of people going

through gate 4, people were pushed and crushed.

-55-

10.4.2 The following contemporaneous record kept by a

representative of Wolf Security in the Joint Operation Centre

gives an overview of the situation:

B at 19:10: there was a message through to his radio

indicating that the tickets were sold out at 19:00 and that

there were still thousands of spectators outside the

stadium.

B at 19:30: gates 5, 7 and 8 were being closed and there

was total chaos.

B at 19:40: total chaos and people were being Athrown from

above@.

B at 19:45: gate 4 was broken open, the fence at gate 6 was

broken down, roller gates at gate 7 and all other roller

gates were broken open.

-56-

B at 19:55: total chaos with all gates broken and the place

being broken down everywhere.

B at 20:05: the police were contacted and arrangements

made for extra police. There was chaos all over.

B at 20:30: several people dead and disaster management

was called in.

B at 20:45: 24 people dead and hundreds injured.

10.4.3 Witnesses gave deeply moving accounts as to what happened.

Take for example the story of one man who was with his two

young children. They had tickets which allowed them in and

they had duly entered through gate 4. They proceeded to the

vomitory leading into the sitting area of the pavilion. As they

reached the first set of stairs that sharply inclined

downwards, there was a sudden push by a large group of

spectators thrusting them forward. He lost his grip on the

one child but managed to protect the other against the

mounting pressure from people who were falling all over

-57-

them. He later realised that one child had been crushed to

death. One woman told how she was trampled upon and lost

consciousness in the process. Another witness related how

he took a cellular telephone from a friend and contacted

emergency police in desperation from where he was in the

stadium. This has been proved to be true as a transcription

of his conversation with the police operator was handed in as

an exhibit. The same witness also testified that when he

realised that there were problems he tried in vain to attract

the attention of the security personnel by setting alight a

piece of newspaper. He also says objects were thrown onto

the pitch for the same reason; again, to no avail. All these

things happened in the north-eastern corner of the pavilion.

The representative of Associated Prevention Services in the

Joint Operation Centre recorded on her contemporaneous

notes that she saw a burning newspaper among the

spectators and that she drew the attention of the PSL

representative in the centre to the incident. She states that

-58-

the PSL representative merely looked at the incident and did

not think much of it. Although the PSL representative

concerned disputes this evidence, it is, on the probabilities,

true.

10.5 The use of teargas, or similar substance

10.5.1 A Captain Molapo was at the stadium that evening as head of

Orlando Pirates security team. He says that once the crowd

became rowdy, got out of control and pushed their way

through gate 4 into the scaffolding, a member of one security

company called on a member of another security company to

Aput them under teargas@ or uttered words to that effect.

He says teargas was then discharged. As this issue was

hotly contested, it is necessary to summarise the evidence

briefly and then give reasons why it is likely that the

allegations are true.

-59-

10.5.2 The Captain describes the person who gave these instructions

as a white male, with a white eye-patch. This description led

to one Kruger being mentioned as the person who had an

eye-patch that night. When he was asked to stand up during

the hearing, Captain Molapo pointed him out. He was at the

stadium that night and did have an eye-patch, although he

says it was a black one.

10.5.3 According to Captain Molapo, a teargas canister was

detonated and thrown amongst the people who were already

in the scaffolding, causing a stampede. Captain Molapo says

he actually saw some smoke. He knows teargas. He

described the uniform of the team whose member discharged

the teargas. It became common cause that the uniform was

that of Viper Security. From the video footage, it became

clear that the witness could only be referring to a member of

this team. He says members of the team carried on their

persons what looked liked teargas canisters. He also

described their helmets. The captain said that he was a few

meters away from Kruger when the call was made.

-60-

10.5.4 The captain also referred to a prior incident at the same venue

during which the same witness sprayed some substance into

the face of a spectator. That spectator turned out be a

Provincial Deputy-Commissioner of SAPS who also testified

before the Commission; amongst other things, he confirmed

the incident. That incident is of course not necessarily proof

of the truth of the allegations of 11 April 2001 levelled

against Kruger.

10.5.5 The video footage viewed does not conclusively show teargas

canisters on the persons of members of the concerned team.

The helmets on the footage do not appear to be exactly as

described by the captain; however, the pictures are not

conclusive on this point either, particularly to someone who

is not familiar with the variety of helmets of that nature.

10.5.6 Reference must also be made to the evidence of one

spectator, a so-called ANo 1" supporter of Orlando Pirates.

-61-

He was seated on the southern side of the stadium. He says

he and others caught the smell of teargas at some stage just

before the game started. They gesticulated to the officials

that there was some smell of teargas. He says Kaizer Chiefs

supporters seated on the western side of the stadium, must

have also caught the teargas smell because they too were

gesticulating to the same effect.

10.5.7 On the video footage, some of the spectators were seen

covering their noses. But counsel pointed out that it is

clear, at least from other footages, that these people were on

the southern or south- western side of the stadium, as

opposed to the northern side where teargas was allegedly

discharged.

10.5.8 A voice from one of the television commentators is clearly

heard from the video sound track saying that they were

having a repeat of the Zimbabwe situation. It is common

cause that this was reference to an incident in Zimbabwe in

2000 at a soccer stadium during a World Cup qualifying game

between that country and South Africa when teargas was

-62-

fired into the crowd inside the stadium. The commentator

does not say why he made this remark. It is fair to say,

however, that one of the reasons was the sight of people

covering their noses.

10.5.9 Evidence was given to contradict the allegations against Mr

Kruger, as well as the use of teargas. Mr Kruger testified and

denied the allegations. He also denied that he had a white

eye-patch; he had a black one on. He says even in the

darkness of night he uses a black one. He admits though,

that at one stage he was in the vicinity of gate 4. He says he

could not have given instructions to a member of another

security company. His task that night was limited to carrying

a two-way radio communicator for his own team, though he

was not the team leader.

10.5.10 Mr Kruger was hardly a convincing witness. He totally

underplayed the role and relationship he had had or still had

with the Ellis Park stadium as on 11 April 2001. It is common

-63-

cause that he is the son-in-law of the head of the Ellis Park

security; that he had been to events at Ellis Park in the past

and been seen in the company of his father-in-law; that he

had worked for Ellis Park before - something he only admitted

during cross-examination. The reasons given for his bizarre

conduct after the game had been stopped to put on a

different bib are not convincing; a bib which was for that

matter, the uniform of a security company of which he was

not an employee. He could not remember whether the bib

was put on top of his own, or whether his had already been

taken off.

10.5.11 There were also other witnesses who said that they did not

see any evidence of teargas having been used. The

implicated security company also denies that it had teargas.

Nothing further needs to be said about them in the light of the

following: the situation was very fluid that night; it is

impossible to determine whether any two people - except

those who moved inseparably at all times - were at the same

-64-

point at exactly the same time; moreover, all the times

mentioned were mere estimates; the crowd was large and

disorderly, making observation difficult.

10.5.12 Reference must also be made to a medical report by one of the

doctors who attended some of the victims that night. She

says in her report that Aone of the victims had to be treated

for teargas effects.@ It is common cause that the doctor=s

report does not constitute her own finding to that effect, but

that she merely recorded the patient=s account. Even so the

report is still of some value because it is proof of the fact

that teargas was mentioned that very same night and is not,

as was suggested, a recent fabrication.

What may not be clear is whether what was used was actually teargas,

and if so, of what nature; for example, whether it was of the same

nature as the one used by the police. The probabilities are, however,

that a gaseous irritant, the exact nature of which is not necessary to

determine, was discharged as alleged.

10.6 Stoppage of the game

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The game started shortly after 20:00. From all accounts, it is clear that

at the time it started many people had already been injured and lives

lost. Eventually, rescue operations were launched. Some of the victims

were taken from the stand and made to lie behind the northern goal

posts while the match was still in progress. It took the then Chief

Executive Officer of the PSL to stop the game; this was at about 20:40.

Victims were shown on the screen in the stadium - a wise move which

made the spectators appreciate why the game had to be stopped. More

bodies and the injured were brought onto the field. The medical and

paramedical teams sprang into action.

10.7 The tragedy.

Many people were crushed to death, and even more injured. The

majority of the victims were on the north-eastern side of the pavilion.

This tragedy started unfolding well before the game started. The

injured were ferried by ambulances and a helicopter to hospital. The

game was abandoned a total of 43 people lost their lives, and 158 were

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injured. Post-mortem reports indicate the death in each case as due to

crush or stampede.

11. FACTORS WHICH PRECEDED THE EVENT AND WHICH LED TO THE

TRAGEDY, AND MISMANAGEMENT

The points herein made are not dealt with in any order of importance.

Secondly, subject to what is said in paragraph 11.1 below, no single factor can

be said to have been decisive: the disaster was the result of a combination of

all of them, each having contributed to a lesser or greater extent.

11.1 Poor Forecast of Match Attendance

On their own version, all the role players grossly underestimated

possible attendance.

The records of the South African Police Services estimated that the

match would be attended by about fifty thousand (50, 000) spectators.

The three operational meetings held by the role players state that the

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number of spectators would be between forty five thousand (45,000)

and fifty thousand (50,000). It is a mystery why this mistake was

made, given in particular the following: the fact that each team enjoys

a huge support; the history of rivalry between the two teams; their

positions at the time on the league=s log, and the fact that both teams

were based in Johannesburg where the stadium was. This was going

to be a crucial game, the results of which could decide the

championship. The match had all the ingredients for attracting a very

large number of people.

Such a gross underestimation of possible attendance, must be seen as

the fundamental cause of the tragedy: no plans were in place to deal

with a capacity crowd, let alone a crowd in excess thereof (as it turned

out to be the case).

11.2 Failure to learn from the lessons of the past.

There has been some failure to put past experiences to good use.

Similar or near similar incidents are discussed in paragraph 8 above; a

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repetition is not necessary here. Such failure was not necessarily

intentional or malicious; rather, it was in all likelihood the result of a

false sense of security resulting from the fact that a preceding game

between the two teams had gone off smoothly. Failure to heed lessons

acquires special importance, given the fact that some recommendations

are going to come from this Commission. It would be unfortunate if the

experiences of 11 April 2001 were also to be ignored. All the role

players were remiss in not adequately taking previous experiences into

account in their planning during the operational meetings.

11.3 Failure by the role players to clearly identify and designate

areas of responsibility.

In some cases, there was either a disagreement or a confusion as to

areas of responsibility. This resulted in certain security functions either

not being carried out properly or at all:

11.3.1 There is a notable disagreement as to whose responsibility it

was to secure the outer perimeter fence against any possible

violation by spectators. There were three possible role

players responsible for this: the PSL security, Stallion and the

Public Order Policing. However, none of them accepted this

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responsibility. The PSL security contended that it had only

marshalling responsibilities; Stallion, although identified in the

operational plans as the entity charged with this task, saw

their responsibilities as being limited only to manning access

gates along the perimeter fence. The Public Order Policing

unit, for their part, contended that their responsibility in that

regard would arise only once public order was threatened;

that is, they had no duty to act pro-actively or to guard the

fence. The result was that nobody acted pro-actively to

prevent the outer perimeter fence from being breached. Once

the breach occurred, thousands of people rushed in and

control of the situation was lost. That was the beginning of

the stampede towards the gates.

11.3.2 No one was tasked with or accepted the responsibility of

monitoring the crowd inside the stadium. There were two

possible role players for this task (none of whom accepts this

responsibility): PSL security or members of Diligence Security

Company.

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S PSL security: according to the minutes of the meeting of

10 April 2001, a suite N523 was to be used by two

spotters, one of whom was to come from the PSL security.

The function of the spotters was to look out for problems

that might arise in the pavilion. It is difficult to

understand how two spotters could effectively monitor a

crowd of about sixty thousand (60,000) spectators.

S Diligence Security Company: some of their employees

were deployed at various places along the field with

supervisors moving from the one half of the field to each

corner. However, they perceived their responsibility as

being no more than ensuring that spectators did not

invade the pitch during play. To this end their

observations were limited to the first five rows of seats

from the pitch, and around the field. Precisely because

there was no effective monitoring of the crowd in the

pavilion, trouble in the north-east corner was not picked

up early enough, nor were the distress signals by the

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spectators such as the burning of newspapers and the

throwing of objects. The result was that the situation

worsened and despite this, play commenced and

continued for about 40 minutes before it was stopped.

11.4 Absence of overall command of the Joint Operation Centre

B The evidence is compelling that there was no particular person in

overall command of the Joint Operation Centre, or of the entire

event, who would receive all the information and take a decision.

Instead, there was a collection of independent heads of security

groupings all of whom, to this day, deny that they carried ultimate

responsibility; nobody had the final authority to issue commands

from the centre. This was a glaring weakness in the security

plans.

S The evidence shows that the joint operation centre was there by

name only, in that the persons therein did not operate in a

collective or co-ordinated manner; at least, not in the way that they

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should have. The individuals who manned the centre were persons

with no authority to take any corrective action on their own if any

was needed. They conceived their responsibilities as being no more

than to receive and relay messages.

S There was also no proper co-ordination of information received in

the centre by representatives of different companies or the police.

Most senior personnel responsible for safety and security were at

various places around the stadium without properly communicating

with each other or sharing vital information that would inform

corrective strategies.

11.5 The inappropriate and untimely announcement that tickets

were sold out

S The evidence indicates that at approximately 19:15 the stadium

manager asked a senior Metropolitan Police representative to

announce around the stadium that the tickets were sold out, that

the stadium was full and that people were urged to go home and

watch the game on television. The announcement, we were told,

was made as a stratagem to discourage the many spectators who

could not be accommodated in the stadium. The announcement

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was made without prior consultation with, or warning to, the Public

Order Policing unit, or some of the other role players. It should

have been realised from previous experiences that whenever a large

crowd of spectators realised that they would not gain access into

the stadium, they would become agitated and try to force their way

in. This is exactly what happened, resulting in the loss of control

over the crowd.

S It is conceivable that had the stadium manager consulted all the

role players prior to the announcement being made, pre-emptive

measures could have been taken such as the early deployment of

the razor wire, the strategic positioning of security personnel

around the perimeter fence and the deployment of mounted police.

11.6 Failure to adhere to FIFA and SAFA guidelines

S Both FIFA and SAFA guidelines are specific that a game should not

start until the situation inside and outside the stadium is under

control. Yet evidence shows that when the game started, there

were still thousands of spectators outside the stadium; many

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places around the stadium were being vandalised; the gates were

being ripped open; security personnel had been overwhelmed by

the crowd; non-ticket carrying spectators were gaining access into

the stadium; security was reporting total chaos outside the

stadium; ticket-booths had been attacked and cashiers escorted

under armed guards back to places of safety and terraces, stair-

and gangways were crowded with spectators. It is clear that the

commencement of the game was therefore in violation of the

guidelines. The problem was that, due to lack of co-ordinated

information, some of the officials inside the stadium, including the

referee and senior soccer officials, were not aware of the scenario

outside the stadium. It was not until 40 minutes into the game

that the Chief Executive Officer of PSL, upon realising the tragedy,

stopped the game. The argument that delaying kick-off could also

have caused rioting is not acceptable; it all depends on how a given

situation is handled.

11.7 Unbecoming spectator behaviour

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11.7.1 South African soccer spectators were described as being

amongst the world=s best behaved. The compliment and the

accolade is valid for the vast majority of spectators and at

most game attendances. It is also true, though, that South

African soccer has recorded occasions of massive damage to

property. The reasons for bad spectator behaviour are often

the result of frustration when access to the stadium is, for

one reason or another, denied, with many of the spectators

having come from far; after all every person going to a

stadium hopes to gain access.

11.7.2 However understandable the anger and frustration may be it

is not acceptable behaviour to storm the stadium with

consequences of damage to property and serious possibility

of bodily harm to other spectators. The behaviour is

reprehensible and deserves censure in the strongest of terms.

There is, moreover, evidence that some of the spectators

arrive at a stadium, without tickets, very close to the time of

the commencement of the game. In the result, pressure is

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brought to bear on the ticket-selling offices, the marshalls, the

security companies, the police and on the flow of people into

the stadium. This is exactly what happened on 11 April 2001.

There is also evidence that some people parked their vehicles

randomly, blocking the roads.

It would therefore be inappropriate to put all the blame on the

game organisers. South African soccer spectators need to

appreciate that their own conduct is as critical a factor as any

other in the maintenance of safety and security at the

stadium.

11.7.3 It must be emphasized, however, as did several witnesses

including those from overseas, that the behaviour displayed

that night was not characteristic of South African soccer

spectators

11.8 Sale of tickets at the venue and unreserved seating

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11.8.1 Failure to pre-sell tickets does not by itself lead to a tragedy

of this nature; it depends on the circumstances, such as the

popularity of a game. There is evidence that tickets were

printed, issued and sold until close to the starting time of the

game. The demand for the tickets kept on growing

particularly from 18:00. On this particular occasion, the sale

of tickets on site and on the day of the match did certainly

contribute to the problems. The game was to be held

midweek and in the evening when many people would only be

able to go to the stadium after work; it was to be a very

important (and possibly decisive) game. For these reasons,

the sale of tickets on site held potential risk. This was

compounded by the fact that seating was unreserved: at peak

hour spectators would become anxious that they might not

easily find a seat; too much movement in the stadium in

search of a seat was the result and, when a seat could not be

found, people stood in the gangways. Spectators already at

the stadium would not readily accept being turned away once

the tickets were sold out because they expected to obtain

them on site.

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11.8.2 When the stadium holds rugby matches, each ticket is

allocated a particular seat. It was suggested that it was

difficult to apply this system to soccer matches. Soccer

spectators are said to be primarily from low-income groups,

and therefore not particularly suited to purchasing tickets in

advance of a match. Even admitting that many soccer

supporters come from the low-income bracket, there is

evidence that tickets had in the past been pre-sold. There

was also an attempt to explain why it was not practical to

implement a system of marked seats where soccer was

involved. It was suggested that soccer spectators of a

particular team would prefer to sit together in one pre-

designated area of the stadium. This cannot be an

insurmountable difficulty; for example, the system of colour-

coding can be used.

11.9 The use of teargas or a similar substance

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A finding has already been made that teargas or a similar substance

was discharged amongst the crowd; the reasons for such a finding are

found in paragraph 10.5 above where the issue is fully dealt with. The

consequence of such an action was a panic reaction which either

caused a stampede or aggravated it.

11.10 Corruption on the part of certain members of the security

personnel

There was evidence, which could not be disputed, that some members

of the security personnel allowed people into the stadium without

tickets in return for money. Not only does this lead to the overcrowding

of a stadium, but also agitates other spectators with or without tickets;

especially the latter who are still in the queue for tickets. This corrupt

practice is a recipe for gate-crashing.

11.11 Dereliction of duty:

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Evidence shows that there was dereliction of duty on the part of certain

security officials. This report limits itself to the following instances in

which there was such dereliction of duty:

11.11.1 One witness after the other stated that there were no security

officers at certain strategic points, and that as a result, there

was nobody to demand tickets upon entry; people went

through without tickets. Once this happened, pressure would

then be brought to bear on the inner entrances. The result

was that such few security officers as were found at the inner

entrance points, could not control the crowd. Furthermore,

as a consequence of such dereliction of duty some of the

spectators were able to enter the stadium with their tickets

intact, and then resell or hand them over to those outside.

We were told that upon noticing this, security officers

intervened. However, the fact is that this lapse of security

contributed towards overcrowding the stadium.

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11.11.2 Failure to pick up trouble inside the stadium at the north-

eastern pavilion (where the disaster occurred). That there

was a disturbance or commotion in that area, especially rows

A 27 - B 27, cannot be denied: the video footages show this,

and the majority of victims came from there. It has already

been mentioned that the situation was so bad that bottles

were thrown onto the field and a newspaper set alight in a

desperate attempt to attract the attention of security

personnel. Spectators also shouted at the top of their voices

for help, to no avail. Despite all these attempts, and also

what ought to have been a visible commotion in the affected

area, the security personnel failed to take notice. If they

were there as they claim, the conclusion is inescapable that

they failed in the execution of their duty. It is in dispute as to

which security grouping was directly charged with this

responsibility; see, on this point, paragraph 11.3 above.

11.12 Failure to use the big screen

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The overwhelming opinion on the use of the big screen was that it could

relieve the pressure caused by spectators who, because they have

arrived late, become anxious to obtain tickets before a game starts.

Indications are that the idea of using the big screen was abandoned

because of cost implications to Kaizer Chiefs; this much is clear from

the concerns expressed by a representative of the team in the

meetings.

During the presentation of evidence on behalf of Kaizer Chiefs, it was

suggested that the use of the big screen was not a unanimous view and

that it was discarded because it was felt that it would have only

achieved the opposite effect. The motivation for this contention was

predicated on the fact that the television broadcast was not going to be

live, but delayed by thirty (30) minutes.

Expert evidence indicates that it is technically possible to have fed a live

coverage on a mobile screen outside North Park Lane notwithstanding

the fact that the television broadcast was going to be delayed.

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There is no cogency to the contention that the live broadcast of the

game at North Park Lane would have yielded undesirable results. On

the contrary, the body of evidence is that it would have had a positive

effect on the spectators still waiting their turn to enter the stadium.

Further, the contention that the big screen would have adverse results

is not borne out by the minutes of the discussions around the issue.

The explanation that marketing and advertising considerations rendered

the deployment of this strategy unnecessary seems to be an after

thought. It is obvious that it is a position taken rather ex post facto as

an attempt to remove the embarrassment that the use of a big screen,

even though necessary, was jettisoned for financial reasons.

11.13 Inadequate public address system

S According to the minutes and transcripts of the operational

meetings, there were discussions about upgrading the public

address system outside the stadium to make it more effective.

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S There were also supposed to be four (4) additional megaphones to

be arranged by Kaizer Chief=s security for use by their designated

members to address the crowd in different languages. According

to the evidence several hand loudhailers were used at various

stages of the evening but were not that effective. The public

address system was also too inadequate to convey critical

messages at material times. This breakdown of communication

with the crowd made its control difficult.

11.14 Failure by the Public Order Police Unit to react timeously and

effectively

The evidence of a representative of Wolf security company, Mr van

Rooyen, is that at about 18h50 he noticed that the situation in the area

of gate 4 was becoming a cause of serious concern; a large number of

spectators were crowding there. He was so concerned, that he called

representatives of other security companies, with the exception of the

police, to a meeting at gate 4 to discuss the situation. Subsequent to

that the outer perimeter fence and its gates were broken down and

people rushed towards gate 4; employees of the Stallion Company

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whose task it was to secure the outer perimeter gates, were

overwhelmed. It was only after about 19h40 that the Public Order

Police unit eventually deployed razor wire. The evidence of Captain

Mkhwanazi, the unit=s commander that night, that there had not been

any need to deploy the razor wire earlier than it was done, cannot be

accepted. While it is not for the Commission to prescribe to the police

as to how to contain a situation, it is nonetheless clear that on this

occasion they deployed the raizor wire too late; a timeous deployment

could certainly have helped stem the tide.

18. GENERAL REMARKS

12.1 The attitude of certain members of Private Security Companies

Evidence has shown that the conduct of some of the employees of

certain security companies left much to be desired.

12.1.1 Firstly there is a complaint particularly by the head of Orlando

Pirates security, that they tended to be hostile to the

spectators. In this respect, evidence was that certain

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members of Wolf security company had a history of such a

tendency; they would push and manhandle people. They

showed on occasions a general disrespect for the dignity of

spectators. Their duty was to assist people; but this they did

not always do with the politeness that they should have

displayed. They also showed contempt towards the PSL

security personnel. In fact, on 11 April 2001, the latter

refused to be debriefed by Ellis Park head of security. This

kind of attitude is detrimental to the effective implementation

of crowd control measures. There was palpable tension

between PSL security and other security groupings.

12.1.2 At the game of 11 April 2001 there was an instance of open

racial discrimination committed by certain security officers.

A black person, who was in the company of his three white

friends (one of whom being the witness who testified about

this) was denied access into the inner stadium while the

friends were to be allowed in; this despite the fact that he too

had a valid ticket. This was around the time when pressure

was mounting. It took vehement protestation from his white

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friends to get him in. The witness was not able to identify

the company concerned.

12.2 Castle complimentary tickets

At the commencement of each season the PSL issues to its

sponsors five thousand (5 000) complimentary tickets. The tickets

are issued in two batches of five thousand (5 000) each. Each

ticket is valid for one unspecified match at any venue throughout

the country. Following the abandonment of the match of 11 April

2001 and its re-scheduling, it was announced that spectators could

still use their tickets. A number of these complimentary tickets

were exchanged for the re-scheduled match. It was from this

process that it was realised that such tickets may well have been

used to attend the game of 11 April 2001. Incidentally, Kaizer

Chiefs say they have objected to the use of these tickets at their

games. There appears to be no system regulating where and when

the tickets will be used; therefore when the total number of

ordinary tickets for a particular game is determined in accordance

with the maximum capacity of the stadium to be used it is not

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possible to predict and take into account the number of

complimentary tickets that may possibly turn up. It is obvious that

the holders of such tickets would overburden the stadium. It is not

possible to say how many holders of such tickets gained access into

the stadium on 11 April 2001; but those who did so would have

contributed towards the overcrowding of the stadium.

Signed at Pretoria on this 4th day of February 2002.

B M NGOEPE: JUDGE PRESIDENT OF THE TRANSVAAL PROVINCIAL

DIVISION OF THE HIGH COURT OF SOUTH AFRICA

CHAIRPERSON OF THE COMMISSION

Signed at Pretoria on this 4th day of February 2002.

ADV I A M SEMENYA, SC

ADDITIONAL MEMBER OF THE COMMISSION