Download - Stampede of Nashik Kumbh 2003_ A Case Study

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STAMPEDE OF NASHIK KUMBH IN

2003: LESSONS LEARNT

Sudhir Rathod

Assistant Professor,

Centre for Disaster Management , Yashada, Pune

[email protected]

9423601109

KUMBH MELA

� Mass Hindu pilgrimage of faith, Held every third year by rotation at Haridwar, Allahabad (Prayaga), Nashik and Ujjain.

� Hindus gather to bathe in a sacred river.

� Around 10 million people visited out of which 5 million people visited on second shahisnan parvani in last Nashik Kumbh in 2003

� Next Kumbh Mela would be held at Nashik in July to August 2015.

� Kumbh Mela and Crowd Disasters

� 1892 Mela at Haridwar - Outbreak of Cholera

� 1954 Prayag Kumbh -Stampede, 500 dead

� 2003 Nashik Sinhasta Kumbh –Stampede, 29 dead.

� 2013 Allahabad Kumbh - Stampede the railway station 36 dead

NASHIK KUMBH MELA IN 2003

� The period - 30th July 2003 to 27th August 2004.

� Special significance to the three Parvani, Shahisnan days

� Three Parvani days in 2003, 17th August, 27th August, 1st September

� Vaishnav sect Sadhus & devotees take holy dip in the waters of Godavari at Ramkund of Nashik City

� Shiva sect sadhus & devotees at Kushavart of Tryambakeshwar, 30 kms from Nashik.

� Akhadas & Khalsas

�Nashik 3 Akhadas about 800 khalsas

� Shree Digambar, Shree Nirmohi and Shree Nirvani Akhadas

� Each Khalsa is a group of 50 to 500 sadhus

SPECIAL CHARACTERISTICS OF NASHIK KUMBH

� Kumbh in Monsoon � Unlike other Kumbh Melas, the Kumbh at Nashik is held in the

monsoon

� Average rainfall at Tryambakeshwar is above 2000 mm. Nashik city is 700 mm. overall district 2600 mm

� Probability floods due to Gangapur dam water release , 10 kms from city

� Space Availability � Very limited space for Kumh Mela

� Location for holy dip (Shahisnan) is in locality and the space for bathe is comparatively very less.

� Sadhugram

� established where space and facilities like water, sewage are provided to Akhadas.

� No Camps for pilgrims

� Pilgrims come before 48 hours in Nashik only on three Parvanis , holy bath days

� No camp established or no space is provided,

� More than 50 lakh floating population of pilgrims for a day

SADHUGRAM TO RAMKUND

TRADITIONAL PROCESSION ROUTE

� through densely populated city,

� very narrow and sloppy, slippery and in monsoon after rain becomes more slippery,

� Sadhus, Akhadas come with Elephants, Camels, Horses and Jeeps

� Many entry points where lakhs of pilgrims stand watching sadhus and waiting for holy dip in Ramkund and in other kunds and ghats near Ramkund.

� Many Pressure points

� Less holding areas and release areas,

� challenging for Police and administration to make fool proof arrangement.

PROCESSION ROUTE THROUGH CITY

NARROW, SLOPPY PROCESSION ROUTE

RAMKUND- VERY LIMITED SPACE

NASHIK KUMBH 1991

NASHIK KUMBH RAMKUND DOWNSTREAM

PREPARATIONS FOR SINHASTHA KUMBH 2003

� Planning started in Dec 1999

� Planning department was coordinating dept at state level.

� DM held meetings with local Purohit Sangh, Sadhu Mahants

� Various committees formed at State & District level

� 4 committees at state level & 11 sub committees at district level

� Apart from committees , Senior officers took reiew meetings

� State Sanctioned 459.03 crore plan for Kumbh

� Sinhastha Kumbh cell created with additional collector & Dy collector, 2 clerks

PREPARATIONS- STRUCTURAL DEVELOPMENTS

� Ramkund area Extension

� 378 sq mtr extended to 1450 sq mtr

� So every 5 minutes 2000 sadhus can take holy dip, in hour 24000 sadhus

� Additional Ghats

� 1.3 km long ghat was concretized leading total 2.1 km of ghat(63000 sq mtr)

� New Procession Route

� 18 km long new procession route was constructed on the left bank of Godavari as the existing route was very narrow, sloppy and congested.

NEW PROCESSION ROUTE

AMARDHAM, FUNERAL PLACE ON NEW ROUTE

Katya maruti

chowk Nag

chowk

Sardar

chowk

Tapovan

Ram

Kund

POLICE DEPT PREPARATIONS FOR CROWD

MANAGEMENT

� Detailed plan for deployment of police personnel,

resources & Barricading were drawn up for crowd

management

� 450 officers, 5500 police force, 8 SRPF companies

� 22168.50 meters barricading on 9 routes

� 10 watch towers

� 10 barracks

� 10 temporary police stations, 20 temporary police

chowkies.

� 87 vehicles

FIRST PARVANI ON 17TH AUGUST, 2003 AT

NASHIK

� Passed off without any incident.

� inordinate time taken by Akhadas.

� Procession ended at 4.45 p.m. exceeding 5.45

hours by the agreed time of 11 a. m.

� Delay led to restlessness amongst pilgrims

� After 1.00 p.m., Pilgrims uprooted the barricades

erected on the way to the bathing site at

Ramkund

� Police and local administration had to permit the

pilgrims to bathe in the portion of the Ramkund

which was not being used by the sadhus while

the Shahisnan of the sadhus was going on.

PREPARATIONS FOR SECOND PARVANI

� DM reported to ACS (Home) apprehending a stampede during the second Parvani

� ACS Planning Secret note to Chief Secretary

� Numbers of review meetings held. Dy CM & Home minister, CP, DM

� Meeting with the sadhus and Mahants of Akhadas on procession time from7 a.m.to 10 a.m.

� ADG, (Law & Order) demi-official letter to CP –

� Police Bandobast plan was revised

� More force was stationed at barricades.

� Barricades were strengthened and their heights increased.

SECOND SHAHI PARVANI ON 27TH AUGUST

� Procession of the sadhus of three Akhadas was

over by 11.00 a.m.

� Decision taken by the police to permit pilgrims to

use the Shahi Marg to go for taking the holy dip.

� Till 12 noon there was no major problem along

the Shahimarg.

BUILDUP OF THE CROWD

� On the shahimarg -Kalaram Mandir via Sardar Chowk to the bathing ghat

� Three factors

� Pressure of people at various points � demanding to be allowed to go for bath.

� Sudden flow of people moving in reverse direction � who had taken their bath conflicting with the massive flow of

pilgrims

� Sadhus from the Chatursampradaya Khalsa with elephants & Jeep

� allowed to move in procession with pilgrims even after the cessation of the morning procession.

� Boycotted by Akhadas, they used procession route after shahi procession was over.

SMALL INCIDENT & DOMINO EFFECT

� All it needed was some small incident, which saw aged pilgrims, particularly older women lose their footing and fall on the ground.

� Had Domino effect with more pilgrims stumbling and falling on those who had fallen earlier.

� The dense crowd was not aware

� underfoot getting trampled and losing their lives in the suffocation that followed.

� 29 Dead.

NUMBER OF SADHUS AND DEVOTEES

PARTICIPATED (NUMBERS IN LAKHS)

Sr

No

Parvani

Holy Dip Day

1991-92 2003-04

Sadhus Devotees Sadhus Devotees

Vehicles

Animals

1 First Parvani 0.40 10.00 1.00 35.00 284 06

Elphnt

02 horse

2 Second

Parvani

0.60 15.00 1.50 50.00 157 04

Elphnt

02

camels

3 Third Parvani 0.50 10.00 1.20 35.00 232 06

Elphnt

04 horse

CAUSES

� Structural causes.

� Narrow, sloppy, slippery route

� Limited space for bath

� Communication gap between agencies

� No effective command & control

� Irresponsible crowd behavior (reverse flow, even

Sadhus)

� Poor crowd control -Inability of the police to halt

the reverse flow and enforce the prohibitory

orders

LESSONS LEARNT

� Lack of Coordination among different government

departments.

� Need of Project Based Approach

� Need of effective integrated Plan with Risk

Assessment.

� Command & control

� Application of IRS &EOC

� Use of Technology

� Structural development

� Need of Training

� Public Awareness & Media

� Strict implementation of existing legal provisions

LACK OF COORDINATION AMONG

DIFFERENT GOVERNMENT DEPARTMENTS.

� Officers EGOs, blame game, no coordinated efforts,

DM, MNC, CP

� All Planning through DM

� CP & MNC Commissioner senior to DM

� Co-ordination gap between Police officers & sector

Magistrate before incident

� Departmental approach / Compartmentalization

� E.g CCTV, Barricading

NEED OF PROJECT BASED APPROACH

� Mela Administrator,

� Senior IAS, PS officers ACS, ADG are given

responsibility to supervise before one/two months

� With no financial or administrative powers, role of

advisor/ in case report to Govt

� Principal Secretary/ADG rank officer with authority

� Appointment before two years

� In 2003, Sinhastha cell, only 2 revenue officers, no

technical staff

� Delegation of authority

� Once the plan is sanctioned, power of administrative

approval to the administrator

NEED OF EFFECTIVE INTEGRATED PLAN

� Integrated Plan with Risk Assessment

� Lack of Anticipation and assessment, Crowd, Behavior

� Identification of Hazards, Size & Diversity of

population

� Prioritization of works

� Resource management, spending only on relevant

works

� Identifying Choke –points, Holding Areas, pressure

points, Barricading plan

� Contingency Plans for meeting emergency situations

0

50

100

150

200

250

Sanction Plan of Rs. 459 Crore Expenditure

Sinhastha 2003

Proposed expenditure

Sanction Plan of Expenditure Sinhastha 2003

MNC

MSEDCL

MJP

PWD

DHO

CS

Police City

Police Rural

Tryambakeshwar

MSRTC

Forest

Archeology

Information off

Collector off

contigency

Saptshrungi

NH bot

ZP

other additional

infrastructure

APPLICATION IRS

� Management tool, system for event management

or for emergency response

� Integrating independent agencies

� Unified command System

� Clear chain of authority,

� Accountability

� Systematic planning process

� Well thought pre-designated roles

� Effective resource management

EOC- EMERGENCY OPERATION CENTRE

� Setting up of integrated EOC- now dept wise

control rooms

� Effective Communications

� Information / Intelligence management-

Gathering Analyzing, Acting ,On time

� Decision making

� Coordination with IRT & different agencies

� Operational control

USE OF TECHNOLOGY

� CCTV- Close circuit Television Camera, no CCTV

in 2003

� Integrated Communication

� Electronic Display Boards

� GIS based system

� PA system

STRUCTURAL DEVELOPMENT

� Shahi procession route widening � In development plan the road is shown 9 meters wide,

opposition in implementation, need of relocation, costly

affair

� Additional bathing ghats reducing crowd

density � Make other areas and ghats available to pilgrims so that at

the time of shahi snan, simultaneously they would take holy

dip in Godavari near ramkund

PILGRIMS CAN BATHE SIMULTANEOUSLY

IF CONVERTED IN GHAT

NEED OF TRAINING

� Training on Crowd management with communication skills to all involved personnel, response teams

� Training Local volunteers, citizens and organizations who have an active role to play in crowd management.

� IRS, EOC trainings

� Rehearsals of emergency response scenarios, Mock drills, functional exercise

PUBLIC AWARENESS & MEDIA

� I & B department no proactive role played in public

awareness

� Kumbh 2003 information broachers received after

kumbh was over

� No answers to contradictory statements and

complaints in print media

� Need of Public education Awareness campaigns,

Signage, pamphlets , Boards, Flex etc.

� Pilgrims route should be decided much earlier.

With signage & direction boards, publicity.

� Media-effective medium to educate people

STRICT IMPLEMENTATION OF EXISTING LEGAL

PROVISIONS

� No Mela Act in Maharashtra like United

Provinces Mela Act 1938, and rules thereof in

1940

� Provisions of Bombay Police Act, 1951,

Maharashtra Provincial Municipal Corporations

Act, The Code of Criminal Procedure, 1973 (CrPc)

are sufficient to handle & manage mass

gathering events.

� Notifications not followed

� Only Strict implementation of existing legislation

is required.

� Now Disaster Management Act 2005

REFERENCES

� 1 Collector Office Nashik, 2004, Mela Administrative

Report

� 2 Ramani V., 14th Feb 2006, Magisterial Enquiry

into the sequence of events leading to the stampede

deaths during the second Parvani (Shahisnan) at the

KumbhMela, Nasik on 27th August 2003

� 3 SomanC.and Jayaswal S. September 2013 Position

Paper on Crowd Management at Places of Mass

Gatherings , IIM Ahmedabad .