The Fact-Finding Inquiry Committee (FFIC), constituted to investigate the tragic Goa stampede that occurred early on the morning of May 3, 2025, during the Lairai Jatra festival in Shirgao, North Goa, recommended that the Goa government dissolve the Shree Lairai temple management committee.

The report, made available on Tuesday (May 13, 2025), stated that the incident, which led to multiple deaths and injuries, was entirely preventable.

“The failure on the part of the organisers are concerned, inter alia, especially with respect to planning and safety, with not taking cognizance of some untoward incidents in the past, and more particularly with their wilful non-compliance with administrative safety directives; consequently, the Committee strongly recommends that the government should explore the possibility of dissolving the Temple Management Committee and appointing an Administrator, after following due process of law, if deemed appropriate,” the report stated.

The Committee’s investigation encompassed site visits, consultations with stakeholders, and a review of administrative records. “The FFIC has concluded that the tragedy was entirely preventable and stemmed from a combination of poor planning, lack of enforcement, ignored directives, and inadequate infrastructure. The recommendations provided in this Report aim to ensure that such incidents do not occur in the future.”

Based on field visits, interactions with eyewitnesses, injured victims, organisers, executive magistrates, police officials, and perusal of available records, the committee found that the stampede was precipitated by a confluence of preventable lapses and oversights among key stakeholders.

The report stated, “The Committee has found that the immediate cause of the stampede was overcrowding on the pathway from Tali to Homkhand, particularly at the upper end of the sloped section near the RBL Bank Branch, Shirgao, aggravated by the unruly behaviour of the Dhonds and lack of proper crowd control measures at that location. The crowd was permitted to enter the pathway from Tali in groups, which were subsequently channelled into a two-by-two queue formation beyond the sloped section leading towards Homkhand.”

This arrangement resulted in a build-up of people on the sloped section, causing overcrowding in that area. The overcrowding, coupled with attempts by some groups of Dhonds to push forward through the crowd and their unruly behaviour, caused instability among devotees walking along the slope.

As a result, it was given to understand that a person fell face-first on the sloped section, triggering a chain reaction in which several people behind and around her lost their balance and fell over each other. Owing to the downward slope, limited visibility, the push of the crowd, and unruly behaviour, people approaching from behind were unaware of the fall and continued moving forward, leading to the stampede, the report read.

“During the inquiry, some injured victims informed the Committee that a minor incident of a similar nature allegedly had occurred in the past, wherein, in one instance, one devotee’s arm was critically injured on the day of the Homkhand,” the 26-page report said, adding that last year, a woman allegedly died due to suffocation at the sloped section of the pathway.

“However, the Committee did not find any record to substantiate such an incident. Notwithstanding the absence of official records, the Committee is of the view that key stakeholders, including the organisers, the district administration, and the district police, should have reviewed past occurrences and undertaken adequate precautionary measures to prevent such untoward incidents.”

Several eyewitnesses and injured victims reported that some groups of Dhonds forcefully attempted to move from Tali towards Homkhand. “The organisers were expected to carry out thorough capacity planning based on the location of key sites and the available access routes. Despite the existence of multiple alternative routes, the Committee found that the organisers failed to develop a multi-route circulation plan to avoid congestion along the primary pathway between Tali and Homkhand. No systematic assessment appears to have been undertaken using historical data, crowd arrival patterns, the festival’s growing popularity, the year-by-year increase in the number of Dhonds, and the nature of the visitors, particularly for high-density events like the Homkhand ritual,” the report read.

The committee stated it was imperative for organisers to conduct a comprehensive risk analysis and preparedness exercise and/or cooperate with authorities, incorporating their input in planning and execution. “However, a review of the minutes of all pre-event meetings conducted by revenue and police officials revealed that the organisers did not provide critical information regarding the expected number of visitors, potential risks based on past incidents, or options for alternative circulation routes. On the contrary, the Committee found that the organisers appear to have disregarded specific instructions issued by the revenue and police authorities regarding crowd management, focusing instead solely on the conduct of religious activities,” the report said.

The report further stated that the organisers neither demonstrated the intent nor undertook any concrete steps to prevent the proliferation of stalls, despite having been clearly informed by the police and revenue officials about the risks involved. “The Committee found that the organisers were fully aware of this constraint and its potential consequences but wilfully failed to initiate preventive measures to mitigate the risk of an untoward incident.”

The Committee observed that although permanent CCTV cameras had been installed within the temple precincts, the organisers did not extend surveillance to high-risk external areas. “It is particularly concerning that no temporary CCTV cameras were arranged (on a rental basis or otherwise) at key locations such as Tali and the pathway leading to Homkhand, including the sloped section, which is well known for overcrowding and the haphazard movement of Dhonds.”

“This critical incident was precipitated by a chain of preventable failures arising from inadequate crowd risk assessment, absence of unidirectional circulation planning, non-implementation of safety directives, ambiguity in sectoral responsibilities, failure to utilise surveillance tools, unregulated roadside vending, and the lack of pre-emptive crowd behaviour management — all pointing to institutional and procedural shortcomings among the organisers, the district administration, the police, and the local body,” the committe observed.

“The Police arrangement order issued by the Superintendent of Police, North Goa District, dated April 29, 2025, refers to the installation of six watchtowers. However, during its interaction with the Police Inspector, Bicholim, the Committee learnt that the watchtower designated near the sloped section was not erected at all, and the two police constables assigned to that location were deployed at other points,” the report added.

Although the Police had deployed a drone for surveillance purposes, the Committee found that it was not utilised during the aforementioned critical period. The reasons for this could not be established at this time, the committee stated.

The State government has issued Show Cause Notices to eight former officials from North Goa District administration, the local police department, and Shirgao panchayat.