Expert report on the Beşiktaş nightclub tragedy... Missing reports, fake plans, blocked exits!..

A four-person expert panel has prepared the second expert report requested by the Istanbul 33rd High Criminal Court, which is presiding over the trial regarding the tragedy at the Masquerade nightclub in Beşiktaş that resulted in the deaths of 29 people.

According to the report by T24 columnist Tolga Şardan, the subject of the 53-page expert report submitted to the court was: “whether the defendants, who were the owners and operators of the workplace, had any fault in the fire that occurred, regarding the safety measures that should have been taken at the workplace, and the deaths of the victims and injuries of the complainants,” and “what those faults were, if any.”

In their comprehensive report prepared based on the available documents, information, and data, the expert panel laid out one by one the faults of the negligent public officials, as well as the workplace owner and operator, within the framework of the applicable laws and regulations.

The picture presented in the second report is summarized as follows:

“(…) * During the process of issuing the workplace opening and operating license for the 1,525 m² “discotheque” activity dated 14.11.2018 and numbered 486; although it was stated that the workplace had been inspected in terms of its distance from formal educational institutions, private tutoring centers, student dormitories, and places of worship, as well as in terms of general public order and security, it was observed that the “fire inspection report” was not reviewed.

* The NACE code in the workplace's activity certificate is 56.30.05, and the type of activity is “beverage service in places such as casinos, nightclubs, taverns, cocktail lounges, etc.” The workplace is in the “hazardous” class. Therefore, according to the legislation on the date of the incident, monthly occupational safety services were required.

* It is understood from the examined forensic medicine and other institutional reports that the workplace, which is a discotheque where the incident occurred, was located in the area described as the cinema and its services in Block B of the structure consisting of blocks A, B, and C, and that 29 people died and others were injured as a result of the fire. When examining the causes of death in the reports obtained from the Council of Forensic Medicine, it is established that the deaths and injuries were due to causes related to the fire.

* Since the existing workplace falls under the definition of a public rest and entertainment venue in Article 47g of the Regulation on Workplace Opening and Operating Licenses, and because the regulation states “excluding public rest and entertainment venues and non-sanitary establishments,” the fire department report for the workplace should have been requested again, but it was not requested by the municipality.

Uncertainty in the Risk Assessment Report

* In the “Masquerade Istanbul Emergency and Fire Evacuation Plan” submitted to the file, it is shown that there is a single exit, and that exit points to the door located behind the section marked as the electrical room, which is the starting point of the fire; the 1st door is written as the “customer entrance”; there is a logo of the Asiltaş Fire and Security Systems company on this plan; and there is no stamp or signature on this document submitted to the file,

* In the 1st article of the Risk Assessment Report, which was prepared by an occupational health expert and is valid until April 24, 2027, it was written that there was a ‘high risk’ in general regarding the lack of a smoke detector, but that the current situation was an acceptable risk, and that emergency exit doors should exist and this equipment should be visible.

* While the number of employees was stated as 103 in the report in question, it was understood that the preparation date in the conclusion section was September 21, 2023, and the validity date was September 21, 2027, that there were no names in the preparation and approval sections, that there were no signatures, and that it was a document for which it could not be determined by whom it was prepared.

Whether fire drills were conducted is unclear

* In accordance with the provisions of the Regulation on Health and Safety Conditions in the Use of Work Equipment; it was observed that there was no document in the existing file proving that periodic checks of the fire installation, fire extinguishing systems, automatic gas extinguishing systems, sprinkler system, fire detection and warning systems, electrical installation, and grounding installation were carried out at least once a year.

* No document could be found regarding whether a fire or evacuation drill, which is mandatory to be conducted at least once a year, was carried out and whether there were any deficiencies.

* According to the provisions of the Regulation on Emergencies in Workplaces; “In works lasting thirty working days or less, special assignments made within the scope of this regulation for emergencies that are likely to directly affect employees due to the nature of the workplace or the work to be done are made by the employer, and employees are informed about those with special duties and emergencies,” but no document could be obtained indicating that the workplace authority/authorities informed the company employees who had special duties and worked there in this direction.

Only one door instead of three emergency exit doors

* According to the provision on emergency exit routes and the number of doors in the regulation regarding health and safety measures to be taken in workplace buildings and annexes, it was determined that there was only one door, whereas there should have been at least 3 emergency exit doors. It was observed that the only emergency exit door in the workplace did not have the quality of a ‘fire door,’ did not have a panic bar, and was in the form of a simple flat iron door.

* It was determined that there was no emergency lighting system connected to a separate energy source that would provide sufficient illumination in case of a power outage in emergency exit routes and doors, although there should have been one.

* In the letter dated April 5, 2024, from the Beşiktaş Municipality Zoning and Urbanization Directorate, it was stated that there was no change in the structure where the business where the fire broke out is located according to its approved project and that the load-bearing system of the building was as in the project. However, during the inspection at the scene, it was determined that the section/sections with the emergency exit staircase were closed.

* During the discovery, it was evaluated that there was 1 entrance and 1 exit door in the workplace, but that a 2nd exit door was made as a result of including a shop that previously belonged to another business in the bazaar into the discotheque area, but that this passage section opened upwards with a screen in a way that did not comply with the regulations, that there was no emergency lighting, and therefore it should not be seen as an emergency exit.

* It was understood that in the Occupational Safety emergency plan in the file, it was stated that the workplace had 1 entrance and 1 exit door and that the plan was made accordingly.

The existence of a hidden door is in the video recording

Meanwhile, the finding of the expert who took part in the expert panel in the report is remarkable.

The expert recorded the discovery of a door in the venue in the report as follows:

“Namely; in the inspection carried out in this area, which falls on the opposite side of the section used as a kitchen at the back of the workplace at the end of the discovery, it was seen that there was a wooden door, but that it did not lead to a room behind the door, but only to a narrow area,

After advancing in this narrow area, a staircase consisting of 7-8 steps appeared, but it was seen that this staircase was terminated and a wall was built in front of it, and it was recorded on video by the crime scene investigation teams.

The dates when these closed staircases were closed could not be determined by us. However, it is contrary to the ordinary flow of life that this staircase behind the wooden door could not be seen or that it was not known what it was by the workplace authorities due to the door existing there.

The reason for the deaths at the scene is the inability to exit/escape from the scene. For this reason, it was concluded that those who closed these exit stairs and those who used the workplace without opening them, knowing that they were closed, were also at fault.”

Who is at fault?

At the end of their work, the expert panel explained the negligence and responsibilities that emerged one by one in the evaluation and conclusion section of the report.

According to the findings, civil servant Lalehan Taşdelen Başkaya, Licensing and Inspection Manager Uğur Türkyılmaz, and Beşiktaş Deputy Mayor Yasemin Saral were found “primarily at fault” due to the workplace opening and operating license issued to the business in 2018; and civil servant Feridun Tayfun Erelmas, Licensing and Inspection Manager Uğur Türkyılmaz, and Beşiktaş Deputy Mayor Ali Rıza Yılmaz were found “primarily at fault” due to the issuance of the workplace opening and operating license in 2020.

In addition, Mechanical Engineer Uğur Türkyılmaz and the then Beşiktaş Deputy Mayor Ahmet Mithat Şermet, who approved and signed the workplace opening and operating license in 2010; and Mechanical Engineer Uğur Türkyılmaz, Licensing Chief Nilüfer Oğuz, and again the then Beşiktaş Deputy Mayor Ahmet Mithat Şermet, who were involved in the licensing procedures in 2011, were found “secondarily at fault.”

Within the framework of negligence and responsibilities in the fire department reports, the experts found no fault or responsibility regarding Fire Department officer Fazlı Yavuz, Fire Department Police Chief Numan Bulburu, Deputy Fire Chief Tuncay Akdağ, and Deputy Technical Fire Chief Şükrü Öztürk in the fire department report issued in 2006.

The then Fire Support Manager Orhan Akyıldız and Deputy Mayor Ahmet Mithat Şermet, as well as the then Beşiktaş District Governor Sadettin Yücel and Istanbul Deputy Governor Derviş Ahmet Set, were found “secondarily at fault” regarding the issuance of the 2011 fire department report required for the opening of the workplace.

It was determined that the workplace owners Şahzade Sekergümüş, Mehmet Menduh Ceylan, and Fatma Dörtgül were “primarily at fault” regarding the fire.

Kahraman Erdem and Çağlayan Altunel, whose responsibilities were determined during the welding process at the nightclub, were found to be in the position of “primarily at fault,” and Dursun Çelik and Sibel Çelik, who were in charge of occupational health and safety, were determined to be “secondarily at fault.” In the same framework, Kadircan Gülhan was found “primarily at fault.”

News Source: 12punto