The panel investigating a blast at an Israel Military Industries installation two weeks ago has found a string of departures from normal safety procedures which led to the explosion.
The July 30 blast killed two workers at the plant and injured 47 people.
The commission of inquiry, headed by reserve Brig. Gen. Amos Horev, presented its findings and recommendations last week to Prime Minister Yitzhak Rabin, who also holds the defense portfolio.
The commission found that the blast was caused by carelessness in storing and handling gunpowder, and that this inattention was compounded by human error.
However, the panel could not pinpoint any particular act or lack of action to establish the exact cause of the initial blast.
The report instead described a sequence of events in which an initial explosion in an under-ground bunker created a chain reaction to other bunker.
It described it as “a series of human errors and a chain of tragic events.”
Horev, who chaired the commission, is a former ammunition corps commander and quarter-master general.
Insufficient attention to safety measures was evident both at the Nof Yam site, north of Tel Aviv, and at other Israel Military Industries installations in which explosions have resulted in loss of life, the report said.
These incidents have all occurred in the Greater Tel Aviv area in recent years.
Explosives had been stored not only in the independent underground and concrete-lined bunkers but also in open spaces around them, facilitating the chain reaction, the commission found.
But the commission did not place blame at the door of any individuals.
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