The government was warned more than a decade ago that overcrowding and poor planning at Lag BaOmer events on Mount Meron could end in disaster, in a scathing report by then-State Comptroller Micha Lindenstrauss.
A stampede at a packed Lag BaOmer event on Mount Meron on Thursday did indeed lead to tragedy, with 45 people losing their lives and dozens more needing hospital treatment, some with critical injuries.
The December 2008 report warned that the tomb of the 2nd century sage Rabbi Shimon Bar Yochai, where ultra-Orthodox Jews gather for the annual festivities, had been neglected for years and that structures built around it to accommodate the all-night prayers and celebrations were a safety risk to the hundreds of thousands of worshippers.
"Fire safety and escape routes are deficient and after emergency services have been issuing warnings for years, no actions have been taken by the religious institutions who manage the site in order to rectify the problems and ensure public safety," the report said.
"This situation must not be allowed to continue at a compound that is of religious and national importance," the comptroller wrote.
In his concluding remarks, Lindenstrauss wrote that the neglect was a systemic failure and that many different authorities were involved in the management of year-round events at the site, culminating in the massive Lag BaOmer celebrations.
Disputes between the various authorities were hampering the much-needed repairs, the report found.
In the wake of the report, the government in March 2009 tasked the Government Companies Authority at the Finance Ministry with looking into the formation of a body to maintain the grave and the surrounding area.
But a State Comptroller's Report published by Lindestrauss in 2011 said that the government never followed through on the maintenance of the site. Only minor repairs were made, the 2011 report said.
The report also noted that despite preparations ahead of Lag BaOmer having improved somewhat, no one body had been tasked with responsibility for the actual events at Lag BaOmer and those at the site year round.
The ombudsman called for the government to rule that the regional council with jurisdiction over Mount Meron must maintain the site - either voluntarily or by order of the Interior Ministry.
In December 2013, then-finance minister Yair Lapid signed an order removing authority over the site from private organizations and placing it in the hands of the Ministry for Religious Affairs.
The question of public safety at the site was also raised in 2017 by the Knesset Internal Affairs and Environment Committee, then headed by Likud MK Dudi Amsalem.
"When you have 300,000 people in one place, someone must be responsible," Amsalem said.
"People go there to pray and not to wonder who is in charge, but someone official must be responsible. We have facilities and parking, but everything is disorganized. That is because no one is required to get a permit to hold an event and everyone can just do whatever they want," he said.
The condition of the site was again raised in a 2018 meeting of the same committee that was attended by just three MKs.
Aryeh Deri, the head of the ultra-Orthodox Shas party, was responsible for religious sites at the time and warned of the danger to public safety.
"We have a very large bonfire in a very small area, and it is very dangerous," Deri said.
"So, we allow the crowd to occupy the surrounding areas so that they can watch the bonfire and there is no longer a need for people to crowd together, which causes us great concern."
Now three years on, after the dire warnings have come to pass, the current State Comptroller Matanyahu Englman has vowed to launch an investigation.
Perhaps this time the safety at the site will be addressed and Israelis will never again be subjected to the kind of terrible tragedy that happened Thursday night.