The tragic death of two people late on Saturday night at Borrowdale Race Course as the large crowd was leaving the venue needs to be thoroughly investigated, so that we can learn all the factors that contributed to these deaths.
The primary purpose of the investigation thus needs to be to find out as precisely as possible what happened and to work out each factor that could have made the event more dangerous.
It is highly unlikely that there is a single major factor; it is more likely to be a series of factors working in series and parallel, and we need to know them all.
While there will be some determined to find someone to blame, this is in many respects the least important part of the investigation, primarily because wrong decisions, or lack of decisions, or lack of advance precautions or whatever may well be contributing factors, but are not likely to be a simple and single cause.
The police have already suggested that the large crowd could have been a primary factor, and that this is something that they would want to see limited in future. The crowd was large.
This was the first major race meeting which anyone could attend since the start of the Covid-19 infections, and was followed by a high-end free music concert, again the largest such concert since the start of Covid-19 and one that anyone could attend needing only to spend small sums on transport and refreshments.
So it was an opportunity for a lot of people to just take a break from all the pressures we have endured over the last two years, and have some fun. Generally it went very well, but obviously several things went wrong at the end.
The police have a point on crowd size, but it is not so much the size of the crowd that matters, since even a few hundred people can trigger a fatal stampede in the right conditions, but how that crowd is distributed and how it moves.
This is why the very large stadiums, these days, are so safe. Seating is divided into bays so you cannot get serious, let alone fatal pressure surges.
Then while entry might have restrictions, since people want to collect entrance charges, the exit is simple and easy, with each bay usually having a dedicated exit so again there can be no pressure surges, and very importantly all exits open.
Borrowdale Race Course has similar seating, of course, and even when all grandstand seating is jammed solid at a major race meeting, the bay partitioning and the way the routes to the exits are organised means that intolerable pressure cannot arise. So sheer crowd size is not necessarily a problem. In fact the largest single crowd ever at Borrowdale Race Course is almost certainly the high mass celebrated by Pope St John Paul II in 1988.
There were no problems at all. The crowd were generally church goers at a church occasion, patient and under some very benign and relaxed crowd control from the parish councillors keeping them in their parish groups. It was also daylight.
So while the crowds spilt into the great central lawns, thus bypassing the barriers that normally control crowd pressure and feed departing people into the gates, there was no pushing or other pressure and everyone could see what was going on.
At a major music concert the crowd will spill out of the grandstands, and that can present a problem unless some temporary crowd control is placed in the open areas, and clear exits are opened and marked.
The exits that can handle full grandstands with ease are not necessary properly connected to the areas where people can sit in the open if there are no races being run. You can get very large numbers trying to simultaneously squeeze into a very small area, and even a narrowing area, and that spells trouble.
At the same time, the problem of lighting needs to be checked out. Presumably the Mashonaland Turf Club has enough basic lighting inside the race course, although an expert needs to check out if what is assumed to be enough is enough.
But as you leave the race course darkness descends. The street lights along Liberation Legacy Way have not been maintained, despite being solar-powered and therefore should be working even if power is down.
The moon that night was a little under half full and almost about to set when the concert ended at 10pm. That means it was low on the horizon at the critical time and mostly hidden by hills and trees before it finally set soon after 10.50pm.
In other words as people got out they were in the dark, and so likely to stop, clogging the exits, while they looked around and got their bearings. But there could have been back-up among those still trying to leave.
The concert was advertised to end at 10pm, and it did. There were some in the crowd who were disappointed, and hoped that it could continue for longer, but it was made clear that this was not going to happen.
So then everyone would suddenly remember that they needed to get out and find their car or find public transport, and those who go out first would be able to drive off first or catch the bus first. That would have created a lot of pressure for the exits, and if some exits were expected to handle those coming from the open areas as well as their designed catchment of the grandstands this could have created a lot of crowd pressure.
The final report of the investigation must not be seeking a single cause, but must recognise and consider each factor, and try and figure out how it contributed to the two tragic deaths.
This in turn will mean that future events, here or at any other venue, will need to take these same factors into account.
And if there is likely to be some danger, then adequate measures can be prepared in advance and these are unlikely to be limited to a single factor, like controlling crowd size, but include a lot more of how to partition the crowd, how to ensure that adequate exits are available for each part of the crowd, how to deal with light and transport and all the other contributory factors.