CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 7 novembre 2023

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margin-bottom:0pt; text-align:justify; font-size:10pt } .s653E6C45 { font-family:Arial; font-size:6.67pt; vertical-align:super; color:#0069d6 } THIRD SECTION CASE OF DURDAJ AND OTHERS v. ALBANIA (Applications nos. 63543/09 and 3 others – see appended list) This version was rectified on 11 March 2024 under Rule 81 of the Rules of Court   JUDGMENT   Art 2 (procedural) • Effectiveness of investigation and ensuing criminal proceedings into explosion at Gërdec weapon decommissioning facility resulting in deaths and grievous bodily injuries • Investigation adequate in that it established circumstances surrounding the incident and led to the identification of those responsible • Applicants granted access to the investigation to the extent necessary to safeguard their legitimate interests • Convictions of main accused relating to life-endangering acts and to the protection of the right to life within meaning of Art   2 • Given case did not involve intentional killings, prison sentences and time spent in prison not manifestly disproportionate to the seriousness of the acts committed • Applicants not afforded an opportunity to participate effectively in the criminal proceedings against the accused • Criminal proceedings against the Former Minister of Defence still pending for over fourteen years, plagued by significant delays, inertia of prosecuting authorities and futile attempts by the applicants to bring him to justice Art 2 (substantive) • Victim • Non-exhaustion of domestic remedies • Adequate relevant domestic legal and regulatory framework providing for several legal bases for seeking compensation from the State • Acknowledgment in substance in administrative proceedings brought by some applicants of State’s responsibility as regards substantive aspect of Art   2 together with award of compensation leading to loss of victim status of those applicants • Failure of remaining applicants to bring civil damage claim against the State   STRASBOURG 7 November 2023 FINAL   07/02/2024   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of Durdaj and Others v. Albania, The European Court of Human Rights (Third Section), sitting as a Chamber composed of:   Pere Pastor Vilanova , President ,   Jolien Schukking,   Yonko Grozev,   Ivana Jelić,   Darian Pavli,   Ioannis Ktistakis,   Andreas Zünd , judges , and Milan Blaško, Section Registrar, Having regard to: the applications (nos.   63543/09, 46707/13, 46714/13 and 12720/14) against the Republic of Albania lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by seventeen Albanian nationals (“the applicants”) on 29   January 2014, 28 May 2013, 28 May 2013 and 9 November 2009 respectively; the decision to give notice to the Albanian Government (“the Government”) of the complaints under the substantive and procedural aspects of Article 2 of the Convention and under Article 13, and to declare inadmissible the remainder of the applications; the parties’ observations; Having deliberated in private on 10 October 2023, Delivers the following judgment, which was adopted on that date: INTRODUCTION 1.     The application concerns the explosion at the Gërdec facility for dismantling decommissioned and obsolete weapons, machinery and equipment of the armed forces which resulted in the death of the applicants’ next of kin or grievous bodily injuries to the applicants. Relying on Articles   2 and 13 of the Convention, the applicants complained that the State had failed to protect their or their next of kin’s right to life and that the criminal investigation into the incident had not been effective. THE FACTS 2.     The applicants were represented by Mr D. Matlija, a lawyer practising in Tirana. The applicants’ details are set out in the appended table. 3.     The Government were initially represented by their Agent, Ms   E.   Muçaj and most recently by Mr O. Moçka, General State Advocate. 4.     The facts of the case may be summarised as follows. Background to the case 5.     Following the collapse of the communist regime, during which a large portion of Albania’s focus and resources were devoted to the country’s defence system, it was estimated that the Albanian armed forces possessed a stockpile of 185,000 tonnes of ammunition stored in 1,300 depots across the country. Faced with the risk that this ammunition posed to the life and health of the population, in particular in the aftermath of the collapse of pyramid schemes in 1997 and the looting of arms depots, the authorities embarked on the process of the decommissioning and destruction of the ammunition stockpile. The decommissioning of ammunition initially took place in three State-owned and controlled military facilities (Poliçan, Mjekës-Elbasan and Gramsh). 6.     On 14 March 2007 the Council of Ministers (the executive branch of the government of Albania) adopted decision no. 138 setting out the procedure for dismantling decommissioned and obsolete weapons, machinery and equipment of the armed forces, both for military and non-military use. Permits for the export of weapons, machinery, equipment, ammunition and explosives were to be issued by the Ministry of Defence. The ammunition, weapons, machinery, equipment and explosives of the armed forces could be sold to museums, for collection purposes or for other civilian use, only after their decommissioning (after becoming non-effective as weapons). The decommissioning procedure was to be set out by order of the Minister of Defence and with the guidance of the Chief of the General Staff of the armed forces. The Military Export-Import Company (“the MEICO”, a company established by government decision under the auspices of the Ministry of Defence) was entrusted with conducting the procedure for the sale of ammunition for decommissioning purposes and with entering into respective contracts. The sale prices were to be fixed and approved by a commission established by order of the Minister of Defence and composed of finance experts, lawyers and economists. A department of the Ministry of Defence’s could destroy and dispose of decommissioned and obsolete weapons, machinery, equipment, ammunition and explosives. Article 4 of Chapter IV of decision no. 138 provided that the dismantling and decommissioning process would be carried out under the strict scrutiny and security of the armed forces. The decision of the Council of Ministers also authorised the sale, dismantling and decommissioning of ammunition with a view to reducing stocks of obsolete small-calibre ammunition. 7.     On 25 April 2007 the Minister of Defence issued order no. 550 on the implementation of decision no. 138 of 14 March 2007 of the Council of Ministers. It stated, inter alia , as follows: “I order ... the requested ammunition (100 million cartridges of 7.62 by 54 mm with brass casings, 20 million cartridges of 12.7 mm with brass casings, and 20 million cartridges of 14.5   mm with brass casings) to be transferred to the MEICO for sale for the purposes of disposal and decommissioning within the country with the help of [Southern Ammunition Company], and (a) instruct the command of the armed forces to provide for this the use of an area of land under the administration of the Ministry of Defence in Gërdec, in Vorë municipality ...” The Joint Forces Command ( Komanda e Forcave të Bashkuara ) was entrusted with (i) making available to the decommissioning process an area of land under the administration of the Ministry of Defence located in Gërdec (Vorë); (ii) transporting the ammunition to the Gërdec facility according to the schedule established with the MEICO; (iii) safeguarding the facility and controlling the entry-exit regime of its employees onto the premises; and (iv)   entering into a lease contract with a US-incorporated company, Southern Ammunition Company (“SAC”). 8.     On 22 October 2007, the Minister of Defence issued order no. 1800 in accordance with which the Minister of Defence placed the property where the Gërdec facility was located under the management of the MEICO, which subsequently made it available to Albademil Ltd, a limited liability company incorporated in Albania, without a lease contract. 9.     On   7 December 2007 the Minister of Defence issued order no. 2044 on the dismantling and decommissioning of ammunition. The MEICO was entrusted with putting the Gërdec facility at the disposal of SAC for the decommissioning process. The MEICO was ordered to enter into a contract with SAC and, among other things, to comply with the contractor’s application of standard safety procedures, fire protection measures and to ensure the protection of the life and health of individuals employed during the dismantling and decommissioning of ammunition under strict observation and security conditions. The MEICO and the Joint Forces Command were to supervise the decommissioning facility and the ammunition depot therein. 10.     In the meantime, on 6 June 2007 the MEICO entered into a five-month contract with SAC for the sale of the ammunition stockpile for decommissioning purposes. The objective of the contract was to dismantle small-calibre ammunition only (7.62-14.5 mm). The contract stipulated that SAC would provide the machinery for the dismantling of the small-calibre ammunition, and provide American experts to supervise the process. According to the contract, SAC would undertake to manage and control the dismantling and decommissioning of the ammunition, subject to conditions and technical safety measures defined in the relevant Albanian legislation, and the MEICO and the Joint Forces Command were to ensure the supervision of the decommissioning facility. In turn, SAC subcontracted the work to Albademil Ltd. 11.     The former plant for manufacturing tanks in Gërdec, an area located 15 km west of Tirana, was designated as the decommissioning facility. Decommissioning was envisaged only for small-calibre weapons (20 mm and smaller). It was reported that the decommissioning had been carried out without significant problems. At the time the weapons-decommissioning facility was being set up in Gërdec, the other specialised military facilities (Poliçan, Mjekës-Elbasan and Gramsh) were still in operation. 12.     On 28 December 2007 the MEICO entered into a second contract with SAC for the dismantling of medium to large-calibre (20-152 mm) ordnance with brass casings, which again subcontracted the work to Albademil Ltd. 13.     On 15 March 2008 at around midday a massive explosion occurred at the weapons-decommissioning facility (“the Gërdec incident”). The incident continued for several hours and twenty-six people died and around 300 were either grievously or lightly wounded. It destroyed the property of 5,829   people, causing material damage in the amount of 2,141,343,616   Albanian leks (ALL) according to the Ministry of Defence’s data at the time of the event. The applicants in the present applications 14.     The applicants in applications nos. 63543/09 and 12720/14, Zamira   Durdaj and Feruzan Durdaj, are the parents of the late Erison Durdaj. At the time of the explosion Erison Durdaj, then aged seven, had been passing by the facility together with his cousin, Roxhens Durdaj (the first applicant in application no.   46714/13), dropping off a lunch box to Roxhens’s mother and Erison’s aunt who worked at the facility. Erison Durdaj was grievously injured in the explosion and was transferred to a hospital in Italy as an emergency measure, where he died on 3 April 2008. Roxhens Durdaj, then aged 11, was grievously wounded by the flames of the explosion. 15.     All thirteen applicants in application no. 46707/13, as well as the second applicant in application no. 46714/13 (Alketa Hazizaj), were working at the facility and were grievously wounded in the explosion. Criminal investigation 16.     On the same day of the explosion, 15 March 2008, the Prosecutor General’s Office opened a criminal investigation into the Gërdec incident. Four suspects, Y.P. (the head of the MEICO), M.D. (the manager of Albademil Ltd), D.M. (the facility manager employed by Albademil Ltd) and S.N. (an employee at the MEICO) were immediately taken into custody. 17.     The authorities were unable to access the facility immediately as the incident continued for several hours. The evacuation of the facility and the surrounding area and the clearance of the remaining ammunition by explosives experts took place in the days following the explosion. 18.     On 29 March 2008 the investigation was extended to include the former Minister of Defence, F.M., who was at the time of the explosion a member of parliament (MP). In order to proceed with the investigation in respect of F.M., Parliament’s authorisation was required in accordance with Article 73 of the Constitution. The Prosecutor General asked for the lifting of F.M.’s immunity, relying on “reasonable suspicion based on evidence demonstrating his guilt of ignoring safety rules which [had] led to the occurrence of the incident and [had] caused great economic damage to the State”. 19.     On 16 June 2008 Parliament authorised the Prosecutor General’s investigation in respect of F.M. 20.     It appears from the evidence submitted to the Court that three expert examinations were carried out in the context of the investigation. The first was conducted by the International Response Team (IRT) of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). The ATF is the primary US federal unit of investigation of explosives incidents and for the enforcement of laws and regulations in that connection. It has national and international investigating authority. The second investigation was conducted by the Prosecutor General’s Office, and the third by the military. ATF-IRT report General findings 21 .     The assistance of the ATF-IRT with the investigation of the Gërdec incident was requested through the United States embassy in Albania. The ATF-IRT was dispatched on 5 April 2008 to assist the Albanian authorities, namely the Prosecutor General’s Office and the Tirana district prosecutor’s office, in processing the site of the incident and conducting interviews. 22.     The fact-finding post-explosion investigation was conducted between 7 and 11 April 2008 at the decommissioning facility to determine the origin and causes of the fire and the explosion. 23.     On 7 April 2008 the ATF-IRT began conducting an incident-scene examination which was completed on 11 April 2008. The incident-scene examination included forensic mapping and photographs. The ATF-IRT assisted in witness interviews, incident-scene examination and forensic mapping and documentation. Its investigation report noted that the facility had been operated by Albademil Ltd and that decommissioning of obsolete military ordnance of calibres from 20 to   152 mm had taken place there. The information gathered during the investigation indicated that the facility had been in operation since January 2008 and up to eight trucks per day had delivered munitions to be dismantled. 24.     The report stated that the process for engaging the workforce had consisted of hiring an individual with his or her entire family to work as a group, including children between 10 and 16 years of age. A specialist would supervise more than one group at a time. The workers earned money based on the amount of munitions dismantled. The investigation report noted that although safety briefings should have been conducted at the beginning of each project and at the beginning of each working day, this had not always happened, including on the day of the explosion. 25.     The report also stated that no regulations on technical safety rules had been made available to workers at the facility. The interviews with workers revealed that they had not had a designated smoking area and no “no smoking” signs had been displayed. Moreover, they had not been impeded from carrying matches, lighters or tobacco on the processing facility’s grounds. 26.     The report further confirmed that no work uniform had been designated for the workers. Additionally, they had not been required to wear non-static clothing (100% cotton), and nor had they received any instruction on avoiding static-electricity hazards. The photographs and video-recording provided by SAC prior to the incident revealed that at least one portable fire extinguisher had been located at the south-east corner of the facility. However, there had been no automatic fire-suppression system in place. 27.     On 15 March 2008 large quantities of ammunition of all kinds had been delivered from 7 to 9 a.m. The report stated that the process of dismantling had started at 9.30 a.m. Around 118 workers divided into twenty groups of three to four people had started opening the boxes in which the ammunition had been stored, extracting the projectiles, casings and gunpowder and placing them in their designated places. 28.     At midday an explosion had occurred. Decommissioning operations had been taking place at the time of the explosion and around fifty workers had been in the main processing area when the fire had occurred. Workers had been unable to extinguish the fire owing to the lack of adequate equipment. At the time of the explosion there had been 1,067,855 tonnes of gunpowder, 286,476 tonnes of various types of combustibles, and 4,365,335   tonnes of TNT casings. This material had been located in various places stretched out across almost the entire surface of the Gërdec facility. Conclusions of the ATF-IRT’s investigation 29.     The explosion had resulted in the deaths of twenty-six people and had injured approximately 300. The explosion had also damaged infrastructure, such as water and power-supply networks, roads, public buildings, schools, kindergartens and health centres. 30.     The weather was not considered a factor in the explosion. On 15   March 2008 at midday the temperature was reported to have been 18 o C, humidity was at 94%, and there were northerly winds of 14.8 km/h, scattered clouds and no precipitation. 31.     The exact reason for the fire remained unknown. However, aspects of the working methods could have led to the fire originating in bags of propellant. It became clear during the investigation that propellants such as black powder and double-base smokeless gunpowder were very sensitive to ignition from heat, static electricity, friction or flame. Based on the ATF-IRT incident-scene examination and the witness statements, it was concluded that the incident had been caused by a fire originating on a pushcart loaded with propellant in plastic bags which had caused an explosion of most of the stores of munitions and propellant at the facility. The fire had originated near the centre of the south end of the yard approximately 10 m inside the gate near the 122 mm decommissioning bench. 32.     The most probable course of the events based on the evidence gathered was that workers had been in the process of moving plastic bags containing propellant onto pushcarts. The propellant on a cart had caught fire spreading to nearby stores of propellants and wooden ammunition boxes. The fire had burned for a short time until eventually it had caused an explosion in the area where fused and unfused military munitions had been stored. 33.     In its conclusion, the report outlined a number of shortcomings based on witness statements and pre-explosion photographs and video-recordings taken a month prior to the incident. It first noted that the procedures used at the Gërdec facility had been unsafe and not in compliance with normal working standards at workplaces dealing with explosives and propellants. It further stated that the dismantling of ordnance had been performed by untrained workers using vehicles which had not complied with safety standards. The photographs taken prior to the incident revealed that rubbish, explosive materials and unsecured fused projectiles and propellant bags had been left on the floor. Furthermore, unsuitable static-producing clothing had been permitted on site and no training on how to reduce static-electricity hazards had been given. Lastly, it stated that an operation of this magnitude should never have been conducted in a location close to public roads and residences. Prosecutor General’s Office report Findings in respect of the first contract 34.     The investigation report established that by 28 December 2006, F.M. had already approved the offer of SAC to enter into a contract for the decommissioning of small-calibre ammunition and informed the Chief of the General Staff of the armed forces. On the same date, Albademil Ltd was set up with two co-owners, P.H. and M.D., who held one-third and two ‑ thirds of the shares respectively. The report also noted that in 2006 P.H. had visited Albania several times and had had several meetings with Y.P. (the head of the MEICO). Y.P. had provided P.H. with information relating to the legal framework applicable in Albania to set up a company. Subsequently SAC had made an offer, the content of which had been included in a fax dated 27   December 2006. 35.     The report stated that the choice of Gërdec as the site of a weapons ‑ decommissioning facility had been made in violation of the law and State regulations. The area had not been licensed for the storage and dismantling of ammunition. During the execution of this contract, the dismantling of small calibre materiel including 7.62 mm, 8 mm, 12.7 mm and 14.5 mm had been carried out. The investigation report stated that children and workers with little or no technical knowledge had been hired to work at the facility. The report also noted that they had not received any training or instructions, nor instruction on safety regulations. Three American experts were present at the facility during the first contract (concerning small calibre dismantling), but not during the second contract (concerning medium and large calibre dismantling) or on the day of the explosion. 36.     The contract had stipulated the need to establish a transportation schedule ( grafiku i transportit ) but this had never been done as the parties had not been able to agree on the conditions. During implementation of the first contract, the MEICO had also been required to provide three licences: (i)   for the dismantling of the ammunition, (ii) for storing the ammunition, and (iii)   for the import and export of the ammunition. The report noted that the MEICO had not issued any of the above licences. The report also indicated that during the period of the first contract, fires had broken out at the weapons-decommissioning facility, but had been extinguished with the assistance of the American experts. 37.     The report concluded that the ammunition had been dismantled in the open without any protection from the rain or the sun. The investigation report also concluded that the dismantling process had greatly increased the level of risk at the weapons-decommissioning facility arising from the delivery, storage, dismantling and decommissioning of thousands of tonnes of dangerous components such as gunpowder, TNT and detonators. On 27   December 2006 the SAC had submitted an offer to dismantle and decommission ordnance which had been unavailable for military use. The offer had been submitted to the head of the MEICO, Y.P., following several prior exchanges by email, fax and in person. Y.P. had informed the Minister of Defence in note no.   1232/523 of the content of the offer, emphasising the financial advantages to the State. Findings in respect of the second contract 38.     On 28 December 2007 the MEICO entered into a second contract with Albademil Ltd. The investigation found that the second contract included the dismantling of large-calibre shells of between 20 and 150 mm even though F.M. had been aware that the MEICO and Albademil Ltd had not possessed the appropriate technology for the industrial dismantling of anything other than small-calibre ammunition. 39.     The investigation report stated that during the execution of the second contract, preparations had been under way to dismantle ammunition that had not been part of the army’s obsolete stock but which could also have possibly been used for arms trafficking. 40.     According to the report, the dismantling of large-calibre shells had started around the third week of January 2008. The main work before the explosion had comprised the extraction of the casings from the shells, the removal of detonators and gunpowder, and the clean-up of the site. 41.     The report also noted that the process for obtaining the workforce had consisted of hiring an individual with his or her entire family to work as a group. A specialist had supervised more than one group at a time and set the daily work quota. 42.     It was reported that a safety briefing had been conducted at the beginning of each project for each particular type of material. It also reported that at the beginning of each working day the workers had been lined up and given a safety briefing. However, it was clear from the report that the briefing had not always happened, including on the day of the explosion. 43.     No regulations on technical safety rules had been made available to workers at the facility. The interviews with workers had revealed that they had not had a designated smoking area and no “no smoking” signs had been displayed. Moreover, they had not been impeded from carrying matches, lighters or tobacco on site. No work uniform had been designated for the workers. Additionally, they had not been required to wear non-static clothing, and nor had they received any instruction on how to prevent static-electricity hazards. The photographs and the video-recording provided by SAC had revealed that at least one portable fire extinguisher had been located at the south-east corner of the facility. However, there had been no automatic fire-suppression system in place. From 12 to 14 March 2018, trucks had brought more than 460 tonnes of shells to the facility. There had been approximately 1,070 tonnes of gunpowder, 286,476 detonators of various types and approximately 4,365 intact shells on site. 44.     Eight trucks had arrived during the night of 14 March 2008, transporting ammunition. The following military munitions had been in the main area of the facility on the day of the explosion: 20 mm high explosive inflammable cartridges; 37 mm anti-aircraft high-explosive shells; and “fixed” shells (100 mm and 122 mm) and “semi-fixed” shells (122 mm, 130   mm and 152 mm), both with a self-destruct mechanism. 45.     The trucks had not been unloaded immediately owing to the late hour and the cold weather. A large quantity of plastic bags containing propellants which had been removed from the shells had been placed in the centre of the facility in a line running north to south. Military ammunition, including 37   mm and 100 mm shells, had been lined up against the east and west walls running the length of the facility. 46.     The Government did not submit a copy of the investigation file. They stated that the issue was in the hands of the Prosecutor General’s Office. 47 .     The Prosecutor General wrote a letter to Parliament for the session where the authorisation for the prosecution of F.M. was requested. The letter reads as follows: “The investigations carried out at this stage indicate beyond reasonable doubt that F.M. committed intentional acts and omissions in violation of the law and by-laws. These acts had a direct effect on the Gërdec incident. F.M. issued order no. 550 of 25   April 2007 on the implementation of Council of Ministers decision no. 138 of 14   March 2007 setting out the procedure for dismantling decommissioned and obsolete weapons, machinery and equipment of the armed forces, both for military and non-military use. The order was adopted without consultation with the General Staff and the Ministry of Defence Department for the Harmonisation of Legislation and Relations with Parliament, which is obligatory. This was in flagrant violation of Article 17 of the Internal Regulations of the Ministry of Defence. Furthermore, the order provided for the dismantling and decommissioning of ordnance to take place in Gërdec. This was in flagrant violation of Article 3 of regulation no. 9603 of 19 September 2003 of the Ministry of Defence, pursuant to which all activities in the field of military munitions should be performed by licensed companies. The licence should be issued by a specific commission established by the Minister of Defence. Thus, the dismantling and decommissioning of materiel in Gërdec was carried out by an unlicensed company, Albademil Ltd, in violation of the above provision. Moreover, the designation of Gërdec as a suitable location to host a weapons-decommissioning facility was approved without seeking the opinion of the relevant military authorities, namely the General Staff. Furthermore, order no. 550 did not define the authority that would ensure the supervision of the decommissioning process at the facility. Lastly, order no. 550 did not mention who would cover the expenses of the loading and transport of ammunition from the army’s depot to Gërdec, but merely entrusted this to the Joint Forces Command. Nor did the order contain the safety measures necessary for the decommissioning facility. The investigation also demonstrated that on 1 September 2007 SAC had submitted a second offer to the Minister of Defence to continue the dismantling of 20 to 152 mm shells with brass casings, despite SAC only having experience in dismantling small-calibre cartridges. In reply to a request for information by the Minster of Defence, SAC replied that it had the necessary equipment for the dismantling of large shells. The Minister of Defence not only approved the second offer but also issued order no. 1800 of 22 October 2007, in which property no. 126 (Gërdec area) was transferred to the MEICO, which subsequently transferred it to Albademil Ltd without a lease contract, in violation of a prior Council of Ministers decision. Furthermore, F.M. enacted order. 2044 of 7 December 2007 on the transfer of ordnance to the MEICO, in accordance with which the dismantling and decommissioning process was performed by an unlicensed company at an unlicensed facility. In point 8 of the order, the MEICO was entrusted with the supervision of safety standards, fire protection measures and security of the life and health of the employees at the facility. This provision was not compliant with Council of Ministers decision no.   138, which stipulated that the dismantling and decommissioning process was to be carried out under the strict scrutiny and security of the armed forces. Having regard to the foregoing, there is enough evidence to initiate the prosecution of F.M.” 48.     On 16 June 2008 the Speaker of Parliament issued a decision giving authorisation to institute criminal proceedings against F.M., an MP at the time, as requested by the Prosecutor General. Military expert report of 10 February 2009 49.     On 10 December 2008 a group of prosecutors from the Prosecutor General’s Office commissioned an expert report. 50.     On 10 February 2009 five experts in military munitions delivered a detailed report. The report stated that the transportation from the arms depot to the Gërdec weapons-decommissioning facility had been carried out using vehicles of the armed forces. There did not appear to have been a transportation schedule in place, in breach of an order issued by the Minister of Defence. 51.     The report could not determine whether the Gërdec weapons-decommissioning facility had been a military site. Having examined the by-laws, the report concluded that the Gërdec area, which had been administered by the Ministry of Defence, had not been licensed to be used as a munitions depot. The decommissioning process had carried a degree of risk in and of itself, since it had consisted of the storage of munitions, their disassembly and the separation and storage of by-products. As such, the designation of the Gërdec military facility for decommissioning purposes should have been accompanied by the licensing of the warehouses and facilities where the decommissioning operations were to take place. This would have involved an analysis of the storage and processing capacities in the light of the conditions which had pertained in the facility. 52.     The report drew no conclusions as to whether the safety measures had been complied with during the unloading and reception of ordnance. However, the report stated that ordnance had not been unloaded and stored in special warehouses, away from the area used for decommissioning operations. There had been no licensed warehouses to store ordnance delivered by the armed forces. The report went on to note that on entering into the second contract with the commercial contractor, a number of measures should have been taken before authorising the supply of materials and the commencement of work. Some of the measures should have included a prior inspection of the disassembly machines, compliance with fire safety measures, assessment of qualifications and training of personnel as regards technical safety measures and of the storage capability of the contractor. No such inspection had been carried out by the responsible State authority. 53.     Relying on employees’ statements the report found that personnel had not read or even seen any regulations concerning technical safety measures, nor had they received any training before starting work. No such information had existed for the period after entering into the second contract on 28   December 2007. 54.     The report further confirmed that the disassembly of the ordnance had not corresponded to its decommissioning as envisaged in the contract. It added that the facility’s infrastructure had not met the safety standards for carrying out decommissioning operations, which had taken place in two open-air locations not protected from exposure to direct sunlight. There had been no explosion-resistant containers with which to carry out dangerous and hazardous operations. The technology used for disassembly had not been safe. No machinery had been used and the equipment had not complied with the safety requirements. As regards on-site transportation, the vehicles used had not satisfied the safety measures required for working with dangerous materiel. The facility had not been equipped with fire extinguishers or an automatic sprinkler system, nor had any lightning protection system been installed. 55 .     The report concluded that the armed forces had been supposed to bear responsibility for securing and protecting the facility, while the MEICO had been expected to have general oversight over the decommissioning activity. It added that it could not be determined with certainty which authority had been meant to have oversight of compliance with the safety measures during the decommissioning process. Medical expert reports 56.     On 18 March 2008 the police requested the forensic medical examination of Roxhens Durdaj (the first applicant in application no.   46714/13). The medical examination was to establish the existence of injuries and their cause. Expert medical report no. 305 of 2 April 2008 established that Roxhens Durdaj had been grievously injured, resulting in Cat   IIB-III burns of 5% on both hands ( combustion mani bilateral ) and the back of his head caused by the flames of the explosion. The report also concluded that the injuries were life-threatening. 57.     On 11 August 2008 a prosecutor from the Tirana district prosecutor’s office ordered a post-mortem examination of the body of Erison Durdaj (the son of the applicants in applications nos. 12720/14 and 63543/09), to be conducted by a forensic medical expert in Tirana. The expert was asked to establish the existence of any external injuries, their nature, method of infliction and the cause of death. The death certificate with the accompanying documents from Perrino Hospital in Brindisi, Italy, where he had been transferred the day after the accident, was also presented to the expert. Expert medical report no. 805 of 19 August 2008 stated that on 15 March 2008 at 1   p.m., Erison Durdaj had been admitted to the intensive-care unit of Mother Teresa University Medical Centre in Tirana, where he had received treatment for second and third-degree burns covering 60% of his body. He had been suffering from headaches and earache. On 16   March 2008 he had been transferred to Perrino Hospital in Brindisi, where he had died on 3 April 2008 at 2.50   a.m. According to the death certificate issued by the hospital, he had died of complications from the second and third-degree burns covering 60% of his body caused by the flames of the explosion. The expert medical report established a causal link between the event which had occurred and his death and established as the cause of death an acute pulmonary oedema following hypovolemic shock. 58.     Medical certificate no. 891 of 5 September 2008 concerning Alketa   Hazizaj (the second applicant in application no. 46714/13) established that she had been severely injured, resulting in burns on 35% of her body caused by the flames of the explosion. The report concluded that the injuries were life-threatening. 59.     The medical reports of all the applicants in application no. 46707/13 concluded that they had been grievously wounded as a result of the explosion at the facility. The Court has not been provided with a copy of their medical certificates. The conclusions of their medical reports were submitted and examined in the domestic proceedings. Proceedings on indictment Proceedings before the Supreme Court 60.     Criminal proceedings were instituted against thirty persons invo