Senior counsel Frank Callanan’s inquiry said there had been no proper threat assessment carried out, which should have governed the level of cover afforded to soldiers serving at the time.
He said the order to send the three men driving up the dirt track to collect stones should not have been made. Troops’ warnings and fears were not addressed, the report states, and the army did not do enough to check the area for mines, despite clear and present danger.
He said it was striking that the Irish battalion held a number of mine detectors at the time but that these were in storage at headquarters and not deployed for daily routines. Mr Callanan said many of the items at issue appeared technical but their importance should not be understated.
“I should make it quite clear that I do not think that the analysis of what went wrong on the track up to the Green Rooms on March 21, 1989, primarily in terms of failure to carry out adequate threat and risk assessment is academic or intellectually grandiose.
“It is not sufficient to analyse what happened in terms of a series of discrete failures or oversights that interacted with bad luck and the malignity of terrorists to bring about the deaths of the three men of the 64th infantry battalion.
“Everything I have heard in the course of this review has impressed upon me the necessity of the undertaking of clear and coherent threat and risk assessments and adoption and observance of force protection measures derived from them. Instinct or intuition may no longer be enough.”
Five specific terms of reference were given, which Mr Callanan worked off. On these points, he said:
* The standard operating procedures were not adequate or appropriate to ensure the safety of Irish soldiers sent to protect communities in south Lebanon.
* There was not enough attention paid to the various threats which the troops were under and, in particular, noises from the militias opposing Israeli occupation of Lebanese lands.
* The device that killed the three men should have and could have been detected if proper procedures were followed.
* Despite the claims of many who served with the battalion the road where the men died on was not out of bounds. All of the officers interviewed said it was available for use and if a sign existed putting it beyond use then the army would have effectively been sending men to disobey a UN order. He did not think this happened.
* The soldiers did not have adequate training. The report contradicted earlier army claims that the men were equipped to carry out low-level mine sweeps if required.
Mr Callanan said the army should have learned from the fatal attack on Lieutenant Aongus Murphy in 1986 that UNIFIL peacekeepers stood to be targeted by resistance fighters.
“There was a deficient assessment of the threat confronting the 64th battalion in UNIFIL both from IEDs and landmines,” he said.