Itaewon, Sewol and the promise of ‘never again’: compliance, speaking up and complex remediation in the realm of public safety*

Chris Hardjasa (郭林纚)

London

chardjasa@yahoo.com

Introduction

When the horrific Sewol Ferry disaster took place in South Korea in 2014, the investigations and prosecutions that followed, along with the public outcry and widespread condemnation, together served to provide sufficient momentum to push through the Improper Solicitation and Graft Act (Anti-Graft Act). Also known as the Kim Young-Ran Act, after its Supreme Court Justice author, the Act had first been proposed in 2012, but faced significant opposition until the ferry tragedy brought it back into the spotlight, when the investigation revealed that corruption and collusion between the ferry owner, the Ministry of Ocean and Fisheries, shipping companies and industry organisations were part of the reason for the disaster.^[1]

In 2014, South Korea appeared to be in the middle of a profound transformation, with the enforcement landscape rapidly evolving.^[2] The Act was considered to be the strictest anti-graft law in the world,^[3] and on its passage, quickly began effecting positive change.^[4] At about the same time, the OECD Working Group on Bribery also reported a number of significant improvements the country had made in foreign bribery enforcement.^[5] Indeed, while 2014 was a year of profound mourning, to international observers it seemed that, as had happened with other countries updating their corruption laws, South Korea may be moving in a similar direction. Perhaps, as some hoped, the tragedy that had befallen its youngest generation had been so devastating, and so monumental, that the promises made by politicians that it would happen ‘never again’ may have been taken seriously.

But on 29 October 2022, another terrible tragedy took place. This time in Itaewon, a popular, busy district in Seoul, on Halloween weekend, claiming the lives of at least 158 mostly young people, including a young teenager attending the festivities with her mother and aunt. The tragedies were circumstantially different – the Sewol Ferry had capsized with 476 passengers and crew onboard, and 304 people, most of them young students and some teachers, drowned. In Itaewon, the 158 individuals were crushed to death, funnelled into a narrow, sloping alleyway as over 100,000 people attended annual Halloween festivities.^[6]

Speaking up and raising red flags: BTS in Busan, and Itaewon

Two weeks before the Itaewon disaster, a BTS (K-pop boy band)^[7] concert was held in Busan, attended by 55,000 fans. There were 2,700 security officers dispatched to handle this event, in stark contrast to the 137 officers sent to Itaewon on the tragic night.^[8] The concert venue had also notably been changed due to repeated outcry and speaking up by Korean fans of the band, collectively known as ARMY, from its original location: a landlocked, isolated plot of land in Ilgwang, Gijang, an old glass factory site in a remote fishing village. South Korean fans conducted site visits once the location was announced, and reported various alarming issues. Most significantly, it could only be accessed by a narrow, two-way lane with no pedestrian path, the site was extremely remote and lacked infrastructure; with limited public transport, combined with the expectation that the concert would host 100,000, fans feared the worst.^[9]

Concerned that funnelling such a large crowd into a single entry/exit point even with numerous crowd control officers would be fatal at worst, Korean fans began a campaign of civil complaints and petitions directed at the Busan City Government, and the Busan Expo Committee, citing the government’s own safety protocols created in 2006 following crush deaths at a concert.^[10] City authorities were minimally responsive, so fans went to reporters and encouraged other ‘armys’ to assist in promoting a wider, broader campaign. The local press began to make their own site visits and report on the lack of infrastructure and safety concerns.^[11] Another group of fans began organising volunteers to prepare for every contingency – including medical professionals, fire fighters and disaster relief experts, anticipating inevitable emergencies.^[12]

The BTS ARMY continued speaking up about the clear dangers, despite many feeling their efforts would be futile, and were warned that the location was highly unlikely to change given the government’s insistence on the Ilgwang venue.^[13] It appeared to be a hopeless pursuit, particularly when fans identified reports from 2021 of the Busan mayor’s wife purchasing large plots of land in Ilgwang, Gijang, while the mayor himself (while a candidate) registered the transaction at lower than the actual acquisition price, a potential violation of the Ethics in Public Office Act.^[14] After the first City meeting regarding the concert, only six weeks before was held, the City announced it had allocated KRW240bn (approx. US$185m) for redevelopment of the land in Ilgwang.^[15] Although they believed it was futile, fans’ speak-up campaigns and petitions began to focus on the potential conflict of interest in the choice of venue, given the mayor’s real estate holdings.^[16]

Then, the Chair of the Democratic Party of Busan echoed the conflict of interest issue in speaking to the press, citing the land development project on hold by the City Council, and issued a statement declaring the Ilgwang site as inappropriate for the concert, with a very high possibility of crush deaths.^[17]

Not long after the conflict of interest red flag was publicly raised, including brought to the attention of international fans, which number millions – it was abruptly announced that the venue had been changed, to the much more suitable Busan Asiad Stadium, which had a number of additional access points.^[18] The event was ultimately attended by approximately 55,000 individuals in relative safety, despite various lapses in security and organisation by the venue and City officers, supported by numerous fan volunteers.

Why, then, did the Itaewon disaster take place, when such a tragedy was prevented in Busan two weeks earlier on 15 October? While the concert was a one-off event, Itaewon’s narrow alleyway has existed for years, and complaints about it have long festered, residents calling attention to it but being ignored.^[19] BTS is the most popular band in the world, with thousands of international fans planning to attend the concert, and both national and international media surrounding the concert was significant and widespread. Popularity alone, however, could not have prevented what would have been inevitable disaster, had the venue not been changed. Without persistent, ongoing speaking up, along with careful research and targeted, focused due diligence and highlighting of critical red flags, most notably the conflict of interest issue, with clear evidence to support the issues raised – the outcome of what was meant to be a celebratory event would almost certainly have been very different. And once the concert had started, it was not luck, or coincidence that avoided a crisis – this was down to real-time risk assessment and quick decision-making by the band’s company staff, who observed the various safety and organisational issues already hampering the event and made last minute changes to elements of the performance to avoid increased risk to fan safety.^[20]​​​​​​​

Investigating two tragedies, root cause analysis and failed remediation

The Sewol Ferry incident was meant to be ‘the tragedy to end all tragedies’, from which the South Korean government learned to prevent and address crises, so that it would never again face such a devastating national disaster. Itaewon’s victims are of the same generation of the victims of the Ferry incident, a generation failed by what appears to be an ongoing failure truly to address systemic failures in the country’s emergency system, emergency services and police chains of command, and failures to address compliance and regulatory gaps in areas where such failures can and clearly do catastrophically result in the deaths of hundreds, perhaps thousands, when crises occur.

In the anti-corruption compliance field, when we conduct internal investigations and subsequent root cause analyses, we seek to identify each critical point of failure that led to the undesired or improper conduct. This assists in the immediate priority of holding individuals accountable for intentional misconduct or negligent conduct.

However, the larger and more important goal is to learn from the investigation, recognise the critical points of weakness in the overall compliance framework that permitted the incident to occur, and implement remediation to prevent and detect future incidents, to ensure no such incident happens again. Often, this broader objective is not prioritised, and even where effective remediation is designed, implementation is inadequate, rendering such remediation as ineffective as it would be had it not been implemented at all.

From significant experience with anti-corruption investigations, this dynamic is not uncommon even in a field of zealous, ongoing regulatory enforcement, with the US leading the world in enforcing the US Foreign Corrupt Practices Act of 1977 (FCPA) since 2008. This has, at times, resulted in new settlements for recidivist companies under the FCPA, but it often remains an uphill battle for compliance practitioners to ‘sell’ remediation. The longer the length of time between an initial incident and remediation, the less receptive a company and/or its business-focused managers and employees will be to the disruption a remedial enhancement may cause.^[21]

This problematic dynamic appears to have manifested itself in the handling of public safety after the Sewol tragedy and is likely to be consistent with public safety regulation and compliance the world over. It is far easier to take advantage of public fervour to push remediation in the short-term, and much more difficult to see them through once the public outcry has died down. In anti-corruption compliance, this is the period in which we stress that newly implemented enhancements should be reviewed and tested, to ensure that implementation occurred and functions in practice, and to identify any additional points of weakness once implementation begins.^[22]

With respect to Itaewon, investigations and targeted raids continue. Several preliminary causes have been reported to date, although investigations are ongoing. Forensic and disaster experts, however, conducting independent assessments using video footage and photos, have said that the disaster was entirely preventable.^[23]

While 100,000 people were expected to be in Itaewon for the Halloween festivities, a typical number for the night every year, over 1,100 police officers were instead sent to rallies near the Yongsan presidential office that day, less than a mile from the site. In total, 4,800 officers were in locations in downtown Seoul controlling rallies earlier that day.^[24] Only 137 officers were sent to Itaewon, the majority of them in civilian clothing, with 40 per cent from the Criminal Department, apparently focusing on conducting a ‘drugs crackdown’ in the area, rather than assisting with crowd control or safety.^[25] Local news reports, however, indicate that a local police officer had posted a request for additional officers for Halloween days before the disaster, and the chief of the Yongsan Police also requested more police from Seoul Metropolitan Police Agency (SMPA) twice – but was denied.^[26] Police officers were regularly sent to protests around the President’s office instead.^[27]

Prior to Itaewon, there were also no plans in place to anticipate the Halloween crowd, despite the event occurring annually, and despite a policy requiring such a plan be developed for events with more than 1,000 attendees. When asked, the district chief stated that the party was a ‘phenomenon’, not a ‘festival’.^[28] There is an existing law on Disaster and Safety Management (Disaster Safety Act), passed in light of these types of incidents in the 2000s, but its provisions are reportedly vague, and generally ignored if the local government does not deem an event a ‘festival’, that is, if an event does not have an official ‘organiser’ or ‘host’.^[29]

On the tragic night, the police chief received his first report nearly two hours after the incident began, by which time there were already news reports of victims in cardiac arrest.^[30] The Ministry of the Interior and Safety, who oversees the police, learned of the accident through a text message from his own ministry, rather than the police. Likewise, over an hour after it began, the President received his first report via the South Korea Fire Service, slightly earlier than the Minister.^[31]

During the Sewol tragedy, there were numerous calls to emergency services, posts to social media, pleas for help. Similarly, during Itaewon, there were over a hundred calls to police asking for help, the first over four hours before the crush began, and prior to Itaewon there have been long-standing complaints regarding the size of the alleyway.^[32] Once the crush in Itaewon had begun, emergency response was delayed, and police have acknowledged their response both before and during the crisis was inadequate.^[33]

The Sewol Ferry tragedy had, in fact, resulted in a nationwide emergency system being implemented. After Sewol, the government had allocated KRW1.5tn (approx. US$1.06bn) to set up a new emergency communication system, which was officially launched in 2021. This Public Safety-LTE (PS-LTE) network purportedly connected 333 public safety institutions, agencies and bureaus, and was meant to remediate the critical issue identified by the previous disaster, which had flagged that the Coast Guard and the Navy were unable to coordinate rescue efforts due to incompatible communications systems.^[34]

The government has publicly stated that the PS-LTE network was implemented, and intended to facilitate rapid joint response by collective government agencies in response to public crises, but was not used to respond in Itaewon until an hour and half after the first death. The Vice Minister for Disaster and Safety Management stated that while officials had been instructed, it was likely that training ‘came up short’ in preparing them to use the network in real-life situations.^[35]

In addition, a disaster medical assistance team (DMAT) was not dispatched in Itaewon until about an hour after the first death was reported. The lag in communication of the emergency to the fire department, which managed the site until the DMAT arrived, meant that rescue and emergency medical response was significantly delayed, and prevented victims from receiving prompt treatment at the site.^[36]

Experts analysing the South Korean Coast Guard (KCG’s) response to the Sewol Ferry disaster also identified a number of issues with the KCG as an institution, noting that it over-emphasised hierarchical accountability and focused on political accountability to the detriment of public safety.^[37] They also noted that there was no place for considerations of professional accountability in the KCG. The former Park administration dismantled the KCG and established the current Ministry of Public Safety and Security to deal with national disasters – the very Ministry which failed to prevent the Itaewon disaster, which experts accurately predicted would not produce a much improved response to national disasters.^[38]​​​​​​​

The Itaewon investigation has also resulted in a raid of the Hamilton Hotel that individuals have pointed out illegally extended its terrace into the downhill part of the alleyway, narrowing the alleyway even further and likely contributing to the crush deaths. The head of the hotel is being investigated for violating building and road laws.^[39] The Seoul city government is further conducting safety inspections into densely populated areas of the city, and other unauthorised building structures, as well as the most packed subway stations that become flooded during rush hour, where residents have long complained of high population density.^[40]

Complex remediation and ‘never again’: individual accountability, regulatory reform and other remediation

With respect to Sewol, former President Park’s administration itself faced consequences for their response to the crisis, and the ship’s captain, who fled the sinking ship while children remained and later drowned, was sentenced to 36 years in prison after being found guilty of gross negligence.^[41] The ship’s chief engineer was found guilty of murder and likewise jailed for 30 years, and 13 other crew members were given sentences of up to 20 years. Individuals were therefore held accountable, and as mentioned above – the emergency system promised by the government was implemented in advance of the Itaewon tragedy – but clearly remediation was incomplete and thus ineffective.

Organisations which do not learn from their past mistakes often repeat them. In the corporate world, we call these companies recidivists. But governments have a greater responsibility to the public, to hold themselves accountable and be responsible for the trust people place in them, to keep the public safe. The public safety realm does not have the developed regulatory guidance, global principles and best practices models developed over the last decades in the anti-corruption compliance field. But the frameworks that have proved effective can be repurposed, as the same overarching, core principles apply.

In response to ongoing public demand for accountability, the South Korean government has already pledged a number of reforms, including to the emergency communications system, a review of construction regulations in the city, and other such critical remediation. The Prime Minister has promised a major reform of police administration, establishing task forces to work on its chain of command and response system.^[42] ‘We will come up with related measures so that a tragedy like this will never happen again’, stated the Prime Minister in November.^[43]

All of these responses are commendable and necessary, but citizens have yet to see concrete steps taken to further these aims, with the government focusing primarily on charging lower-level individuals along the relevant chains of command, including the head of the Yongsan Fire Department, although he had arrived on scene and directed the rescue effort.^[44] Two individuals being investigated have been found dead, including a Yongsan Police Intelligence Chief, who was being investigated for spoliation of evidence relating to safety concerns in advance of Halloween weekend in Itaewon.^[45] Experienced observers know that without actual, targeted and concrete changes, combined with longer-term follow-up, testing and review, the remediation promised after Itaewon, like the remediation after Sewol, will not be sufficient.

For example, reviewing construction regulations is important, but will such reviews be conducted in five years from now? In ten years from now? Will anyone ensure that the review was actually, in fact, conducted? If other hotels in other narrow alleyways build illegal structures, how will this be detected in seven years from now? Are there systems in place to review/audit inspection results, if inspections of hotels such as the Hamilton Hotel have been insufficient to identify the illegal structures? With respect to the emergency communication system, there is already awareness that there was a failure to train officers on its use, but will there be accountability assigned for who will be responsible for training the different agencies/officers? Will everyone receive the same training, or different training depending on their agency? How in-depth will the training be? Will they be tested on their knowledge? Will the training be periodically refreshed? Will the emergency communication system itself be tested periodically to ensure it continues to function? In five years? Ten?

In addition, reforming the police administration and reviewing the chain of command and response system is clearly vital, given what occurred in Itaewon. But local, lower-level police did, in fact, speak up and request additional resources in advance of Halloween, and were ignored by those higher up the hierarchy. How will reform address these issues? Will it take into account deeper issues with respect to what experts have identified as over-emphasis on hierarchical accountability, and law enforcement’s top-down culture,^[46] or will it focus more on holding specific individuals to account and be limited to more superficial structural changes or re-organisation, as occurred after Sewol?^[47]​​​​​​​

Complex, detailed and comprehensive long-term frameworks and planning are critical in order to establish the answers to these questions and assign responsibility, accountability and timeframes for systemic remediation; as well as account for transitions in power, as they must survive between administrations and ensure there remains accountability for systems so critical for public safety. These frameworks must address and plan for systemic change that targets root causes.

Conclusion

The promise of ‘never again’ may prove hollow, when compliance failures lay unaddressed, where reforms are implemented but remain unused or do not function as designed. ‘Never again’ requires a much deeper, multifaceted and systemic commitment that goes beyond appeasing public anger and making superficial reforms. It requires an in-depth understanding of the root causes of the failures that caused the issues, especially where there have been multiple, significant incidents – and committing to address each of the root causes identified, until they no longer pose an unacceptable level of risk.

Otherwise, issues that remain unresolved and risks that remain unaddressed, or addressed only with superficial solutions, will continue to arise, and in the realm of public safety, that unfortunately means that lives are likely to continue to be at that unacceptable level of risk. As concert-goers would have faced in Busan, but for the tireless efforts of K-pop fans – potential disasters are always just around the corner, and what protected fans in Busan were these sustained and targeted efforts, as well as on-site risk assessment and immediate, reactive remediation during the event by company staff.^[48] However, it is the government’s duty, to keep the public safe and protect individuals, especially from avoidable, foreseeable disasters, and as commendable as the efforts of private citizens were, they should never have been required.

Likewise, had anyone in the government listened to ongoing complaints about the crowded conditions in the Itaewon alleyway, including the allegedly illegal extension at Hamilton Hotel, perhaps lives could have been saved – but even had that happened, they should not have had to depend on individual whistleblowers. It is the government’s duty, to keep the public safe, be able to respond to timely respond to a crisis, to have systems in place to prevent emergencies from arising at all. It should not and cannot be outsourced to more responsible citizens and private companies.

Ultimately, without a more complex long-term, overarching compliance plan or framework in place, that addresses these systemic issues and the true root causes for these terrible tragedies, scattered remedial measures along with harsh discipline will satisfy immediate public demand for individuals to be held accountable, and may provide the appearance of ongoing change – but that change will not persist.

It is abundantly clear that many advocate for and support such change in South Korea. This has been consistent since even before its passage, extremely high support remains for the Anti-Graft Act among the South Korean population (at 87.8 per cent). For each of the events in this article, there were individuals loudly speaking up, calling attention to clear dangers and highlighting red flags.^[49] Sometimes, remediation fails in companies due to lack of support from the wider employee base. There is no such obstacle here. Consequently at this critical time, the government has a momentous opportunity to dedicate its resources to fulfilling the outspoken wishes of its public, and truly honour its promises of ‘never again’.