The Department of Field Support (DFS) has transmitted to Security Council members the executive summary of the UN Headquarters Board of Inquiry Report on the circumstances of the clashes that occurred in the UNMISS Protection of Civilians (PoC) camp in Malakal, South Sudan, on 17-18 February 2016, which resulted in approximately 30 internally displaced persons killed and 123 injured. As agreed with the UN Security Council during a briefing on 22 June, DFS is also today publicly releasing this Executive Summary [scroll down].

As reflected in the Executive Summary, the Board found that a combination of causes, including political factors, resulted to the February incident. The Board noted it was highly likely that the attack was planned, or at a minimum supported by SPLA and/or affiliated militia to facilitate the ethnic reconfiguration of Malakal.

The Executive Summary also highlights the  recommendations made by the Board in response to the incident, including on the PoC site concept, on safety and security, and on command and control.

On the UNMISS response, the Board  found, inter alia, that the Mission failed to manage the crisis effectively. Although UNMISS procedures including on command and control were adequate to respond when faced with such an incident, they were not properly coordinated or understood among the various components (civilian, military and police) in the mission, nor were they appropriately applied by some of the TCCs deployed in Malakal. The Board further concluded that inaction on the part of several components stationed at the Field Office in Malakal contributed to the negative effects of the incident. 

Executive summary of the United Nations Headquarters Board of Inquiry Report on the circumstances of the clashes that occurred at the United Nations Protection of Civilians site in Malakal, South Sudan
on 17-18 February 2016
Introduction.
1. On 16 March 2016, the Under Secretary-General for Field Support (USG, DFS) constituted a United Nations Headquarters Board of Inquiry to review and prepare a report on the circumstances of the clashes that occurred at the United Nations Mission in South Sudan (UNMISS) Protection of Civilians (PoC) site in Malakal, South Sudan on 17-18 February 2016. The clashes resulted in approximately 30 Internally Displaced Persons (IDPs) killed and 123 injured.
2. The Board of Inquiry conducted its proceedings in Juba (UNMISS Headquarters) and at the UNMISS Field Office in Malakal between 14 and 21 April 2016. The Board conducted interviews with a cross-section of Mission personnel from the civilian, police and military components.
Background
3. The impact of the conflict which broke out in South Sudan in December 2013 on the civilian population of the country has been immense, with tens of thousands of civilians fleeing conflict affected areas, including targeted attacks and killings. To date, the conflict has resulted in the displacement of over 2 million people. Over the course of the last two and half years, some 200,000 of those displaced civilians have sought protection at nine UNMISS premises. At present, there are approximately 180,000 IDPs seeking refuge in six UNMISS protection of civilians (“PoC”) sites across the country.
4. The UNMISS Malakal PoC site is part of the UNMISS premises located to the northeast of Malakal town in the Upper Nile region of South Sudan. The region has been at the center of the conflict between the Sudan People’s Liberation Army (SPLA) and Sudan People’s Liberation Movement/Army- in Opposition (SPLM/A-IO), with Malakal town, itself, changing hands between the belligerent parties a total of 12 times. Currently, the town is under the control of the Government and SPLA forces. Over the course of the last two and half years, a combination of active hostilities and dire humanitarian conditions in the area contributed to an influx of 48,000 IDPs into the UNMISS Malakal PoC site.
5. Unlike other UNMISS PoC sites, the site in Malakal is host to IDPs from three different ethnic groups (Dinka, Nuer, and Shilluk), all of whom have a stake in the national crisis. Despite the civilian character of the PoC site, inter-communal tensions mirroring the shifting alliances of these different ethnic groups between the Government and the SPLM/A-IO have often spilled over into minor clashes, especially between the different youth groups in the PoC site, thus creating unique and continuous challenges to maintaining the internal stability of the PoC site.
6. In October 2015, Executive Order 36/2015 increasing the number of States in South Sudan from 10 to 28 (“28 States Order”, further complicated ethnic relations in the PoC site, given that the Order provides for the carving of Upper Nile State which includes
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Malakal) into three States: Eastern Nile (including Malakal) with a majority Dinka population, Western Nile with a majority Shilluk population and Latjor with a majority Nuer population, effectively dislodging historical Shilluk ties/claims to land east of the White Nile River, including Malakal town.
7. Disaffection for the 28 States Order among the IDPs in the Malakal PoC site was further compounded, when on 1 February, the Governor of Eastern Nile State (according to Executive Order 36/2015) issued Administrative Order No 1, essentially terminating the employment of all Shilluk and Nuer civil servants who served in the Upper Nile State administration (now Eastern Nile Sate administration). In the weeks and days leading up to the incident in the PoC site, SPLA forces blocked Shilluk IDPs from accessing Wau Shilluk, the Shilluk heartland on the western bank of the White Nile River. Moreover, the increased presence of SPLA soldiers deployed in the vicinity of the UNMISS PoC site contributed to regular confrontations between Shilluk youth and SPLA soldiers and increased reports of arbitrary arrest, abduction, sexual and gender based violence (SGBV) against Shilluk IDPs by armed elements, often in SPLA uniforms.
Chronology of Events
8. On 16 February 2016, UNMISS-contracted security guards and UNPOL manning the “Juliet” access gate into the Malakal PoC site confiscated two AK-47 magazines loaded with fifty-eight rounds of ammunition from two men (in civilian attire) attempting to enter the PoC site. During questioning by UNPOL, the two men identified themselves as SPLA soldiers who had come from Malakal town to visit their families living inside the PoC site. Shortly thereafter, a number of men in civilian attire, suspected of being SPLA soldiers, gathered around the Juliet gate in an attempt to negotiate the release of the two detained men. The situation quickly deteriorated into a confrontation between the crowd and UNMISS security guards and members of the Formed Police Unit (FPU) guarding the gate. In the midst of the melee, one FPU police officer was dragged outside of the UNMISS premises and beaten by the crowd, while the two detainees escaped.
9. Later that evening, UNMISS FPU personnel reported rising tensions between Shilluk and Dinka youths residing in the PoC site. UNMISS military and police personnel increased their presence and the tension appeared to subside. In the early morning hours of the 17 February, UNMISS military and police responded to an incident of Shilluk and Dinka IDPs throwing stones and sticks at each other. Although the situation was brought under control, throughout the course of the day, the situation remained volatile with a number of security incidents involving Shilluk and Dinka individuals taking place in and around the PoC site. During the morning of 17 February, UNMISS security personnel reported a breach in the eastern perimeter fence of the PoC site and the outer perimeter berm and the presence of SPLA soldiers around the breached berm. The breach, which was in the vicinity of the Dinka quarters of the PoC site, was being guarded by members of a PoC site Community Watch Group (CWG) from the Dinka IDP community who complained to UNMISS personnel that Dinka IDPs feared using the Juliet access gate because of harassment and attacks perpetrated by Shilluk IDPs.
10. In light of the growing tensions in the PoC site, UNMISS leadership decided on a number of mitigating measures, including (1) strengthening security along the perimeter fence of the PoC site and reinforcing night patrols inside the PoC site; (2) engaging with SPLA interlocutors in order to remove SPLA soldiers from the eastern berm of the PoC
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site and ensuring that the soldiers do not involve themselves in the intercommunal tensions brewing in the PoC site; (3) continued engagement with the IDP leadership of the various communities to diffuse tensions; and (4) repair of the breaches in the perimeter fencing and berm. All actions were undertaken except for the repair of the perimeter breach given the lateness of the hour.
11. At approximately 2220 hours, UNMISS FPU personnel observed a group of agitated Shilluk youth, armed with spears, machetes and sticks, along the container bridge linking the Shilluk area and the Dinka area of the PoC site. The FPU attempted to diffuse the situation by blocking the advance of the Shilluk youth with tear gas to disperse the violent crowd. Simultaneously, the UNMISS police personnel heard shots fired in the Shilluk quarters of the PoC site followed by an exchange of small arms fire between the Shilluk and Dinka quarters. The situation intensified with indiscriminate machine gun fire and a few grenade explosions. Meanwhile, UNMISS military reported that Dinka IDPs were streaming out of the PoC site through the breached eastern perimeter. At approximately 2330, as a result of the escalation of the fighting, the FPU personnel withdrew from the PoC site and redeployed to protect the entrance to the UNMISS log base.
12. At approximately midnight, UNMISS leadership at the Malakal Field Office convened a field-level Crisis Management Team meeting (CMT) during which Sector North (military) was allowed to assume command and control of the situation. Sector North tasked UNMISS military to deploy Armored Personnel Carriers (APCs) at all flash points and to maintain robust patrolling between the Shilluk and Dinka quarters of the PoC site; to enhance and secure the outer perimeter with a view to deterring any external intrusion; to enhance security of the log base; and for UNMISS military and police to support the evacuation of casualties to the clinics and hospitals within the UNMISS base. The security alert status for the base was escalated and all UN personnel instructed to limit movement.
13. During the early morning hours of the 18 February, intermittent exchange of small arms fire and grenade explosions continued in the PoC site. A fire was observed in the Nuer quarters of the PoC site. At approximately 0230 hours the UNMISS fire truck was ordered to enter the POC site to extinguish the fire, accompanied by three APCs for protection. Despite instructions by military command, two out of three APCs remained outside. Shortly thereafter, the fire truck and the accompanying military personal with one APC were forced to abort the operation when they came under fire. Meanwhile, UNMISS personnel continued to observe Dinka IDPs streaming out of the PoC site through the breached eastern perimeter; SPLA personnel reportedly facilitated the departure, including with trucks.
14. At approximately 0800 hours, the Malakal Field office CMT reconvened to take stock of the situation. It was agreed that that UNMISS military would continue robust patrols within and outside the UNMISS perimeter, while the UNMISS civilian components would continue engagement with the community to contain the situation. At approximately 0930 hours, members of the Malakal Field Office leadership team met with the local authorities including the Governor, SPLA Sector II Commander, and the acting SPLA Division II commander to brief on the developments in the PoC site and urge the Governor and the SPLA to refrain from involvement in the situation, in particular restraining SPLA soldiers seen milling around the perimeter of the PoC site. The local authorities accused UNMISS of failing to protect civilians under its protection
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and stated that the SPLA soldiers who were seen on the eastern berm of the PoC site were only there to help evacuate the Dinka IDPs who were allegedly being attacked by the Nuer and Shilluk IDPs. This notwithstanding, the local authorities pledged to cooperate with UNMISS to bring the situation under control.
15. Shortly after 1000 hours, UNMISS military personnel began reporting that SPLA soldiers had entered the PoC site. At approximately 1030 hours, the sentries guarding the eastern edge of the POC, unable to stop the intruders, abandoned their positions. At approximately 1150 hours, IDPs fleeing the violence in the PoC site, began to cut the fencing near the log base and forcefully began to enter the log base until the gate was opened by UNMISS military personnel at approximately 1200 hours. Members of the Malakal Field Office leadership team who received this information in real time during their meeting with local officials, shared these developments in the PoC site with the Governor and SPLA officials.
16. At approximately 1140 hours, the SPLA forced UNMISS military personnel to withdraw from their positions at Malakal Airport. MLOs arriving at the scene found a company strength SPLA force with anti-aircraft weapons/machine gun mounted vehicles securing the airport. After discussions between the SPLA Liaison Officer and the SPLA officer in charge of the airport, UNMISS cargo trucks and personnel were permitted to leave the airport. Later SPLA soldiers also withdrew from the airport.
17. At 1341 hours, UNMISS personnel reported that SPLA troops were trying to enter into the UNMISS Logbase at Malakal. The Sector North Commander ordered that troops should use its APCs to engage the SPLA troops by firing back on them and that under no condition should SPLA soldiers enter the Logbase. Some troop commanders hesitated about the use of lethal force and sought written authorization for it. The Sector Commander’s orders were then communicated via email to all UNMISS military to use all necessary means to expel all armed elements from the PoC Site. These orders were reinforced during a CMT meeting chaired by the Officer in Charge (OiC) Special Representative of the Secretary-General (SRSG) from UNMISS headquarters in Juba. At approximately 1545, UNMISS military began a clearance operation led by the Sector Commander and by approximately 1630 hours all armed elements had been pushed out of the UNMISS premises.
Conclusions
18. The Board found that a combination of causes resulted in the incident which transpired on 17-18 February. These included the broader national political dynamics at play in Malakal and the impact it had on the various ethnic groups, namely the Shilluk, Dinka and Nuer, residing in the PoC site. In particular, the October 2015 Executive Order 36/2015 creating new States in South Sudan and the subsequent changes to the administration of the Upper Nile region complicated ethnic relations in the PoC site, especially among the Shilluk IDPs who perceived the implementation of the Executive Order by a Dinka administration as negating their historical claims to land east of the White Nile, including Malakal town. Given these political dynamics and the increasing presence and confrontation between IDPs and SPLA elements in the lead up to the incident, the Board also found it highly likely that the attack was planned, or at a minimum supported by, SPLA and/or affiliated militia to facilitate the ethnic reconfiguration of Malakal as the capital of a Dinka state.
19. Beyond these political factors, the Board found that the PoC site concept had set
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unrealistic expectations for the protection that UNMISS could feasibly afford 48,000 IDPs residing in a congested environment, where civilians can move in and out freely, where weapons and ammunition can easily be smuggled in and hidden and where even SPLA soldiers in civilian clothes could enter freely to visit friends and relatives. Expecting the police component (UNPOL and UNFPU) and the military component in particular, to provide protection in Malakal to the IDPs at the time of the incidents, and increasing numbers since then due to the services that are provided in the POC sites, is not realistic.
20. The Board further found that, with sufficient information available vis-à-vis rising tensions in and around the PoC site in the lead up to the incident, the Mission failed to prepare and mitigate such an occurrence. Moreover, once the security situation began to deteriorate, the Mission, at all levels, failed to manage the crisis effectively, leading to the negative effects of the incident. This failure to manage the crisis, in particular, manifested itself in a lack of urgency to enhance the security within and around the PoC site, the reluctant attitude of the units of some of the TCCs present in Malakal to be proactive, including requesting written confirmation to use force as in the rules of engagement (ROE); the absence of external perimeter patrolling around the PoC sites; and culminating in the abandoning of sentry posts when armed elements were approaching the berm leaving the PoC site fully exposed and, ensuring that civilians would be placed in serious risk in the very location to which they had come for protection.
21. The Board found that many of the applicable UN/UNMISS procedures, regulations and rules including on command and control vis-à-vis civilians and uniformed personnel, UNMISS ROEs, Force Directives and Orders were adequate to respond when faced with such an incident, however, they were not properly coordinated, disseminated or understood among the various civilian, military and police components in the mission, nor were they fully/appropriately applied by some of the TCCs deployed in Malakal. Moreover, with regard to the UNMISS military operations, the Board underscored that this was not the first instance in which military units in Malakal had demonstrated an unwillingness to proactively implement ROE, Force Directives and Orders. However, this persistent underperformance had not been reported through the appropriate chain of command.
22. The Board further concluded that inaction on the part of several components at the Field Office in Malakal contributed to the negative effects of the incident. In particular, the Board found that the Field Office acted without urgency to repair the breach in the PoC fence which had been reported as early as noon on 17 February, failing to cease an opportunity to better manage the developing security situation. Thereafter, Sector North Command failed to follow-up on measures to be taken by the military to cover the breached PoC fence and perimeter berm as the security situation deteriorated on the night of the 17th and the 18th. UNMISS military sentries abandoned their posts as well as failed to engage on 18 February, after reporting that armed persons in SPLA uniforms were approaching the PoC site and then subsequently breached the eastern perimeter berm. An UNMISS military contingent requested written orders from the Sector North Commander on the use of force, despite the ROEs, demonstrating both a lack of knowledge of the ROE and an unwillingness to act. This combination of inaction, abandonment of post and refusal to engage made the situation harder to contain and contributed to the negative effects of the incident.
23. The Board concluded that the external and internal physical protection infrastructure of the PoC site was not sufficient, nor its repair when breaches were reported. Moreover, the Board found that the PoC site infrastructure which humanitarians have advocated for, i.e. a
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structure similar to “regular” IDP camps in which IDPs can come and go freely, is at odds with the need for the Mission to afford any meaningful level of security to the civilians in the PoC sites. As far as supporting resources was concerned, the Board found that the military lacked a proactive or forward stance to mitigate threats to the PoC site. UNPOL lacked the manpower to manage the internal security of the sites. The Board also noted that the use of locally contracted security guards drawn from the three tribes, many of them residing in the PoC site, was not conducive to properly securing the base and PoC site.
24. The Board concluded that despite relevant guidance, beginning with the Mission’s Chapter VII PoC mandate and including standing orders on PoC operations, and particularly with regard to the ROEs, the TCCs were not adequately trained or familiar with the manner in which they were to respond. The lack of regular, targeted table top exercises was one example of a failing in this regard. The Board further found that the UNMISS uniformed personnel detailed to protect the PoC site were not adequate in number or properly skilled and equipped to fulfill the given mandate. The number of UNPOL was inadequate for the task of maintaining the internal security of a PoC site housing 48,000 people. Communications was a challenge for the UNMISS military and the lack of a common language was a serious obstacle to seamless operations. Moreover, the military units, in some instances had insufficient or no night vision equipment to facilitate operations during the night.
25. In relation to security/intelligence information, the Board found that the Mission has a relatively comprehensive early warning system in place. However, the translation of that information into appropriate and/or timely actions remains elusive.
26. With regard to arrangements and procedures to respond to emergency security situations between UNMISS and the host government authorities/national security forces, the Board found that both the UNMISS civilian and uniformed components responded properly in interactions with host government authorities. However, the utility of this was negligible at best.
Recommendations:
27. The Board made the following salient recommendations in respect of the incident:
POC site concept
 UNMISS Senior Leadership, UNHQ New York and the Security Council should review the concept of Protection of Civilian sites, taking into consideration realities on the ground, related challenges and existing resources, so as to avoid creation of false expectations.
 UNMISS should develop a public information campaign to explain its PoC mandate and related activities and to explain its limitations on the protection of civilians in the country and POC sites based on limited number of troops, and logistical and access constraints.
Safety and Security
 UNMISS should ensure that all IDPs residing within the UNMISS Malakal Log Base are re-settled into the PoC site to improve their current substandard living
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conditions and to avoid any outbreak of disease.
 UNMISS should ensure that a system is put in place to properly register IDPs to facilitate the control of their entry and exit from the PoC sites, enhancing the security of the PoC sites.
 UNMISS should ensure that the perimeter of its premises are reinforced to ensure that the entrance and egress of IDPs are confined to the manned gates.
 UNMISS should ensure that procedures are developed assigning clear responsibility for maintaining the internal and external perimeters of the PoC sites.
 UNMISS, in coordination with UNHQ departments, should increase the strength of the UNPOL (IPOs and FPU) to fit better the tasks assigned – i.e. maintenance of public safety and security within the PoC sites.
 UNMISS military and police to ensure the provision of proactive robust security activities, furthered through the distribution of best practices mission-wide to ensure accountability.
UNMISS, in consultation with relevant UNHQ departments, to consider the use of additional proven police tools and techniques to improve the maintenance of public safety and security within the PoC sites (e.g. canine units, overall PoC site searches, etc.)
Command and control / Military, Police & Civilian interaction / Leadership
 UNMISS should ensure that the terms of reference (TOR) of the Malakal Head of Field Office, Sector North Commander, UNPOL POC Coordinator, FPU Commander, etc. are revised to provide clear and unambiguous delineation of the tasks and responsibilities between all uniformed and civilian components. A briefing on the TOR on arrival should be mandatory for any of those persons.
 UNMISS military and police should ensure mandatory training in command and control issues for all newly arrived uniformed personnel.
 UNMISS military and police should ensure that a comprehensive induction training/briefing package for a military/police commander (of a unit, battalion, sector, etc.) is introduced.
ROE/Contingency preparedness
 UNMISS military leadership should ensure that training in the practical application of the ROEs and use of force is conducted regularly in accordance with the guidance from the DPKO Military Advisor with a focus on scenarios relevant to the current operational situation in a concrete location.
 UNMISS military component should conduct day and night patrols immediately outside the external berm to ensure the security of the UNMISS premises and deter any armed elements (including SPLA soldiers) from congregating close to UNMISS PoC sites. SPLA leadership should be advised that their soldiers and militias should be at a distance to avoid unfortunate encounters.
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 The Force Commander and Police Commissioner, in consultation with the SRSG, should immediately take action in cases where units show a lack of knowledge of ROEs or demonstrate a lack of will to use force beyond self-defence. Each case of underperformance of troops and police should be thoroughly investigated and the results reported to the UNHQ and the Permanent Missions of the involved TCCs/PCCs. Decisive action should be taken to hold the TCC contingents accountable, up to repatriating Commanders and / or Units.
 UNMISS should ensure that joint military/FPU/police/civilians Table Top Exercises (TTX) exercises on responding to emergency situations are conducted on a regular basis in synchronization with each rotation of the uniformed personnel. The participation of the managerial/commanding staff in such exercises should be mandatory. Lessons learned from these exercises should be clearly recorded, disseminated and incorporated into relevant policies, plans and procedures.
 The Mission should ensure that guidelines/directives on military/police/civilian cooperation and coordination in responding in emergency situations are disseminated and fully understood among relevant actors (including those who may be in line to take up OiC roles).
 A mechanism to respond to early warning indicators should be developed within the Mission and all components should be aware of their responsibilities.
 Long Duration Patrols (LDP) of approximately 72 hours or more should be prioritized in order to increase mobility, ability to react quickly and in a more flexible manner to unexpected situations, to ensure a secure environment without a large footprint, and to make a more efficient use of the available manpower. Military personnel should be trained and equipped to undertake LDPs, including with Night Vision Equipment.
 Contingents should be equipped with mortar illumination rounds and hand-held illumination rockets/flares to improve their night operations by provide area illumination.