Aisyah Llewellyn, Medan, Indonesia – When two police officers involved in the Kanjuruhan Stadium crush walked free from a Surabaya courtroom two months ago, Indonesians were outraged.
Families of the 135 people who died when police fired tear gas at supporters at the end of a football match in the city of Malang in East Java last October had hoped those on the field would be held accountable for the decisions they made that night, especially after an official report concluded: "Tear gas was the main cause of deaths, injuries and trauma in the Kanjuruhan humanitarian tragedy."
The National Commission on Human Rights (Komnas HAM) report, which was commissioned by the government and released in November, argued there were two ways in which the tear gas probably killed those inside the stadium.
Firstly, the gas killed victims directly because it built up in the stairwell and tunnel leading to the exit at Gate 13 where many died as they struggled to escape. It noted this would need to be confirmed by autopsy.
Secondly, the gas killed indirectly, because it left people with burning eyes, scalding skin and breathing difficulties that added to the chaos as fans scrambled desperately for the exits and were crushed and trampled in the melee.
But as Judge Abu Achmad Sidqi Amsya read his verdict in the Surabaya District Court in April, he said the tear gas had not travelled as far as the seating areas – known as tribunes – where the majority of the spectators had been seated.
"[...] the smoke produced by the tear gas was blown by the wind to the south towards the middle of the field," he said. "And when the smoke reached the sidelines, the wind blew it upwards and it never reached the south stands," he added.
Despite Judge Amsya's verdict and his assertion that no tear gas was fired directly into the tribunes or at spectators, multiple witnesses who were in Kanjuruhan told Al Jazeera that the gas did indeed reach the south stands and suffocated spectators in the 13th and 14th tribunes.
Now, with two more civil cases against the police looming in the city of Malang, the debate over whether spectators died after panicking and getting caught in the crush or by direct suffocation has become increasingly important to the legal arguments over who was responsible for the tragedy.
The first scenario would allow for an element of police deniability but if the second were proved, the force could be directly culpable.
'Bam, bam, bam'
Factory worker Angel, who preferred not to share her full name, said she usually attended every game.
Her husband works for the Indonesian Football Association (PSSI) and Angel would run an informal first aid station at Kanjuruhan, helping those overcome by the heat or calming fans alarmed by the large crowds that could congregate for the games.
On October 1, Angel said she left the stadium at about the 80th minute of the match as the game was about to end and she assumed her services would no longer be required. Outside the stadium, everything was peaceful, she said, until about 20 minutes later.
"I just heard, bam, bam, bam. One shot after another, after another, on and on and on," she said. Almost immediately, Angel said she could see clouds of tear gas beginning to drift outside the stadium. Looking down, she saw that her mobile phone was ringing.
It was her 17-year-old son who was still inside the stadium. "Ma help us... help us, we can't get out, the doors are locked," he begged her.
Police originally said they were responding to what they thought was a pitch invasion when they started firing tear gas at the end of the match – despite its use being banned inside stadiums under guidelines from the world football body FIFA.
Angel told Al Jazeera that she managed to get inside the stadium and climb onto a small stage in front of the VIP area. She hoped that because it was slightly elevated, her son would be able to see her, or she would be able to see him.
"People everywhere were screaming," she said. "People were calling for ambulances, someone shouted that there were so many victims still in the stands."
As spectators poured out of the stands and onto the field from the 13th and 14th tribunes where the tear gas was thickest, a young woman staggered up to Angel, struggling to breathe.
"I told her 'You can do it' and 'You need to fight this'," she recalled. "I modelled how to breathe in and out and put my hand on my chest to show her. I told her, 'Look at Aunty, breathe this way'. She gave me a little smile and, without even taking a full breath, she died in my arms," she said.
Angel said the young girl, who she estimated was about 18 years old, appeared to have died from the gas. "She had difficulty breathing and there were no marks on her body as if she had been trampled. Everyone looked as if they had been poisoned that night. They had foam coming out of their mouths and it smelled like tear gas."
Angel said that everyone who came out of the stands was blue in the face, their eyes reddened and that they were struggling to breathe.
"I am sure that they died because of the gas," she said. "If it wasn't the gas, then what was it?"
Five shots would have been enough
Devi Athok's daughters, 16-year-old Natasya Debi Ramadhani and 13-year-old Naila Debi Anggraini, regularly attended matches at Kanjuruhan and were in the 13th tribune on the night of the tragedy.
Athok had been preparing to pick them up at the end of the match when his phone rang before he left the house. It was a neighbour who had also been at the game. "Sir, Tasya died in the stands," the neighbour told him, he said.
"At first, I thought there must have been a fight between rival supporters that she got caught up in," Athok said. "But there were no rival supporters there that night."
When he got to the stadium, Athok found his daughters laid out on the floor of the VIP area, along with the corpses of countless others who had died and been carried down from the stands.
"There is no way they were crushed or trampled or they would have been found by the doors. You could smell the gas coming from them," he told Al Jazeera. "My children died in the stands because of the gas. I got to the hospital at midnight that night to accompany my daughters' bodies and there were people there still red and itching from the gas. Why did the police fire so many times? Five shots would have been enough to stop a pitch invasion."
According to Komnas HAM's official report, police fired 45 rounds of tear gas inside the stadium. The gas also dated from 2019 and had expired, the report added.
Tear gas is usually made up of chemicals such as toxic air pollutants chloroacetophenone, chlorobenzylidene malononitrile, chloropicrin, bromobenzyl cyanide and dibenzoxazepine, according to the American Lung Association.
"Long-term health effects from tear gas are more likely if exposed for a prolonged period or to a high dose while in an enclosed area," according to the association. "In these instances, it can lead to respiratory failure and death."
Komnas HAM's report echoed that statement. "While the main character of tear gas doesn't kill [...] in certain conditions it can cause death," it said.
Uli Parulian Sihombing, the commissioner of monitoring and investigations at Komnas HAM who authored the report, told Al Jazeera: "There was tear gas in the tribunes. Those who died were at Gate 13 and there was tear gas at Gate 13. Some people were crushed at Gate 13. The spectators were surprised by the tear gas and panicked and were pushing to get out."
When asked directly whether tear gas could have killed any of the spectators, Sihombing said: "The majority of the victims who died at Gate 13 were blue in the face and their eyes were red. Komnas HAM has not conclusively concluded that the tear gas was the reason for the deaths of the Kanjuruhan victims."
Yet, Elmiati, whose husband, Rudi Hariyanto, and three-year-old son, Muhammad Virdy Prayoga, died in the crush, told Al Jazeera she had been in the stands and saw victims dying in front of her in the 13th tribune.
"I am sure that all the victims who died had foam coming out of their mouths and they were blue around their eyes. They died because of the tear gas," she said.
Bodies intact and clothes clean
Dr Abdul Gafar, a forensic pathologist at Universitas Muhammadiyah Sumatera Utara in Medan, who reviewed photographs of the deceased including Tasya and Naila, said it was difficult to ascertain how people died based on external factors alone.
"Logically, tear gas stings the eyes and the nose, so people will do anything to get away from it and many people in the stadium were crushed when they were trying to find a way out," he said.
"Crushing happens when people can't get enough oxygen because their lungs are compressed. When the lungs can't inflate and fill with oxygen, people suffer from crush-asphyxia. This causes foam around the nose and mouth because carbon dioxide can't be expelled from the body and is trapped in the lungs, causing foam to form."
As a result, Gafar said, the foam seen that night by a number of witnesses was not necessarily caused by the tear gas.
Yet, some have questioned whether victims could have been crushed or trampled to death without any other outward injuries being found on their bodies.
These include Imam Hidayat, a lawyer who represents some of the families of the victims including Athok, who told Al Jazeera he did not believe all of the victims died as a result of being crushed because "their bodies were intact and their clothes clean".
He added that the families wanted new autopsies to be done by an independent forensic pathologist, something other experts Al Jazeera spoke with, including forensic pathologist Gafar, agreed would be the best way forward.
"We need a toxicology report to see if people were poisoned," Gafar said. "Being blue in the face doesn't necessarily indicate that they were poisoned by the tear gas as we would find this with crush-asphyxia as well. We need urine and blood samples. Bones don't have to break for someone to be crushed to death. If you sit on someone's chest they can die because their lungs can't inflate, but they would not have any broken bones."
When asked about the results of the previous autopsies conducted by the police, Dr Erwin Zainul Hakim, the police medical examiner for East Java, told Al Jazeera that he received and read all the autopsy and toxicology reports on the Kanjuruhan victims and was satisfied with the findings.
Autopsies were carried out only on the victims whose families had decided to take legal action.
"The autopsies were carried out by forensic pathologist Dr Nabil Bahasuan [the head of the East Java branch of the Indonesian Association of Forensic Medicine], and when we received the reports, the toxicology tests were negative. The autopsies concluded that the victims were crushed and did not die from the tear gas," he said.
Athok, however, describes himself as "1 billion percent dissatisfied with the investigation and legal process".
He has joined the two civil cases, which aim to push for further police accountability in the form of financial damages for the alleged negligence that led to the loss of life at the stadium, one of the worst football disasters anywhere in the world.
"I will keep fighting for justice for my daughters for as long as I can," he said.
Others who were on the field that night agreed that the police investigation and the subsequent court case in Surabaya that led to the police acquittals had failed the victims.
Five people were charged in the criminal case, accused of negligence leading to injury and death, including Hasdarmawan, the commander of the 3rd Mobile Brigade Company of the East Java Police, Wahyu Setyo Pranoto, the chief of operations of the Malang Regency Police, and Bambang Sidik Achmadi, the head of the Prevention Unit of the Malang Regency Police.
Pranoto and Achmadi were found not guilty, while Hasdarmawan was sentenced to one-and-a-half years in prison. The public prosecutor said it would appeal the two acquittals.
Two civilians, security officer Suko Sutrisno and match organising committee chairman Abdul Haris, were sentenced to one and one-and-a-half years in prison, respectively, for their part in the tragedy. The prosecution is also appealing these convictions, having asked for sentences of six years and eight months for both men.
"Indonesia's state ideology, Pancasila, guarantees justice," said Angel. "But justice for whom?"