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The report from the Education Ministry's commission of inquiry into the death of Netanel Irani, a Jerusalem 10th-grader who drowned six months ago on an annual school trip, reveals a long list of failures and mistakes on the part of the staff of his school, Ort Givat Ram.

Irani drowned while bathing in the Tiberias hot springs.

No teachers were present while the students were in the pool, the report states. The activity took place in the evening after a full dinner, and the students were given no safety instructions. Nor did the school follow most of the required ministry safety rules. The commission recommended principal Moti Alkaslasi be investigated.

Though the report was completed two months ago, the ministry has yet to carry out its recommendations. "We are making an effort to complete the necessary processes as soon as possible," the ministry said.

The case is under investigation by the northern district prosecutor's office.

Despite the serious findings, the report "evades the question of who is responsible for there being no supervision at all," said Merav Zamir, who is Irani's sister and a lawyer. "This is a classic 'covering your ass' on the part of the people who are supposed to be protecting our children. It is outrageous and saddening. Despite the great pain over my brother, who could have been saved if the school had followed the regulations, it's 'lucky' there was only one death," she said.

Netanel Irani drowned on March 25 in a heated sulphur pool at the Tiberias hot springs (Hamei Teveria). The students were on a trip to the Golan and that day, the second evening of the trip, they had dinner at the hot springs. After dinner, at about 8 P.M., they were allowed to go swimming. Irani was pronounced dead at 8:30.

The past seven years have seen nine children or youths die on such trips, and 38 investigative commissions were set up.

The report, which Haaretz has obtained, states Irani was in the hot springs with five other students, apparently for 15 to 20 minutes. There is a sign at the pool entrance saying its use is limited to only 15 minutes. Most of the other students were in other pools.

It is clear from student testimony to the commission that supervision was superficial, if it existed at all: "After we finished eating, they told us to go wherever we wanted, including the pools," said one student. "The light by the pool was okay, but you couldn't see inside. I don't remember if the teachers gave us instructions. Not a single teacher watched over us in the pool ... Suddenly, the lifeguard called me and told me come to him. I came close and then saw Netanel. The lifeguard thought he was diving. He told me to dive and look in the water. I dove and touched him, and he didn't move. The lifeguard told me to take him out, and he pulled him out. I was in shock. There were no teachers by the pool," said the student.

There were 230 pupils on the trip, accompanied by 15 teachers and 12 other adults.

The commission's recommendations include setting up a team to investigate all the staff involved in organizing the trip, increasing supervision of safety matters on all school trips in the Ort school network and more. But even though the report was finished in mid-August, nothing has happened. The ministry said the report has yet to be given to its director general.

The Ort school network said: "We have still not received the report. When it is received, we will act to implement its conclusions as necessary."

The principal, Alkaslasi, said: "I cannot comment on information I do not have. We are not evading anything. The report is supposed to be given to the school, and only then will we be able to relate to the matter," he said.

Tiberias hot springs' representatives were unavailable for comment.