- There was a blind spot in SMG’s CCTV system on the mezzanine. The lack of coverage of the Blind Spot should have been apparent to SMG prior to May 2017.
- SMG’s Arena Manager, Facilities Manager and Event Duty Manager did not know about the existence of the Blind Spot.
- SMG did not have in place a system which sought actively to identify and address blind spots in the CCTV system. As a result, there was no robust management of the challenge created by gaps in the CCTV system’s coverage.
- Neither the Showsec Head of Security on 22nd May 2017 nor the Showsec staff in the City Room on that day knew about the Blind Spot.
- SA chose to hide in the area of the Blind Spot because it was the most obvious place to hide in the City Room.
- It was SMG’s responsibility to identify the existence of the Blind Spot and take steps to mitigate the risk it posed. SMG’s failure to identify the existence of the Blind Spot was one of the consequences of SMG’s deficient approach to risk assessment.
- There were a number of straightforward ways in which SMG could have addressed the risk created by the Blind Spot, including additional cameras and/or the deployment of Showsec staff.
- While it is not possible to determine exactly what would have happened had the Blind Spot been addressed, if it had been, it is likely that the Attack would have been disrupted, deterred or, at the least, fewer people would have been killed and injured.
- SMG’s general approach to the use of CCTV was inadequate. The CCTV was not constantly monitored during show mode and as a result the CCTV system was not a reliable method of identifying suspicious activity.
Control rooms and CCTV
SMG operated two control rooms: Whisky Control and Sierra Control. Whisky Control was staffed 24 hours a day, including days when events did not take place.Days on which events did not take place were referred to as “dark days”. Sierra Control was only staffed immediately before, during and immediately after events, a period referred to as “show mode”. On 22nd May 2017 show mode began at 18:00.
On dark days and event days there were two roles based in Whisky Control: Control Room Operator and Patrol Officer. On event days, a Fire Safety Officer was also based in Whisky Controlalbeit not permanently. On 22nd May 2017, these roles were occupied by Michael Edwards, Stephen Noone and Paul Johnson respectively. Paul Johnson spent most of the Ariana Grande concert in his office, which is adjacent to Whisky Control.
It was the responsibility of the Control Room Operator to watch the CCTV screens, listen to the radio and monitor the heating system.There were CCTV screens within Whisky Control onto which live images from the CCTV system were displayed. The cameras were spread across the Victoria Exchange Complex. There were many more CCTV cameras than there were screens in Whisky Control. As a result, the majority of the screens displayed images from 16 cameras. This meant that each camera feed took up just a small proportion of each available screen, which were not large. There was a facility to display images from a single camera on a screen.
When in show mode, those in Whisky Control were expected to watch the CCTV monitors, among their other duties.When watching the CCTV, the Control Room Officer looked out for suspicious behaviour. When something suspicious was identified on the CCTV, either the Patrol Officer or the Control Room Operator would leave Whisky Control to investigate.
The Patrol Officer, when present in Whisky Control, was available to assist the Control Room Operator in their duties.Among the duties of the Patrol Officer was watching the CCTV screens. There were other tasks, such as investigating the breakdown of lifts, which might take the Control Room Officer away from Whisky Control for a short period. When the Control Room Officer left Whisky Control, they relied upon the Patrol Officer and, if present, the Fire Safety Officer to watch the CCTV. When all three members of staff were present, more than one of them may watch the CCTV screens at the same time.
During show mode Sierra Control was staffed. There were four people based in Sierra Control: the SMG Event Manager; the Showsec Head of Security; a representative of Emergency Training UK (ETUK) and a member of Showsec staff whose role was to monitor the Showsec radio. On 22nd May 2017, those people were Miriam Stone, Thomas Rigby, Michelle Ramsbottom and Jade Duxbury.
Sierra Control also had screens displaying images from some, but not all of the CCTV cameras.The agreement within SMG was that when in show mode, Sierra Control would take charge of the operation of the CCTV system. This agreement meant that if Whisky Control wished to move or zoom a camera during an event, permission from Sierra Control had to be obtained.
CCTV in the City Room and the Blind Spot
For some years prior to 22nd May 2017, the configuration of the CCTV cameras in the City Room meant that there was part of the mezzanine level in which a person could conceal themselves out of sight of any camera. As I indicated in Part 1, I have referred to this as the Blind Spot.
Three cameras in the City Room provided views of parts of the mezzanine. One camera, Unit 2 Cam 1, was positioned in the area of the Fifty Pence staircase. This is the staircase that leads up from the NCP car park. This camera provided a very limited view of part of the JD Williams’ side the mezzanine. The focus of this camera was, though, on the top of the Fifty Pence staircase, not the mezzanine. Anyone viewing the images from the camera would naturally have their eye drawn to the top of the Fifty Pence staircase and landing area at the top. This was an immoveable camera with no zoom function. Figure 16 shows the extent to which Unit 2 Cam 1 captured the mezzanine.
Figure 16: Image from Unit 2 Cam 1 showing limited view of the mezzanine
Another camera, Unit 3 Cam 14, provided a distant view of a small part of the mezzanine area outside the building which had formerly been occupied by McDonald’s. This was also an immovable camera with no zoom function. Figure 17 show an image from Unit 3 Cam 14 with the highly limited and distant view of part of the mezzanine marked in the top left corner.
Figure 17: Image from Unit 3 Cam 14 showing limited view of the mezzanine
The camera capable of providing the best view of the mezzanine level, Unit 2 Cam 2, was able to tilt, pan and zoom.Its extent and limitations were covered in detail by the evidence of Michael Edwards and Michael Cowley. I was also given considerable assistance in relation to this camera by Detective Sergeant Michael Russell of GMP who co-wrote the CCTV policy for GMP’s investigation into the Attack.
Unit 2 Cam 2 provided good coverage of significant parts of the City Room. It provided a particularly good view, from an elevated position, of the Arena entrance/exit doors to the City Roomand the box office. A large number of the images from Unit 2 Cam 2 the Inquiry considered from 22nd May 2017 showed these areas. There were images from the night when it is clear that the operator had moved it for periods of time so that it captured the full width of the mezzanine level that it covered.
However, even when Unit 2 Cam 2 was focused on the mezzanine level, there remained parts of the mezzanine which were not visible. The principal cause of this is the raised area above the Grey Doors which blocks the sightline from Unit 2 Cam 2 to the area immediately behind this raised area.
Figure 18 shows the view captured by Unit 2 Cam 2 when directed towards the mezzanine. Unit 2 Cam 2 was also capable of panning further to the right than is shown in this image to capture the area of the mezzanine outside McDonald’s nearest the exit from the City Room onto the overbridge.
Figure 18: Image from Unit 2 Cam 2 showing the extent of the view of the mezzanine
By sitting, kneeling or crouching, a person could completely conceal themselves from the sight of Unit 2 Cam 2.The area was large enough to accommodate and conceal a number of people. It was large enough to conceal a person with a large backpack. Figure 19 shows the positioning of the relevant cameras and the approximate area of the Blind Spot. Figures 20 and 21 depict the approximate area of the Blind Spot, viewed from the JD Williams’ side and the McDonald’s side of the mezzanine respectively. In each case, the approximate area of the Blind Spot is shaded in yellow.
Figure 19: Relevant City Room cameras and the Blind Spot (shaded in yellow)
Figure 20: The Blind Spot (shaded in yellow): view from McDonald’s side
Figure 21: The Blind Spot (shaded in yellow): view from JD Williams side
It was in this area that SA chose to conceal himself during a significant proportion of the period after 20:30. Across both visits to the City Room he spent in excess of an hour and a quarter on the mezzanine before he detonated his bomb.I do not consider he did so purely by chance. Setting aside the CCTV system, this was the best hiding place within the City Room. In the words of Colonel Latham: “it was a good place to hide”. This is not a conclusion I reach with the benefit of hindsight, but from simply considering the layout of the City Room as it was on 22nd May 2017. I find that this must also have been the conclusion SA reached as a result of his hostile reconnaissance of the City Room.
The fact that this obvious place of concealment was not covered by a camera was, therefore, a significant gap in the CCTV system’s coverage. The problem this gap created was compounded by the fact that the only camera which gave any coverage on either side of the Blind Spot was not permanently focused on that area. As a result, unless Unit 2 Cam 2 was, by chance, pointed at the mezzanine, once a person had ascended either set of stairs up to the mezzanine, anyone viewing the cameras would have no idea whether that person had gone to JD Williams or hidden themselves. It is a striking feature of the evidence that there are no images from the CCTV which capture SA on the mezzanine on 22nd May 2017.This is despite the fact he spent in excess of an hour and a quarter in that area. There are two reasons for this. The first is that when SA was not in the Blind Spot, such as just before he descended the McDonald’s side staircase, Unit 2 Cam 2 was not pointed at the mezzanine. The second is because he was concealed in the Blind Spot on every one of the limited number of occasions when Unit 2 Cam 2 was pointed at the mezzanine.
The Inquiry heard from a number of those who viewed the CCTV screens as part of their job. They were each asked whether they knew about the existence of the Blind Spot. Only one witness, Michael Edwards, the Control Room Operator in Whisky Control on 22nd May 2017, said he was aware of the Blind Spot.Michael Edwards stated he had known about it since he started working at SMG, 14 years prior to the Attack. He stated he thought everyone knew about the blind spots in the CCTV system. He stated that anyone who had worked in Whisky or Sierra Control would have known about the Blind Spot. While Michael Edwards might have believed this, having heard evidence from a number of key people at both SMG and Showsec, it is my view that he was mistaken as to how widely known the existence of the Blind Spot was.
The evidence was that James Allen,Michael Cowley and Miriam Stone did not know about it. Consequently, Miriam Stone did not make any allowance for the Blind Spot when planning for events or in discussion with Showsec. James Allen accepted he should have known about it. He stated he did not learn of it until he heard about it through this Inquiry. James Allen stated that SMG operated a system in which, if a blind spot was identified, a person would be deployed to cover it on the ground. In reality, there was no system employed by SMG which sought actively to identify and address blind spots in the CCTV system. As a result, I find that this was a theoretical aspiration, rather than robust management of the challenge created by gaps in the CCTV system’s coverage.
Paul Johnson, the Fire Safety Officer on 22nd May 2017 was not sure whether or not he knew about the Blind Spot in 2017.He had also held the role of Security Supervisor since 2005. He had never discussed the Blind Spot with anyone in that capacity.
So far as Showsec was concerned, neither Thomas Bailey nor Thomas Rigby, who both acted as Head of Security at events at the Arena, knew about the Blind Spot.As a result, no account was taken of it by them when planning the deployment of Showsec staff at events and the route taken by patrols. On the ground, the Showsec City Room senior supervisor, David Middleton, did not know about it despite having worked at the Arena for 21 years. The same was true of all of the other Showsec staff who worked in the City Room on 22nd May 2017.
It was only in the summer of 2020 that the Blind Spot was completely eliminated by SMG making alterations to its CCTV system.
Mitigating the Blind Spot
As owner and principal operator of the CCTV system, it was SMG’s responsibility to identify the existence of the Blind Spot. It should have done so as part of the proper conduct of its risk assessment process. Had SMG identified the Blind Spot as part of a suitable and sufficient risk assessment, consideration would have been given to what steps were required to mitigate it. This, in turn, would have led to the consideration of adding cameras or agreeing a deployment by Showsec of its staff to mitigate the Blind Spot during events. This could have included regular and frequent patrols to the area out of the view of the camerasor the positioning of a static member of Showsec staff who had a clear view of the area the camera could not see.
Had SMG added an additional camera, this would have increased the possibility that SA would have been detected in the City Room before he detonated his bomb. However, the way in which the CCTV system was used by SMG in May 2017 required substantial improvement before this was likely to have made a difference. I will deal with this below.
The alternative way in which the Blind Spot should have been addressed was through the use of Showsec staff. Had this been identified as a control measure, as James Allen stated was his intended approach, it may have had one of a number of effects on what occurred on 22nd May 2017. The presence of Showsec staff on the mezzanine may have deterred SA altogether. However, I consider this to be unlikely. It may have led to the Attack being disrupted by causing him to wait elsewhere within the Victoria Exchange Complex. This would have reduced his ability to time his Attack as he wished. I think this is the probable effect of SA realising that he would be detected if he hid for a lengthy period in the area of the Blind Spot. Had SA not been disrupted in this way, it is likely Sierra Control may have been notified, which may have led to SA being spoken to. What would have then occurred is heavily dependent upon the timing of this intervention. It is not possible to say that any one of these outcomes was more likely than not to have occurred.
It is not possible for me to determine exactly what would have happened had the Blind Spot been addressed through patrolling and/or proper monitoring of an adequate CCTV system. I am able to conclude that if it had been, it is likely that the Attack would have been disrupted, deterred or, at the least, fewer people would have been killed and injured.
Deficiencies in SMG’s approach to CCTV
CCTV is an essential counter-terrorism measure for any organisation in SMG’s position: that of an operator of a large public entertainment venue. The sheer number of people who could attend an event, coupled with the mixing that would inevitably take place around the Arena with members of the public passing through, meant that having a comprehensive overview of all the important areas around the Arena was a necessity. The complexity of keeping people safe in this environment required SMG to maximise the prospect of identifying suspicious activity as soon as possible.
The NaCTSO guidance “for Stadia and Arenas” at the time stated that CCTV could be constantly monitored or the recordings regularly checked.As this document states, it is “not site specific and all stadia and arenas are different”. For activities as well attended and complex as those which took place at the Arena, real time monitoring was necessary, if there was to be any prospect of using it as a counter-terrorism measure during an event.
The importance of effective CCTV monitoring was underlined by Michael Edwards’ evidence. He stated that had he noticed the full extent of SA’s movements and appearance on 22nd May 2017, he would have regarded them as being suspicious.I accept this evidence. Paul Johnson gave evidence, which I also accept, that if someone in Whisky Control had noticed that SA had gone on the mezzanine and remained there for some time this would have been called through to Sierra Control. SA was not noticed by those in Whisky Control as being suspicious and this was not just because of the Blind Spot.
There was a general problem with SMG’s CCTV system and its approach to it. During show mode, those in Sierra Control, who assumed responsibility for control of the CCTV system, did not monitor it constantly.What I mean by monitor in this context is a person constantly reviewing images in real time, proactively, with a view to identifying suspicious activity.
The SMG Event Manager and Showsec Head of Security in Sierra Control used the CCTV for crowd management.If a specific request came in from a member of staff on the ground, then focus would be given to that by those in Sierra Control.
There was an expectation that those in Whisky Control would monitor the CCTV.However, there were five problems with this as a reliable method of identifying suspicious activity.
First, the arrangements that SMG had in place did not guarantee that there would be constant monitoring before, during and after events. They should have.All three people in Whisky Control had duties beyond the CCTV. The Control Room Operator did not exclusively devote his attention to watching the CCTV. Michael Edwards stated that on 22nd May 2017 his other tasks had taken him away from watching the CCTV screens in the course of the evening. This included being out of Whisky Control for a few minutes during the period SA was on the mezzanine in the hour before the detonation. There is no criticism of Michael Edwards for having done so: he was undertaking his duties as he had been instructed to.
I accept that those in Whisky Control who gave evidence to this Inquiry worked collaboratively with each other,but I find that it was not regarded as essential by them that someone was viewing the CCTV monitors at all times. I do not accept that there was always someone monitoring the CCTV during events. From the totality of the evidence I heard, I did not accept that SMG’s system was sufficiently robust to guarantee continual monitoring. It needed to be.
As to the number of people who should have been monitoring at any one time, it is beyond the scope of the Inquiry to conduct an exhaustive examination of the extent of the CCTV system. I did not receive enough evidence to reach any firm conclusion as to the minimum number of people who should have been devoting themselves exclusively to monitoring the CCTV during an event. However, my impression from the substantial body of evidence I heard about CCTV was that just one person monitoring it may not be sufficient.I make clear, however, that in saying this I am making no finding so far as the minimum number of people who should have been monitoring the CCTV on 22nd May 2017. I conclude that it should have been at least one and that this was not the case during the Ariana Grande concert because of the number of things that were occurring in Whisky Control.
Second, the way the system itself was set up meant that almost all of the images from each camera were small. This was also true in Sierra Control.This meant that identifying the subtle cues that might mark activity as suspicious was harder to detect. I agree with the evidence of Paul Johnson, when he stated that identifying SA in these circumstances would not be easy. Paul Johnson, who was in a very good position to know, stated that “the images are too small to pick out one person” when the images were not enlarged. While it would have been impractical to have all of the images of a substantial size, having a number of substantial sized images of key areas in Whisky Control would have improved the prospect of suspicious activity being detected.
Third, the agreement between Sierra and Whisky Control that Sierra took over the operation of the CCTV system during show modecould cause problems. Sierra Control used the CCTV system reactively and did not monitor it continuously. Despite this, Sierra Control was primarily responsible for which cameras were moved. Whisky Control could ask for control back and, I accept, did so on occasions. However, this arrangement created difficulties in two ways. Michael Edwards mistakenly believed that Sierra Control was watching the CCTV throughout an event. Further, Sierra Control having primary control over the CCTV system would not have the effect of encouraging Whisky Control to monitor proactively the feeds on a continuous basis.
Fourth, at the time when large groups of people were moving through the venue, such as at egress, the focus of those watching the CCTV was on the event-goers leaving the Arena, rather than looking out for suspicious activity.Unit 2 Cam 2’s superior view of ingress and egress meant that it was directed away from the mezzanine at those times. This had the effect that the entire mezzanine was not monitored by CCTV at the time when substantial effort should have been devoted towards looking out for threats. This too was a product of the failure of the risk assessment process. This should have identified that particularly careful monitoring of all areas of risk was required at times and in places of high crowd density. This was not SMG’s approach and it should have been.
Given the importance of monitoring, if it was to be done by Whisky Control during an event, the relationship and arrangements between the two control rooms should have been better than they were.
Fifth, I regard the approach to the training of those who were responsible for continuous CCTV monitoring to be deficient for the reasons I have set out above.
I consider that SMG’s approach to CCTV was inadequate. This inadequacy in the approach to CCTV, including the lack of coverage of the Blind Spot, should have been apparent to SMG prior to May 2017.