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The Manchester Arena Inquiry has now concluded. The closure notice from the Inquiry Chairman is available here.

Volume 2 is divided into two sub-volumes: Volume 2-I and Volume 2-II. Volume 2-I is 695 pages long. Volume 2-I begins with a Preface and then continues with Parts 9 to 16. Volume 2-II is 189 pages long. It contains Parts 17 to 21 and the Appendices. A list of the names of the twenty-two who died is at page vii of Volume 2-I and at page iii of Volume 2-II.
A large format version combining Volume 2-I (ia, ib and ic) and Volume 2-II is also available.
Volume 2-I (standard format)
Volume 2-II (standard format)
Volume 2 (large format)

The Joint Operating Principles

Key findings

  • In January 2016, the third edition of Responding to a Marauding Terrorist Firearms Attack and Terrorist Siege: Joint Operating Principles for the Emergency Services (JOPs 3) was published.
  • JOPs 3 provided a series of principles guiding the way in which the emergency services should respond to such a situation.
  • The Foreword to JOPs 3 made it clear that it was guidance.
  • JOPs 3 applied in the event a police service declared Operation Plato.
  • JOPs 3 defined three Operation Plato zones: hot, warm and cold. The definitions needed to have been clearer than they were.
  • JOPs 3 expected that the boundaries of these zones would be reviewed frequently.
  • JOPs 3 envisaged that there may be circumstances in which non‑specialist resources would be deployed into an Operation Plato warm zone. The way in which this was expressed in JOPs 3 could have been clearer.


In January 2016, the third edition of Responding to a Marauding Terrorist Firearms Attack and Terrorist Siege: Joint Operating Principles for the Emergency Services (JOPs 3) was published.64 It is a JESIP‑badged publication.

It is important to remember that JOPs 3 becomes applicable on the declaration of Operation Plato. Only the police are able to formally identify that a Marauding Terrorist Firearms Attack is under way and declare Operation Plato. As a result, any failure to follow JOPs 3 is the responsibility of those GMP officers who knew that the Operation Plato declaration was in place, and of GMP for failing to share such a declaration.

There were occasions during the Inquiry oral evidence hearings when people who were unaware of the declaration of Operation Plato sought to justify their decisions by reference to JOPs 3. It is unlikely that consideration of JOPs 3 played any part in their decision‑making on 22nd May 2017. As a result, analysing decision‑making by reference to something that was not under consideration at the time was not of assistance to me.

On 22nd May 2017, GMP declared Operation Plato at 22:47. GMP was the lead agency. To the extent JOPs 3 prescribed a different approach to that under the Joint Doctrine, it was GMP’s responsibility to follow JOPs 3 and lead others, unless there was a clear and good reason not to.


The Foreword stated:
“Welcome to the third edition of Responding to a Marauding Terrorist Firearms Attack and Terrorist Siege: Joint Operating Principles for the Emergency Services. This guidance has been revised to reflect recent live exercising and operational learning that has taken place and influenced the response. It has also been revised to incorporate the national standard for multi-agency interoperability as described in the Joint Doctrine: The Interoperability Framework.
… This guidance should be used to inform existing major incident procedures and must be used in conjunction with local and national Standard Operating Procedures. …
… It is essential that specialist responders and commanders are competent in the implementation of these Joint Operating Principles, are familiar with their use and are trained appropriately. Organisations are responsible for ensuring systems are in place for training, monitoring and assessment of staff.”65

The reference to the Joint Doctrine is to the first edition, although the impending publication of the second edition is acknowledged.


The Glossary contained the following definitions:

Cold Zone Area where it has been assessed that there is no immediate threat to life.
Warm Zone Where the attackers are believed to have passed through but could enter/re‑enter imminently. These areas cannot be guaranteed as safe.
Hot Zone Where the attackers are present and/or there is an immediate threat to life.
On-scene commander An appropriate police, FRS [fire and rescue service] or ambulance commander at the scene who is responsible for undertaking an ongoing joint assessment of risk and for decision‑making on the deployment of their organisation’s assets at that location. On‑scene commanders will therefore ensure the emergency services’ response is effectively co‑ordinated at scene.
Tactical Firearms Commander (TFC) Develops, commands and coordinates the overall tactical response in accordance with strategic objectives.
Strategic Firearms Commander (SFC) Determines the strategic objectives and sets any tactical parameters. Retains strategic oversight and overall command responsibility.
Table 1Selected definitions from Glossary in JOPs 366

The footnote to the on‑scene commander entry stated:
“For FRS [fire and rescue service] and ambulance this is the equivalent of the operational commander role as defined in the Joint Doctrine … However given the specific nature of police command and control for firearms incidents the term on-scene commander has been retained for an MTFA [Marauding Terrorist Firearms Attack].”67

In Part 13, I will consider the approach taken on the night of the Attack to the issues of the police on‑scene commander and zoning, by reference to these definitions. For reasons I will set out in Part 13, I find that the JOPs 3 zones were concerned exclusively with the threat from a terrorist with a firearm. It is sufficient to say at this stage that, given the disputes that emerged during this Inquiry, the definitions provided by JOPs 3 needed to be clearer.


The introduction to JOPs 3 stated:
“A terrorist attack involving the use of firearms in a way designed to inflict large numbers of casualties and fatalities would present significant
challenges for the emergency services. A marauding terrorist firearms attack (MTFA) may involve:

  • Shooting
  • The use of explosives [redacted text]
  • [Redacted text]
  • Other injuries
  • [Redacted text]”68

The recognition that a Marauding Terrorist Firearms Attack may involve the use of explosives meant that the explosion caused by SA was capable of being interpreted as forming part of such an attack. This was the basis of the FDO Inspector Dale Sexton’s declaration of Operation Plato on the night of the Attack.

Joint Operating Principles

The aim of JOPs 3 was explained as follows:
“These Joint Operating Principles (JOPs) provide further guidance on the key aspects of any rapid joint response that are critical to saving life and ensuring the protection of emergency service personnel. Use of the JOPs is intended to support the aim of working together, saving lives and reducing harm.
The principles detailed in this document are not prescriptive but are intended to provide an overarching framework for a standardised approach across the UK.”69

It is important to note that principles within JOPs 3 were described as “guidance” and “not prescriptive”.70 This meant that operational discretion should play a part as well.71 What this means in practical terms is that those who know they are operating under JOPs 3 should apply the principles, departing from them where there is a clear and good justification for doing so. This was not the approach that all of those responding on the night of the Attack believed they had been taught.72

Identification, mobilisation and scene assessment

Paragraph 4.1

Paragraph 4.1 of JOPs 3 stated:
Personnel from any emergency service should not hesitate to report that an MTFA is underway. Information on a suspected MTFA should be shared amongst emergency service control rooms immediately. The police are responsible for formally declaring that an MTFA is occurring and that the response, Operation Plato, will be used.
Operation PLATO is the multi-agency response to the incident, whilst MTFA describes the type of incident. Early identification of an MTFA and rapid implementation of an appropriate joint response will be crucial to protecting the lives of both members of the public and responders. If a declaration is made in error then it can be rescinded.”73

On 22nd May 2017, Operation Plato was mentioned by firearms officers at 22:3874 and 22:43.75 Operation Plato was formally declared by the FDO, Inspector Sexton, at 22:47.76 I consider this declaration to be justified based on the guidance and training at the time.

Paragraph 4.2

Paragraph 4.2 of JOPs 3 stated:
“The police will inform emergency service partners immediately once an MTFA has been declared to enable FRS and Ambulance services to put their contingency plans into effect.
As soon as the police have declared an MTFA, the ambulance and FRS control rooms should be notified immediately. It is imperative that this action is undertaken straight away so that MTFA contingency plans for those services can be initiated to enable a co-ordinated, multi-agency response. …
Any delay in notifying emergency service partners of the declaration could place lives at risk and hinder the implementation of an effective joint services response. Advice to police forces in developing contingency plans for responding to an attack of this type clearly identified early notification to other emergency services partners as a priority.”77

Contrary to the requirement of paragraphs 4.1 and 4.2 in JOPs 3, none of the control rooms for the other emergency services were informed by GMP immediately.

Paragraph 4.3

Paragraph 4.3 of JOPs 3 stated:
“An attack of this kind will probably involve the use of firearms and potentially explosives or other types of weapons used by terrorists.
A robust response will be required by the police in deploying armed officers to identify, locate and confront the threat. This deployment is likely to be initially authorised and commanded by the Initial Tactical Firearms Commander located in the relevant police force control room. Over time, this Initial Tactical Firearms Commander may be replaced by a dedicated Cadre Tactical Firearms Commander located as part of the Tactical Coordinating Group (TCG) in a control/operations room. A Strategic Firearms Commander will also be notified as soon as practicable.”78

In accordance with the above principle, Inspector Sexton undertook the role of Initial Tactical Firearms Commander. He was not relieved of this role for over an hour and a half. The on‑call Cadre Tactical Firearms Commander did not relieve him. Another officer, who had not been on call or on duty, assumed the Tactical Firearms Commander role after midnight on 23rd May 2017.79

Assistant Chief Constable Deborah Ford was the on‑call Strategic Firearms Commander and she took up that role in response to the Attack 20 minutes after it had occurred.80

Paragraph 4.4

Paragraph 4.4 of JOPs 3 stated:
The Police will instigate a three-way telecommunication link between the emergency services’ control rooms.…The provision of unbroken communication links between the emergency services’ control rooms should enable the timely passing of information and intelligence that will inform deployment decisions. It will also facilitate the effective management of a co-ordinated response in deploying key decision-making personnel (i.e. on-scene commanders at the scene of attacks).

It should also be noted that in the initial response to an MTFA, the initial police on-scene commander may not be a TFC [Tactical Firearms Commander]. Where this is the case, they will work under the command of the TFC located at the control/operations room until a TFC arrives and assumes the role of police on-scene commander. When a TFC does assume the role of the police on-scene commander, a review of the command protocol with the control/operations room based TFC should be undertaken.”81

No three‑way telecommunication link between control rooms was instigated on the night of the Attack by GMP or any other responder agency during the critical period of the response.

A Tactical Firearms Commander did not arrive at the Victoria Exchange Complex until shortly before the end of the golden hour, that is, the first hour of the emergency response.82 Prior to this point, the command structure for GMP was not clear. The Operational/Bronze Commander and Operational Firearms Commander acted independently of each other at the scene. The Operational Firearms Commander was directly answerable to the Initial Tactical Firearms Commander, Inspector Sexton. From 22:50, the Operational/Bronze Commander was directly answerable to Temporary Superintendent Arif Nawaz, who relieved Inspector Sexton of the Tactical/Silver Commander role at that point. The Operational/Bronze Commander did not know of the Operation Plato declaration.83 He did not know he was supposed to be operating under JOPs 3.

Paragraph 4.5

Paragraph 4.5 of JOPs 3 stated:
The police control room will, as a matter of priority, liaise with ambulance and FRS control room managers to jointly agree a rendezvous point (RVP) for the initial response.84

This requirement of paragraph 4.5 was not fulfilled on the night of the Attack. There was no jointly agreed Rendezvous Point (RVP). By the time Operation Plato was declared, each emergency service had decided for itself a rendezvous or muster point.85 Four minutes after the declaration of Operation Plato, GMP Control informed NWAS Control that they should send ambulances to Hunts Bank.86 This was not adopted immediately by NWAS for all of its personnel. I shall return to this in Part 14.

Paragraph 4.8

Paragraph 4.8 of JOPs 3 stated:
The police on-scene commander, in consultation with FRS and ambulance counterparts is responsible for identifying a suitable FCP for specialist emergency service personnel.
For a MTFA response, FCPs are points where the multi-agency on-scene command team function and operate. Specialist emergency personnel will deploy into hot and warm zones from the FCP.” 87

No Forward Command Post (FCP) was established by the police or any other agency during the critical period of the response.88

Paragraph 4.9

Paragraph 4.9 of JOPs 3 stated:
Owing to the dynamic nature of the incident there may be insufficient time to establish an FCP.89

An FCP could and should have been established by GMP approximately 30 minutes after the explosion.90

Paragraph 4.10

Paragraph 4.10 of JOPs 3 stated:
The police on-scene commander will lead a joint assessment of risk at the FCP (or RVP) with ambulance and FRS counterparts to determine when and where to deploy emergency service responders, taking into consideration all available information. Whilst this process will be led by police, each emergency service will be responsible for deploying its respective resources.
A joint assessment of risk will take place at the FCP (or RVP in the event that FCPs cannot be established).
A joint assessment of risk is necessary primarily to ensure that all attending emergency responders are aware of the nature of the threat and the risks that they may face on entering warm zones.”91

No joint assessment of risk took place at the scene during the critical period of the response. The only personnel on scene who knew of the potential existence of any Operation Plato zones were the GMP firearms officers.92 In fact, as I will set in Part 13, inadequate thought was given to the Operation Plato zones on the night of the Attack.

Paragraph 4.11

Paragraph 4.11 of JOPs 3 stated:
In conducting a joint assessment of risk the police, FRS and ambulance on-scene commanders will use the Joint Decision Model detailed in JESIP Joint Doctrine. This process will be led by the police but on-scene commanders from all three services will be informed by their own service’s agreed risk management processes.
The use of a single methodology for assessing the risk to emergency service personnel is considered the most efficient means for determining when, and under what circumstances, deployments into warm zones take place. The joint assessment of risk is intended to enable the on-scene commanders to work towards a common understanding of the threats, hazards and risks that may be present in warm zones.

Whilst it will remain the responsibility of the respective on-scene commanders to determine when to deploy their organisation’s personnel, it is preferable that appropriate resources from across the three services are deployed in unison. This will maximise levels of operational effectiveness in warm zones to achieve collaborative aims.”93

During the golden hour, none of the NWAS personnel or unarmed police officers at the scene knew that Operation Plato had been declared. However, the approach to risk assessment expected by JOPs 3 was the same as that expected by the Joint Doctrine. As I set out in paragraph 11.109 and will discuss further in Parts 13 and 14, no joint assessment of risk took place during the golden hour between the commanders at the scene.

Paragraph 4.12

Paragraph 4.12 of JOPs 3 stated:
The boundaries of the hot, warm and cold zones must be frequently reviewed.
On-scene commanders from each service need to ensure that there is clear understanding in relation to the agreed boundaries of hot, warm and cold zones and agreed LoE [Limits of Exploitation], and that these are effectively communicated to operational personnel being deployed forward from the FCP.
Continuous assessment and review of the zones and LoE should be a priority. The use of the JDM [Joint Decision Model] will influence the establishment of the zones where practicable and as soon as safe to do so, consideration should be made to re-zoning the warm zone into a cold zone in order to allow non-specialist responders to deploy, continue casualty management and save life.”94

During the golden hour, there was a substantial failure by GMP to impose Operation Plato zones and review them. Having declared Operation Plato, GMP was under an obligation to identify which, if any, areas of the Victoria Exchange Complex were ‘hot’, which were ‘warm’ and which were ‘cold’. It was the imposition of these zones and the approach to the deployment of the emergency services within them that gave Operation Plato its unique character.

Despite this, zones were not identified by those GMP personnel who were aware of the Operation Plato declaration during the golden hour. No attempt was made to inform the unarmed GMP officers or emergency service partners of the zoning that had been applied. There was no review of the zones during the critical period of the response. It is notable that there was disagreement between the witnesses who gave evidence as to what the appropriate zoning was for the City Room during the course of the emergency response.95

Paragraph 4.16

Paragraph 4.16 of JOPs 3 stated:
Emergency personnel who are not in possession of full ballistic protection (ballistic body armour and helmets) for the threat will not normally be deployed into warm zones.
A police commander however may consider that the prevailing circumstances require that unarmed officers with standard personal protective equipment (PPE) be deployed to support warm zone activity. Such deployments will be subject to a joint assessment of risk and in doing so commanders should take into consideration existing advice for responding to firearms incidents, such as the Stay Safe principles. Then only when, in the particular circumstances, it is assessed that it is reasonable to deploy officers with standard personal protective equipment should deployment take place.”96

This is an important principle. It is important because the text in bold makes clear that there is no absolute prohibition under JOPs 3 on the deployment of emergency personnel without full ballistic protection into the warm zone. This conflicts with the evidence given by some witnesses who believed that such deployment was completely forbidden.97 This should not have happened.

There is a potential for confusion caused by the non‑bold text within paragraph 4.16. The use of the word “however” in the first sentence is capable of being read as meaning that there was only one exception to who would “normally be deployed into warm zones” and that exception was the police. This was the way in which the GMP’s Ground Assigned Tactical Firearms Commander, the NWAS Operational Commander and the National Interagency Liaison Officer from GMFRS understood JOPs 3.98 It was not the intended meaning.99

The intended meaning was that operational discretion existed for the deployment of personnel from any of the emergency services, as implied by the passage in bold. The non‑bold passage was intended to provide some additional specific guidance to police commanders.100