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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)

British Transport Police preparedness

Key findings

  • British Transport Police’s (BTP’s) Major Incident Manual was deficient in a number of respects which were relevant to BTP’s response to the Attack.
  • The Major Incident Manual had not been updated to reflect the introduction of the Joint Emergency Services Interoperability Programme in 2012. It should have been.
  • BTP did not have a site‑specific plan for the Victoria Exchange Complex. It should have done.
  • Although BTP officers had received some training in the Joint Emergency Services Interoperability Programme, the principles were not sufficiently embedded.
  • BTP officers were not adequately trained in first aid. This was a national issue and not the fault of BTP.
  • BTP’s approach to participating in multi‑agency exercises should have been more rigorous than it was.


BTP provides policing to the railway network across England, Scotland and Wales. It is expert in the policing of the railway network, which contains complex hazards and restrictions.

BTP is governed by the British Transport Police Authority. This is a statutory body appointed by the Secretary of State for Transport.161 The British Transport Police Authority is the governing body which checks that BTP is delivering against its agreed plans. It sets out the strategic direction of BTP and arranges the budget.162

BTP’s jurisdiction was determined by Section 31 of the Railways and Transport Safety Act 2003. This provided BTP officers with the powers of a Constable in a number of areas associated with the railway, including the track, stations, other land used for the purpose of or in relation to the railway, and any land for which the freehold is held by Network Rail.163

BTP used the terms Bronze, Silver and Gold for its Operational, Tactical and Strategic Commanders.164

C Division

BTP divided the areas it was responsible for into divisions. Manchester fell into C Division, which was the largest of the divisions and included the other major transport hubs of Birmingham and Leeds.165 In May 2017, the C Division Commander was Chief Superintendent Allan Gregory.166

There were three BTP police stations in the Manchester area, including one at the Peninsula Building which is less than five minutes’ walk from the Victoria Exchange Complex. The C Division headquarters was based at a different police station in Manchester.167

There was one explosives detection dog based in Manchester.168 In 2017, BTP did not have a firearms capability outside London.169

BTP Control

The control room for BTP (BTP Control) was located across two sites: Force Control Room London and Force Control Room Birmingham. The Force Incident Manager and Senior Duty Officer operated from London.170 On the night of the Attack, the Force Incident Manager was Inspector Benjamin Dawson171 and the Senior Duty Officer was Chief Inspector (CI) Antony Lodge. The Deputy Force Incident Manager operated from Birmingham.172

The Force Incident Manager’s role in a Major Incident was to take initial command. The Force Incident Manager undertook the duties of the Silver Commander until one could be appointed by the Gold Commander.173

The Senior Duty Officer role was created by BTP in 2015.174 It was not the subject of any specific training.175 CI Lodge understood his role in a Major Incident to be ensuring the appropriate response and resources were provided for an incident. He described his role as having “oversight” of the incident, “informing a number of key internal/external stakeholders” and spotting “any gaps”.176

Force Control Room Birmingham generally managed the C Division calls and radio traffic.177 The calls and radio traffic related to the Attack were handled by Force Control Room Birmingham. This was despite the fact that, until after the golden hour, a term I define in Part 10, had passed, BTP’s response was commanded by Inspector Dawson in London.178

Major Incident Manual

The Major Incident Manual in force at the time of the Attack was produced in 2011.179 It had not been updated to reflect the Joint Emergency Services Interoperability Programme, although an updated draft was under way which had not been finalised.180 It ran to 127 pages. It encouraged joint working, listing that the “first priority” was to “work with the other emergency services”,181 and it provided a structure within which BTP could respond to a Major Incident. The document was too long to be useful to anyone while they were responding to the early stages of a Major Incident.182


ACC O’Callaghan accepted on behalf of BTP that the Major Incident Manual in 2017 did not embrace the Joint Emergency Services Interoperability Principles (JESIP) in important ways.183 I agree.

Had the Major Incident Manual been reviewed and properly rewritten in light of JESIP and the Joint Doctrine: The Interoperability Framework (the Joint Doctrine), as it should have been, it would have been more focused on the substance of a multi‑agency response. One example of where the Major Incident Manual failed to keep up with the changes in the Joint Doctrine is that it referred to the predecessor to the METHANE mnemonic.184 I set out the METHANE mnemonic in Figure 23 in Part 11.

First officer on scene

The role of first officer on scene was defined in Appendix C of the Major Incident Manual. That person’s role was: “To access the incident and provide immediate information to FCR(L) [Force Control Room London] or FCR(B) [Force Control Room Birmingham]. To declare a major incident (when appropriate).185 The predecessor to the METHANE mnemonic was again listed. That mnemonic also included consideration of a Major Incident declaration.186

The first officer on scene was expected to assume interim command until relieved, establish a Forward Command Post (FCP) and complete a dynamic risk assessment. There was emphasis on maintaining communication with BTP Control.187


Also set out in Appendix C were command roles. These were described by reference to the responsibilities of each position. This could have been improved by listing the actions expected of each. NWAS, by contrast, operated a system of action cards which complemented its Major Incident Response Plan.188 The use of action cards is an effective way to give a commander responding to a Major Incident a ready checklist of what they need to remember to do.

Another matter that was not satisfactorily addressed by the Major Incident Manual was scene command. It correctly recognised that the BTP Silver Commander, unlike some other emergency service responders, may not be at the scene.189 This is because, as a national police service, it will not always be practicable for the Silver Commander to reach the scene in sufficient time to discharge the responsibilities of that role. As the events of 22nd May 2017 demonstrated, a better decision may be for the Silver Commander to travel to BTP Control and operate from there.

However, this makes ensuring the timely arrival of a person undertaking the Bronze Commander role all the more important. The Major Incident Manual required the Bronze Commander to be appointed by the Silver Commander.190 This is in contrast to the approach of GMP on the night of the Attack, whose Operational/Bronze Commander was on duty and self‑appointed.191 Between the two, I think GMP’s approach is the better one.

GMFRS’s approach to on‑scene command was that the most senior officer on scene took command.192 That person was then relieved, following a handover, by a more senior officer when they arrived.193

BTP’s approach as set out in the Major Incident Manual had the potential to build in delay. Inspector Dawson, as Force Incident Manager, was the initial Silver Commander. He did not appoint a Bronze Commander. The Bronze Commander was appointed by Chief Superintendent Gregory, who was to assume the role of Silver Commander. The appointment of a Bronze Commander did not occur until over 40 minutes after the explosion.194

BTP should review its processes for appointing a Bronze Commander in the event of a Major Incident. The time it took to appoint a Bronze Commander and the time it took for that person, Superintendent Kyle Gordon, to reach the scene and take up that role meant that BTP did not have a functioning Bronze Commander for the entirety of the critical period of the response. By the critical period of the response, I mean the period from the explosion at 22:31 to the removal of the final living casualty from the City Room at 23:39.

As I said in Part 10, GMP’s Operational/Bronze Commander, Inspector Michael Smith, performed his role to a high standard. Given how geographically spread BTP is, BTP should ensure that all its Inspectors are able to undertake a Bronze Commander role in the event of a Major Incident and that they are empowered to self‑appoint into this role, subject to ratification once the Silver Commander is able to do so.

It is essential that the system ensures that a competent Bronze Commander, of whichever rank, is on scene as soon as possible.195 They can always be relieved by a more senior officer if the incident continues to develop.

Sergeants should also receive training in what is required of a Bronze Commander, so they are able to ensure that important initial steps are taken before an Inspector arrives on scene.


The Major Incident Manual addressed the question of which police service, whether a Home Office police service or BTP, should take the lead in the emergency response. It stated: “Agreement on responsibilities between BTP and the local police force will be subject to negotiation with all relevant local police forces at the outset of any major incident.196 Inspector Dawson stated in evidence that this should occur “as early as possible”.197

On the night of the Attack, agreement was not reached until after 01:00 on 23rd May 2017.198 Many of those who responded proceeded on the basis that GMP was leading the response. However, discussions still took place within BTP about this issue during the critical period of the response.199 This was time that would have been better spent focusing on more urgent things which needed to be done.

It is important that this issue is not overstated. It did not absorb large quantities of time during the response. There is no basis to conclude that any casualty did not receive attention from a BTP officer when they could have, because of it. At most, it was a distraction for some.200 It should not have been.

Agreement as to the circumstances in which either of the two police services, GMP and BTP, would lead a response should have been reached in advance. During a Major Incident, this issue should require no more than a confirmation from one control room to another as part of the early communication in which situational awareness is shared. In no circumstances during the early stages of a Major Incident should it require “negotiation”201 as suggested by the Major Incident Manual.

Once agreement has been reached as to the factors that determine which police service has primacy in a Major Incident, it should be stress‑tested in exercises. All police officers and staff should then be trained in it.

Senior Duty Officer

Finally, the Major Incident Manual made no provision for the Senior Duty Officer role or what part that person should play during a Major Incident.202 The Senior Duty Officer was capable of playing an important role in a Major Incident. The Senior Duty Officer role within a Major Incident should have been specified in BTP’s plan. It should have had a corresponding action card.

Although there was a Senior Duty Officer manual which did give some guidance as to what a Senior Duty Officer should do in a Major Incident,203 this should have been integrated into the Major Incident Manual so there was a single, unified plan.

Site-specific plan

The Victoria Exchange Complex comprised a number of significant elements from a policing point of view. It functioned as a substantial transport hub, with six national railway platforms, four Metrolink tram platforms, a large indoor car park and an outdoor car park. It also functioned as an entertainment centre, with the Arena one of the largest and busiest venues in Europe, with a capacity of 21,000,204 and a go‑karting track. In addition, there was office space, which increased the footfall further.205

The freehold interest in the Arena was owned by Network Rail. This meant it was within BTP’s jurisdiction.206 The only part of the Victoria Exchange Complex not policed by BTP was the Metrolink tram platforms. These were policed by GMP.207

While BTP has considerably larger transport hubs within its remit, the Victoria Exchange Complex was unique as it included the only major leisure venue it had responsibility to police.208 This fact alone should have been sufficient justification for BTP to operate under a site‑specific plan for the Victoria Exchange Complex. The fact that the same site hosted a busy transport hub and other facilities made the need for such a plan a necessity.209

ACC Robin Smith was the BTP Gold Commander on the night of the Attack. He was based in the south of England. He did not know the geography of the Victoria Exchange Complex. In evidence, he stated that he would have benefited from a site‑specific plan when commanding BTP’s response to the Attack.210 His evidence provided a good example of why such a plan is necessary.

This site‑specific plan should have been drawn up and approved at a multi‑agency level. GMRF was the natural place for this work to have been done. I note the Policing Experts stated that site‑specific plans were not ordinarily prepared by local resilience forums.211 BTP was the obvious organisation to take the lead in preparing this plan. GMRF was the obvious place for it to be considered and approved by all Category 1 responders.

GMP had a site‑specific contingency plan for the Arena.212 I will return to this plan when I address GMP preparedness later in this Part at paragraphs 12.135 to 12.368.

Training and equipment


The Policing Experts were “satisfied that all front line [BTP] officers had access to JESIP training”.213 This was in the form of College of Policing approved online learning, which provided for three levels of training: Police Constables and Police Community Support Officers (PCSOs); Sergeants and Inspectors; and Chief Inspectors and Superintendents. The latter two categories also received classroom‑based JESIP training.214

Major Incident awareness training was delivered as part of the initial training package.215

The College of Policing provided training courses for Bronze, Silver and Gold Commanders. These accredited officers to command events and respond to incidents. BTP required officers to pass the public order command course in order to be authorised to command incidents. Inspectors could be trained up to Bronze level, Chief Inspectors to Silver level and Superintendents to Gold level.216

There is no doubt that BTP officers at the scene worked well with their counterparts at GMP to provide what treatment they could and assist casualties from the City Room. A Rendezvous Point (RVP) was also identified by a Police Constable within 15 minutes of the explosion.217

However, none of the officers at the scene sought to provide a METHANE message of their own volition. Inspector Dawson repeatedly asked for a METHANE message before receiving one. All BTP officers should have been prepared by their training to recognise that at a very early stage of a Major Incident it was important for at least one of them to step back and provide a METHANE message.

The desire to help, which all of those from BTP who bravely entered the City Room were operating under, is natural and powerful. It is the function of training to override this desire when to do so is in the interests of a more effective response. The training provided by BTP failed to achieve this in any of the officers who responded.

I accept the evidence of the officers who said they had an understanding of what JESIP was.218 But there was a failure to embed JESIP into the muscle memory of BTP officers at the scene. This was well explained by CI Lodge, when he candidly said of his own experience of the JESIP training: “[A]t the time I felt trained in it, but looking back, I think with just one input I think some of those principles should have been further inset in my mind and maybe they weren’t.” 219 As a Chief Inspector, he had access to the highest level of JESIP training provided by BTP, including a classroom‑based component which Police Constables and PCSOs did not. As Senior Duty Officer, he was expected to “spot any gaps”220 and oversee the response. It is of substantial concern that the training had not equipped him to do this adequately.

First aid training was provided to new recruits over four days. There was a requirement for it to be refreshed annually with four hours of further training. The initial course included the provision of CPR and managing blood loss. The course was intended to enable officers to provide first aid until paramedics arrive.221 The evidence I received from a number of BTP officers was that they did not believe their first aid training was sufficient for the scale of the challenge with which they were confronted.222 This is inevitable to a degree. This does not mean that improvements cannot be made.

For unarmed officers, the first aid training given to BTP officers did not include the applications of tourniquets.223 The College of Policing course did not include this on its curriculum.224 I will return to the issue of tourniquets when addressing the Care Gap in Part 20 in Volume 2‑II.


The equipment generally available to BTP officers in May 2017 included leg restraints and an optional first aid pouch.225 The optional first aid pouch contained one “revive aide”, which is used to provide mouth‑to‑mouth resuscitation, a pair of gloves and antiseptic wipes.226

BTP officers were not issued with tourniquets as part of their personal kit. Tourniquets were not included in the green first aid kit in the cab of BTP patrol cars or in the orange grab bags which were also stored in those vehicles.227 I have included mention of leg restraints here because, without access to tourniquets, some officers on the night of 22nd May 2017 improvised using their standard issue leg restraints.228


Exercise Kestrel was a tabletop classroom training package for Major Incidents. Although it was in existence at the time of the Attack and BTP officers in the South East had received training in it, it was not delivered in C Division until after the Attack.

By the time of the Attack, many BTP officers had participated in “the Ickenham terrorism immersive exercise”.229 This was not a live exercise, in the sense that it involved role play, but it was interactive and required the discussion of a terrorist scenario.230

As I set out in Part 7 in Volume 1, two BTP police officers attended Exercise Sherman in July 2016. This was a multi‑agency exercise hosted by GMRF which involved a terrorist scenario in the City Room. It resulted in no learning for BTP,231 despite being an opportunity to consider how primacy in the response might quickly be established between BTP and GMP. BTP’s approach to exercising for scenarios like the Attack should have been more rigorous than it was. Thoughtful participation in well‑designed exercises, with an effective debrief process, would have eliminated many of the problems with BTP’s response on the night of 22nd May 2017. The JESIP teaching should have been robustly put to the test. This did not occur.