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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)

Greater Manchester Fire and Rescue Service preparedness

Key findings

  • Greater Manchester Fire and Rescue Service (GMFRS) was well equipped to respond to a Marauding Terrorist Firearms Attack.
  • GMFRS specialist personnel were adequately trained to respond to a Marauding Terrorist Firearms Attack. There was room for improvement in the Joint Emergency Services Interoperability Principles (JESIP) training.
  • GMFRS had an established Marauding Terrorist Firearms Attack capability.
  • It created the Technical Response Unit and Specialist Response Team. These were equipped and trained to respond to a Marauding Terrorist Firearms Attack.
  • GMFRS was one of the national leads in creating the National Interagency Liaison Officer role. It worked hard to embed the role as part of its Marauding Terrorist Firearms Attack capability.
  • GMFRS was actively involved in leading, preparing and delivering multi‑agency training and exercises.
  • GMFRS failed, with other organisations, to learn the lessons identified from multi‑agency exercises.
  • GMFRS failed to involve North West Fire Control (NWFC) sufficiently, or sometimes at all, in multi‑agency training.
  • GMFRS failed to create sufficiently clear action cards for NWFC to respond to an explosion, such as the one that occurred during the Attack.
  • GMFRS failed to embed use of the action cards by NWFC through training and exercises.

Responsibilities, governance and structure


GMFRS is one of the largest fire and rescue services outside of London.817 It covers approximately 500 square miles and the ten boroughs of Greater Manchester, which has a population of 2.5 million.818 Its core functions are set down in law, supplemented by guidance and policies.

The Fire and Rescue Services Act 2004 required fire and rescue authorities to make provision for fire safety, firefighting and road traffic accidents, and for responding to other emergencies.819 The latter was a broad function.

GMFRS considered that it included a fire and rescue service responding to a terrorist incident.820 Each of the statutory functions required the provision of trained personnel, services and equipment for the fulfilment of its obligations. Arrangements had to be made to deal with emergency calls and to mobilise personnel.821

At the time of the Attack, there was no agreement between the Fire Brigades Union and fire and rescue service leadership nationally about whether responding to a terrorist attack was a contractual requirement for a Firefighter. This had no impact on the response by GMFRS on the night. However, there were concerns at the time about ensuring the safety of firefighters in a Marauding Terrorist Firearms Attack situation.822

The Fire and Rescue National Framework set country‑wide priorities and objectives for fire and rescue authorities.823 The framework in place in May 2017 dated from 2012. It required collaboration and interoperability with other emergency services.824 General reference was made to terrorism but not, until updated guidance was issued in May 2018, to the need for a Marauding Terrorist Firearms Attack capability.825

GMFRS was a Category 1 responder under the 2004 Act. This meant that it must participate, together with other Category 1 responders, in GMRF. A core purpose of any resilience forum was to ensure that all Category 1 responders co‑ordinated a joint approach.826

The purpose of GMFRS, set out in its Corporate and Integrated Risk Management Plan 2016-20, was “to save, protect and improve the lives of the people of Greater Manchester”.827 Its aims, set out in the same plan, were grouped into six themes. They included planning and preparing for emergencies and helping to reduce the risk of them occurring.828

I will consider the extent to which GMFRS was adequately prepared to meet these responsibilities and, in particular, to respond with partner emergency services to a major terrorist attack. I will consider the structure and governance of GMFRS, its equipment and specialist capabilities, training and exercising, and the preparation of plans and policies to respond to a terrorist incident.


The Mayor of Greater Manchester had overall responsibility for the governance, strategic and financial management of GMFRS. The Mayor was the Fire Commissioner for GMFRS. Secondary legislation establishing the responsibility of the Mayor for GMFRS came into force shortly before the Attack, on 8th May 2017.829

Strategic leadership of GMFRS was provided by a corporate leadership team. In May 2017, this included Chief Fire Officer Peter O’Reilly, Deputy Chief Fire Officer Argyle, and two Assistant Chief Fire Officers, Geoffrey Harris and David Keelan.830

Concerns were expressed during the Inquiry about aspects of the governance of GMFRS. There were, for example, differences in leadership style between senior GMFRS officers and more junior staff. Chief Fire Officer O’Reilly considered it was a difference that arose from the need for senior officers to focus on fire safety, not operational issues.831

While there was a failure by GMFRS to respond to the Attack, the evidence did not suggest the corporate leadership team were not competent to lead the organisation.

Rank structure

Not everyone will be familiar with the rank structure commonly operated within fire and rescue services. The entry rank is that of Firefighter. This can also be used as a general term to describe all members of a fire and rescue service. Above the rank of Firefighter is Crew Manager. A Crew Manager may be in charge of a fire appliance. Senior to a Crew Manager is a Watch Manager.

The Watch Manager is in charge of Firefighters and Crew Managers on his or her shift.

Fire stations are managed by Station Managers. Above Station Managers are Group Managers, who are responsible for a number of fire stations. Senior to Group Managers are Area Managers.

At the top of the hierarchy are Assistant Chief Fire Officers, Deputy Chief Fire Officer and Chief Fire Officer.832

Approach to incident command

GMFRS took a different approach to incident command from other emergency services operating in Greater Manchester. In doing so, GMFRS was acting in accordance with what I understand to be the approach to incident command by other fire and rescue services across the country.

The approach was for the Incident Commander to be the most senior person on the scene of the incident. To take a simple example, this meant that if a single fire appliance responded, the Crew Manager of that fire appliance would take charge upon arrival. In the event that further resource was required, the arriving Watch Manager would receive a handover once they reached the scene and would assume command. This approach was capable of being extended up the ranks.833

The Incident Commander was expected to command the response to the incident. GMFRS had a Command Support Room at its headquarters, which could be staffed by senior officers. However, the role of these senior officers was to provide support and manage the impact of the incident on GMFRS’s other responsibilities. This meant that the Incident Commander was not directly answerable to those in the Command Support Room in the way the Operational/Bronze Commanders of BTP, GMP and NWAS were to their respective Tactical/Silver Commanders.834

GMFRS did recognise the Strategic, Tactical and Operational Commander roles.

Those terms were applied as follows. Incident Commanders at the rank of Crew Manager and Watch Manager were classed as Operational Commanders.

Incident Commanders at the rank of Station Manager and above were classed as Tactical Commanders. As the role of Incident Commander required attendance at the scene, the Tactical Commander was always at the scene.

There was a duty Assistant Principal Officer and duty Principal Officer for every shift. It was the duty Assistant Principal Officer’s responsibility to decide who would attend any Tactical Co‑ordinating Group which might be arranged.

It was expected that the duty Principal Officer would attend any Strategic Co‑ordinating Group meeting which might be arranged.835

I have no reason to think that this approach is not effective for the vast majority of GMFRS’s work. It gives rise to two issues in relation to an event such as the Attack.

First, the Incident Commander role was dependent upon arrival at the scene of an incident, as presence at the scene was the trigger for the most senior person present to take up the position. I shall return to this in Part 15 as GMFRS’s approach to incident command played an important part in causing the GMFRS response to stall.

Second, GMFRS’s approach did not map exactly onto the Strategic/Gold, Tactical/Silver and Operational/Bronze Commander roles operated by other emergency services. GMFRS operated in a silo during the critical period of the response. For this reason, it is not possible for me to reach any view on whether this difference is capable of hindering joint working at the scene.

However, the fact that GMFRS did not have a Tactical Commander who operated away from the scene meant that there was no automatic deployment of a Tactical Commander to GMP HQ. This was in contrast to the approach of NWAS and GMP on the night of the Attack. Had the deployment of a GMFRS Tactical Commander to GMP HQ happened at an early stage, it is likely that GMFRS would have gained situational awareness much sooner than it did.


In 2005, GMFRS created the Interagency Liaison Officer role.836 This role, which required enhanced security clearance, was created to allow sensitive operational information to be shared by the police with the ambulance and fire service.837 Group Manager Fletcher stated that the role was “intended to be to an intelligence led liaison to fast track information through secure channels to enable a swift and co-ordinated response”.838 After the London Fire Brigade, GMFRS was the next fire and rescue service to create this capability.839

Group Manager Fletcher considered that the Interagency Liaison Officer role at GMFRS was a great success and that greater inter‑agency liaison in Manchester paid “dividends”.840 This role became known as the National Interagency Liaison Officer (NILO) when it went nationwide in 2010.841 Station Manager Lawlor was the GMFRS NILO lead and regional lead officer at the time of the Attack. This was a post he had held for around six years.842

Station Manager Lawlor explained that the role of the NILO was intended to be a Tactical Advisor to the Incident Commander.843 In a Marauding Terrorist Firearms Attack incident, the NILO was intended to act as the on‑scene commander at the FCP, on the edge of the Operation Plato warm zone.844 The specialist training given to NILOs was designed to ensure better inter‑agency liaison so as to co‑ordinate a Marauding Terrorist Firearms Attack response.845 A key point of information for the NILO would be the police Tactical Firearms Commander.846

A NILO was also mobilised whenever a Strategic Co‑ordinating Group was convened. In this situation, the NILO provided tactical advice to the GMFRS Gold Commander and maintained a written incident log.847


GMFRS, together with London Fire Brigade, facilitated the NILO course at the Fire Service College.848 It was held five times a year. Station Manager Lawlor was a lecturer and facilitator on the course. In that role, he was focused on multi‑ agency working.849

As the GMFRS NILO lead, Station Manager Lawlor stated that he attended regular security briefings with the police and ambulance service. These provided updates on the current threat level. Station Manager Lawlor stated that all NILOs were aware of the UK’s ‘severe’ threat level. It was known by all NILOs that a terror attack was highly likely.850

GMFRS was well prepared to respond to terrorist attacks, including a Marauding Terrorist Firearms Attack.

Once every three years, all GMFRS NILOs were required to attend a Technical Response Course at the Fire Service College. Similarly, they attended a training course called Saton Force. This was focused on pre‑ and post‑bomb scene management. It was multi‑agency training for organisations in Greater Manchester to ensure a co‑ordinated response to a suspicious package.851

The NILO role was central to GMFRS’s response to a terrorist attack. It was a Tactical Advisor role that should ensure there was swift liaison with other emergency services. GMFRS played an important part in the national development of the NILO role. It adopted it early and embedded it as part of its multi‑agency planning. GMFRS should have been well prepared to ensure an effective, co‑ordinated response with the police and ambulance service to a terror attack in Manchester.

What had not been intended or planned, as the Fire and Rescue Expert explained, was for a NILO to become the “de facto” Incident Commander in the early stages.852 As GMFRS acknowledged, this was a specific gap in the procedures governing its response to terrorist incidents. It meant that there was a risk everyone involved thought someone else was in charge when in reality no one was in charge. This is what eventuated on the night of the Attack.853

Equipment and resources

In May 2017, GMFRS had about 1,400 uniformed employees. Of these, 64 were involved in the emergency response to the Attack.854 In May 2017, there were 41 fire stations with 56 frontline appliances and 44 specialist vehicles.855 Six

of the GMFRS fire stations were within a 4km radius of the Arena, including Manchester Central Fire Station and Philips Park Fire Station.856 The latter was designated as a muster point for GMFRS on the night of the Attack. Figure 34 shows the location of these fire stations relative to the location of the Arena. G16 is the location of Manchester Central Fire Station. G18 is the location of Philips Park Fire Station.

Figure 34: Location of fire stations in Greater Manchester857

A standard GMFRS fire appliance had a long board858 and a trauma bag.859 The trauma bag provided equipment for basic life support.860 It included a defibrillator, airways, masks for use with an oxygen cylinder, dressings and a tourniquet.861 All firefighters were trained to provide basic life support. Some were trained as trauma technicians to provide enhanced first aid.862

Key specialist vehicles available to GMFRS included those operated by the Technical Response Unit and the Specialist Response Team.863 I recognise everyone who works for a fire and rescue service will be specialist in what they do. When I use the term ‘specialist firefighter’ in my Report, I am referring to members of the Technical Response Unit and Specialist Response Team.

The Technical Response Unit was deployed to a variety of incidents, such as road traffic accidents or a building collapse.864 In common with a standard fire appliance, it had one trauma bag. The Technical Response Unit’s significance for an event such as that on 22nd May 2017 was that it had personnel specifically trained to respond to a Marauding Terrorist Firearms Attack.865 They received training for operating in an Operation Plato warm zone.866

The Specialist Response Team vehicle was equipped with trauma equipment for blast and ballistic injuries. This included tourniquets, blast bandages and chest seals.867 Personnel on a Specialist Response Team vehicle had enhanced trauma training provided by NWAS HART.868

Specialist Response Team personnel were trained to work with NWAS HART in an Operation Plato warm zone. The Specialist Response Team were issued with ballistic personal protective equipment. They were trained to treat and remove casualties.869 A Specialist Response Team vehicle had five SKED stretchers.870

A SKED stretcher was designed to permit casualties safely to be dragged away from danger and towards medical help.871

GMFRS had three command support vehicles. They acted as a mobile command base during larger incidents.872 They were not deployed on the night of the Attack.873

GMFRS had a Command Support Room at its headquarters. The purpose of the Command Support Room was to provide support to the Incident Commander and to the Strategic Co‑ordinating Group.874 On the night of the Attack, the Chief Fire Officer and a number of other senior officers, including Assistant Chief Fire Officer Harris and Group Manager Fletcher, went to the Command Support Room.875

Each fire appliance carried up to five handheld radios. These radios were used for communication between firefighters and commanders at an incident.

They did not allow communication with non‑GMFRS emergency responders.876

Each fire appliance had an Airwave radio. This allowed two‑way communication with NWFC. A duty Fire Officer was equipped with an Airwave radio. This allowed that person to communicate with NWFC and other Airwave radios, including those used by GMP, BTP and NWAS.877

GMFRS had all the necessary equipment, personnel and resources to respond to the Attack. In particular, it had specialist equipment and personnel that could be used in an Operation Plato warm zone to assist with the prompt evacuation of casualties.


JESIP training

GMFRS had a legal duty to train its personnel.878 Depending on their rank and role, firefighters were expected to undertake a variety of training to prepare for a Major Incident. This included training on immediate trauma care, trauma technician clinical care and Marauding Terrorist Firearms Attack incidents.879

Assistant Chief Fire Officer Keelan stated that JESIP was “at the heart of all GMFRS training”.880 GMFRS was the lead organisation in Greater Manchester for providing JESIP training to all emergency services. Each GMFRS officer received a pocketbook aide‑memoire with the JESIP principles.881

All GMFRS firefighters and operational commanders must complete JESIP level 1 training. GMP and NWAS jointly developed the training with GMFRS. All GMFRS personnel involved in the response to the Attack had received this training.

Following the Attack, GMFRS has facilitated refresher training for GMP, NWAS and its own staff.882

Generally, GMFRS had an adequate system for training its firefighters in JESIP. However, there was room for improvement. A number of frontline staff did not recall receiving JESIP training or had only undertaken an e‑learning package.883

The Fire and Rescue Expert noted that non‑specialist firefighters had not received the same level of training as their specialist colleagues to respond to an event such as the Attack. This included JESIP training. Despite this, he

considered that they were “adequately trained and equipped” to carry out their role on the night of the Attack.884 Although there was evidence of classroom‑ based practical learning in JESIP, more interactive classroom training would have benefited GMFRS personnel.

Command and other training

Assistant Chief Fire Officer Keelan gave a detailed statement to the Inquiry explaining the extensive training provided to the different levels of GMFRS command at Operational/Bronze, Tactical/Silver and Strategic/Gold level. His statement explained that there were four qualifications of command. Any firefighter, from a Crew Manager upwards, must undertake this training.

All GMFRS officers in a command role on the night of the Attack had received the appropriate command training.885

All levels of GMFRS command were trained in operational discretion. This underpinned the training for all safe operating procedures.886 This policy was introduced in 2014. GMFRS was one of the first fire and rescue services to introduce this.887 Under the policy, operational discretion was available in circumstances in which following normal procedures would be a barrier to resolving an incident, or when there was no suitable procedure in place.888

Assistant Chief Fire Officer Keelan gave examples of operational discretion being used to save human life or to take immediate and decisive action to prevent an incident escalating.889 The operational discretion policy is sensible and pragmatic. At key moments during the night of 22nd May 2017, operational discretion was not used when it should have been to break the inertia which set in to GMFRS’s response. This was recognised by GMFRS personnel who gave evidence.890

GMFRS issued all staff with ‘Ops Alerts’ and ‘Safety Alerts’. Ops Alerts provided general operational information. Safety Alerts were used to circulate safety‑critical information. Alerts were printed at each fire station. It was the responsibility of each Firefighter to confirm they had read the alerts.891 These alerts were also issued to ensure awareness after Major Incidents and when the national threat level was changed.892 Five Safety Alerts were circulated in the 12 months before the Attack.893 This is a good way of disseminating important information to all operational GMFRS personnel.

Marauding Terrorist Firearms Attack training

Station Manager Gaskell was the GMFRS lead for Marauding Terrorist Firearms Attack training. This was a position he had held since 2011. The GMFRS Marauding Terrorist Firearms Attack capability went live in late 2011.894

A chronology provided by Station Manager Gaskell set out the development of this capability prior to May 2017.895

Station Manager Gaskell described the preparation for the GMFRS Marauding Terrorist Firearms Attack capability as a “very lengthy and intensive programme”.896 It involved establishing a training programme and procuring equipment and vehicles. NWAS played an important role, for example in developing trauma training, and obtaining SKED stretchers and dressings.897 By January 2016, GMFRS was assessed to have established a Marauding Terrorist Firearms Attack capability in all areas.898

A three‑day initial Marauding Terrorist Firearms Attack training course was delivered for firefighters by GMFRS in December 2016 and January 2017. As a result, all Technical Response Unit personnel, who also had to attend a ten‑week modular course, and all the GMFRS NILO cadre were qualified to attend a Marauding Terrorist Firearms Attack incident.899

Station Manager Gaskell ran various multi‑agency courses to establish the Marauding Terrorist Firearms Attack capability across Greater Manchester.900 This included a Marauding Terrorist Firearms Attack enhanced trauma training course, Marauding Terrorist Firearms Attack commander awareness training, Marauding Terrorist Firearms Attack refresher training and Marauding Terrorist Firearms Attack firefighting training.901 All the GMFRS officers on duty on 22nd May 2017 had received training on JOPs 3. All the command officers had also attended multi‑agency tabletop and live exercises.902

Watch Manager Jonathan Nolan was a member of the Specialist Response Team on the night of the Attack. He gave evidence that, at the time, he considered his training was “reasonably sufficient” to respond to a Marauding Terrorist Firearms Attack.903 He stated it was too formalised and “didn’t deal with the potential chaos that may ensue”.904 The training reflected an incident that was stabilised with all the emergency services present. Watch Manager Nolan stated that more training focused on the start of an incident would have been beneficial.905 He did not consider that the training was too risk averse.906

GMFRS succeeded in establishing a Marauding Terrorist Firearms Attack capability, maintaining regular Marauding Terrorist Firearms Attack training for its personnel, and working with GMP and NWAS to deliver multi‑agency training.

However, GMFRS, in common with other agencies, was not ready for the chaos which there will inevitably be at the start of an incident such as occurred on 22nd May 2017. Further, NWFC was not included sufficiently, or sometimes at all, in aspects of this Marauding Terrorist Firearms Attack training. In particular, it did not participate in the multi‑agency training.907 This was a significant failure, for which GMFRS, alongside NWFC, must bear responsibility. It had a substantial impact on the fire and rescue service response on 22nd May 2017.


GMFRS had a well‑established team involved in planning for a response to a terror attack. It grew from a national programme that GMFRS participated in called ‘New Dimensions’.908 This was established after the 9/11 terrorist attacks in the United States. Its purpose was to support a fire and rescue service response to terror threats and natural disasters.909 Group Manager Fletcher and Station Manager Lawlor were both seconded to the New Dimensions team. It became part of the Contingency Planning Unit within the Emergency Response Department at GMFRS.910 New Dimensions is now known as ‘National Resilience’.911

The Contingency Planning Unit prepared Standard Operating Procedures (SOPs). It planned and organised exercises, including with other emergency service partners.912 In describing the importance of the unit, Station Manager Lawlor stated: “In my time in GMFRS we have gone from minimal activity to substantial multi-agency engagement with particular success in planning.”913

GMFRS had a number of SOPs to ensure a co‑ordinated response to Major Incidents, including a Marauding Terrorist Firearms Attack. There were four guidance documents: ‘MTFA Mobilisation: Emergency Response’,914 a ‘Firearms’ guidance document,915 ‘Major Incident: Emergency Response’916 and an ‘Emergency Response and Recovery’ guidance document.917 GMFRS had a number of plans that would have helped it to play a resilient and effective role in a co‑ordinated multi‑agency response to a Major Incident, such as the Attack.

GMFRS used an operational intelligence system. This provided key information on a location in the event of a fire. GMFRS had an operational intelligence record and risk assessment for the Arena, dated 14th December 2012.918

It identified the location of hydrants and other important information to help with firefighting. The operational intelligence record was not prepared with any other type of emergency response in mind. The details of an evacuation strategy would be for each site to implement.919

I have already commented in relation to BTP, GMP and NWAS on the importance of site‑specific plans, prepared or endorsed at local resilience forum level. The conclusions apply equally to GMFRS. A multi‑agency site‑specific plan for the Victoria Exchange Complex should have been prepared and used on the night of the Attack.

Action plans

The action plans used by NWFC for the Greater Manchester area were owned by GMFRS. It was GMFRS’s responsibility to ensure they were accurate. As I have already explained, the difference in views between GMFRS and NWFC over which action plans might apply and how to interpret them was unsatisfactory.

The deficiencies in the action plans revealed a failure by GMFRS to work with NWFC to plan and train on mobilising resources to a Major Incident. It was the responsibility of GMFRS to devise clear action plans and ensure that they were understood by NWFC. As it accepted, GMFRS failed to do this.920


GMFRS participated in and organised a large number of exercises. This included lectures and both tabletop and live exercises.921 Generally, the evidence showed that GMFRS took a rigorous approach to its responsibilities to exercise, but it failed to include NWFC sufficiently, or sometimes at all, in exercises.

I will consider GMFRS’s involvement in multi‑agency exercising and, in particular, Exercise Winchester Accord at the end of this Part.


GMFRS was well prepared to meet the challenges posed by a terrorist attack in Greater Manchester. It worked hard in the years before the Attack to develop its Marauding Terrorist Firearms Attack capabilities, to train its personnel in JESIP and to work with emergency service partners. Although there were some problems with its training, it had the necessary equipment and specialist resources to respond to a Marauding Terrorist Firearms Attack. There were, however, failings in it its preparation, in particular how it worked with NWFC and the action plans it created for it to mobilise fire resources to an Operation Plato incident. It also failed adequately to consider the role of the NILO at the beginning of an incident and what should happen if a NILO were effectively in charge.