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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)

North West Fire Control preparedness

Key findings

  • North West Fire Control’s (NWFC’s) training lacked a sufficient practical, real‑life component.
  • The Joint Emergency Services Interoperability Principles (JESIP) training was not embedded sufficiently within NWFC staff. This meant that, on the night of the Attack, NWFC staff failed in their core JESIP responsibility to share situational awareness.
  • NWFC was not sufficiently involved in multi‑agency exercising. This was a significant failure to ensure NWFC gained practical experience.
  • NWFC did not have sufficient, or sufficiently clear, written plans and action cards to respond to a Major Incident.
  • With better preparation, the failures in NWFC’s response which occurred on the night of the Attack would have been reduced or eliminated.

Establishment of NWFC

In 2004, the government launched a project to create nine regional control centres. These were to replace the 46 fire and rescue service control rooms operating at that time around the country.648 The national project was terminated in 2010,649 but some regional control centres were still set up. NWFC was one of them.650

NWFC was established in July 2007.651 It began operating on 14th May 2014.652 It was a local authority owned company.653 It was jointly owned by Cheshire Fire Authority, Cumbria County Council, Greater Manchester Combined Authority and Lancashire Combined Fire Authority.654 Each local authority was a shareholder. Merseyside Fire and Rescue Service withdrew from the project before it went live.655

NWFC had an Agreement for Services with each local authority.656 The Agreement for Services set out the detail of the services it provided and how it delivered them. The Agreement for Services with GMFRS was dated 28th May 2014.657 Under the terms of the Agreement for Services, NWFC was required to mobilise resources in accordance with the mobilising policy and procedures supplied to it by GMFRS.658 NWFC did not provide a command function.659

The core purpose of NWFC was to handle all fire and rescue 999 emergency calls and to be responsible for mobilising firefighters and fire appliances to incidents in Cumbria, Lancashire, Greater Manchester and Cheshire.

Structure of NWFC


NWFC had Articles of Association that governed its structure. It had a board of directors, two from each of its shareholders. The board set the strategic direction of NWFC and managed its financial resources.660 The Head of NWFC, Sarah‑Jane Wilson, was appointed in October 2016.661 She held responsibility for “NWFC meeting its objectives and service standards”, including management of people, financial resources and contracts.662 As Head of NWFC, she reported directly to the board.663

There was no head of NWFC between 2014, when it began to operate, and Sarah‑Jane Wilson’s appointment in 2016.664 She accepted that the lack of a head of the organisation for such a long period adversely affected the business of NWFC.665

Sarah‑Jane Wilson indicated that governance issues arose from the focus on transitioning to a joint control room. At the time of the Attack, the strategic direction of NWFC was dictated by a ten‑year business case. This set out the basis for continuing with the transition in spite of the withdrawal of government support for the project.666 Sarah‑Jane Wilson said that opportunities to put in place a robust governance structure were missed.667

The governance problems meant that there was less focus on practical training and exercising by NWFC staff than there ought to have been, particularly joint training with fire and rescue services.668 This is a point to which I will return in paragraphs 12.534 to 12.554.

Operational roles

Sarah‑Jane Wilson’s role as Head of NWFC was not operational.669 Tessa Tracey was the Senior Operations Manager. She had responsibility for overseeing the Operations Managers, who in turn managed the Team Leaders. The Control Room Operators were managed by the Team Leaders.670

NWFC provided cover for a population in the North West of England of approximately 5.5 million people.671 In the course of the six months between January and June 2017, it handled 60,123 emergency calls.672 Shift patterns were organised based on anticipated peak and low demand.673 Demand was usually at its lowest after 22:00.674

When it was set up, NWFC managed its work through a regional operational group. This was known as the “Ops Group”.675 It met every six weeks with operational representatives from each of the four fire and rescue services it served. NWFC also appointed a Single Point of Contact to work with each fire and rescue service.676 The NWFC Single Point of Contact for GMFRS was Janine Carden, an Operations Manager.677 Her counterpart at GMFRS was Group Manager Levy.678 They had what was described as an “extremely good, professional relationship”.679


NWFC operated from a purpose‑built facility in Warrington.680 The layout of the NWFC control room, as it was on the night of the Attack, is shown in Figure 33.

Figure 33: NWFC control room, with Team Leader and Operations Manager placement highlighted681

The NWFC control room was separated into four desk areas. These were referred to as pods and were organised by the fire and rescue services. The pod to the top of the image was for Lancashire and the pod to the right was for Manchester. The pod at the bottom of the image was shared between Cheshire and Cumbria.682 The Team Leaders and Operations Manager would sit at the pod to the left‑hand side.683

Michelle Gregson, a Team Leader, said that she introduced the pod system as there was previously no order to the way things were being done.684 Each Control Room Operator was allocated to a pod. Each pod was responsible for ensuring everything was operating correctly in its area and acted as a point of contact for its fire and rescue service.685 The Control Room Operators answered emergency calls from any area, irrespective of the pod where they were working.686 The Control Room Operator who answered an emergency call would respond to the immediate request and send the resources required. Having completed the initial ‘mobilisation’ of resources, the call would then be passed to the relevant geographical pod, which would continue to manage the incident.687

I accept that this is a logical way of working, but it is dependent on operational planning, rigorous training and exercising. There was a written plan for how the pod system would work in high‑intensity situations, known as “spate condition”.688 This was for pre‑planned events such as Bonfire Night.689 There was no plan for a no‑notice significant event.690 The failure to have a written plan for a no‑notice incident was an oversight on the part of NWFC.

Responding to an incident

A member of the public dialling 999 who requested the fire and rescue service would have been transferred to NWFC by a BT emergency operator. Other emergency services and organisations could also contact NWFC. They used a dedicated emergency telephone number.691

I was told that NWFC used a “state of the art” computer‑aided dispatch system. This was designed to handle emergency calls and mobilise fire and rescue resources.692 Michelle Gregson, who was a Team Leader on the night of the Attack, stated that the technology was better than any she had worked with previously.693 She also noted there were significant challenges in translating the system to common ways of working across four fire and rescue services. An example of this was that commonly used acronyms had different meanings in different fire and rescue services.694

An automatic call distribution system allocated a call to a Control Room Operator. This required Control Room Operators to indicate when they were ready to answer an emergency call. The Control Room Operator who had been waiting the longest received the next call.695 Emergency calls appeared on a touchscreen.696 The Control Room Operator must answer the emergency call within five seconds.697 An emergency call had a high tone. It appeared as red or amber on the computer‑aided dispatch system.698

The computer‑aided dispatch system automatically generated a “New Incident Form” when an emergency call was answered.699 The Control Room Operator inputted into the form the location, the nature of the incident and any other useful detail. This in turn created an incident log. Any decisions or actions made by NWFC staff were recorded on the incident log. This process was the same for any incident, and multiple logs were created for larger incidents.700

Four incident logs were generated as a result of the Attack. I heard that it was common practice for there to be more than one incident log for large incidents,701 but I consider having this many should have been unnecessary. It caused confusion in NWFC’s mobilisation of the GMFRS response. It led to a failure to capture crucial information in one place. This in turn increased the risk of critical information not being communicated to others.702 The Fire and Rescue Expert concluded, and I agree, that having a single source of information would have improved situational awareness within the control room.703

On the computer‑aided dispatch system, a Control Room Operator allocated an incident type and a priority. A priority of ‘1’ was the most serious with a significant risk to life or property.704 Certain locations and types of incident would have a pre‑determined attendance that sets the level of resources sent.

Once resources were mobilised, Control Room Operators must follow an action plan. These were provided by the fire and rescue services and listed any additional actions that the Control Room Operator must take following the initial mobilisation.705 Michelle Gregson explained that NWFC could not use discretion in its application of GMFRS action plans706 and that there was a lack of training about how to apply them.707 I shall return to the issue of action plans when I consider NWFC’s written plans at paragraphs 12.563 to 12.592.

Once an emergency call was on the system, the computer‑aided dispatch system allocated a radio talk group to the incident. All attending fire appliances must switch to the dedicated talk group. NWFC was able to transmit group messages, and all fire resources attending could communicate directly with each other. NWFC did not constantly monitor these talk groups.708

Sarah‑Jane Wilson conceded that there was not adequate use of the multi‑agency radio channels by May 2017. She was not aware of many, if any, incidents where they had been used to communicate between control rooms.709 Failing to ensure adequate communication between the emergency services was a critical shortcoming in the response by all the emergency services.

Failures in preparedness

The context for the establishment of NWFC and how it was set up, governed and operated is important for understanding its preparedness, or in places the lack of it, for an incident such as the Attack.

Despite the detailed and careful work to establish it, when I heard evidence from the Head of NWFC, she began by saying that NWFC was responsible for “significant failures in the management of information” on the night of 22nd May 2017.710 She was right to say this.

The response of NWFC fell below what was required. NWFC failed to capture and communicate proper situational awareness. This contributed to the serious and unacceptable delays in the deployment of GMFRS resources to the scene of the Attack.

The remainder of this section of the Report will analyse why this happened by looking at the preparedness for a Major Incident of NWFC prior to 22nd May 2017. In common with other emergency services, I will consider a number of areas of preparedness. I will look at the adequacy of the training of NWFC staff. I will then turn to consider NWFC’s role in exercises. Finally, I will examine the written plans and protocols that NWFC had in place for an event of the type which occurred at the Arena.

NWFC staff training

Training generally

NWFC training was competency based and divided into four phases and pathways.711 It covered an introductory, four‑week course for new entrants. There was further training to develop competent Control Room Operators, Team Leaders and Operations Managers.

Generally speaking, the NWFC training was conducted to a reasonable and acceptable standard. Sarah‑Jane Wilson, however, accepted that NWFC overlooked the practical application of training.712 I agree with her.

One of the Control Room Operators on the night of the Attack, Dean Casey, explained that to pass his Phase 1 training as a Control Room Operator he had four weeks of classroom‑based learning. He said that to be confident in his role he needed more real‑life training. He said that his training would have been better if there had been practical exercises in the control room.713

I was told that, after completing the four weeks of classroom‑based training, a Control Room Operator was shadowed by a competent member of staff for two weeks. Their calls were monitored, and they would be talked through what to do. After those two weeks, a Control Room Operator was permitted to take calls on their own. Some calls would still be monitored, but they were deemed competent to deal with emergency calls from that point.714

JESIP training

From 2015, Senior Operations Manager Tessa Tracey was the JESIP lead for NWFC. As part of that role, with two colleagues, she attended a national training course on JESIP at the College of Policing. She then worked with colleagues in the ambulance and police services to deliver regular tri‑service training in JESIP.715

Tessa Tracey stated: “In the light of the training, I personally felt that I had a good understanding of the ways of working and felt confident and prepared should we receive a terrorist incident within our region.”716 She conceded, however, that “JESIP on the night did not achieve what we were expecting it to achieve in lines of communication there had been practical exercises in”.717

Other NWFC witnesses echoed this failure in the application of their JESIP training.718

Michelle Gregson stated that she was confident in her JESIP training and knowledge. She did not, though, feel confident in applying it in practice.719 The training was integrated into a PowerPoint presentation about responding to a Marauding Terrorist Firearms Attack. It looked at the reasons for the inception of JESIP and the principles.720

Shortly after notification of the Attack at 22:38, Michelle Gregson issued a reminder to her team to use their “JESIP training and multi-agency working”.721 This was a sensible step to take. She reminded those in the control room that they needed to communicate any relevant information received.722 Despite this, she recognised when giving evidence that there was an absence of sharing critical information in helping to manage the emergency response.723 Information‑sharing is a key part of JESIP.

Lisa Owen, who was also a Team Leader on the night of 22nd May 2017, stated that she had only had the PowerPoint presentation on JESIP. She did not attend an external multi‑agency training course. She felt that would have given her a different insight. She accepted that a multi‑agency response was possibly not her mind‑set.724

In evidence, the Control Room Operators on duty on the night of the Attack generally stated that they understood JESIP but that they would have welcomed more training.725 David Ellis felt he needed real‑life exercising, particularly on mobilisation. He explained that would “help manage the room” and “pre-empt a what-if situation”.726 The training has since been improved and takes a more in‑depth approach.727

Sarah‑Jane Wilson accepted that NWFC had “viewed JESIP as a process and not necessarily a dynamic way of thinking”.728 That was an appropriate concession to make. Staff were not adequately trained to seek information proactively from other control rooms. I have heard that changes implemented post‑Attack have been designed to make the control room more proactive in its response to an incident.729

Sarah‑Jane Wilson acknowledged that there were substantial problems with JESIP on the night of the Attack.730 She was asked about the JESIP assurance visit in August 2017. This identified that individuals across all grades had not completed the JESIP e‑learning or had an input since 2015.731 This was an unsatisfactory state of affairs.

Operation Plato training

Station Manager Gaskell was the Marauding Terrorist Firearms Attack lead for GMFRS. He had held this position since February 2011.732 Part of this role required Station Manager Gaskell to develop and deliver training to NWFC. In his evidence, Station Manager Gaskell spoke about a PowerPoint presentation on Marauding Terrorist Firearms Attack incidents he gave to NWFC staff.733

The training emphasised that, in a terrorist incident, the police were the lead agency. In a Marauding Terrorist Firearms Attack situation, NWFC staff were trained first to contact the duty National Interagency Liaison Officer (NILO). This was to gather any further information before mobilising fire resources.734

Janine Carden was NWFC’s designated Single Point of Contact with GMFRS. She received Marauding Terrorist Firearms Attack training from Station Manager Gaskell and training about the role of a NILO from Station Manager Michael Lawlor.735 NWFC Team Leaders and Operations Managers were also present at Marauding Terrorist Firearms Attack training events.736 Station Manager Gaskell stated when giving evidence that Janine Carden and other NWFC staff were invited to GMFRS training events because they were relevant to the actions of NWFC.737 Janine Carden stated that the training was, in the event of a suspected Marauding Terrorist Firearms Attack, to always “tell a NILO”. She said that felt contrary to ordinary instinct within a control room, which was “if in doubt, turn out”.738

The training was clear that, if a Marauding Terrorist Firearms Attack were suspected, NWFC should not mobilise immediately and should instead speak to the NILO. Janine Carden could not recall if written guidance to this effect was issued.739 The PowerPoint presentation used by Station Manager Gaskell stated, “Should any contact be made to the FRS [fire and rescue service] for assistance or become aware of an incident involving firearms, then the on-call NILO must be contacted.740 Janine Carden confirmed that Station Manager Gaskell left his training package with NWFC so that it could be disseminated to its staff.741

Not all NWFC personnel knew that the NWAS HART and the GMFRS Specialist Response Team trained and exercised together. Team Leaders Michelle Gregson and Lisa Owen each stated they were not aware of this.742 Janine Carden stated that the Marauding Terrorist Firearms Attack training covered who could go into what Operation Plato zone. She knew about HART and the Specialist Response Team working together, and she thought others would be aware.743 The fact that this does not seem to have been widely known within NWFC is an example of a lack of cohesion in the multi‑agency delivery of the Marauding Terrorist Firearms Attack training. Lisa Owen said that, if she had known this, the importance of speaking to NWAS on the night of 22nd May 2017 would have been clearer to her.744

In 2016, Janine Carden participated in an audit of GMFRS Marauding Terrorist Firearms Attack policies.745 The audit was conducted principally by the National Fire Chiefs Council and the Chief Fire and Rescue Adviser. Station Manager Gaskell also participated. He was told that the purpose was “to look at the processes in place, the action cards in place and to ensure that they [NWFC] had the adequate training to respond to an attack of this nature”.746 As part of the audit, the GMFRS action plans for an Operation Plato incident were inspected. Janine Carden was questioned about her knowledge of Operation Plato and Marauding Terrorist Firearms Attack incidents.747 The audit findings commended Janine Carden for her knowledge of GMFRS’s mobilising procedures and wider Marauding Terrorist Firearms Attack incident implications.748

This shows that there was, generally, a good system of theory‑based training in place for responding to a Marauding Terrorist Firearms Attack incident. A senior NWFC staff member had a good working knowledge of what was expected of them by GMFRS should a Marauding Terrorist Firearms Attack‑type incident occur.

I agree with the view of the Fire and Rescue Expert that NWFC staff were adequately trained to respond to a terrorist attack such as the one that occurred at the Arena on 22nd May 2017.749 What was lacking was exposure to testing that knowledge in real‑life exercises. This is something that many NWFC witnesses repeated.750 Sarah‑Jane Wilson explained that she did not consider asking fire and rescue services to invite NWFC to participate in live training and exercising. She accepted that was a failing.751 As Michelle Gregson put it: “I felt confident with my training and knowledge. What I didn’t feel confident in is perhaps applying that practically because we never had the chance to do that in a simulated situation.”752

Training deficiencies and failures on the night of the Attack

The events on 22nd May 2017 exposed the problems that arose from NWFC not participating in real‑life, practical training. This contributed to a failure to understand the importance of sharing critical information about the nature of an incident.

The duty NILO was not informed of critical information. This information included that, at 22:44, GMP had an officer at the scene and, at 22:46, there were more GMP officers on the way.753 Nor was the NILO informed of GMP Control’s report to NWFC at 22:54 that the “paramedic Bronze has just arrived on scene”.754 There was a failure to understand the importance of the NILO saying he could not reach the FDO. There was a failure to understand the use of the multi‑agency talk group.755

Better training, which includes exercising, would have given NWFC staff more confidence in dealing with a difficult and complex situation. It would have allowed them to maximise the opportunities to share situational awareness.

In the event, NWFC staff were less proactive than they should have been. They did not interrogate the information they received, they did not seek information proactively and they failed to share information. These failings had consequences.

Incident types and action plans

NWFC did not provide a command function. It was required to respond to emergency calls by following action plans for pre‑determined incidents. Some witnesses referred to these as “action cards”.756 The action plans determined how NWFC would respond to any given incident through mobilising pumps, equipment and personnel.757 Some of the action plans required that NWFC obtained advice or guidance from a GMFRS NILO before mobilising to a scene.758

Action plans were provided to NWFC by the fire and rescue services. They set out the pre‑determined mobilisation response which NWFC was required to follow under the Agreement for Services with each fire and rescue service. GMFRS was responsible for devising and providing these mobilisation instructions to NWFC for Greater Manchester.759

Action plans were linked to incident types. A Control Room Operator could search for action plans or incident types. Once a relevant action plan had been identified, it was added to the log.760 The Control Room Operator had to confirm any mobilisation prompt before a notification was sent to the relevant fire stations for a crew to deploy.761

The action plans were accessed on the computer‑aided dispatch system through a drop‑down menu. Originally, they were physical cards in the control room: the Control Room Operator would flip through to get to the correct one. Over time, the action plans were converted to Word documents and the content uploaded onto NWFC’s system. This meant that the Word document became redundant for NWFC and could not be accessed by the Control Room Operator. However, GMFRS kept the Word version on which updates were marked..762

‘Explosion’ and ‘Bomb-general’ action plans.

There were two types of action plan which were considered in detail during the evidence. The ‘Explosion’ action plan was attached to an incident type of the same name. It was to be used for responding to a suspected explosion. Following the steps on this action plan meant deploying the Technical Response Unit, a number of fire appliances, a Station Manager and the duty NILO directly to the scene of the incident.

In the Word version of the ‘Explosion’ action plan, under the heading “Triggers”, it stated: “Cause of explosion could trigger different ITAPs [Incident Type Action Plans] – Gas, Bomb, Cylinders, Chemicals, Impact.763 There was no Incident Type Action Plan specific to an explosion caused by a bomb.764 This was a failure by GMFRS given that the Word version of the ‘Explosion’ action plan anticipated that there would be one.

The ‘Bomb‑general’ action plan was attached to an incident type of the same name. It was intended for use where an unexploded bomb had been identified.765 An example was given of unexploded ordnance from the Second World War.766 This action plan required NWFC first to seek guidance from the duty NILO on the actions to be carried out, before any mobilisation of resources.767 This was to ensure the scene was safe of secondary devices and other hazards before personnel were deployed.768

The Fire and Rescue Service Expert stated that the action plans had the potential to confuse.769 I agree.

NWFC witnesses stated that they were uncertain about when each plan applied.770 Michelle Gregson stated that the information on the night of the Attack was “vast” and “vague”.771 She said that she did not know which plan fitted but concluded that she needed to contact the duty NILO. She regarded the duty NILO as the expert who could help with decision‑making.772 She stated that there was a reliance on and expectation that Control Room Operators had been trained in the detail of the action plan and would remember it.773

Joanne Haslam explained that she had no training on the use of the ‘Bomb‑general’ action plan.774

Sarah‑Jane Wilson stated that, at the time of the Attack, her understanding was that the ‘Bomb‑general’ action plan related to any type of bomb incident; whereas she thought that the ‘Explosion’ action plan was for a non‑malicious explosion.775 Another witness gave the example of a domestic gas explosion.776

GMFRS Group Manager Fletcher accepted that an exploded bomb, with the risk of secondary devices, was a situation in which “you’d be caught between the two action plans”.777 Station Manager Gaskell acknowledged that there was the possibility for confusion.778 However, he said he did not have any feedback from NWFC that the ‘Bomb‑general’ action plan was confusing.779

At the start of the oral evidence hearings, it was accepted on GMFRS’s behalf that the ‘Explosion’ action plan should have been clearer.780 I agree. There was clearly considerable room for doubt over which action plan applied and the appropriate steps to take.

The ‘Bomb‑general’ and ‘Explosion’ action plans were not clear enough. They did not make clear the incident type to which they each applied. There was a risk that a Control Room Operator who was told that a bomb had caused an explosion or that a bomb had gone off, would use the ‘Bomb‑general’ action plan, rather than the ‘Explosion’ action plan. Responsibility for this issue lies with GMFRS, which owned the action plans.

Since the Attack, GMFRS has introduced revised action plans. Specifically, the ‘Bomb’ action plan now includes a direction that the ‘Explosion’ action plan must be used if the device has detonated.781 The pre‑determined attendance for an unexploded bomb is to send firefighters and assets to the incident ground, not to inform the duty NILO and obtain an RVP.782 If faced with an incident type involving a bomb which has exploded, NWFC are now required to mobilise firefighters and resources to the scene. The requirement for NWFC to obtain instructions from the duty NILO before mobilising has been removed.783

Operation Plato action plans

NWFC had three action plans for responding to an Operation Plato incident.784

The first of these, ‘Operation Plato (Standby)’, was used to ensure resources were put into a state of readiness. Station Manager Gaskell referred to it as a “heads up” to get resources standing by for the implementation phase.785 The first prompt under this action plan was to contact the duty NILO.786

The Word version of the ‘Operation Plato (Standby)’ action plan had text before the prompts which stated: “NWFC Actions upon receiving information from Fire Crews, GMP, NWAS that a firearms incident is on-going.”787

When asked about the ‘Operation Plato (Standby)’ action plan, Michelle Gregson stated she thought Operation Plato was limited. She thought that there had to be a reported firearms incident before the plan could be followed and that Operation Plato had to be called by the police. She went on to say that she could have done with some more training around it.788

Station Manager Gaskell said that the training focused on JOPs 3. He stated that the key was the attack methodology, namely whether or not it was a deliberate terrorist act. According to Station Manager Gaskell, gunshot wounds or shrapnel in isolation would not be sufficient to use the Operation Plato action plans.789

Sarah‑Jane Wilson stated that the Marauding Terrorist Firearms Attack training was designed to help Control Room Operators and Team Leaders recognise an unfolding terrorist incident as opposed to a “normal explosion incident type”.790

GMFRS’s training in relation to the use of the ‘Operation Plato (Standby)’ action plan did not align precisely with the text in the Word version. There was greater focus in the training on identifying whether or not they were dealing with a terrorist attack than on whether it was a firearms incident. I am not critical of this training, as it better reflected JOPs 3. However, it did give rise to a tension with the ‘Explosion’ action plan, which I will address at paragraphs 12.590 to 12.598.

The second of the Plato action plans, ‘Operation Plato (Implementation)’, required NWFC to inform the duty NILO and take advice. The Word version of this action plan prefaced the prompts with: “NWFC Actions when informed that a firearms incident is on-going and that the Implementation Phase should be applied.” 791

Both Word versions were marked as last updated in December 2015 by Group Manager Levy and Janine Carden, following a meeting with Group Manager Fletcher.792

The third action plan, ‘Operation Plato (Stand down)’, was to be used once the whole scene was a cold zone, and there was no longer a perceived threat.793

Tension between two action plans

The crucial first step of the ‘Operation Plato (Standby)’ action plan was to contact the duty NILO before any mobilisation. This was different from the ‘Explosion’ action plan which involved deploying firefighters straight to the scene immediately.

Information coming into NWFC at an early stage may be incomplete, inaccurate or may exaggerate the true state of affairs. An example of this occurred at 22:43 on 22nd May 2017 when David Ellis was informed by GMP Control that a “police officer just said injured party with gunshot wound to the leg outside the entrance to Victoria Station”.794 This information, no doubt given in good faith, was wrong.

At the heart of the challenge for the staff at NWFC was that an explosion may be a single, isolated incident or it may be the start of a Marauding Terrorist Firearms Attack. According to JOPs 3: “A marauding terrorist firearms attack (MTFA) may involve: … The use of explosives.” 795

Station Manager Gaskell stated that it would be “unusual” for NWFC to have information that an explosion was caused by a bomb.796 The timing of the notification that a bomb was involved appeared to be Station Manager Gaskell’s explanation for why he did not think the two action plans were in tension.797

Station Manager Gaskell stated that he gave periodic training to NWFC staff on Marauding Terrorist Firearms Attack procedures. It included updates on JOPs and mobilisation procedures. Station Manager Gaskell delivered training to NWFC in October 2014 and November 2015. He believed that the training was “well received and well attended”.798 A PowerPoint presentation entitled ‘Marauding Terrorist Firearms Attack (MTFA)’ was used.799 It focused on firearms attack methodology. It advised that, if fire and rescue assistance were needed, the duty NILO must be contacted first.800

At 22:35 on the night of the Attack, prior to a mobilisation decision, NWFC was informed by GMP Control that “a bomb has exploded”.801 The information was that the bomb had exploded at an iconic venue, the Arena. This created the very real possibility that a terrorist attack had occurred. Under JOPs 3, it may have signified that a Marauding Terrorist Firearms Attack was under way. As I said in Part 10, I am not critical of GMP for declaring Operation Plato on the basis of an exploded bomb.

On the information it was presented with on 22nd May 2017, NWFC could have followed either the ‘Explosion’ action plan or the ‘Operation Plato (Standby)’ action plan. Given that NWFC was required by the Agreement for Services to follow GMFRS’s mobilisation plan, it is highly unsatisfactory that there were two potentially applicable action plans which required different initial steps.

One final aspect of this issue is that GMFRS had created guidance on Marauding Terrorist Firearms Attacks entitled ‘MTFA – Mobilisation Emergency Response’. Version 1 is dated February 2017 and authored by Group Manager Fletcher.802 Station Manager Gaskell stated it contained “cast iron mobilisation instructions for NWFC to follow”.803 If a Marauding Terrorist Firearms Attack were suspected, the guidance directed NWFC to obtain as much information as possible and to inform the duty NILO as a priority.804

None of these documents made reference to the possibility of an explosion being related to a Marauding Terrorist Firearms Attack, nor did they encourage the same application of operational discretion by NWFC staff as permitted to GMFRS officers.805

Major Incident Plan

On 22nd May 2017, NWFC did not have a Major Incident Plan. This was a weakness in NWFC’s preparedness to respond to a terrorist attack or other large incident. As a result of the communication failures on 22nd May 2017, NWFC has now developed a Major Incident Plan.806

Sarah‑Jane Wilson explained that the purpose of this plan, at its core, is to provide Team Leaders with a prompt “to actively seek out and share information”.807 It directs the co‑ordination of communications between the emergency services by providing contact information to NILOs, and monitoring inter‑agency communications and fire service involvement at all operational command levels.808

NWFC’s involvement in exercises

NWFC did not participate in any joint‑agency Marauding Terrorist Firearms Attack, JESIP or Operation Plato exercises.809 There was broad agreement from NWFC witnesses that this should not have occurred. One witness described it as “extraordinary” that NWFC was not involved.810 I agree.

Despite incidents usually starting with a telephone call to a control room, NWFC was “overlooked”.811

In his evidence, Group Manager Fletcher accepted that, prior to the Attack, the ability of the NWFC control room to respond to a Marauding Terrorist Firearms Attack had not been tested. The training which had been conducted by multi‑agency partners only ever covered what was to happen from the point of mobilisation onwards.812

Station Manager Gaskell suggested that NWFC was not involved in exercises because it was under‑staffed. It could not, he stated in evidence, carry on business as usual and participate in live exercises.813 Janine Carden disputed Station Manager Gaskell’s assertion. She said that NWFC would always want to be involved in exercises and she was passionate about it.814

Attending live exercises would have allowed NWFC staff a chance to practise in circumstances that mirrored real life. This would have increased their awareness of potential problems. It would also have involved NWFC in debriefs where issues were discussed. Michelle Gregson stated that participating in a multi‑agency exercise would have enabled her to act differently on the night of the Attack: it would have given her the foresight to ask questions, understand communication difficulties and probe issues more.815 Joanne Haslam, who was a Control Room Operator on the night of the Attack, stated that being involved in such an exercise would have been beneficial and a great advantage: it would have kept actions and information up to date.816

I agree with Michelle Gregson and Joanne Haslam. NWFC should have been involved in multi‑agency exercises. Had NWFC been involved in such exercises, it would have allowed for mobilisation to be tested in a multi‑agency context. In turn, this is likely to have led to the identification and elimination of the problems that occurred on the night of the Attack.


NWFC prepared its staff before 22nd May 2017 to meet some of the challenges posed by a terrorist attack. In particular, it had a good training structure to develop staff for working in a control room, and it had modern ways of working with access to good IT systems.

However, NWFC failed to prepare its staff adequately for the real‑world challenges posed by a Marauding Terrorist Firearms Attack or a terrorist attack on the scale of what occurred on 22nd May 2017. It did not participate in multi‑agency exercises. As a result, the importance of joint working, information‑sharing, a knowledge of how the fire and ambulance services worked together, and an understanding of JESIP were not part of the muscle memory of NWFC staff.

This preparedness was further hindered by a lack of clarity in crucial action plans for responding to a terrorist attack involving a bomb. This was not solely the responsibility of NWFC. NWFC personnel had a general understanding of how to respond to different types of Major Incident. They were not sufficiently trained to be dynamic in managing a complex emergency response, particularly in gathering and sharing information.