Greater Manchester Fire and Rescue Service response

Introduction

In Part 12, I concluded that GMFRS was well prepared for a Marauding Terrorist Firearms Attack or other terrorist attack. Despite this, GMFRS officers did not attend the Victoria Exchange Complex until two hours and six minutes after the explosion. There are a number of causes of this unacceptable delay.

As I set out in the section addressing NWFC’s response, at paragraphs 15.206 to 15.211, NWFC’s communication with GMFRS and other emergency services was inadequate. There were also inadequacies in the way that the other emergency services communicated with NWFC. This adversely impacted on NWFC’s ability to play its part. The difficulty contacting the FDO was also very significant at an early stage in the incident.

In addition, there were occasions of inadequate communication between GMFRS officers, assumptions made by some of them on insufficient information, and instances of critical challenge failing to take place and poor decision‑making by some.

There was also a structural issue, which GMFRS had failed to foresee. It operated a system in which the Incident Commander only took up the command role on arrival at the scene. In a situation where no one goes to the scene, there is then no GMFRS Incident Commander. The lack of a single person in charge of the incident made a major contribution to the delay.

In its closing statement, GMFRS stated:
“No one can doubt that GMFRS firefighters, including officers and commanders, take real risks on a day to day basis, putting themselves and those they command into dangerous situations to rescue others. They do so willingly without complaint. It cannot fairly be said that there is a general aversion to risk within GMFRS. It is clear, however, that the GMFRS response on the night of 22 May 2017 could fairly be described as risk averse.”²⁸⁶

The topic of risk aversion is one to which I will return at the conclusion of this section.

Finally, before turning to the detail of GMFRS’s response, in the course of this section I have had to resolve a number of disagreements in the evidence between senior GMFRS officers as to what they told each other over the telephone in the early stages of their involvement. I accept that all witnesses were doing their best to give accurate and truthful evidence. Resolving those disputes is not always straightforward.

On the one hand, the fact that there are differences in the ways in which senior colleagues remember events might be viewed by some as a positive thing. It demonstrates that each witness is giving their own account, without having been influenced by the recollection of another.

On the other hand, it is capable of leading to confusion and of obscuring what actually happened. On occasions, this has led to me criticising individuals on a factual basis that does not fit with their own memory of events. This is regrettable but necessary.

This clearly illustrates the need for there to be a recording of what is said. This record could be through the use of a recorded communication system, the operation of a Dictaphone or a body‑worn video camera.

It is not just for the benefit of a public inquiry. Any subsequent review for the purpose of learning or investigating liability will have an accurate record of who said what to whom. This can form the foundation of any investigation or debrief. It will bring the focus on why things were said and done, rather than focusing on resolving what was said and done. It will also improve the prospect of real change, as people are more likely to accept criticism and feedback if they agree with the facts on which it is based.

In Part 19 in Volume 2‑II, I shall return to the issue of the recording of what occurs during a Major Incident more generally.

Mobilisation by duty NILO

Call from NWFC to Station Manager Berry (22:40)

Station Manager Berry was the duty NILO. In paragraphs 15.72 to 15.82, I rehearsed significant parts of the conversation he had with Michelle Gregson at 22:40.²⁸⁷ Station Manager Berry should have challenged Michelle Gregson when she stated, “obviously we are not mobilising”.²⁸⁸ Station Manager Berry did not have the GMFRS action plans or Major Incident Plan in front of him at the time of call.

As I said in paragraph 15.75, the use of the word “obviously” by Michelle Gregson was unfortunate. It implied that it was inevitable that mobilisation to the GMP RVP would not immediately occur. Station Manager Berry should have challenged Michelle Gregson’s use of the word “obviously” so as to better understand her thought process.²⁸⁹

Station Manager Berry’s reaction was to say, “[W]e would normally muster them [the fire appliances] at one of the stations wouldn’t we?”²⁹⁰ This response endorsed Michelle Gregson’s use of the word “obviously”. It was not GMFRS normal procedure to muster at a fire station. For an Operation Plato situation, GMFRS action plans envisaged mobilisation to an RVP nominated by the FDO.²⁹¹ For an explosion, the GMFRS action plan directed mobilisation to the incident.²⁹² Station Manager Berry was wrong in expressing himself in this way.

Following Michelle Gregson’s unfortunate use of “obviously” and Station Manager Berry’s endorsement of it, by mis‑stating the normal position, Station Manager Berry decided to mobilise four fire appliances to Philips Park Fire Station.²⁹³

Station Manager Berry’s decision-making

Station Manager Berry explained his selection of Philips Park Fire Station on the basis that he was “drawing cordons in [his] mind”.²⁹⁴ He stated that, although Manchester Central Fire Station was outside the cordon he drew, he ruled it out on the basis that if the incident “shifts” it would be inside the cordon and compromised as a location.²⁹⁵ He stated that he ruled out the RVP given to him from GMP as it was “quite close” and that if the incident were to “become an MTFA [Marauding Terrorist Firearms Attack] … it would be within that cordon”.²⁹⁶ He stated that he did not think to evacuate Manchester Central Fire Station.²⁹⁷

Station Manager Berry stated that he “assumed that this has just happened” and it may be a prelude to something else.²⁹⁸ He stated that he wanted “some reassurances because I thought it had just happened … and the RVP being nominated so fast”.²⁹⁹ He stated that “it was never in [his] mind that two of the [fire appliances] would be selected” from Manchester Central Fire Station and mobilised to Philips Park Fire Station.³⁰⁰

Station Manager Berry stated that he accepted now that Manchester Central Fire Station was “probably a better location” for a muster point than Philips Park Fire Station.³⁰¹

I accept Station Manager Berry’s evidence about his decision‑making process. I also accept that he was doing his best in difficult circumstances. However, he made unjustified assumptions, he acted outside the training he had been given and not in accordance with GMFRS’s plan for this type of incident. I recognise that officers in his position must be granted operational discretion. A deviation as great as this required clear justification, which was lacking.

There was no adequate basis for Station Manager Berry’s rejection of the GMP‑nominated RVP.³⁰² If the issue of the timing of the explosion was a determining factor, Station Manager Berry should have asked Michelle Gregson when exactly it had occurred. Instead, he made an assumption, and then based his decision‑making on this assumption. He should not have done this.

Had fire appliances been mobilised to the GMP‑nominated RVP, they would have picked up situational awareness.³⁰³ They would also have been sufficiently close to cautiously investigate the scene from that location.

Having decided to reject the RVP, it was still open to Station Manager Berry to make a limited deployment to the location in order to gain situational awareness and co‑locate with other emergency services.³⁰⁴

Manchester Central Fire Station was an obvious and correct choice for a GMFRS muster point, if the RVP was to be rejected. It brought fire appliances to a close but safe distance from Victoria Exchange Complex. Station Manager Berry’s concern that there may be a marauding terrorist and that that terrorist might maraud in the direction of Manchester Central Fire Station, which is in the opposite direction to the city centre, was unjustifiably cautious.

The effect of Station Manager Berry’s selection of Philips Park Fire Station was to send two fire appliances further away from the Victoria Exchange Complex and added further minutes to any response. Philips Park Fire Station was sufficiently far away to completely isolate GMFRS from the incident.

Before turning to Station Manager Berry’s next actions, it is important to recognise that, although Station Manager Berry’s initial decision was flawed, it could have been reversed quickly had he been able to speak to the FDO immediately and gain important information.

Next actions of duty NILO

Calls to Force Duty Officer

As soon as he had finished his call with Michelle Gregson, Station Manager Berry got his laptop out in case he needed to make notes. He then called the FDO. He had the FDO number pre‑programmed into his mobile phone.³⁰⁵ Station Manager Berry did not get through to the FDO. He heard the engaged tone. He tried calling the FDO number several times. In his witness statement, Station Manager Berry estimated that he tried the FDO seven times before he left home. None of the calls connected to the FDO.³⁰⁶

Station Manager Berry did not attempt to use the multi‑agency hailing talk group to contact the FDO. He was not aware of this facility.³⁰⁷ He should have been. It was GMFRS’s failing that he was not.

Station Manager Berry stated that he expected the FDO, or one of the FDO’s team, to contact him.³⁰⁸ At no point during the critical period of the response, by which 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, did anyone from GMP Control call and speak to the GMFRS duty NILO, Station Manager Berry. As I set out in Part 13 in the section addressing GMP’s response, the FDO was overburdened. As a result, important inter‑agency communication did not take place. This was a failing on the part of GMP, which had not provided adequate support for the FDO. I have dealt with this criticism in detail in Part 13.

Shortly before 22:48, Station Manager Berry received a call from Group Manager Peter Buckley. Group Manager Buckley was part of the Specialist Response Team. Group Manager Buckley had heard of an incident at the Arena. He wanted to know if the Specialist Response Team could be released from a road traffic incident. Station Manager Berry instructed the Specialist Response Team to leave that incident if they could, return to their fire station and put on their ballistic protection. Station Manager Berry instructed the Specialist Response Team to meet him at Philips Park Fire Station.³⁰⁹

At 22:48, Station Manager Berry called NWFC and spoke to the Control Room Operator Dean Casey. By the time of the call, Station Manager Berry was probably in his car setting off for Philips Park Fire Station.³¹⁰ At the outset of the call, Station Manager Berry stated: “I’ve been trying to get hold of the Force Duty Officer, but they’re not picking up for obvious reasons, they’re probably really busy.”³¹¹ In saying this, Station Manager Berry correctly identified the reason for the difficulty in communication. His recognition of this should have caused him to reassess his plan. As I explained in paragraphs 15.87 to 15.94, Station Manager Berry was not assisted in this by the fact that Dean Casey did not provide an adequate update. Station Manager Berry informed Dean Casey that he had spoken to Group Manager Buckley and instructed the Specialist Response Team to muster at Philips Park Fire Station.³¹²

Station Manager Berry stated that he expected NWFC to try and get through to the FDO on his behalf.³¹³ He did not give Dean Casey an instruction to that effect. Station Manager Berry should not have assumed that NWFC would try to contact the FDO. It is important that, in a fast‑moving incident in which the capacity of all the emergency services will be stretched, clear instructions are given in relation to important tasks.

Opportunity to re-evaluate

By the end of his call with Dean Casey, Station Manager Berry had been aware of the Attack for over 10 minutes. In fact, 20 minutes had passed since the explosion, but Station Manager Berry was not aware of this because he had not asked. He had mobilised resources three miles away from the location of the Attack. He had made numerous attempts to contact the FDO, all of which were unsuccessful. He had recognised that the FDO was very busy. He set off in his car to the muster point at Philips Park Fire Station.

Before getting into his car, Station Manager Berry should have re‑evaluated his strategy. He should have asked what NWAS and BTP were doing. Had he thought to ask these specific questions of NWFC, he would have learned that ambulances were being dispatched to the scene, as the NWAS approach was set out in clear terms in the NWFC Arena log. An instruction to NWFC to call BTP and request information would have quickly revealed that BTP officers had reached the seat of the explosion fewer than two minutes after the detonation.

Like GMFRS, NWAS operated a system of NILOs. At no point during the critical period of the response did Station Manager Berry contact his equivalent NILO at NWAS, whether through NWFC or any other means. This was an error on his part. It was an obvious way to mitigate the problem he was faced with. While I am critical of Station Manager Berry for not doing this, principal responsibility for him not doing so lies with GMFRS.

As I set in out in Part 12, the FDO becoming overburdened during a Major Incident, such as the Attack, was well known within GMP prior to 22^nd May 2017. In all of its planning, training and exercising, GMFRS failed to identify this fact and make provision for it.³¹⁴ GMFRS had not, for example, ensured that its own NILOs had the contact details of NWAS NILOs.³¹⁵ It should have done so.³¹⁶ Station Manager Berry had received no training on what he should do if he could not speak to the FDO.³¹⁷ Although I am critical of Station Manager Berry for not trying to find out what other emergency services were doing, he had not been adequately prepared by GMFRS for the situation in which he found himself on 22^nd May 2017.

Decision to travel to Philips Park Fire Station

Station Manager Berry was at home when he received the call from Michelle Gregson. At over 20 miles from Philips Park Fire Station, he expected his journey there to take at least 30 minutes.³¹⁸ He travelled under blue lights.³¹⁹ On the night, roadworks caused Station Manager Berry to become lost. This added to the stress he was under and diminished his ability to make the best decisions.³²⁰

At the time he departed, Station Manager Berry was not to know that these problems would occur. But a journey of that length, at speed and at night was always going to give rise to a risk of delay. It would never have provided an ideal environment in which to focus on important telephone calls and make decisions critical to the GMFRS response.

Station Manager Berry would have been better placed participating in the incident from his home, rather than travelling to Philips Park Fire Station. The issue of whether or not the NILO should mobilise or perform his or her function remotely had not been tested by GMFRS prior to the Attack.³²¹ This was a failing on the part of GMFRS, which placed Station Manager Berry in a position where he was left doing what he thought was right based on the information he had.³²²

Journey to Philips Park Fire Station

The tracking system on Station Manager Berry’s vehicle recorded him as setting off at 22:56. In fact, he set off earlier than this, probably prior to 22:48. He arrived at Philips Park Fire Station at 23:40.³²³ During the journey, he continued to try calling the FDO.³²⁴

While he was driving, Station Manager Berry participated in a number of telephone calls with senior GMFRS personnel. He also called NWFC at 22:48, 22:52 and 22:57.³²⁵ During those calls, NWFC did not inform Station Manager Berry that there were police and paramedics at the scene. Nor was he told that the NWAS “Bronze Commander”³²⁶ was at the scene.

Station Manager Berry stated that, if he had been given this information, “we’d quite clearly deployed probably straight to the arena, proceeding with caution”.³²⁷ In my view, it is possible that Station Manager Berry would have mobilised GMFRS resources to the scene if he had been given this information. I am not convinced that he would have done so. During this period, Station Manager Berry was focused on contacting the FDO as the route by which his decision would be reviewed. That is what Station Manager Berry believed he needed to do. Challenged as he was by the incident and his particular circumstances, Station Manager Berry was not thinking flexibly at that time. The circumstances were far from ideal for making what could be life‑saving decisions.

At 23:02, Station Manager Berry called Group Manager Nankivell back, having missed a call from him earlier. They spoke for over two minutes.³²⁸ At 23:13, Station Manager Berry spoke to Group Manager Fletcher for over two minutes.³²⁹

Station Manager Berry spoke to Group Manager Levy at 23:18 for over a minute. By this stage Group Manager Levy had been mobilised as a NILO and had just spoken to NWFC.³³⁰

At 23:26, Station Manager Berry was called by Crew Manager Anthony Henshall. Crew Manager Henshall had missed a call from Station Manager Berry at just after 23:00.³³¹ Crew Manager Henshall was Station Manager Berry’s support officer and delivered training to the Specialist Response Team officers in Marauding Terrorist Firearms Attack response. Station Manager Berry asked Crew Manager Henshall to mobilise and assist with the response to the Attack. He directed Crew Manager Henshall to Philips Park Fire Station.³³²

Station Manager Berry told Crew Manager Henshall that he “had tried to get hold of the FDO but couldn’t get hold of them via phone”.³³³ It had been over 40 minutes since Station Manager Berry had first tried the FDO. A different approach was required and should have been explored in the preceding 40 minutes.

Shortly after his arrival at Philips Park Fire Station at 23:33, Group Manager Meakin rang Station Manager Berry. They spoke for nearly two minutes.³³⁴ At 23:37, Station Manager Berry spoke to Group Manager Fletcher for a second time.³³⁵

At 23:40, Station Manager Berry arrived at Philips Park Fire Station.³³⁶

I shall consider some of the calls I mentioned above in due course. Before I do, I shall set out what happened as a consequence of Station Manager Berry’s mobilise instruction to NWFC.

Mobilisation of non-specialist fire appliances

At Philips Park Fire Station

Following her call with Station Manager Berry, at 22:45 Michelle Gregson called Watch Manager Helmrich at Philips Park Fire Station.³³⁷ She informed him that Philips Park Fire Station had been made the muster point by Station Manager Berry “because you are some distance from … the incident”.³³⁸ She told Watch Manager Helmrich that the FDO was being spoken to. In the course of the call, Michelle Gregson said, “[T]here’s confirmed … gunshot wounds.”³³⁹

The information in relation to gunshot wounds reflected an entry made in the Arena log by David Ellis in the course of his call with GMP Control. The entry was made at the same time as Michelle Gregson’s call to Watch Manager Helmrich.³⁴⁰ By the time GMP Control had provided updated information confirming that the injury in question was from shrapnel, Michelle Gregson’s call with Watch Manager Helmrich had ended.

It is unfortunate but unavoidable in situations such as the Attack that some people involved in a response may receive only a snapshot of information, and that information may then turn out to be incorrect. I am not critical of Michelle Gregson for providing this information: it was information that was recorded on the Arena log as she was speaking to Watch Manager Helmrich. I heard no evidence that led me to conclude that the provision of this information to Watch Manager Helmrich adversely affected the emergency response. Watch Manager Helmrich’s reaction was to believe it was “just a local issue” as “gunshot wounds [are] not uncommon in Greater Manchester”.³⁴¹

There was one fire appliance at Philips Park Fire Station on the night of the Attack.³⁴² At 22:49, this fire appliance was allocated to the GMFRS response to the Attack.³⁴³ As it was already at Philips Park Fire Station, it was already at the muster point identified by Station Manager Berry.

From Manchester Central Fire Station

On the night of 22^nd May 2017, Watch Manager Simister was in command of a crew manager and six firefighters at Manchester Central Fire Station. There were two fire appliances available to him. Watch Manager Simister and his team had come on duty at 19:00.³⁴⁴

Watch Manager Simister heard the explosion when the bomb was detonated. He was used to hearing bangs and did not realise the noise he had heard was from a bomb.³⁴⁵

At 22:38, a pre‑alert was sent to Manchester Central Fire Station because David Ellis had selected it, on the Arena log, as the closest fire station to the Arena. Manchester Central Fire Station is 1.2 kilometres from the Arena.³⁴⁶ Watch Manager Simister and his team got into their “fire gear” and waited for confirmation of the mobilising instruction.³⁴⁷ Eight minutes later, a second pre‑alert was automatically transmitted to Manchester Central Fire Station.³⁴⁸

At about the time of the second pre‑alert, one of Watch Manager Simister’s team answered a call from Watch Manager Julie Walker at Gorton Fire Station, asking why the Manchester Central team had not mobilised to the Arena. Watch Manager Walker informed the Manchester Central team that a bomb had gone off.³⁴⁹ I will deal with how Watch Manager Walker came to learn of the Attack in paragraphs 15.273 to 15.277.

Watch Manager Simister thought that he and his team would be mobilised to the Arena at “any minute”.³⁵⁰ He instructed his crews to open the fire station doors and board their fire appliances. He could see “a sea of blue lights heading towards the arena”.³⁵¹ He stated that he and his crew wanted to go to the Arena “because that’s our job … We’ve got first aid capabilities … people are in distress and that’s our job to go.”³⁵² The standard fire appliances based at Manchester Central Fire Station each had a type of stretcher called a spinal board, a tourniquet and dressings on board.³⁵³

Once they were in their firefighting gear following the first pre‑alert, it would have taken Watch Manager Simister and his team, travelling in the two fire appliances, three minutes to reach the Arena.³⁵⁴ Eight firefighters could have been at the Arena by 22:45, had they been mobilised to go there at 22:42.

The mobilisation instruction came through to Manchester Central Fire Station at 22:49: Watch Manager Simister and his team were directed, not to the Arena but to Philips Park Fire Station.³⁵⁵ As he was leaving, Watch Manager Simister saw two ambulances pulling on to the forecourt of Manchester Central Fire Station. The driver of Watch Manager Simister’s fire appliance was told by one of the occupants of the ambulances: “[W]e’ve been told to come here.”³⁵⁶ These two ambulances were the first of six ambulances which assembled at Manchester Central Fire Station between 22:49 and 23:02. Those ambulances drove to Hunts Bank in convoy at 23:06.³⁵⁷

At 22:54 and 22:55, the two fire appliances from Manchester Central Fire Station arrived at Philips Park Fire Station.³⁵⁸

From Gorton Fire Station

Crew Manager Mottram was on duty at Gorton Fire Station on the night of the Attack. Gorton Fire Station is approximately three miles from Manchester Central Fire Station.³⁵⁹ Also present was his line manager, Watch Manager Walker.

Shortly after 22:30, Crew Manager Mottram received a telephone call from his wife, Helen Mottram, who worked as a paramedic for NWAS. She was on duty that night. At 22:37, the ambulance she was in was allocated by NWAS Control to attend the Arena.³⁶⁰ Helen Mottram asked her husband whether he had heard anything about a bomb going off at the Arena. She told him that she had been mobilised to attend and was on her way to the Arena.³⁶¹

In due course, Helen Mottram was diverted by NWAS Control to Manchester Central Fire Station. She arrived there at 22:53. She subsequently drove to Hunts Bank, with five other ambulances, leaving the fire station at 23:06.³⁶²

Crew Manager Mottram told Watch Manager Walker about the telephone call from Helen Mottram. Together, they investigated what GMFRS mobilisations to the Arena had occurred. They discovered that there had been none. Watch Manager Walker telephoned Manchester Central Fire Station and had the conversation I described in paragraph 15.268.³⁶³

At 22:49, the fire appliance to which Crew Manager Mottram was assigned was mobilised to Philips Park Fire Station.³⁶⁴ He arrived five minutes later.³⁶⁵

Mobilisation of specialist crews

Mobilisation from Fire Station A

On the night of 22^nd May 2017, Watch Manager Jonathan Nolan was based at a fire station in the Greater Manchester area (Fire Station A). Watch Manager Nolan was the leader of the Specialist Response Team and was in command of four of its operatives³⁶⁶ located at Fire Station A. There was one Specialist Response Team appliance at Fire Station A on the night of the Attack.³⁶⁷

Specialist Response Team appliances did not have a firefighting capability. The design of the vehicle was suitable for operation in an area where there might be firearms. The vehicle was equipped with ballistic protection for the Specialist Response Team operatives. It contained first aid equipment over and above that of a standard fire appliance. The first aid equipment included a blast dressing, ballistic dressings and blood clotting dressings. It contained chest seals for puncture wounds and tourniquets. This equipment was carried in a rucksack by Specialist Response Team operatives attending an incident. Specialist Response Team appliances also carried five skeds: a type of stretcher designed for the rapid evacuation of casualties. Specialist Response Team operatives were trained in the use of this equipment. They trained with NWAS’s Hazardous Area Response Team (HART) operatives. This training anticipated that they would operate alongside paramedics and top up their first aid equipment from paramedics.³⁶⁸

At the time of the Attack, Watch Manager Nolan and his Specialist Response Team colleagues were attending a road traffic collision about one mile from Fire Station A. They had attended in a standard fire appliance. All of the Specialist Response Team equipment was at Fire Station A.³⁶⁹ Shortly before 22:45, Watch Manager Nolan was informed by police officers, who had attended the road traffic incident, that something had happened in Manchester City Centre and the police officers needed to leave.³⁷⁰

Watch Manager Nolan instructed Crew Manager Andrew Waterhouse to contact the duty NILO through NWFC. At 22:42, Crew Manager Waterhouse spoke to Rochelle Fallon. He explained that he needed to speak to the NILO. Rochelle Fallon called Station Manager Berry at 22:44.³⁷¹ The call went to Station Manager Berry’s voicemail and Rochelle Fallon left a message.

Watch Manager Nolan then spoke to Group Manager Buckley, who was also present at the road traffic incident. Group Manager Buckley called Station Manager Berry. Station Manager Berry instructed Watch Manager Nolan’s Specialist Response Team crew to leave the road traffic incident, if they could, and put on their kit for a Marauding Terrorist Firearms Attack.³⁷²

In his call to NWFC at 22:48, Station Manager Berry informed Dean Casey that he had spoken to Group Manager Buckley. He told Dean Casey: “They [the Specialist Response Team crew] are going to pick the vehicle up and the capability for the MTFA [Marauding Terrorist Firearms Attack] … And they are going to rendezvous at Philips Park, until we are instructed otherwise and get some more information about this incident.”³⁷³

At 22:53, Watch Manager Nolan called NWFC. He informed the Control Room Operator he spoke to that, “On the instruction of Station Manager Berry we’re taking [the Specialist Response Team appliance] to Philips Park … that’s the rendezvous point isn’t it?”³⁷⁴

Watch Manager Nolan’s Specialist Response Team appliance was mobilised on NWFC’s system by Joanne Haslam at 23:02. At this point, Watch Manager Nolan and his Specialist Response Team crew were at Fire Station A and were close to leaving.³⁷⁵ Eight minutes later, NWFC was notified by radio that the Specialist Response Team appliance was en route to the RVP.³⁷⁶

At 23:21, Watch Manager Nolan’s Specialist Response Team appliance arrived at Philips Park Fire Station.³⁷⁷

Mobilisation from Fire Station B

Watch Manager Nolan’s team were not the only specialist firefighters mobilised to Philips Park Fire Station. At 22:52, Station Manager Berry had directed NWFC to “make … MTFA capability two”.³⁷⁸ At 23:02, Joanne Haslam mobilised a second Specialist Response Team appliance.³⁷⁹ This Specialist Response Team appliance was based at Fire Station B.

At 23:03, Lisa Owen telephoned Fire Station B and spoke to a watch manager. Lisa Owen explained that she was mobilising two Specialist Response Team appliances. She mentioned the Technical Response Unit “with MTFA capability”.³⁸⁰ This was because shortly before this call Group Manager Nankivell had directed Joanne Haslam to mobilise the Technical Response Unit “with their MTFA kit”.³⁸¹

The watch manager that Lisa Owen spoke to said: “[W]e’ve just been talking about that. We’re gonna take the TRU [Technical Response Unit] and MRU [Major Response Unit], so we’ll take three vehicles but we will have got the MTFA capability and … we’ll have the ballistics sets as well.”³⁸² The Major Response Unit appliance is an enhanced response vehicle with rescue capabilities.³⁸³

As a result of this conversation, three specialist vehicles mobilised from Fire Station B: a Specialist Response Team appliance, a Technical Response Unit appliance and a Major Response Unit appliance.³⁸⁴ By 23:46, these specialist vehicles had arrived at Philips Park Fire Station.³⁸⁵

Before considering what took place at Philips Park Fire Station, it is necessary to deal with the mobilisation of a number of senior GMFRS officers, two of whom were to attend Philips Park Fire Station.

Mobilisation of duty Group Manager

Call from NWFC (22:52)

Group Manager Nankivell was the duty Group Manager. The initial call from NWFC to him was at 22:52. I set out in paragraphs 15.114 to 15.120 the information he was given. He was told that there had been an explosion at the Arena, that a bomb had gone off, and that fire appliances had been mobilised to Philips Park Fire Station. He was also told that there was an unconfirmed report of an active shooter. Joanne Haslam started to tell him about the GMP RVP, but Group Manager Nankivell spoke across her to ask if a Major Incident had been declared. He was told that NWAS had a “bronze commander … at the scene”.³⁸⁶

Group Manager Nankivell stated that the significance of the information about the NWAS “bronze commander” did not register with him, as he was thinking about his next actions.³⁸⁷ I accept his evidence. While it was a failing on his part, he should not have been the only GMFRS officer given this information by NWFC.

So far as the use of Philips Park Fire Station was concerned, Group Manager Nankivell stated: “I took the view that the duty NILO had made that decision for a tactical or strategic reason and that’s why we were sending the pumps [fire appliances] to Philips Park.”³⁸⁸ Group Manager Nankivell should have challenged this decision when he spoke to Station Manager Berry.³⁸⁹

In the course of the call, Group Manager Nankivell directed Joanne Haslam to mobilise the Technical Response Unit “with their MTFA kit” to Philips Park Fire Station.³⁹⁰

Call to Station Manager Berry (23:02)

At 23:02, Group Manager Nankivell called Station Manager Berry. Group Manager Nankivell informed Station Manager Berry that he was mobilising to the Command Support Room. Station Manager Berry informed Group Manager Nankivell that he had mobilised additional NILOs.³⁹¹

Group Manager Nankivell stated that he was not told by Station Manager Berry about difficulties in contacting the FDO.³⁹² Station Manager Berry stated that he did tell Group Manager Nankivell this.³⁹³ I prefer Station Manager Berry’s evidence on this point, as I think it is more likely to be correct in view of what was happening at the time. This is for a number of reasons. First, Station Manager Berry mentioned that he was having difficulty getting hold of the FDO in a conversation with the Control Room Operator Dean Casey approximately 15 minutes earlier, to Crew Manager Henshall about 20 minutes later and to Group Manager Meakin half an hour later. Second, Group Manager Nankivell accepted that his recollection of the conversation was “a bit grainy”.³⁹⁴ Third, getting hold of the FDO had been Station Manager Berry’s preoccupation for some time. I consider it unlikely that he would not have mentioned that fact in his first call with the duty Group Manager.

Although I accept that Station Manager Berry informed Group Manager Nankivell that he was having difficulties getting hold of the FDO, I do not consider that Station Manager Berry made it sufficiently clear to Group Manager Nankivell that GMFRS’s whole mobilisation strategy was dependent on speaking to the FDO. If Station Manager Berry had informed Group Manager Nankivell of this, I consider it likely that Group Manager Nankivell would have remembered being told and would have reacted. Station Manager Berry should have been clearer with Group Manager Nankivell about the strategy.

Station Manager Berry stated that he asked Group Manager Nankivell to contact the FDO, to which Group Manager Nankivell responded “Right.”³⁹⁵ Although I accept Station Manager Berry’s evidence that he did mention the difficulties he was having contacting the FDO, I consider Station Manager Berry to be mistaken in his recollection that he asked Group Manager Nankivell to call the FDO.

As I set out at paragraph 15.297, Group Manager Nankivell had no recollection of the FDO being mentioned at all. While he was very experienced, Group Manager Nankivell was not and never had been a NILO. Group Manager Nankivell struck me as a conscientious officer, doing what he could to support the GMFRS response.³⁹⁶ Group Manager Nankivell saw Station Manager Berry “as the incident commander”.³⁹⁷ In my view, if Group Manager Nankivell had received a clear request from Station Manager Berry to contact the FDO, he would have done so.

Station Manager Berry stated that he had told Group Manager Nankivell that he hadn’t deployed to the scene or the RVP.³⁹⁸ Again, I consider Station Manager Berry to be mistaken in his recollection of the GMP RVP being mentioned by him. Station Manager Berry believed he had mentioned this to other GMFRS officers, but they did not recall him doing so. I will deal with these calls in paragraphs 15.366 to 15.372, 15.376 to 15.387 and 15.425 to 15.427. Station Manager Berry had rejected the GMP RVP early in his involvement. On balance, I consider it more likely that Station Manager Berry did not mention the rejected GMP RVP to Group Manager Nankivell. As I have already said, deciding between two different recollections of phone calls is not easy.

Station Manager Berry should have told Group Manager Nankivell that GMP had provided an RVP early in the incident, which he had rejected on safety grounds.

Other calls before arrival at Command Support Room

In the section dealing with NWFC’s response, from paragraph 15.139 onwards, I set out a number of calls Group Manager Nankivell had with NWFC after his call with Station Manager Berry. In his call with NWFC at 23:11, Group Manager Nankivell confirmed that he was content that the Major Response Unit appliance and Technical Response Unit appliance from Fire Station B had been mobilised to Philips Park Fire Station.³⁹⁹

Group Manager Nankivell made a number of other calls before arriving at the Command Support Room. Those calls were with the duty Assistant Principal Officer, duty Principal Officer, Group Manager Fletcher and Group Manager Levy. I will address those calls as I come to consider the start of each of those GMFRS officers’ involvement in the response.

Group Manager Nankivell arrived at the Command Support Room at approximately 23:41.⁴⁰⁰

Mobilisation of duty Assistant Principal Officer

Call from Group Manager Nankivell (22:57)

Following his call with NWFC at 22:52, Group Manager Nankivell called the duty Assistant Principal Officer, Area Manager Paul Etches. They spoke at 22:57 for just over two minutes. Area Manager Etches was concerned to establish whether this was a real incident rather than a live exercise. They both sought to find out more from the news. They agreed to meet at the Command Support Room.⁴⁰¹

As a result of Group Manager Nankivell failing to register the significance of the information from Joanne Haslam, regarding the NWAS “bronze commander” being at the scene, as mentioned in paragraph 15.293, he did not pass this information on to Area Manager Etches.⁴⁰² Group Manager Nankivell did not pass this information on to any other GMFRS officer at any point during the critical period.

After the call had concluded, Area Manager Etches watched the television news reports on the Attack, to try to get some situational awareness.⁴⁰³

NWFC’s incident logs can be viewed via the iNet platform. In common with other GMFRS officers who responded to the Attack, Area Manager Etches had access to iNet via a laptop. Area Manager Etches did not seek to obtain situational awareness though iNet, and neither did other GMFRS officers. Area Manager Etches and those other GMFRS officers should have done so.⁴⁰⁴

I am not critical of Area Manager Etches and his colleagues for not doing this. It was a training and exercising failure by GMFRS. It was not part of the culture of a GMFRS response to a Major Incident for officers to review iNet as a way of learning more about a Major Incident while it was ongoing.⁴⁰⁵

There was evidence of one GMFRS officer, who did not become involved in the response to the Attack during the critical period, using iNet. I shall address that in paragraphs 15.391 to 15.392.

A number of GMFRS officers had an opportunity, in the early stages of their involvement in the response, to take a few minutes and access the NWFC incident log on iNet. Had they done so, this would have improved the GMFRS response. It is highly likely that the presence of police and paramedics at the scene would have been identified and acted upon sooner by senior GMFRS officers.

It is notable that Station Manager Michael Lawlor stated that his reason for not asking NWFC for an update was concern at how busy NWFC was. This should not have been a deterrent to proper communication with NWFC for any GMFRS officer. One way in which GMFRS officers could occupy less of NWFC operatives’ time could be if they also referred to the incident log in appropriate circumstances.

Such checks should not take priority over individuals mobilising to an incident ground. Nor should such checks replace direct communication with NWFC. NWFC staff are more expert in the interpretation and management of information in their incident logs. It is also very important that NWFC and GMFRS work together and maintain an ongoing dialogue. Agreement will need to be reached between GMFRS and NWFC on the circumstances in which the checking of incident logs by GMFRS officers will occur so that each organisation knows what the other is doing.

I recommend GMFRS and NWFC conduct a joint review of the circumstances in which it is appropriate for GMFRS personnel to check the NWFC incident log. Policies should be written by both organisations to reflect the outcome of this review and training delivered to embed it into practice.

Call from Group Manager Nankivell (23:09)

Group Manager Nankivell telephoned Area Manager Etches for a second time at 23:09, immediately after Group Manager Nankivell had spoken to the duty Principal Officer.⁴⁰⁶ I will address Group Manager Nankivell’s call with the duty Principal Officer in paragraphs 15.325 to 15.331. Area Manager Etches stated that he thought, but was not sure, that it was in this second call, rather than the first, that Group Manager Nankivell informed him about the mobilisation to Philips Park Fire Station.⁴⁰⁷

It is not necessary for me to resolve whether it was in this first call or the second. By reason of a call made by Area Manager Etches at 23:11, which I deal with in paragraphs 15.159 to 15.163, I am satisfied that it was in one of those two conversations that Area Manager Etches was told about the Philips Park mobilisation.

They did not discuss whether or not Philips Park Fire Station was an appropriate RVP. Group Manager Nankivell’s view was that this was a decision for the duty NILO to make.⁴⁰⁸

Based on what he knew, Area Manager Etches considered the choice of Philips Park Fire Station to be an appropriate one. He did not know, however, that approximately 30 minutes or more had passed since the explosion. He assumed that he would have been contacted earlier on in the incident response.⁴⁰⁹ He accepted, in evidence, that he should have asked how long it had been since the explosion.⁴¹⁰

Call to NWFC (23:12)

Shortly after his second call with Group Manager Nankivell, Area Manager Etches contacted NWFC at 23:12. He spoke to Rochelle Fallon. The purpose of his call was recorded on the incident log as mobilising to the Command Support Room.⁴¹¹ It is clear from what he says in this call that Area Manager Etches had learned from Group Manager Nankivell about the deployment to Philips Park Fire Station.

In the course of the call, Area Manager Etches asked Rochelle Fallon whether NWFC had “had anything back from anywhere?”.⁴¹² Area Manager Etches then informed Rochelle Fallon that he had spoken to Group Manager Nankivell and knew of the Philips Park Fire Station mobilisation. Rochelle Fallon told Area Manager Etches that they were getting more information from the police and ambulance services “every time they get anything about a fatality”.⁴¹³

Area Manager Etches stated in evidence:
“I think potentially I was seeking more information … they were just getting more information from ambulance and police and we got that update around the fatalities at that point in time. It started to paint the picture. I’m not sure I was seeking more at that time in my role.”⁴¹⁴

I set out my criticism of NWFC’s role in this call with Area Manager Etches in paragraphs 15.159 to 15.163. In Area Manager Etches’ case, given that this was his first contact with NWFC and he had not reviewed the incident logs himself, he should have made a clear request for a comprehensive briefing on the incident.

At 23:22, Area Manager Etches left his home.⁴¹⁵ He arrived at the Command Support Room at 23:40.⁴¹⁶

Mobilisation of duty Principal Officer

At 23:08, Group Manager Nankivell called the duty Principal Officer, Chief Fire Officer Peter O’Reilly. The call lasted one minute and 20 seconds.⁴¹⁷ Group Manager Nankivell called Chief Fire Officer O’Reilly a second time at 23:23 for approximately 40 seconds.⁴¹⁸ At 23:37, Chief Fire Officer O’Reilly spoke to Group Manager Nankivell on the telephone for a third time in a call lasting nearly three and a half minutes.⁴¹⁹

Call from Group Manager Nankivell (23:08)

In the first of these calls, Group Manager Nankivell informed Chief Fire Officer O’Reilly that there had been an incident at the Arena. Group Manager Nankivell said that he and Area Manager Etches were going to open up the Command Support Room.⁴²⁰ Chief Fire Officer O’Reilly said that he would meet Group Manager Nankivell at the Command Support Room. This surprised Group Manager Nankivell as his expectation was that, as Gold Commander, the duty Principal Officer would go to GMP HQ.⁴²¹

Group Manager Nankivell stated in evidence that he had informed Chief Fire Officer O’Reilly of the mobilisation to Philips Park Fire Station.⁴²² Chief Fire Officer O’Reilly stated, when he gave evidence, that he did not believe he was told about the mobilisation to Philips Park Fire Station until a call at 23:37 with Group Manager Nankivell. Chief Fire Officer O’Reilly stated that he was told in that later call that the Marauding Terrorist Firearms Attack capability was at Philips Park Fire Station. He also stated that he assumed the Marauding Terrorist Firearms Attack resources were being held back and that other resources were at the scene.⁴²³

I prefer the evidence of Group Manager Nankivell on this point. In my view, it is likely that Group Manager Nankivell did tell Chief Fire Officer O’Reilly about the mobilisation to Philips Park Fire Station in the earlier conversation.

Group Manager Nankivell told Area Manager Etches about the mobilisation to Philips Park Fire Station prior to 23:12. At 23:12, Area Manager Etches called NWFC and informed Rochelle Fallon that Group Manager Nankivell had told him about the mobilisation to Philips Park Fire Station.⁴²⁴ This could only have come from Area Manager Etches’ calls with Group Manager Nankivell at 22:57 and/or 23:09. I consider it unlikely that Group Manager Nankivell would have provided this information to the duty Assistant Principal Officer but not to the duty Principal Officer, especially when the conversations occurred at around the same time. It is probable that Chief Fire Officer O’Reilly is mistaken as to when Group Manager Nankivell provided this information.

I accept Chief Fire Officer O’Reilly’s evidence that when he was told about Philips Park Fire Station he incorrectly assumed it was being used for resources that were being held back.

Following the first call with Chief Fire Officer O’Reilly, Group Manager Nankivell informed NWFC at 23:11 that Chief Fire Officer O’Reilly would be mobilising to the Command Support Room.⁴²⁵ At 23:15, a mobilisation to the Command Support Room notification was sent by NWFC to Chief Fire Officer O’Reilly.⁴²⁶

Call from Group Manager Nankivell (23:23)

Group Manager Nankivell made a second call to Chief Fire Officer O’Reilly at 23:23. It related to Group Manager Nankivell’s intention to inform NWFC not to authorise GMFRS resources to Manchester City Centre unless there were a threat to life. Chief Fire Officer O’Reilly ratified this decision by saying “good call, Dean”.⁴²⁷

At the conclusion of this short call, Group Manager Nankivell immediately telephoned NWFC. He spoke to the Control Room Operator David Ellis and gave the instruction.⁴²⁸

Call to Group Manager Nankivell (23:37)

After missed calls both ways in the minute before, at 23:37 Chief Fire Officer O’Reilly called Group Manager Nankivell. He informed Chief Fire Officer O’Reilly that news of the Attack was starting to be reported in the media. He told Chief Fire Officer O’Reilly that Group Manager Levy was on his way to Philips Park Fire Station.⁴²⁹ By the end of the call, Group Manager Nankivell was at the Command Support Room with Area Manager Etches.

Chief Fire Officer O’Reilly replied to say that he was only a short distance from the Command Support Room.⁴³⁰

Decision to mobilise to Command Support Room

In the call at 23:08, Chief Fire Officer O’Reilly decided to mobilise to the Command Support Room. In evidence he stated:
“Based on the information that I had at that time, I was quite confident that going to my own headquarters, to speak to the CSR [Command Support Room], to see what the incident actually was, was the best course of action.”⁴³¹

Chief Fire Officer O’Reilly could have chosen to go to GMP HQ. This would have provided him with a greater understanding of at least two things: where GMP had deployed its resources and what GMP knew about the incident. He might also have spoken to representatives of NWAS who were present. By 23:15, Annemarie Rooney, the NWAS Tactical Commander, was at GMP HQ.⁴³²

At the time Chief Fire Officer O’Reilly decided to go to the Command Support Room, no one from GMFRS had been allocated to attend GMP HQ. Chief Fire Officer O’Reilly did not learn that GMP planned for emergency response commanders to go to GMP HQ until half an hour after he made the decision to go to the Command Support Room.⁴³³ In my view, it would have been better if Chief Fire Officer O’Reilly had gone to GMP HQ rather than the Command Support Room.⁴³⁴ My conclusion is not based on hindsight, but on the information Chief Fire Officer O’Reilly had at the time.

On the information Chief Fire Officer O’Reilly was given by Group Manager Nankivell, the response to the Attack was inevitably a multi‑agency one. The scale of the incident also meant that it was inevitable other agencies would appoint Strategic/Gold Commanders. Group Manager Fletcher stated that it was well known from the policies and procedures in place that multi‑agency discussions would take place at GMP HQ.⁴³⁵ Group Manager Meakin’s expectation was that “if a Gold structure is established, then the Principal Officer for the evening would ordinarily go to Gold Command … generally at Force [GMP] Headquarters.”⁴³⁶ Chief Fire Officer O’Reilly did not think it was likely that the GMP Strategic/Gold Commander would be at GMP HQ. He was incorrect. Assistant Chief Constable (ACC) Deborah Ford arrived at GMP HQ at 23:15.⁴³⁷

Much later that night, shortly after 02:00, Chief Fire Officer O’Reilly went to GMP HQ. He did so having been notified of a Strategic Co‑ordinating Group meeting at 02:30. Chief Fire Officer O’Reilly arrived in the Silver Command Room at GMP HQ at 02:10.⁴³⁸ In the end, the meeting took place at 04:15.⁴³⁹

Returning to consider Chief Fire Officer O’Reilly’s decision‑making process: at 23:08, Chief Fire Officer O’Reilly had not been told that GMFRS had any resources at the scene. The only location mentioned was Philips Park Fire Station. It was of paramount importance for GMFRS to gain situational awareness. The best way to do that was to co‑locate with partner agencies. GMP HQ was the obvious place to do that. It was the expectation of Group Manager Nankivell and Group Manager Meakin that the duty Principal Officer would ordinarily go to GMP HQ in response to a Major Incident.⁴⁴⁰

I recognise that there was no written GMFRS policy directing the duty Principal Officer or Gold Commander to GMP HQ during a Major Incident. There should have been. The GMFRS guidance on the Command Support Room stated: “The duty APO [Assistant Principal Officer] will ordinarily take command of the CSR [Command Support Room] supported by a suitably trained CSRO [Command Support Room Officer].”⁴⁴¹ References to the duty Principal Officer in this guidance did not indicate where the duty Principal Officer should locate themselves. The most assistance it gave was, “The CSR will ordinarily be led by the duty APO, or in some circumstances by the duty PO [Principal Officer].”⁴⁴²

The role of Gold Commander in the GMFRS is not to command the incident, but to act in support.⁴⁴³ Group Manager Nankivell and Area Manager Etches were capable of managing the Command Support Room.

Chief Fire Officer O’Reilly needed to make a short journey from his home in any event, whether going to the Command Support Room or to GMP HQ. The balance of the decision about where to go may have been different if Chief Fire Officer O’Reilly had already been in the Command Support Room when he learned of the incident.

Chief Fire Officer O’Reilly arrived at the Command Support Room at 23:49.⁴⁴⁴

Assistant Chief Fire Officer Keelan

Assistant Chief Fire Officer David Keelan was off duty on the night of the Attack. After he returned from a meal out, he saw a news report on Sky News. At 23:02, he forwarded a tweet from Sky News to a GMFRS NILO WhatsApp group. The headline read: “Greater Manchester Police warning people to stay away from Manchester Arena as officers respond to ‘incident’ amid reports of an explosion.” At 23:08, he sent a message to the same WhatsApp group enquiring, “Any update?”⁴⁴⁵

He sent the messages because “that’s something we would do for incidents that occurred that we were aware of”.⁴⁴⁶

Assistant Chief Fire Officer Keelan played a very limited role during the critical period of the response. He received three calls: at 23:28, 23:35 and 23:37. These were from Group Manager Fletcher, Group Manager Nankivell and Station Manager Lawlor respectively.⁴⁴⁷ He also sent some messages to the GMFRS command leadership team.⁴⁴⁸

Assistant Chief Fire Officer Keelan made the decision not to involve himself further that night. He was conscious that the response by emergency services would not be confined only to the night of 22^nd May 2017. He recognised that at some point it would fall to him to take over strategic leadership from Chief Fire Officer O’Reilly.⁴⁴⁹ In my view, Assistant Chief Fire Officer Keelan made an appropriate decision. Any criticism levelled at him for not self‑deploying is misplaced.

Mobilisation of second NILO

Call from NWFC (23:10)

Group Manager Meakin was on call at 23:06, when he received the pager message mobilising him to the incident. He was at home, approximately 12 or 13 miles from the centre of Manchester. He was one of a number of on‑call incident commanders. He was not mobilised in this capacity, but in his NILO capacity.⁴⁵⁰

In paragraphs 15.123 to 15.127, I addressed the content of the pager message at 23:06 mobilising Group Manager Meakin to Philips Park Fire Station and his subsequent call at 23:10. I also addressed the shortcomings in this call by both participants.

Group Manager Meakin realised from the pager message that he was being mobilised to what might be a very serious incident.⁴⁵¹ Following the call with NWFC, Group Manager Meakin got in his car and drove to Philips Park Fire Station.

Journey to Philips Park Fire Station

In the course of the journey, Group Manager Meakin did not make any calls to GMFRS colleagues. His expectation was that Station Manager Berry was contacting the FDO. Group Manager Meakin did not try to contact the NWAS NILO. It did not occur to him to do so. He did not have the contact number for the NWAS NILO, although he believed he could have got it from NWFC.⁴⁵²

It was not part of Group Manager Meakin’s training to contact the NWAS NILO.⁴⁵³ He was in a different position from Station Manager Berry. Group Manager Meakin was the second NILO to become involved. As the first contacted NILO, Station Manager Berry was responsible for the strategy to mobilise to Philips Park Fire Station and contact the FDO. Station Manager Berry knew that he could not get hold of the FDO.

While I have criticised Station Manager Berry for not contacting the NWAS NILO, I do not criticise Group Manager Meakin for not doing so. I am critical of GMFRS for not training Group Manager Meakin to do this in these circumstances. The NWAS NILOs presented an opportunity for Group Manager Meakin to add to GMFRS’s situational awareness.

Group Manager Meakin arrived at Philips Park Fire Station at approximately 23:25.⁴⁵⁴

Mobilisation of third NILO

Group Manager Levy was at home when he received the pager message mobilising him to the incident. He was one of a number of duty NILOs.⁴⁵⁵ At 23:06, he received the same pager message as Group Manager Meakin, which included: “NILO THREE AND MTS CAPABILITY 2 TO RVP AT PHILLIPS PARK.”⁴⁵⁶ Like Group Manager Meakin, he recognised that “MTS” was a typographical mistake, which he interpreted as “MTFA” or “MTA”.⁴⁵⁷ Four minutes later, he was sat in his car ready to leave. He thought the likelihood was that he was responding to a Marauding Terrorist Firearms Attack.⁴⁵⁸

As he was about to depart, Group Manager Levy saw that he had a message from the NILO WhatsApp group. This was the message sent by Assistant Chief Fire Officer Keelan. Group Manager Levy did not read it until he reached Philips Park Fire Station.⁴⁵⁹

Group Manager Levy lived approximately 18 miles from Philips Park Fire Station. He travelled there under blue lights.⁴⁶⁰

Call to NWFC (23:12)

After he had set off, at 23:12, Group Manager Levy made a call to NWFC, which was answered by Michelle Gregson.⁴⁶¹

I addressed the content of that call and the NWFC shortcomings during it in paragraphs 15.128 to 15.138.

When he received the pager message, Group Manager Levy assumed that the incident had just occurred. During the call, Group Manager Levy realised that this assumption was incorrect. He stated that, if he had been given the information on the Arena log about other emergency services, “without a doubt” he would have advised a mobilisation of GMFRS to the scene earlier than occurred.⁴⁶²

Group Manager Levy stated that, if he had been provided with the JESIP information on the Arena log and arrived at Philips Park Fire Station to find that there had been no mobilisation, “[W]e’d have just driven straight towards the city centre, not gone via Manchester Central.”⁴⁶³ Group Manager Levy said that he would have held some resources at Philips Park Fire Station and sent the Specialist Response Team to the Victoria Exchange Complex.⁴⁶⁴ I accept this evidence from Group Manager Levy.

If Group Manager Levy had been provided with information from the Arena log about the police and paramedics being at the scene in his call with NWFC at 23:12, it is likely that GMFRS’s Specialist Response Team would have been at the Victoria Exchange Complex before 00:00 on 23^rd May 2017. While this is outside the critical period of the response, it was a considerable improvement on what was achieved by GMFRS on the night of the Attack. Even at 00:00, there remained a substantial opportunity for the trauma skills of the Specialist Response Team to make a positive contribution in helping the casualties in the Casualty Clearing Station and the walking wounded still at the scene.

During the call with Michelle Gregson, a hazard zone was discussed. Group Manager Levy stated, in evidence, that he “suspected” the Attack had been declared as a Marauding Firearms Terrorist Attack, and “expected” NWFC to have elements of the Operation Plato action cards in front of them.⁴⁶⁵ Group Manager Levy did not task Michelle Gregson with finding out from GMP whether Operation Plato had been declared. Bearing in mind his thoughts at the time, he should have done so.

Call to Station Manager Berry (23:18)

At 23:18, Group Manager Levy called Station Manager Berry. Station Manager Berry explained his reasoning for selecting Philips Park Fire Station, saying it was “because he didn’t have a rendezvous point or words to the effect of”.⁴⁶⁶ Group Manager Levy stated that he agreed with Station Manager Berry’s decision on the basis of what Station Manager Berry told him.⁴⁶⁷ Group Manager Levy was not aware of GMP having nominated an RVP earlier and Station Manager Berry’s rejection of it. These were significant facts that Group Manager Levy did not have when he concluded during this call that Station Manager Berry had made the correct mobilisation decision.⁴⁶⁸

Station Manager Berry should not have told Group Manager Levy that there was no RVP. He should have told Group Manager Levy about the GMP RVP.

Station Manager Berry also informed Group Manager Levy that he had been unable to get hold of the FDO, but would keep trying.⁴⁶⁹ Station Manager Berry stated that, in his call with Group Manager Levy, he had asked Group Manager Levy to make his own efforts to contact the FDO.⁴⁷⁰ Group Manager Levy stated that he had not understood that Station Manager Berry was experiencing a real problem getting through.⁴⁷¹

In my view, Station Manager Berry did not make the extent of the difficulty he was having getting through to the FDO sufficiently clear to Group Manager Levy. This was a failing on Station Manager Berry’s part. Group Manager Levy assumed that Station Manager Berry had been informed of the incident at the same time that he had.⁴⁷² The way Station Manager Berry spoke in this call did not dispel that assumption.

There was no reason for Group Manager Levy not to have made his own attempt to contact the FDO, if he had been asked to or had realised that Station Manager Berry was experiencing substantial problems doing so himself. Group Manager Levy was a conscientious and highly experienced NILO.⁴⁷³

I accept Group Manager Levy’s evidence when he stated:
“I’d been a NILO for many years at that point and made many telephone calls to the force duty officer. I had two telephone numbers for the force duty officer on my phone and I think with the experience I’ve had, had another NILO said to me, ‘I cannot get through to the force duty officer, please will you try’, I’d have considered that quite significant and that would have been quite an early warning sign.”⁴⁷⁴

Following his call with Station Manager Berry at 23:21, Group Manager Levy spoke to Station Manager Lawlor. I shall deal with this call when I come to Station Manager Lawlor’s involvement in paragraphs 15.394 and 15.395.

Call to Group Manager Nankivell (23:26)

At 23:26, Group Manager Levy telephoned Group Manager Nankivell. He told Group Manager Nankivell that he was on his way to Philips Park Fire Station. Group Manager Nankivell said that he wanted all messages to go through NWFC.⁴⁷⁵

Group Manager Levy arrived at Philips Park Fire Station fewer than ten minutes after this call, at almost exactly 23:35.⁴⁷⁶

Mobilisation of Contingency Planning Unit manager

Group Manager Fletcher was the manager of the Contingency Planning Unit at GMFRS. In that role, he was in charge of GMFRS’s NILO capability. Group Manager Fletcher was also a NILO.⁴⁷⁷ Group Manager Fletcher received notification of the Attack through a message sent to a GMFRS NILO WhatsApp group at 23:02.⁴⁷⁸

Call to Station Manager Berry (23:13)

At 23:13, Group Manager Fletcher called Station Manager Berry. The call lasted two and a half minutes. As the person in charge of the Contingency Planning Unit, Group Manager Fletcher was Station Manager Berry’s line manager.⁴⁷⁹ Station Manager Berry stated that he had a high regard for Group Manager Fletcher and trusted him.⁴⁸⁰

Station Manager Berry began by informing Group Manager Fletcher “that it was a bomb and an active shooter”.⁴⁸¹ Group Manager Fletcher replied that he had not seen anything about either. Station Manager Berry stated that it was both. The reference to “active shooter” had come from the Control Room Operator Dean Casey in the call with Station Manager Berry at 22:48.

Just prior to this call, the Control Room Operator David Ellis had, in fact, just entered new information onto the Arena log: “*** FROM THE POLICE – NOT GUNSHOT WOUNDS LOOKS LIKS [sic] SHRAPNEL ****”.⁴⁸² As I set out in paragraphs 15.87 to 15.104, Dean Casey did not pass this information on. Nor was it passed on to Station Manager Berry in his call with Vanessa Ennis at 22:52 or in his call with Joanne Haslam at 22:57.

The picture which had developed in Station Manager Berry’s mind was that he was organising the GMFRS response to a Marauding Terrorist Firearms Attack. He thought that the explosion at the Arena may be a prelude to such an attack.⁴⁸³ At the time, he thought the attack would be “multi-seated”.⁴⁸⁴ The NILO training at the time had a focus on multi‑seated attacks, such as those in Paris and Mumbai, so it was reasonable for Station Manager Berry to include in his consideration the possibility that a Marauding Terrorist Firearms Attack might be under way.⁴⁸⁵ Being informed that there were reports of “an active shooter” would inevitably increase the likelihood that it was a Marauding Terrorist Firearms Attack in Station Manager Berry’s mind.

It is well recognised that false or exaggerated information can be provided on a well‑intentioned basis in the early stages of a Major Incident. It was important for Station Manager Berry to remain open‑minded. It was also important for him to seek regular updates from NWFC as the intelligence picture was capable of developing by the minute.

Finding out what mobilisation decisions other emergency services were making was capable of improving Station Manager Berry’s decision‑making. He should also have tried to find out the situational awareness of other emergency services beyond GMP. There was no good reason why he did not try and contact his equivalent at NWAS. He should also have attempted to hear BTP’s view. It was important that Station Manager Berry should challenge his own assumptions.

In his call with Group Manager Fletcher at 23:13, Station Manager Berry set out his mobilisation decision.⁴⁸⁶ Group Manager Fletcher asked Station Manager Berry why he had selected Philips Park Fire Station rather than Manchester Central Fire Station. Station Manager Berry’s reply was that Manchester Central Fire Station was “too close, the MTFA [Marauding Terrorist Firearms Attack], I know the area … I used to work there”.⁴⁸⁷ Group Manager Fletcher stated that he may have told Station Manager Berry that he would have used Manchester Central Fire Station.⁴⁸⁸

Group Manager Fletcher also stated in evidence that he did not challenge Station Manager Berry’s selection of Philips Park Fire Station. He stated that he had been told that “it was a bomb and an MTFA, this was going down the Plato response, it was a specialist response that we would need to go in”.⁴⁸⁹ He stated that GMFRS needed to wait for the identification of the FCP, “which we were expecting to come fairly quickly”.⁴⁹⁰

Group Manager Fletcher stated that he was not told about the GMP RVP.⁴⁹¹ Station Manager Berry stated that he did inform Group Manager Fletcher of the GMP RVP.⁴⁹² For a number of reasons, I prefer Group Manager Fletcher’s evidence. First, from the outset Station Manager Berry had rejected the GMP RVP as an appropriate location. This provides an explanation for why Station Manager Berry would not mention what was otherwise important information. Second, Group Manager Fletcher gave persuasive evidence about his own thought process and what his reaction would have been if he had known about the RVP. Third, Group Manager Fletcher’s evidence is consistent with Group Manager Meakin and Group Manager Levy’s evidence that they were not told about the GMP RVP by Station Manager Berry in conversations at around the same time.⁴⁹³

Station Manager Berry should have told Group Manager Fletcher about the GMP RVP. Group Manager Fletcher stated that if he had known of the GMP RVP he may have told Station Manager Berry to mobilise to that location or he would have told him to use Manchester Central Fire Station.⁴⁹⁴ I accept Group Manager Fletcher’s evidence. If Station Manager Berry had told him about the GMP RVP, it is likely that GMFRS appliances would have been moved to within one mile of the Arena by 23:30. From that position, it is probable that GMFRS would have deployed to the Victoria Exchange Complex sooner than they did.

In the course of the call, Station Manager Berry asked Group Manager Fletcher to contact the FDO. Station Manager Berry said that he was having real difficulties contacting the FDO and was having problems on his journey.⁴⁹⁵ Group Manager Fletcher said that he would try the FDO for him “to take some of that load off him”.⁴⁹⁶ Group Manager Fletcher called the number he had for the FDO “a couple of times” before his call with Group Manager Nankivell and “several times” after that, but the line was engaged and there was no voicemail facility.⁴⁹⁷

Group Manager Fletcher stated that Station Manager Berry seemed significantly distressed and frustrated on the telephone call, due to the problems he was having on his journey.⁴⁹⁸

Call to Station Manager Lawlor (23:16)

After his call with Station Manager Berry, Group Manager Fletcher called Station Manager Lawlor at 23:16. Group Manager Fletcher gave Station Manager Lawlor a short briefing. Group Manager Fletcher said that he planned to go to the Command Support Room. They discussed Station Manager Lawlor travelling to GMP HQ instead.⁴⁹⁹

It was a good idea for Station Manager Lawlor to go to GMP HQ. If Chief Fire Officer O’Reilly had decided to go to GMP HQ, as was the expectation of some, Station Manager Lawlor’s attendance there would have been less significant. Station Manager Lawlor was not on duty or on call, but he was able to respond to the incident. GMFRS accepted in the Inquiry that it should have had a plan, specifying in advance, who would go to GMP HQ in the event of a Major Incident.⁵⁰⁰ I agree. Either the duty Principal Officer should go or he should nominate another senior officer who could get there sooner or at about the same time.

Call to Group Manager Nankivell (23:18)

Group Manager Fletcher called Group Manager Nankivell at 23:18. He informed Group Manager Nankivell of his intention to travel to the Command Support Room. Group Manager Fletcher was being cautious about self‑mobilising, as self‑mobilisation can lead to confusion about command structures and deployments. Group Manager Nankivell approved of Group Manager Fletcher’s plan to go to the Command Support Room, which he described as “a right move, a good move so far as I was concerned”.⁵⁰¹ Group Manager Nankivell regarded Group Manager Fletcher as having a good knowledge of NILOs, the FDO, Operation Plato and the Airwave radio network used by emergency services. Group Manager Nankivell instructed Group Manager Fletcher not to make any decisions without informing him first.⁵⁰²

During Group Manager Fletcher’s call with Group Manager Nankivell, at 23:18, a GMFRS NILO posted on the NILO WhatsApp group: “Just on inet Dave it looks really bad. Police are reporting minimum number of 18 fatalities! Dean is DGM [duty Group Manager] and I think opening CSR [Command Support Room]. Andy Berry in NILO and stepping up MTFA [Marauding Terrorist Firearms Attack] capability.”⁵⁰³

The reference to “inet” was to iNet, NWFC’s incident log system.⁵⁰⁴ I explained in paragraph 15.312 why GMFRS officers should have considered checking iNet, in the early stages of their involvement in the incident. It was an opportunity to gain situational awareness.

Shortly after his call with Group Manager Nankivell, Group Manager Fletcher set off for the Command Support Room under blue lights.⁵⁰⁵ Near the start of his journey, at 23:25, Janine Carden at NWFC telephoned him. I dealt with this call in paragraphs 15.168 to 15.172 in respect of NWFC’s response to the Attack.

Call from Station Manager Lawlor (23:26)

Station Manager Lawlor called Group Manager Fletcher at 23:26. Group Manager Fletcher confirmed the plan they had agreed in their previous call.⁵⁰⁶

By this stage, Station Manager Lawlor had spoken to Group Manager Levy, as I will set out in paragraphs 15.402 to 15.403. Group Manager Levy said that he was making his way to Philips Park Fire Station. Station Manager Lawlor believed that this was “a second rendezvous point for other resources”.⁵⁰⁷ He assumed at this time that GMFRS “would have had resources there [at the scene]”.⁵⁰⁸ As a result, he did not query the use of Philips Park Fire Station.⁵⁰⁹

Call to Station Manager Berry (23:37)

At 23:37, Group Manager Fletcher called Station Manager Berry. They discussed the FDO and the fact that neither of them had managed to get through to him. They discussed whether this incident was a “Paris-type scenario”.⁵¹⁰ This was a reference to the multi‑seated terrorist attack in Paris in November 2015. As a result, Group Manager Fletcher decided that a further crew with Marauding Terrorist Firearms Attack capability needed to be put on standby.⁵¹¹

By the end of this call, Station Manager Berry had nearly reached Philips Park Fire Station.⁵¹²

Call to Area Manager Etches (23:40)

As a result of his discussion with Station Manager Berry, Group Manager Fletcher telephoned Area Manager Etches and advised that a further crew with Marauding Terrorist Firearms Attack capability should be put on standby.⁵¹³

Group Manager Fletcher arrived at the Command Support Room about ten minutes after this call, at 23:49.⁵¹⁴

Mobilisation of NILO lead

Station Manager Lawlor was the NILO lead for GMFRS and the North West region. He was the GMFRS single point of contact around contingency planning, working with multi‑agency liaison officers in GMP HQ. He had been embedded for a number of years in Counter Terrorism Policing North West at GMP HQ.

For the majority of the time, Station Manager Lawlor worked at GMP HQ.⁵¹⁵ Station Manager Lawlor was not on duty on the night of 22^nd May 2017. He was at home asleep following an 80‑hour on‑call weekend.⁵¹⁶ He was woken up by the NILO WhatsApp group messages sent at 23:02 and 23:08. Five minutes after the second WhatsApp message was sent, Station Manager Lawlor attempted to speak to Station Manager Berry. The two calls he made did not connect. This was because Station Manager Berry was on the telephone to Group Manager Fletcher at that time.⁵¹⁷

Call from Group Manager Levy (23:21)

As I set out in paragraphs 15.388 to 15.389 and 15.394 to 15.395, Station Manager Lawlor spoke to Group Manager Fletcher at 23:16 and 23:26. Between those calls, at 23:18, Station Manager Lawlor received a call from Group Manager Levy. It lasted just under three minutes.

Group Manager Levy said that he was travelling to Philips Park Fire Station. They agreed to speak on the NILO talk group. Station Manager Lawlor did not query the choice of Philips Park Fire Station as a muster point.⁵¹⁸

Call to Group Manager Fletcher (23:33)

At 23:33, Station Manager Lawlor called Group Manager Fletcher. Station Manager Lawlor had already spoken to Group Manager Fletcher at 23:16 and 23:26. The purpose of this call was to let Group Manager Fletcher know that Station Manager Lawlor was leaving his house.⁵¹⁹

Call to NWFC (23:35)

Two minutes after calling Group Manager Fletcher, Station Manager Lawlor called NWFC to notify the control room that he was on his way to GMP HQ. In the course of this call, Station Manager Lawlor did not ask NWFC for any information about the incident. When asked why he had not, he stated: “I do know from historic events or incidents how busy North West Fire Control can be, and officers phoning them up for various bits of information. I do know how impactive that can be on North West Fire Control.”⁵²⁰

Station Manager Lawlor was implying that a reason for GMFRS officers not to ask for information was because of a concern that it interrupted NWFC at busy times. If this is a widely held view and/or the explanation for why any of the GMFRS officers did not ask for information when speaking to NWFC, both GMFRS and NWFC must move swiftly to address it.

The time it takes for information or an update to be given during a Major Incident can be reduced through at least two routes. First, through the appropriate GMFRS use of the iNet system. Second, by improvements to the way in which key information is captured and stored on the NWFC incident logs.

Station Manager Lawlor should have asked NWFC for an update. He should also have been offered an update by the Control Room Operator to whom he spoke.

Station Manager Lawlor was going to GMP HQ to represent GMFRS as a liaison officer. He had obtained relatively little information from Group Manager Fletcher and Group Manager Levy. So low was the level of his understanding of the incident that he mistakenly believed that GMFRS had resources at the scene. He did not appreciate that the explosion had been caused by a terrorist.⁵²¹ Station Manager Lawlor stated that, had he realised that GMFRS had not mobilised to the scene, he “would have definitely been making more phone calls to the people who were attending or mobilised the on-call officers”.⁵²²

Philips Park Fire Station (23:00 to 23:53)

Having set out in some detail how the GMFRS senior officers came to be mobilised, I return to consider the situation at Philips Park Fire Station.

Four original fire appliances

By 23:00, the four fire appliances Station Manager Berry had requested to muster at Philips Park Fire Station were present at the station.⁵²³ Watch Manager Simister was on board one of those fire appliances. He had come from Manchester Central Fire Station. Another contained Crew Manager Mottram, who had come from Gorton Fire Station.

Shortly after he arrived at Philips Park Fire Station, Crew Manager Mottram received a second telephone call from Helen Mottram. She informed him: “[I]t’s some form of nail bomb, there was several fatalities and at least 60 casualties, and that they were proceeding to the scene.”⁵²⁴ Crew Manager Mottram understandably described himself as feeling “[v]ery frustrated that we weren’t there as well”.⁵²⁵

Watch Manager Simister made two calls to NWFC after he arrived at Philips Park Fire Station: one at 23:06 and one at 23:25. In the first, Watch Manager Simister told NWFC that he had seen ambulances arriving at Manchester Central Fire Station. In the second, having spoken to Crew Manager Mottram,⁵²⁶ Watch Manager Simister informed NWFC that there was “a fireman here whose wife is a paramedic and she’s on scene”.⁵²⁷

Arrival of first Specialist Response Team appliance (23:21)

Between the two calls from Watch Manager Simister to NWFC, Watch Manager Nolan arrived at Philips Park Fire Station at 23:21, on the Specialist Response Team appliance.⁵²⁸ By 23:25, Watch Manager Nolan regarded his Specialist Response Team crew as ready to deploy to an incident.⁵²⁹

Arrival of Group Manager Meakin (23:25)

Group Manager Meakin arrived at Philips Park Fire Station at approximately 23:25.⁵³⁰ On arrival, he spoke to Watch Manager Simister. Group Manager Meakin was told by Watch Manager Simister that there were ambulances at Manchester Central Fire Station. Group Manager Meakin accepted that he did not know whether Station Manager Berry knew this information.⁵³¹ Station Manager Berry did not know this information at that time.

Group Manager Meakin then called NWFC at 23:28.⁵³² I rehearsed the detail of that call in paragraphs 15.174 to 15.178. Group Manager Meakin informed NWFC what he had been told by Watch Manager Simister.

When asked during his evidence why he did not act upon the information given to him by Watch Manager Simister, Group Manager Meakin described the information from NWFC as being “conveyed in an assured tone”.⁵³³ He stated that he thought that Station Manager Berry had chosen Philips Park Fire Station “based on intel that he’d potentially got from the FDO”.⁵³⁴

Group Manager Meakin was asked whether the information Lisa Owen did not pass on to him in that call, about the police and paramedics, would have changed his decision‑making. Group Manager Meakin’s evidence was that he would have contacted Station Manager Berry to provide him with that information if he had received it from Lisa Owen.⁵³⁵ I accept his evidence on this point. Had he contacted Station Manager Berry, it is possible that he and Station Manager Berry would have agreed immediately to mobilise to the scene or, at the very least, send a firefighter back to Manchester Central Fire Station to investigate further.

When asked why, in that call, he asked NWFC for instructions, Group Manager Meakin stated:
“My belief at that time was that Andy Berry, as the duty NILO, would be or was in touch with [the] force duty officer. I was surprised on arrival at Philips Park that I was the first one and that there was no further information that came during that journey from any of the officers who had been mobilised. I asked that question because I was keen, having got there, for us to be able to deploy.”⁵³⁶

Group Manager Meakin was asked during his evidence who the Incident Commander was at this stage. He stated that at that time there were three advisers, the NILOs, but no Incident Commander.⁵³⁷ Under GMFRS’s approach at the time, Group Manager Meakin was correct.⁵³⁸ No GMFRS officer had reached the incident ground. Consequently, no GMFRS officer had become Incident Commander.

Group Manager Meakin was asked in evidence whether, at this stage, it would have been a reckless decision to have deployed staff in ballistic personal protective equipment (PPE) to Manchester Central Fire Station. He stated that it would not have been a reckless decision. He accepted that it would have been a reasonable decision. I agree and go further. In my view, Group Manager Meakin should have given that direction. There was no good reason not to. It would have resulted in co‑location between GMFRS and NWAS for the first time. From this, situational awareness could have been shared.

In evidence, Group Manager Meakin agreed that if he had deployed specialist resources forward to Manchester Central Fire Station at 23:30, they would have discovered that there were ambulances at the scene. He was correct about this.

At 23:40, NWAS Ambulance A720 pulled up on the forecourt of Manchester Central Fire Station. It remained there for just under an hour. It had been allocated to the NWAS response to the Attack and was using Manchester Central Fire Station as an RVP, while it waited to be called forward. At 00:37 on 23^rd May 2017, it left Manchester Central Fire Station and travelled to the Victoria Exchange Complex.⁵³⁹ Ambulance A720 was not the only NWAS vehicle to use Manchester Central Fire Station during this period.

I have no doubt that any firefighter who had gone to Manchester Central Fire Station would have spoken to the NWAS staff in Ambulance A720. They would have immediately discovered that NWAS was sending ambulances to Hunts Bank in significant numbers and had been for over an hour.

At 23:33, Group Manager Meakin called Station Manager Berry. Station Manager Berry reported to Group Manager Meakin that he was having “some difficulties” getting hold of the FDO.⁵⁴⁰

Station Manager Berry stated that he gave Group Manager Meakin “the information that I had” in that call.⁵⁴¹ Group Manager Meakin stated he was not told about the rejected GMP RVP. Group Manager Meakin stated that he would have regarded this information as important. He stated that, in the absence of contact with the FDO, he would have expected GMFRS to deploy to the GMP RVP.⁵⁴²

I accept Group Manager Meakin’s evidence on this point. I am satisfied that he would have regarded information about the GMP RVP as sufficiently important to have remembered being told. In my view, Station Manager Berry had dismissed that GMP RVP from his mind at an early stage and, in common with conversations he had with other GMFRS officers, he did not mention it to Group Manager Meakin. He should have done so. It was capable of informing Group Manager Meakin’s approach to the incident. Telling him may have resulted in an earlier mobilisation from Philips Park Fire Station.

At some point between 23:25 and 23:34, Crew Manager Mottram tried to tell Group Manager Meakin what he had learned from Helen Mottram. Group Manager Meakin said that he could not speak to Crew Manager Mottram because he was busy.⁵⁴³ I am not critical of Group Manager Meakin for not speaking to Crew Manager Mottram during the time when Group Manager Meakin was the only NILO at Philips Park Fire Station. This was a period of fewer than ten minutes, during which Group Manager Meakin spoke to Watch Manager Simister, NWFC and Station Manager Berry. Group Manager Meakin also spoke to Watch Manager Nolan, who said that there were ten Specialist Response Team responders ready to deploy.⁵⁴⁴ I can, however, understand that Crew Manager Mottram would have felt considerable frustration about not being able to tell Group Manager Meakin the important information he had.⁵⁴⁵

GMFRS incident command (23:30)

Before dealing with the arrival of the other NILOs at Philips Park Fire Station, it is worth pausing to take stock of where GMFRS had reached in terms of incident command at 23:30.

A number of watch managers and crew managers had mustered at Philips Park Fire Station. Each was capable of being the Incident Commander under the GMFRS command policy. The most senior would have become Incident Commander upon arrival on the incident ground. This rule did not apply automatically to arrival at RVPs.⁵⁴⁶

Station Manager Berry had made some initial mobilisation decisions as the NILO but was still travelling to Philips Park Fire Station at this time. His role was advisory. Group Manager Meakin had arrived but was also in an advisory role. Group Manager Levy was still en route. He was also an adviser.

Group Manager Nankivell, as duty Group Manager, had a support role. Area Manager Etches, who at this time had just arrived at the Command Support Room, also had a support role as duty Assistant Principal Officer. Chief Fire Officer O’Reilly, as duty Principal Officer, had a strategic responsibility for the whole of GMFRS. He had not, by this time, arrived at the Command Support Room.

Two other senior GMFRS officers, the Contingency Planning Unit manager and the NILO lead, had put themselves on duty and been mobilised. Neither was intending to attend the scene. Neither was the Incident Commander.

The standard response time for GMFRS is six minutes.⁵⁴⁷ This is measured from the time resources are mobilised by NWFC to the arrival of the first appliance on the incident ground.⁵⁴⁸

It is astonishing and completely unacceptable that, one hour after the explosion, GMFRS did not have an Incident Commander. Between two Station Managers, four Group Managers, an Area Manager and the Chief Fire Officer, all of whom were participating in the response, not one was in charge of the response to the incident nor did they attempt to take charge.

The incident needed to be gripped by one person who regarded themselves as responsible for the GMFRS response.⁵⁴⁹ In the case of the Group Managers and above, any of them was of sufficient seniority to decide to grip the incident, given that the GMFRS response had clearly stalled. Each could have authorised the mobilisation of GMFRS resources towards the Arena shortly after they became involved. I shall return to the question of why they did not at the conclusion of this section.

Arrival of Group Manager Levy (23:35)

Group Manager Levy arrived at Philips Park Fire Station at 23:35. On arrival, Group Manager Levy saw the NILO WhatsApp group messages.⁵⁵⁰

Arrival of Station Manager Berry (23:40)

Station Manager Berry arrived at Philips Park Fire Station five minutes later, at 23:40.⁵⁵¹ At the time of Station Manager Berry’s arrival, there were four standard fire appliances, two Specialist Response Team appliances, the Technical Response Unit appliance, the Major Response Unit appliance and three NILOs assembled at Philips Park Fire Station.⁵⁵²

Crew Manager Mottram stated that he “told the NILOs” that ambulances were being deployed to the scene.⁵⁵³ Group Manager Levy stated that he did not recall being told that. He stated that it was “quite possible” that he was told that information but in the midst of everything that was happening and everything he was being told he just missed it.⁵⁵⁴

I accept Crew Manager Mottram’s evidence that he told the NILOs that ambulances were going to the scene. I also accept Group Manager Levy’s evidence that, in what was becoming a heated and difficult environment,⁵⁵⁵ Group Manager Levy and the other NILOs did not register that information. I accept Group Manager Levy’s evidence that he would have been “quite strong in … [his] reaction” if he had registered what Crew Manager Mottram was saying.⁵⁵⁶

At 23:42, Group Manager Meakin spoke to Area Manager Etches on the telephone for just over two minutes.⁵⁵⁷ The purpose of Group Manager Meakin’s call was to try to obtain some information from the Command Support Room. Group Manager Meakin told Area Manager Etches that ambulances were at Manchester Central Fire Station. In light of what he was told, Area Manager Etches should have encouraged Group Manager Meakin to send at least some resources to Manchester Central Fire Station. He did not. He stated, “All the energy was around communication with GMP.”⁵⁵⁸

Group Manager Levy: Incident Commander (23:45)

Group Manager Levy had always expected that he would be Incident Commander. He was the most experienced of the three NILOs who had been deployed. He was one of the two group managers who had been mobilised. He was an experienced commander.⁵⁵⁹ By 23:45, Group Manager Levy “realised the stresses that Mr Berry had been under over the last hour”.⁵⁶⁰ Group Manager Levy recognised that he was probably fresher and in a better position to take control. At approximately 23:45, Group Manager Levy informed Station Manager Berry that he was taking up the role of Incident Commander.⁵⁶¹

NWFC was notified that Group Manager Levy had assumed the role of Incident Commander in a call he made at 00:15 on 23^rd May 2017.⁵⁶²

Forward Command Post

At 23:46, NWFC called Station Manager Berry. In the course of the call, Group Manager Levy, who was next to Station Manager Berry when the call came in, spoke to NWFC and asked for the location of the Forward Command Post (FCP) to be obtained from GMP. This started a series of calls involving NWFC, GMP Control and NWAS Control. I dealt with these calls in paragraphs 15.179 to 15.199.

While those calls were taking place, at 23:47 Group Manager Meakin switched on the Dictaphone he had on him. It was only on for a few minutes.⁵⁶³ At the start of the recording, Group Manager Meakin spoke to an unidentified individual and asked the person if he had got hold of the FDO yet. Group Manager Levy said that he had spoken to NWFC and asked whether there was an FCP “that we can go and co-locate with police and ambulance”.⁵⁶⁴ During the recording, a firefighter asked Group Manager Meakin: “What’s the chance of us actually going?”⁵⁶⁵ Group Manager Meakin replied: “Well as soon as they declare forward control point we’ll go to wherever that is and then we’ll start getting people into the warm zone.”⁵⁶⁶

During the period when Group Manager Meakin’s Dictaphone was recording, at 23:50, Station Manager Berry got through on the FDO’s telephone line. He spoke to David Myerscough, a member of police support staff. I dealt with how David Myerscough came to be answering the FDO line in Part 13, in the section in which I addressed GMP’s response to the Attack. I repeat that there is no criticism of David Myerscough in this regard.

Station Manager Berry’s conversation with David Myerscough was unsatisfactory. This was due to the fact that David Myerscough should not have been answering the FDO’s telephone line. Station Manager Berry asked for an FCP. David Myerscough replied, “I think they’ve been liaising at the Cathedral.”⁵⁶⁷ This was in reference to the GMP RVP, which Inspector Smith had declared but then replaced minutes later.⁵⁶⁸

Station Manager Berry rejected this, saying, “[W]e’ll need somewhere to go … and co-locate with the ambulance service.”⁵⁶⁹ David Myerscough said that he would ask a colleague. When he returned, David Myerscough said: “Nothing at the moment but it’s being updated.”⁵⁷⁰ Station Manager Berry replied: “We’re not going to deploy anywhere until we have a nailed-on co-location point … a forward control point.”⁵⁷¹

David Myerscough suggested GMP HQ, to which Station Manager Berry responded, “[T]hat might be an RV but we need a forward control point.”⁵⁷² The call concluded with David Myerscough saying that he had spoken to “the Inspector”. He asked GMFRS to go to “the Old Boddington’s car park, near the Arena”.⁵⁷³ Station Manager Berry said: “The ambulance service apparently are at Thompson Street [Manchester Central] Fire Station … We’re going to muster there.”⁵⁷⁴

Station Manager Berry’s evidence about this call was that: “The person at the other end of the phone didn’t seem to know what I was talking about, so it made it difficult … So I wasn’t really convinced the information was right.”⁵⁷⁵ Station Manager Berry stated that he “didn’t think at the time” to ask to speak to the FDO or the Force Duty Supervisor.⁵⁷⁶

The call was highly unsatisfactory from Station Manager Berry’s point of view. However, it was inappropriate for him to reject a location given to him by GMP on the FDO phone line and end the call simply by telling the person he was speaking to what GMFRS was doing. At the point at which Station Manager Berry realised he was not speaking to someone whom he could rely upon, he should have asked to speak to someone more senior.

JESIP requires co‑location. It requires co‑ordination. Station Manager Berry knew this was a terrorist attack. When he arrived at Philips Park Fire Station, Station Manager Berry still believed that there was a gun battle going on in the City of Manchester. This was his state of mind because “No one has told me there was not a gun battle going on.”⁵⁷⁷ GMP was the lead agency. Station Manager Berry had been trying for over an hour to speak to GMP. It was his responsibility to ensure that he obtained information that he regarded as reliable and could act upon. The resolution of this telephone call by Station Manager Berry was the antithesis of JESIP.

I am critical of Station Manager Berry for the way he approached the call with David Myerscough. I am also critical of GMP for putting David Myerscough, and therefore Station Manager Berry as well, in that difficult position. Station Manager Berry was correct to perceive that David Myerscough was out of his depth. It was this fact that generated the response from Station Manager Berry. I have no doubt that, if Station Manager Berry had managed to speak to the FDO or Force Duty Supervisor, he would have accepted what he was told by them. At that stage in the evening, it is likely that the FDO or Force Duty Supervisor would have made clear that it was safe enough for at least specialist resources to be at the Victoria Exchange Complex.

While Station Manager Berry was speaking to David Myerscough, NWFC called Group Manager Levy at 23:52 and informed him that NWAS had advised that their ambulances were rendezvousing at Manchester Central Fire Station.⁵⁷⁸

Immediately following this call at 23:53, Group Manager Levy called Chief Fire Officer O’Reilly. By this time Chief Fire Officer O’Reilly had reached the Command Support Room.⁵⁷⁹

Command Support Room (23:40 to 00:05)

Arrival

At 23:40, Area Manager Etches reached GMFRS HQ. Area Manager Etches attracted the attention of a security guard and was let into the building. There was no one else in the Command Support Room and it was in darkness. Area Manager Etches switched on the equipment in the Command Support Room.⁵⁸⁰

It would have been better, as GMFRS recognised in its closing statement, if the job of getting the Command Support Room up and running had fallen to someone other than the duty Assistant Principal Officer while he was involved in responding to a Major Incident.⁵⁸¹ Area Manager Etches had contacted a Command Support Room officer, but Area Manager Etches arrived first. Resolution of this issue is something that GMFRS informed me is under consideration. It should have been resolved before the hearing.

Group Manager Nankivell arrived at the Command Support Room very shortly after Area Manager Etches.⁵⁸² At 23:46, Group Manager Nankivell spoke to Janine Carden at NWFC. I dealt with some of the content of that call in paragraph 15.142. The call lasted 3 minutes.

Group Manager Nankivell began the call by saying, “Just to let you know me and Paul [Etches] are in the command support room now, and the chief is … is two minutes away.”⁵⁸³ As he was concluding the call, he said: “[J]ust to let you know John Fletcher and the Chief are now in the command support room.”⁵⁸⁴ By 23:50, all four senior GMFRS officers who had mobilised to the Command Support Room had arrived.⁵⁸⁵

Two minutes later, Chief Fire Officer O’Reilly sent a text message to Assistant Chief Fire Officer Geoffrey Harris, instructing him to come to the Command Support Room. This text was in reply to an earlier query from Assistant Chief Fire Officer Harris as to whether Chief Fire Officer O’Reilly needed anything.⁵⁸⁶ Chief Fire Officer O’Reilly instructed Assistant Chief Fire Officer Harris to come to the Command Support Room for two reasons. First, because Chief Fire Officer O’Reilly considered at that stage that it was possible that he would deploy to the incident. If that happened, he wanted to make sure that another Principal Officer could go to the Strategic Co‑ordinating Group meeting. Second, Chief Fire Officer O’Reilly regarded Assistant Chief Fire Officer Harris as having substantial experience in dealing with a multiple fatality incident.⁵⁸⁷

Assistant Chief Fire Officer Harris arrived at the Command Support Room at 00:07 on 23^rd May 2017.⁵⁸⁸

Call from Group Manager Levy (23:53)

At 23:53, Group Manager Levy telephoned Chief Fire Officer O’Reilly. Group Manager Levy informed Chief Fire Officer O’Reilly that there were ambulances at Manchester Central Fire Station. Group Manager Levy’s evidence was that he had told Chief Fire Officer O’Reilly that he had decided to mobilise to Manchester Central Fire Station to co‑locate with NWAS and to deploy from there to the scene. Group Manager Levy stated in evidence that he called Chief Fire Officer O’Reilly as the most senior officer involved in the incident because he was about to break protocol. The protocol breach, as Group Manager Levy saw it, was that he was attending an incident without having been mobilised to it by NWFC.⁵⁸⁹

Group Manager Levy also stated that he did not present his decision as a request. He stated: “I don’t know how I would have phrased it, but any recipient of that call would have known this is my decision and this is what we are doing.”⁵⁹⁰ Group Manager Levy’s evidence was that Chief Fire Officer O’Reilly instructed him to wait at Manchester Central Fire Station. He stated that Chief Fire Officer O’Reilly’s instruction “didn’t surprise me” as “I’m moving towards potentially a hot zone, I’m breaking a policy and procedure, I’m taking additional risk”.⁵⁹¹

Chief Fire Officer O’Reilly’s evidence was that he did not realise that Group Manager Levy had assumed command. Chief Fire Officer O’Reilly also disputed that he had told Group Manager Levy to wait at Manchester Central Fire Station. He stated that Group Manager Levy had told him that GMFRS resources were mobilising to Manchester Central Fire Station, to which Chief Fire Officer O’Reilly stated that he had replied: “Absolutely, go for it.”⁵⁹²

Area Manager Etches, who spoke to Group Manager Meakin at 00:01 on 23^rd May 2017, gave the following evidence about the mobilisation from Philips Park Fire Station:
“The decision was to relocate everything to Central. Whether … they were going to find out more information when they got to Central that gave them a richer picture of where people were actually working from, ambulance crews, and for them to take that decision, then I was anticipating when they got to Central, they’d find that golden piece of information that said, right, this is where we are now we need to go.”⁵⁹³

Area Manager Etches stated that, once GMFRS resources reached Manchester Central Fire Station, “[t]hey would find out more”.⁵⁹⁴

Group Manager Fletcher was present with Chief Fire Officer O’Reilly when the conversation between Chief Fire Officer O’Reilly and Group Manager Levy took place. His evidence was:
“Mr Levy informed the chief of the information that was received at Philips Park about ambulances initially turning up at Manchester Central fire station and rendezvousing there, so the decision was made then to co-locate our resources with theirs.”⁵⁹⁵

Group Manager Fletcher’s evidence was that he was “party to one side of a conversation”, in which he thought, “Mr Levy had said that he was incident commander, but what time that was, [he] couldn’t definitely say.”⁵⁹⁶ Group Manager Fletcher was asked whether it was well known by everyone in the Command Support Room that Group Manager Levy was Incident Commander. He stated: “I couldn’t actually say. I think I picked it up on hearsay … but I couldn’t actively state now that I definitely knew Mr Levy at that time was the incident commander.”⁵⁹⁷

In light of all the evidence I heard, I make the following findings about this conversation. First, although Group Manager Levy had assumed incident command at this stage, he did not make this clear to Chief Fire Officer O’Reilly. Given the policy at the time, he should have been more explicit about his decision. Second, Group Manager Levy did not clearly communicate to Chief Fire Officer O’Reilly that it was his intention to go on from Manchester Central Fire Station. This led to a misunderstanding between the two of them, which left Group Manager Levy with the impression that he should not go further than Manchester Central Fire Station.

If Group Manager Levy had said to Chief Fire Officer O’Reilly, ‘I have assumed incident command. I am mobilising to Manchester Central Fire Station. Once there I will deploy some resources forward to the Arena’, the misunderstanding would not have occurred. I accept that this was what Group Manager Levy thought he was conveying, but he failed to do so. As he believed he was Incident Commander, it was Group Manager Levy’s responsibility to challenge Chief Fire Officer O’Reilly if he believed he was being countermanded.

I am satisfied that the other GMFRS officers would have been aware that Chief Fire Officer O’Reilly had given a clear countermand of the intention to go to the scene, if that had occurred. Instead, both Area Manager Etches and Group Manager Fletcher understood that the mobilisation was to Manchester Central only. I am also satisfied that Group Manager Levy misinterpreted Chief Fire Officer O’Reilly’s endorsement of mobilising to Manchester Central Fire Station as an instruction not to go any further.

I acknowledge that Group Manager Levy showed considerable initiative by assuming the position of Incident Commander within minutes of arrival at Philips Park Fire Station. He instigated the chain of events that finally got GMFRS to the scene. He was an impressive officer, who struck me as being highly competent. He was also in a difficult situation which was not of his making. He was doing his best to fix it.

The conversation Group Manager Levy was having was further complicated by the fact that he was speaking not just to the duty Principal Officer but to the Chief Fire Officer. Group Manager Levy perceived Chief Fire Officer O’Reilly to be “authoritative”.⁵⁹⁸ Chief Fire Officer O’Reilly accepted of himself that he could be “autocratic” when a decision needed to be made.⁵⁹⁹

Nevertheless, Group Manager Levy was a senior officer best placed to decide what needed to be done. In order to achieve grip in a chaotic situation, which policy did not provide for, Group Manager Levy needed to speak plainly and firmly. Had he done so, the misunderstanding would not have occurred.

In my view, having considered all of the evidence, if Chief Fire Officer O’Reilly had understood that Group Manager Levy, as Incident Commander, intended to deploy forward from Manchester Central Fire Station, Chief Fire Officer O’Reilly would not have countermanded that deployment at that stage.

Call from Janine Carden (23:58)

Following the broadcast on the proposed multi‑agency control room channel, at 23:58 Janine Carden called Group Manager Fletcher. She also spoke to Group Manager Levy one minute later.⁶⁰⁰

Following these calls, Janine Carden made the following entries on the NWFC incident logs. At 00:01 on 23^rd May 2017, she wrote in the Command Support Room log: “Called on [proposed multi-agency control room talk group] GMP Silver [Control Room] asking if fire or amb monitoring confirmed fire monitoring. GM Fletcher informed and asked for GM Levy to be informed.”⁶⁰¹

At 00:02, she input into the Philips Park log: “Following liaison with Chief Fire Officer O’Reilly and in absence of forward control point being declared by GMP, crews have moved forward to … Thompson Street [Manchester Central Fire Station] to co-locate with ambulance standby.”⁶⁰²

Call to Force Duty Officer (00:03)

At 00:03 on 23^rd May 2017, Group Manager Fletcher got through on the FDO telephone line. His call was answered by David Myerscough. Group Manager Fletcher informed David Myerscough of the following: that the proposed multi‑agency control room talk group was being monitored; that the Command Support Room was open; that Station Manager Lawlor was going to GMP HQ; and that GMFRS was mobilising to Manchester Central Fire Station. Group Manager Fletcher asked for a GMP presence at Manchester Central Fire Station.⁶⁰³

David Myerscough replied that he would speak to the FDO and “see what I can do”.⁶⁰⁴

In the notes made after the incident, Group Manager Fletcher recorded that in this call he asked for an FCP. He wrote: “[D]uring the conversation I asked him if the ‘active shooter’ threat had been neutralised which he was unable to do and I confirmed with him that this time, it was still a viable threat.”⁶⁰⁵ The document is headed: “The log below was commenced on 23 May 2017, whilst events of the incident were still fresh in my mind.”⁶⁰⁶

Group Manager Fletcher did not ask David Myerscough for an FCP. He did not ask David Myerscough about an active shooter. He was not told by David Myerscough that GMP thought an active shooter was still a viable threat. These facts are known because GMP recorded the call. Had the call not been recorded, I would have been adjudicating between Group Manager Fletcher’s account and that of David Myerscough. I have no doubt these notes would have been relied upon in good faith.

I accept Group Manager Fletcher’s explanation that he became confused about this conversation having spoken to others in the immediate aftermath. I accept that it was an honest mistake on his part.⁶⁰⁷ But it was a mistake that could have significantly changed the analysis of this period of the event. If GMP had told GMFRS that there might still be an active shooter, then that would be a good reason for great caution by GMFRS at that stage. As it was, this is not what GMP was telling GMFRS.

This example serves to reinforce the importance of contemporaneous recording of what is said by commanders during a response to a Major Incident. What learning and improvement can be derived from an event is determined by what is understood to have occurred. If changes are made based on a false understanding of events, the necessary alterations to policies and procedures will not be made.

Mobilisation to Manchester Central Fire Station

Philips Park Fire Station to Manchester Central Fire Station (23:55 to 00:05)

Group Manager Levy’s call with Chief Fire Officer O’Reilly ended at around 23:55. This was at the same time as Station Manager Berry’s call with GMP.⁶⁰⁸ Group Manager Levy was not told by Station Manager Berry that GMP had given the Boddingtons car park as an RVP/FCP in that call or that Station Manager Berry had rejected it.⁶⁰⁹ Station Manager Berry should have given Group Manager Levy this information.

At this stage, Station Manager Berry knew that Group Manager Levy was the Incident Commander. I can understand why Station Manager Berry was frustrated by his call with David Myerscough, but, having taken the approach to the call that he did, he should have informed Group Manager Levy what he had been told.

Group Manager Levy’s evidence was that, if he had known what GMP had said about Boddingtons car park, he would have mobilised resources there, but would probably have held some back at Manchester Central Fire Station.⁶¹⁰ I accept Group Manager Levy’s evidence on this point. It would have formed a basis for explaining to Chief Fire Officer O’Reilly why he was going beyond Manchester Central Fire Station, which is what Group Manager Levy wanted to do. The Boddingtons car park was on Trinity Way, diagonally opposite the Trinity Way tunnel exit of the Victoria Exchange Complex.

Following his conversation with Chief Fire Officer O’Reilly at 23:55, Group Manager Levy directed the GMFRS resources at Philips Park Fire Station to mobilise to Manchester Central Fire Station. The first GMFRS appliance to reach Manchester Central Fire Station did so at 00:02 on 23^rd May 2017.⁶¹¹

Station Manager Berry arrived at Manchester Central Fire Station at 00:05. By 00:08, Group Manager Levy was also at Manchester Central Fire Station. At that time, Group Manager Levy called Chief Fire Officer O’Reilly.⁶¹²

Command Support Room (00:05 to 00:18)

Call from Group Manager Levy (00:08)

Shortly before Group Manager Levy called Chief Fire Officer O’Reilly at 00:08 on 23^rd May 2017, Chief Fire Officer O’Reilly had spoken, on the telephone, to the NWAS Chief Executive, Derek Cartwright. In this call, Chief Fire Officer O’Reilly learned that the NWAS Deputy Director of Operations, Stephen Hynes, was at the scene. Stephen Hynes was someone Chief Fire Officer O’Reilly knew. Derek Cartwright told Chief Fire Officer O’Reilly to “Ring Steve, he is at the scene.”⁶¹³ Derek Cartwright informed Chief Fire Officer O’Reilly that NWAS had “one of their … Golds on the way to police headquarters”.⁶¹⁴ This was a reference to the Strategic Commander Neil Barnes.⁶¹⁵

In Group Manager Levy’s call to Chief Fire Officer O’Reilly at 00:08, Group Manager Levy said that he was ready to go from Manchester Central Fire Station to the Victoria Exchange Complex.⁶¹⁶

Call to Stephen Hynes (00:12)

Having learned that Stephen Hynes was at the scene, Chief Fire Officer O’Reilly telephoned him at 00:12. By this stage, Stephen Hynes was the NWAS Operational Commander, having relieved Daniel Smith at 23:57. Chief Fire Officer O’Reilly was outside the Command Support Room when he spoke to Stephen Hynes.⁶¹⁷

Stephen Hynes informed Chief Fire Officer O’Reilly that GMFRS “needed to get down there”.⁶¹⁸ Chief Fire Officer O’Reilly asked Stephen Hynes, “[W]hat did he need?”⁶¹⁹ Stephen Hynes replied that he “just needed 12 firefighters”.⁶²⁰ Chief Fire Officer O’Reilly asked Stephen Hynes if the Marauding Terrorist Firearms Attack crew with ballistic protection was needed. Stephen Hynes responded, “Absolutely not, I just need 12 firefighters … and an officer.”⁶²¹ Chief Fire Officer O’Reilly also recalled that Stephen Hynes added “that the NWAS MTFA [Marauding Terrorist Firearms Attack] resource was still at Manchester Central fire station at the direction of GMP”.⁶²² Stephen Hynes stated that the firefighters were “to help with casualty recovery from the scene”.⁶²³ Chief Fire Officer O’Reilly said, “Leave it with me, I’ll get them there as soon as I can.”⁶²⁴

Stephen Hynes’ recollection of this short conversation was that he said words to the effect “it’s not MTFA Peter. We just require your fire fighters down here.”⁶²⁵ He stated that what he wanted was support in basic trauma and moving equipment such as stretchers or trolleys. In his witness statement he described asking for “12 trauma-trained firefighters and a commander”.⁶²⁶ In fact, as a later message demonstrates, Stephen Hynes wanted “trauma technicians”.⁶²⁷ I will return to the evidence for that and what a trauma technician is in paragraphs 15.518 to 15.525.

Chief Fire Officer O’Reilly did not recall a request for “trauma-trained” firefighters from Stephen Hynes.⁶²⁸

I am unable to resolve exactly what was said in this call. What is clear is that Stephen Hynes stated that support from specialist firefighters was not required by NWAS.

After the call, Chief Fire Officer O’Reilly returned to the Command Support Room.⁶²⁹

Deployment decision

There were five senior GMFRS officers in the Command Support Room at this point. Group Manager Nankivell, Group Manager Fletcher and Area Manager Etches were all of the view that the specialist responders should be sent to the Arena.⁶³⁰ Having spoken to Stephen Hynes, it was Chief Fire Officer O’Reilly’s view that non‑specialists should be sent in.⁶³¹ Assistant Chief Fire Officer Harris, who had arrived at the Command Support Room just before Chief Fire Officer O’Reilly returned to the room, agreed with Chief Fire Officer O’Reilly.⁶³²

The reasoning behind the two positions was explored in the evidence. There were a number of relevant considerations. First, the capabilities of the Specialist Response Team in terms of their enhanced first aid abilities, as against the non‑specialist firefighters. Second, there was the question of hazards. At this stage, those in the Command Support Room were unaware that Operation Plato had been declared. Even so, the possibility that the Specialist Response Team might be able to go into areas that unprotected firefighters could not was also a consideration.

Both those factors were debated. In the end, despite strong professional disagreement, Chief Fire Officer O’Reilly decided to follow Stephen Hynes’ request. This was a difficult decision. The only direct situational awareness was coming from Stephen Hynes who was at the scene. In my view, Chief Fire Officer O’Reilly cannot be criticised for acting upon what he had been told. It is essential that the emergency services work together. Deferring to the NWAS Operational Commander, who had a better situational awareness and a better understanding of what was required, was a reasonable position.

I am not critical of either side of this debate for having a short, professional and robust discussion. It was right that they did so. But a decision needed to be made. In the circumstances, Chief Fire Officer O’Reilly’s decision was a reasonable one at the time he made it.

The problem with the decision to mobilise 12 non‑specialist firefighters and a commander lay with the Operation Plato declaration. At this time, no one in GMFRS knew that Operation Plato had been declared. GMFRS officers were rightly wondering if Operation Plato would be declared, but Chief Fire Officer O’Reilly had raised this with Stephen Hynes, who had dismissed it as a concern. Stephen Hynes had dismissed the need for crews that were ballistically protected because Stephen Hynes did not become aware of the Operation Plato declaration until over half an hour after this discussion.

I do not criticise Chief Fire Officer O’Reilly’s decision on the basis of this problem. Nor do I criticise Stephen Hynes for saying that he did not want Marauding Terrorist Firearms Attack specialists on this basis. Responsibility for this incorrect decision lies with GMP and Inspector Dale Sexton for failing to communicate the Operation Plato declaration. I discuss this in Part 13.

Call to Group Manager Levy (00:15)

At 00:15, Group Manager Levy notified NWFC that he was the Incident Commander. Immediately following this, he made a call to Chief Fire Officer O’Reilly. In that call, Chief Fire Officer O’Reilly informed Group Manager Levy of his conversation with Stephen Hynes. Group Manager Levy queried whether NWAS required operatives with Marauding Terrorist Firearms Attack capability. Chief Fire Officer O’Reilly informed him that Stephen Hynes had said NWAS did not.⁶³³

Chief Fire Officer O’Reilly stated he wanted Group Manager Levy to know as “a courtesy”.⁶³⁴ Chief Fire Officer O’Reilly stated that this was the instruction the Command Support Room was going to give to NWFC for mobilisation. He wanted Group Manager Levy to know what the Command Support Room was asking NWFC to send to the scene.⁶³⁵ Group Manager Levy was not happy with this decision. He challenged it.⁶³⁶

GMFRS policies did not envisage a situation in which the Command Support Room would give mobilisation instructions to the Incident Commander. The policies expected the opposite: the Incident Commander in full command of the incident, with the Command Support Room in a support role. However, GMFRS policies also did not envisage an Incident Commander with only second‑ or third‑ hand situational awareness, none of which came from a commander of another emergency service.

Decisive action was required. Chief Fire Officer O’Reilly had better situational awareness than Group Manager Levy following his conversation with Stephen Hynes. It was reasonable for Chief Fire Officer O’Reilly to direct NWFC to provide Group Manager Levy with a mobilisation instruction. It is regrettable that this mobilisation decision was, for the reason I gave in paragraphs 15.501 to 15.503, flawed.

As Incident Commander, Group Manager Levy did not regard himself as obliged to follow the instruction from Chief Fire Officer O’Reilly. In his mind was the thought “if I’d … disobeyed the chief … and something terrible had happened”.⁶³⁷ Although Group Manager Levy’s plan to mobilise the Specialist Response Team was correct, I am not critical of him for acting upon the instruction he received. It was important that a command hierarchy be maintained. Group Manager Levy was also correct to take the view that Chief Fire Officer O’Reilly might have access to better information than he did.

GMP Headquarters (00:05 to 00:18)

Arrival at GMP Headquarters (00:05)

Station Manager Lawlor made his way from his home to GMP HQ. He arrived at 00:05. This was approximately the same time that firefighters arrived at Manchester Central Fire Station. Station Manager Lawlor made his way to the Silver Control Room. He described the atmosphere in the Silver Control Room as “busy, as you would expect, but no different, really, to any other event that we support in Silver”.⁶³⁸ He took up his place at the desk allocated to GMFRS.⁶³⁹

At approximately 00:15, Station Manager Lawlor was approached by GMP Temporary Superintendent Hill. Temporary Superintendent Hill asked Station Manager Lawlor, “Mick, are you aware of Operation Plato being declared?”⁶⁴⁰ Station Manager Lawlor replied, “[N]o. … When was it declared?”⁶⁴¹ Temporary Superintendent Hill said that he was not sure and would get back to Station Manager Lawlor.⁶⁴² Station Manager Lawlor’s evidence was that Temporary Superintendent Hill informed him in this conversation that: the Arena itself was the Operation Plato hot zone; the Operation Plato warm zone was the outer perimeter of the Arena, still within the Victoria Exchange Complex; and the Operation Plato cold zone was outside the Victoria Exchange Complex.⁶⁴³

Station Manager Lawlor communicated the Operation Plato declaration over the NILO talk group. Station Manager Lawlor’s evidence was that he passed on the information about zoning.⁶⁴⁴ Zoning of the Victoria Exchange Complex is not something that appears in Station Manager Lawlor’s notes in his 00:15 entry. There is no record timed earlier than 04:01 on 23^rd May 2017 in Station Manager Lawlor’s notes about zoning.⁶⁴⁵ Temporary Superintendent Hill stated that he did not have a conversation with anyone about zones until 00:51, at which point he spoke to Chief Inspector (CI) Mark Dexter about zoning.⁶⁴⁶

I am satisfied that Station Manager Lawlor was notified of the zoning after 00:51. I am also satisfied that Station Manager Lawlor did not ask Temporary Superintendent Hill about zoning when Temporary Superintendent Hill first notified him of the Operation Plato declaration at 00:15. Station Manager Lawlor should have asked about zoning when learning of the Operation Plato declaration. This information should have formed part of the information he was giving to the NILOs and the Command Support Room. It was capable of affecting the mobilisation decision. It is likely that if he had asked Temporary Superintendent Hill about zoning at 00:15, Station Manager Lawlor would have prompted GMP to think more rigorously about the zoning of the Victoria Exchange Complex at that stage.

Command Support Room (00:18 to 00:22)

Call from Station Manager Lawlor (00:18)

At 00:18, Station Manager Lawlor telephoned Group Manager Fletcher.⁶⁴⁷ Station Manager Lawlor informed Group Manager Fletcher of the Operation Plato declaration.⁶⁴⁸ Group Manager Fletcher spoke to Chief Fire Officer O’Reilly about deploying the Specialist Response Team in light of the information about Operation Plato.⁶⁴⁹ Chief Fire Officer O’Reilly replied that just the non‑specialist firefighters would be deployed.⁶⁵⁰

Chief Fire Officer O’Reilly’s reasoning for this was as follows. First, he stated that he was responding to the request from NWAS. Second, he stated: “What we wanted – the priority for us – was to have an incident commander there, and that incident commander would then have immediate situational awareness because they would be speaking to ambulance Bronze and … the police Bronze.”⁶⁵¹

Chief Fire Officer O’Reilly’s decision at this stage was flawed.⁶⁵² He should have immediately recognised that, once his non‑specialist firefighters arrived, they might not have been able to assist the paramedics in some areas.⁶⁵³ He was entitled to place substantial weight on Stephen Hynes’ knowledge from the scene. However, the new information demonstrated that Stephen Hynes’ information was incorrect: in the call at 00:12 Stephen Hynes had dismissed the suggestion that this might be a Marauding Terrorist Firearms Attack.

On learning of the Operation Plato declaration, Chief Fire Officer O’Reilly should have mobilised the Specialist Response Team. This would have provided GMFRS with an immediate Operation Plato warm zone capability at the scene, if it were required. Adding to what Stephen Hynes had requested was justified in light of the new information. Waiting for Station Manager Berry to arrive, before potentially discovering that there were areas in which his firefighters could not operate, and only then mobilising resources, had the potential to waste precious time. Which is what, in fact, occurred to a modest degree.

Call to NWFC (00:18)

At 00:18, Group Manager Nankivell telephoned NWFC. In the call, Group Manager Nankivell informed NWFC:
“We’re sending two [fire appliances] … they’re going down now to … Corporation Street to meet with HART … with Andy Berry, is gonna be taking them down there.”⁶⁵⁴

Call to NWFC (00:21)

At 00:21, Group Manager Nankivell spoke to Janine Carden at NWFC. In the course of the call, Janine Carden informed Group Manager Nankivell that NWFC was in the middle of a call with NWAS Control.

In the call between NWFC and NWAS Control, NWAS Control said, “I’ve got a request from our Gold Commander at the scene.”⁶⁵⁵ This was a reference to Stephen Hynes, who was a qualified Strategic/Gold Commander, but was acting as Operational/Bronze Commander.⁶⁵⁶ NWAS Control went on, “Can we have 12 firefighters, equivalent to 3 pumps and one officer … To support the movement of casualties. If possible, trauma technicians … And we want them to go to Victoria Station.”⁶⁵⁷

In her call with Group Manager Nankivell at 00:21, Janine Carden relayed the substance of what NWAS Control was asking for. This included raising the fact that trauma technicians were being requested “if possible”.⁶⁵⁸

Group Manager Nankivell, in evidence, explained what a trauma technician was. He said:
“Trauma technicians are trained to the same level as a firefighter but then they go on a hospital placement or out with a paramedic and they learn the slightly more technical things to do with life-saving interventions.”⁶⁵⁹

Group Manager Nankivell stated: “[W]e tried to have one [a trauma technician] on every appliance, but it didn’t always work out that way.”⁶⁶⁰

After this call, Group Manager Nankivell drew Chief Fire Officer O’Reilly’s attention to the request for trauma technicians. Chief Fire Officer O’Reilly’s recollection of his response to this was that he said: “[E]ven if we wanted to, we wouldn’t be able to get 12 trauma technicians on the one fire engine.”⁶⁶¹

Chief Fire Officer O’Reilly should have paused at this stage to reflect. Again, he had new information. The substance of what he was being asked for was firefighters with greater first aid skills than standard firefighters possessed. It would have been acceptable for him to have telephoned Stephen Hynes to clarify the request that had been made. It would also have been acceptable for him to have deployed the Specialist Response Team, on the basis that they would bring additional first aid skills above those of a trauma technician. What he should not have done is continue on as planned.

Chief Fire Officer O’Reilly accepted during his evidence that he “should have acknowledged” the representations made by Group Manager Nankivell “better”.⁶⁶² He also stated that he “should have made a decision to include an element of the specialist response team in that response to the arena”.⁶⁶³

Mobilisation to Victoria Exchange Complex (00:19 onwards)

Call to NWFC (00:19)

At 00:19, Group Manager Levy called NWFC. He spoke to David Ellis. Group Manager Levy notified NWFC that “Station Manager Berry proceeding to … Rendezvous point … At Corporation Street with [three fire appliances] … All of the resources remaining stand by at Thompson Street [Manchester Central Fire Station].”⁶⁶⁴

Group Manager Levy spoke to Station Manager Berry shortly after this call. He did so just as Station Manager Berry was setting off. Group Manager Levy is likely to have learned of the Operation Plato declaration either over the NILO radio broadcast made by Station Manager Lawlor or from a call he had with Group Manager Fletcher at 00:20.⁶⁶⁵

Group Manager Levy informed Station Manager Berry that Operation Plato had been declared.⁶⁶⁶ Group Manager Levy asked Station Manager Berry to wait. Group Manager Levy instructed Station Manager Berry not to deploy with the standard fire appliances because of the Operation Plato declaration.⁶⁶⁷

Call from Assistant Chief Fire Officer (00:25)

Assistant Chief Fire Officer Harris stated that Group Manager Nankivell, Group Manager Levy and Group Manager Fletcher continued to discuss the potential to mobilise the Marauding Terrorist Firearms Attack capability. Assistant Chief Fire Officer Harris considered that this conversation was not taking into account the information received from Stephen Hynes.⁶⁶⁸

At 00:25, Assistant Chief Fire Officer Harris called Group Manager Levy. Assistant Chief Fire Officer Harris said words to the effect of, “I’ve heard you on the radio, Ben. I know you are trying to be helpful, but we don’t need anything else from you now.”⁶⁶⁹ Group Manager Levy interpreted this as effectively relieving him of command. Assistant Chief Fire Officer Harris’s evidence was that he did not intend it in this way.⁶⁷⁰

By this stage, the pressure that all GMFRS personnel felt under meant that the risk of misunderstanding was high. It was the responsibility of both of these senior officers to guard against this. Both should have expressed themselves with greater clarity and ensured that they had been understood correctly. In particular, if Group Manager Levy considered that he was being relieved of command, he should have asked directly whether this was what was happening. As it was, Assistant Chief Fire Officer Harris was unaware that Group Manager Levy had appointed himself as Incident Commander.

Following the conversation with Assistant Chief Fire Officer Harris, three non‑specialist fire appliances deployed to Station Approach.⁶⁷¹

Group Manager Levy’s initial countermand of the mobilisation instruction was a product of the chaotic position GMFRS was in by this stage. It caused further delay. The lack of clarity around whether Group Manager Levy or Chief Fire Officer O’Reilly was in command meant that conflicting orders were given.

By this stage, the errors that I have identified above had compounded to create an impossible situation for Group Manager Levy. He had rightly put himself in command in an effort to get the response moving. He was also right to recognise that the Operation Plato declaration meant that the Specialist Response Team were the right team to deploy because of their ability to operate in the warm zone. The Specialist Response Team’s enhanced first aid skills were also likely to be an asset.

Simultaneously, Chief Fire Officer O’Reilly was right to regard himself as the person in the best position to make command decisions. However, he failed to adjust his thinking in light of the new information. This led to an impasse with Group Manager Levy.

The situation was resolved by Assistant Chief Fire Officer Harris instructing Group Manager Levy to defer to Chief Fire Officer O’Reilly’s decision.⁶⁷² At this point, Group Manager Levy was left with no real choice. He knew that he did not have the full picture. Two more senior officers, including the head of GMFRS, were insistent on the non‑specialist deployment. That decision was not so obviously wrong as to justify additional protest, which would only delay the GMFRS response further. As a result, I have concluded that Group Manager Levy was correct to adopt the position he did and acquiesce on the deployment of non‑specialists.

Arrival on Station Approach (00:36)

Station Manager Berry travelled to the scene in a GMFRS car in convoy with the fire appliances.⁶⁷³ He made telephone calls during the period between 00:27 and 00:33, involving the Command Support Room, Group Manager Levy and NWFC. Station Manager Berry also spoke to NWAS, in order to establish where the ambulances were located at the scene. The answer from NWAS Control was that the RVP was Manchester Central Fire Station.⁶⁷⁴

Station Manager Berry had been directed to travel to the corner of Miller Street and Corporation Street. Station Manager Berry did not find the ambulances he expected at this location. At 00:33, he spoke to Group Manager Nankivell who told him to go to Hunts Bank.⁶⁷⁵

At 00:36:59, the first fire appliances arrived on Station Approach near the junction with Hunts Bank.⁶⁷⁶ Station Manager Berry arrived seconds later.

Entry to Victoria Exchange Complex (00:43)

At 00:39, Station Manager Berry approached Stephen Hynes outside the War Memorial entrance to Manchester Victoria Railway Station. Also present was CI Dexter. It was apparent to Station Manager Berry that emergency service personnel were operating in that area without ballistic protection. In Station Manager Berry’s mind, this “didn’t add up” with the Operation Plato declaration.⁶⁷⁷

Station Manager Berry asked Stephen Hynes what GMFRS could do to help. Stephen Hynes asked for blankets to be collected and for any GMFRS staff not dealing with that to help with P3 casualties, those who were ‘walking wounded’.⁶⁷⁸ Stephen Hynes informed Station Manager Berry that inside the Victoria Exchange Complex was a “warm zone”.⁶⁷⁹

When Stephen Hynes told Station Manager Berry this, Stephen Hynes did not know that Operation Plato had been declared. What Stephen Hynes was seeking to communicate was that the inside of the Victoria Exchange Complex was an NWAS Major Incident warm zone.⁶⁸⁰ Because Station Manager Berry knew about the Operation Plato declaration, he interpreted it as being an Operation Plato warm zone.⁶⁸¹ This is a clear example of why the use of hot, warm and cold zones for two different emergency responses can create problems.

Station Manager Berry issued an instruction not to go into the Victoria Exchange Complex. He stated in evidence that he did so because what he was seeing in terms of unprotected responders did not add up with an Operation Plato declaration.⁶⁸² This was unduly risk averse and overly cautious in light of the circumstances.

At 00:43, an NWAS paramedic directed a firefighter carrying an oxygen bottle into the railway station through the War Memorial entrance.⁶⁸³ One minute later, GMFRS personnel were spoken to by the NWAS Advanced Paramedic Patrick Ennis on Station Approach outside the War Memorial entrance.⁶⁸⁴ At 00:46, firefighters walked past the War Memorial entrance on Station Approach, carrying an oxygen bottle and a first aid kit.⁶⁸⁵ At 00:47, firefighters were captured on CCTV pulling casualty trolleys along Station Approach in the direction of the War Memorial entrance.⁶⁸⁶ Two minutes later, they wheeled the casualty trolley through the War Memorial entrance into the Victoria Exchange Complex.⁶⁸⁷ By 00:54:39, firefighters were present in the Casualty Clearing Station, near the bottom of the staircase to the raised walkway.⁶⁸⁸ They had understandably decided to enter the complex, notwithstanding Station Manager Berry’s instruction.

At 00:53, Chief Fire Officer O’Reilly telephoned Station Manager Berry. It is not clear whether that call connected. Later in the same minute, Station Manager Berry called Chief Fire Officer O’Reilly back. The call lasted for just under five minutes.⁶⁸⁹ In the initial part of the call, Station Manager Berry informed Chief Fire Officer O’Reilly that he was trying to get information about where he could deploy firefighters. Chief Fire Officer O’Reilly stated that he was surprised at this. His evidence was:
“It came as a real surprise to me that I was getting a phone call at all with regards to the deployment of resources. My expectation would have been that an officer arriving on scene would have spoken to the other two Bronze Commanders on scene, that they would have had a full debrief to give Andy … It would have been my expectation then that what Andy would have done as a result of that … he would have done what we always do in the Fire Service … contacted North West Fire Control … asked for additional resources, based on the hazards and risk that he had been identified to and what the tactical plan was.”⁶⁹⁰

In light of the fact that Chief Fire Officer O’Reilly called Station Manager Berry first, Chief Fire Officer O’Reilly’s evidence that he was surprised to get a call was probably a mis‑recollection on his part. However, the substance of what Chief Fire Officer O’Reilly was saying was that he did not expect an Incident Commander on the incident ground to be asking him about the deployment of resources.

I am less surprised. Chief Fire Officer O’Reilly had intervened to make the mobilisation decision. He had overruled a senior NILO about which resources should be deployed. While I am not critical of him for his initial intervention, his subsequent overruling of Group Manager Levy when the Operation Plato declaration was known created a situation in which Station Manager Berry had resources at the scene that were not suited for all parts of the scene as Station Manager Berry understood it to be.

At 00:54:55, Station Manager Berry approached CI Dexter on Station Approach. CI Dexter had his Dictaphone on, so what was said was recorded. Station Manager Berry asked, “Are you the GMP Bronze?” CI Dexter answered, “Ground Assigned TFC [Tactical Firearms Commander].” Station Manager Berry said, “Sorry, I’ve got the Chief on the phone … We haven’t got ballistic gear on, I need authorisation off our Chief.” CI Dexter responded, “To do what?” Station Manager Berry explained, “To go in the warm zone.” CI Dexter responded: “It’s warm going cold.”⁶⁹¹

Following this exchange, Station Manager Berry offered the phone to CI Dexter so he could speak to Chief Fire Officer O’Reilly. CI Dexter then proceeded to give Chief Fire Officer O’Reilly a briefing, which included:
“[I]t’s purely IED [Improvised Explosive Device] there is no ongoing firearms threat that we are aware of, I’m not going to object to them wearing ballistic protection if that’s what they need to wear but at the minute I would say that, that risk is probably quite low.”⁶⁹²

A little later in the call with Chief Fire Officer O’Reilly, CI Dexter said: “Yeah, I would say there is potential for a second IED albeit it is diminishing so yeah if you go with it, from a firearms point of view at the moment its low.”⁶⁹³

After the conversation ended, Station Manager Berry asked CI Dexter what was said. CI Dexter replied, “[H]e’s on about ballistic protection – I said if you want to wear ballistic protection, wear ballistic protection but there is no firearms threat at the moment.” Station Manager Berry asked, “[W]as he happy with that?” CI Dexter responded, “God knows.”⁶⁹⁴

This conversation demonstrates why Chief Fire Officer O’Reilly was wrong not to send specialists when he discovered that Operation Plato had been declared. The whole point of Operation Plato is to declare zones. This is what keeps the emergency personnel as safe as possible. If Station Manager Berry had had the Specialist Response Team with him, he could have deployed them straight into the “warm zone” when informed of it by Stephen Hynes.

Before Station Manager Berry began to speak to Chief Fire Officer O’Reilly at 00:53, firefighters had already gone into the Victoria Exchange Complex. I found it extraordinary that they had not been directed to do this very shortly after their arrival. The firefighters were less concerned for their own safety than their commanders were. The conversation about entering the railway station with ballistic gear was, by then, academic: most, if not all, of the firefighters were already in the Casualty Clearing Station, despite the instruction that had been given by Station Manager Berry. The firefighters disobeyed the instruction to remain on Station Approach and entered the Victoria Exchange Complex to try to help.

Contribution to emergency response

The firefighters provided support to the paramedics in the Casualty Clearing Station. At 00:43 on 23^rd May 2017, the first firefighter was captured on CCTV assisting NWAS.⁶⁹⁵ By this time, over an hour had passed since the final casualty had been moved from the City Room. By this time, GMFRS could make no contribution to the extraction of casualties from the City Room to the Casualty Clearing Station.

There were still 28 casualties in the Casualty Clearing Station at 00:43 on 23^rd May 2017.⁶⁹⁶ The 13 firefighters were able to make a contribution to support NWAS, despite arriving so late on the scene.

They were too late to offer any assistance to those who died.

I am critical of Chief Fire Officer O’Reilly’s decision not to send the Specialist Response Team to the Victoria Exchange Complex. However, it is important that I acknowledge the fact that, even though those who were sent were non‑ specialists, it did not prevent them from going where they needed to go at the Victoria Exchange Complex, other than for a short period of time immediately after they arrived.

I am not able to say whether the enhanced first aid capabilities of the Specialist Response Team would have made a difference to those in the Casualty Clearing Station. By 00:50 on 23^rd May 2017, there were 21 ambulances at the scene. By 01:40 on 23^rd May 2017, this had risen to 32 ambulances.⁶⁹⁷

However, it took more than two hours from the arrival of GMFRS at the Victoria Exchange Complex for some of those in the Casualty Clearing Station to be moved to hospital.⁶⁹⁸ It is possible that having firefighters with enhanced first aid skills would have freed up NWAS staff to take people to hospital faster. In saying this, I recognise that no additional request for firefighters beyond the initial 13 was made by NWAS.

Conclusion: why it went so wrong for GMFRS

As I stated at the beginning of this section, GMFRS made a frank concession in its closing statement that it would be fair to describe GMFRS as risk averse on 22^nd May 2017.⁶⁹⁹ Having heard the accounts of the GMFRS officers, it is important that I acknowledge that none of them was risk averse in relation to their own personal safety. I have no doubt that every single member of GMFRS who responded on the night was a person possessing significant personal courage.

There is no doubt that GMFRS personnel wanted to join the emergency response. All GMFRS personnel who gave evidence expressed how unhappy they were, and how unsatisfactory they thought the GMFRS response was. There was a substantial quantity of evidence that this dissatisfaction during the period of inertia was being raised passionately by frontline firefighters on the night of the Attack. In the early hours of the morning of 23^rd May 2017, many frontline firefighters turned their backs to Assistant Chief Fire Officer Harris when he came to debrief them.⁷⁰⁰

The apparent aversion to risk lay principally with Station Manager Berry. He had been best placed to get the GMFRS response moving in the right direction, but the effect of his first decision was to direct some resources away from the scene. He assumed at an early stage that GMFRS was responding to marauding terrorists with firearms. His attitude was that, until he received positive evidence to the contrary, he was proceeding on that basis. I have no doubt that he would have given that impression to everyone to whom he spoke.

The NILO training Station Manager Berry received had focused on incidents similar to the Paris 2015 attacks. It was right to do so, as undoubtedly such attacks are the most complex and dangerous to respond to. I have no doubt that Station Manager Berry’s inability to contact the FDO also contributed to his sense that an event of extraordinary proportions was taking place. It was, however, in an information vacuum, that Station Manager Berry overestimated the risk.

The length of Station Manager Berry’s journey compromised his ability to re‑evaluate initial decisions and consider alternative options. It would have been better if Station Manager Berry had discharged his responsibilities from home.

There was an apparent unwillingness by other senior officers to intervene as time passed. This was a different sort of aversion to risk. It was an aversion not to danger but to stepping outside of their role.

The unavailability of the FDO played a very significant role. Even allowing for this, the response of an entire fire and rescue service should not stall just because one person does not answer the telephone. The lack of the use of an alternative route to getting key information was striking. GMFRS should have identified multiple alternative routes before the night of the Attack. Speaking to the GMP Tactical/Silver Commander or the GMP Strategic/Gold Commander should have been well established as a means of communicating. Even if they were not the subject of pre‑planning, these routes should have occurred to someone from GMFRS on the night of the Attack. They did not.

When the FDO was unavailable, obtaining information from GMFRS’s partner agencies should have been a previously well‑used route to gaining situational awareness. It did not occur to anyone from GMFRS to find out whether NWAS or BTP had spoken to the FDO. Nor did it occur to anyone at GMFRS to find out where BTP and NWAS were sending their personnel. If this latter question had been asked, GMFRS would quickly have realised that it should mobilise resources to the Victoria Exchange Complex.

Finally, the approach to the appointment of the Incident Commander was exposed as being flawed in these circumstances. Relying on arrival at the incident ground as a trigger to appointment is a system that works well for GMFRS’s daily activity. It is extraordinary that no one in GMFRS prior to 22^nd May 2017 thought to ask how GMFRS would respond if it did not mobilise to the scene. It meant that, until Group Manager Levy’s intervention at around 23:45, no one from GMFRS regarded themselves as being in command of the incident response. This meant that all momentum was lost.