Hillsborough – systemic lessons from “the blunder upon opening the gate”

“It could have been done if I’d had any warning that that’s what we was going to do, we could have done that and we could have diverted them around the other pens, which is the other side of the stand. That’s with some warning. But we never had any warning…I would have expected a warning from them [police control]. If nothing was received, they could have sent someone to my position and passed the message on verbally that the gate was going to be opened.” – Goldring Inquest evidence of William Crawford, Sergeant overseeing Serial 14 on the concourse side of the West terracing turnstiles, explaining why his serial did not fall back from the turnstiles to block the central tunnel to pens 3 and 4 before Exit Gate C was fatally opened.

“That is fair.  I was there and no information was passed out, no information came my way.  I cannot react to what I’m not told…All I’d have to do is bring two to four men back [to block the central tunnel] initially.  The gates would have been shut and then it’s a matter of just deviating them around the corner.” – Goldring Inquest evidence of Harry White, Inspector commanding Serials 14 & 15 on the concourse side of the West stand/terracing turnstiles.

A rare digression from structural/systemic problems in Welsh rugby to arguably perhaps the most notorious structural/systemic breakdown in British sporting history; the policing operation at Hillsborough in 1989.  A terrible reminder why good structures/systems are critically important in all walks of life and sport.

The horrific events at Sheffield Wednesday’s Hillsborough Stadium for the Liverpool v Nottingham Forest FA Cup semi-final match on 15 April 1989 and the breakdown of the policing operation (below, the view of the West Stand/Terraces – Leppings Lane end – from the police control box occupied by South Yorkshire Police match commander Ch Supt David Duckenfield & his deputy (the control box commander) Supt Bernard Murray).

The quotes above, from the Goldring Inquest testimony of Sergeant William Crawford and Inspector Harry White, go to the crucial last seconds before disaster after we below go through the long-term causes, the short-term causes and the triggers.

For what was the point of Serial 14 continuing to deploy behind West Terracing turnstiles A-G, searching for weapons and alcohol, if Exit Gate C had been opened and thousands of fans were walking around their left flank unimpeded and unchecked.  The need was to pull back part or all of that serial, or to specifically deploy a reserve serial, to block access to the central tunnel and the already crowded central pens 3 and 4.

For we know that (the deceased) PC Anthony Lang, ironically within Serial 14 in 1989 but deployed on West Stand seating stairwell duty at the semi-final between the same teams a year earlier, had blocked access to the central tunnel before the 1988 FA Cup semi-final.  On whose authority/instructions that was done a year earlier will perhaps remain the greatest Hillsborough mystery of all, as no senior or middle ranking commander has ever admitted responsibility for issuing that order to PC Anthony Lang.

For those of us above a certain age, we will never forget the tragedy, but it does seem a lifetime ago, with many of the key police command leadership and witnesses now dead, so it is strange to realise that the Goldring  Inquest brought in a verdict of “unlawful killing” yesterday and so long after a controversial Popper Inquest “accidental death” verdict so long ago in 1991.  In essence, that the actions of match commander Chief Superintendent David Duckenfield amounted to “gross negligence” (the key legal hurdle in arriving at that verdict).

Lord Taylor of Gosforth has himself been dead nearly 20 years, and he filed his Interim Report (link) in August 1989 and some 4 months after the disaster.  It is fair to say that his report came as a rather nasty shock to the South Yorkshire Police, who had been trying to pass much of the blame onto allegedly mass drunken Liverpool fans.  Always a contentious approach as most of the fatalities were amongst the early arrivals towards the front of the central pens and tragically all too sober for the compression asphyxia they suffered.

He openly, perhaps almost provocatively, entitled his pivotal Chapter 11 on causation as “The blunder on opening the gates“.  That despite everything that had systemically gone wrong, the entire breakdown of the policing operation at the West Stand/Terracing end, nobody would have died upon the extraordinary opening of Exit Gate C if the commensurate follow-up action had still been undertaken by South Yorkshire Police – access to the central pens had been blocked and fans redirected to the wing pens.  Another “near miss” at a capacity Hillsborough, perhaps, but without fatalities.

Despite the obfuscation and withholding of evidence, he had still worked out that the disaster was primarily the result of a policing operation gone awry, a loss of police control, that the public order focus upon hooliganism had blinded the police to the fact that their primary duty with such crowds, a large 54,000 capacity on geographically convenient neutral Hillsborough’s regular FA Cup semi-final duty, was to ensure public safety.

That a bad situation had been allowed to build-up and develop at the West Terracing turnstiles bottleneck and which became catastrophic when imported into the narrow confines of the stadium without additional police action.  For when an exit gate was ordered open to relieve the pressure, but without corresponding action being taken to direct those fans away from the tunnel directly in front of them to the already full central pens and instead to be redirected to the empty wing pens, itself the product of a letting the terracing fans “find their own levels” mentality and despite lateral fencing within terracing that no longer permitted such sideways movement, disaster became inevitable.

Lord Justice Taylor (as he then was) did not mince his words in 1989 – this omission “was a blunder of the first magnitude“.  And then cuttingly that “In all, some 65 police officers gave oral evidence at the inquiry. Sadly I must report that for the most part the quality of their evidence was in inverse proportion to their rank.”

The controversy with this disaster, and especially and understandably for the grieving families, has mostly focussed on Ch Supt David Duckenfield.  Not just his actions on the day, but how he came to be in command at all?  He was not prosecuted by the DPP, and the jury in a private prosecution failed to agree on a verdict.  The same jury acquitted his deputy in the police box that afternoon, the long deceased Supt Bernard Murray.  And Hillsborough is a classic example of the difficulties involved in focussing on one or more personalities, when a defective system finally implodes when the wrong man or men make the wrong decisions without systemic safeguards.

So what were among the key elements in the chain of causation at Hillsborough…?

Long-term causes

Mostly elderly unmodernised late-Victorian/Edwardian stadiums in British football, poorly supervised by the FA and local councils, many in residential areas with poor signage and entrance/exit arrangements?

A football hooligan problem, leading to a police focus on public order/crowd segregation and fan caging to prevent pitch invasions and a focus away from public safety?

A very hierarchical and regimented police culture (including in, and particularly in, South Yorkshire under the authoritarian Chief Constable Peter Wright?)?

Short-term causes

A failure to learn the lessons of the Spurs v Wolves 1981 FA Cup semi-final “near miss” (below), where there was a crushing incident even before the perimeter caged West Terracing was converted into 3 individual pens and then further sub-divided into 5 pens?

An invalid safety certificate at Hillsborough, with clear breaches of the Green Guide including in relation to crush barriers and permitted official capacity on the West Terracing?

The inclusion of lateral radial fences to create pens, in addition to the perimeter fencing, and preventing (apart from one rear gate, almost useless in a packed pen) sideways movements with the creation of pens and all without providing dedicated turnstiles for each pen to centrally monitor and control numbers?

Public order concerns leading to the smaller Nottingham Forest fan base being allocated the larger East (Spion Kop Terracing) end and the larger Liverpool fan base received the smaller West Stand/Terracing (Leppings Lane) end?

A defective police operational order, that was tight on police numbers, did not “systemically” monitor and filter the crowd build-up, with an unfortunate demarcation line between Supt Marshall and (the unsighted) Supt Greenword at the Leppings Lane perimeter gates (de facto at the turnstiles), that did not provide for the police to monitor and control each pen, did not make provision for operational use of the West Terracing central tunnel being blocked (the so-called “Supt Freeman tactic“), that had 10,100 West Terracing fans using 7 turnstiles, and which did not factor in less special trains from Liverpool in 1989 and therefore less certainty over fan arrival times than in previous years (that is, a “system” that was not a system at all but a process that was reliant upon the informal expertise of those on duty and especially of the traditional match commander Ch Supt Brian Mole)?

Triggers

The replacement several weeks before of the veteran Ch Supt Brian Mole (considered by many a national, for just the force, expert on football policing) as match commander with the inexperienced and newly promoted Ch Supt David Duckenfield a few weeks before the FA Cup semi-final, in the fall out from the Ranmoor probationer incident (link) within the division?

The failure to delay the kick-off when an unusual arrival pattern was clearly developing and it was becoming obvious that large numbers of fans would not get in via the antiquated limited West Terracing turnstiles?

The failure to filter the crowd as it approach the West Stand/Terracing end, including the stopping of traffic and the use of perimeter gates as cordons?

And then, having lost control outside the turnstiles, the catastrophic failure (if using exit gates to avoid crushing fatalities at the turnstiles, itself well outside any operational order because of the issues in admitting fans without searching for weapons and alcohol or even for tickets) to allocate a police serial to block access to the already full central pens via the central tunnel before opening any such exit gate?

Thoughts 

So what happens now, in terms of criminal liability?  Clearly, if police officers have perjured themselves or been involved in a cover-up, and it is not looking good for some, then they should face prosecution and the CPS and IPCC will need to deal with this.  One suspects this will be the remaining story.  The “police line”, and in particular the post-disaster role of officers such as Norman Bettison and the interesting and apparently unauthorised amendment of police statements before submission. The current Chief Constable of South Yorkshire Police has been suspended today, given the perception of the police approach to the Goldring Inquest.

But what in terms of causation and systemic failure, and that mainly means the responsibility of Ch Supt David Duckenfield (with Chief Constable Peter Wright and Supt Bernard Murray long dead)?  He clearly did himself no favours on the day, initially telling then FA secretary Graham Kelly that fans had forced the exit gates.  He clearly froze, as the enormity of what had happened dawned on him, and he has now admitted that.  But few would argue other than the day destroyed his career and his life.

Will a jury convict a 71 year old over events that happened 27 years ago, a day that destroyed his career and life?  Should he have been placed in that position by the authoritarian deceased former Ch Constable Peter Wright and ACC (Personnel) Stuart Anderson?  Should ACC Walter Jackson, present at Hillsborough on a jolly (sorry, as a guest of Sheffield Wednesday FC), have not intervened earlier?  He was after all the Operations ACC, not just any old ACC.  And had previously policed Maine Road in Manchester earlier in his career as a match commander Ch Supt.  Surely Ch Supt David Duckenfield should have been shadowing another match commander in 1989, preferably Ch Supt Brian Mole?

When Ch Supt David Duckenfield inexplicably failed to think through the implications of opening an exit gate in relation to the central pens, did not (the deceased) Supt Murray fail to speak up and point out what should have been even more blindingly obvious to him given his Hillsborough expertise?  Was not Ch Supt David Duckenfield’s biggest mistake not asking for Ch Supt Brian Mole to run the operation and for him to learn from him, and what promoted employee wants to begin with that admission and especially if Ch Supt Brian Mole was being moved as a punishment for the probationer incident?

Within months, and notwithstanding the police smokescreen, Lord Justice Taylor had cut through to exactly what had gone wrong with the policing operation.  His later Final Report (link) changed the face of British football forever, leading to the Premier League and all-seater stadia (many new builds, well away from residential areas).  The huge football policing operations of the 1980s seem episodes from another world.  Hillsborough Stadium remains, but the West Terracing like the rest of it is now all-seater and the overall stadium capacity has been reduced from 54,000 to under 40,000.  Ch Supt David Duckenfield now just cuts a tragic figure, a reminder of a darker era in football and policing, newly generally promoted and policing a specialist event beyond his experience and competency.

Staying within the control box, in sharp contrast to the out and about approach of Ch Supt Brian Mole and who one suspects would have ended-up at the problematic West Terracing turnstiles around 2.30pm and personally dealt with the emerging problem. For the suspicion has always existed that there were a number of police officers on duty that day that wanted Ch Supt David Duckenfield to “screw up”.  Not to the extent of a single fatality, let alone 96 fatalities, but for the “newly promoted West Bar disciplinarian freemason” to very publicly fall flat on his face.

But all the structural/safeguards were gone by 2.30pm on 15 April 1989.  The difference between another “near miss” and a tragedy would now come down to individual actions and omissions in the next 22 minutes with the unusual late arrival pattern creating the perfect storm, without any remaining systemic “safety net” left:

(a) Did the police radio network continue to work?  No, it broke down almost entirely and all communications became difficult.

(b) Did Supt Roger Marshall, the West approach commander, manage to retain control outside the turnstiles through belated filtering and cordons, and by getting kick-off delayed and/or instituting a ticket tearing system via an exit game to increase the turnstile throughput ?  No.

(c) Did Supt Roger Greenwood, the unsighted ground commander, go behind the West Stand and realise the growing problem and successfully regain control?  No.

(d) Did Insp Harry White, the West concourse ranking officer, or a subordinate recognise the growing problem and take action of his/their own to block the central tunnel (the “Supt Freeman tactic“)?  No.  [Insp White had apparently already fallen out with Supt Murray over manning levels and the “find their own levels” filling of the pens, and was inexplicably absent for a key period assisting taking a drunken fan to the match room behind the North Stand].

(e) When Supt Roger Marshall requested the opening of an exit gate to relieve crushing outside the turnstiles, did he or Ch Supt David Duckenfield recognise the ramifications of opening and the follow-up action required i.e. either order Insp Harry White to block the central tunnel or allocate a reserve serial to undertake the task?  No.

(f) Did Supt Bernard Murray, whose control box overlooked the already packed central pens in the ground (see above photo),  recognise the ramifications and warn Ch Supt David Duckenfield of the follow up action required, when the latter failed to grasp?  No.

So Exit Gate C was opened and the fans admitted mostly headed straight for the central tunnel directly in front of it/them and disaster was inevitable.

Perhaps we should also finish with Sergeant William Crawford, with a paragraph deleted by South Yorkshire Police’s lawyers from his original 1989 statement before submission to Lord Justice Taylor:

“I personally thought we were very light on manpower at this end compared with previous years. I have worked at this end of the ground, either outside the turnstiles, inside searching or in the West Stand for several years at cup ties, FA Cup semi-finals and league matches, with a lot more manpower. In fact, I have seen more manpower at this end during league matches. Normally, we have had a serial [a group of officers] at the centre tunnel to direct fans to the North or South pens when the centre pens had been filled. This was not the case at this match and several of my serials remarked on this.“