View Full Version : Manchester Arena Bombing Report

off watch
27th Mar 2018, 20:26
I have no connection at all with the events at Manchester but I find the reaction of the Interim Fire Chief to the report pathetic. Asked if any officers had been disciplined for their handling of events, Docx said: “We are very much a learning organisation. We are not seeking to go down a discipline route.” My question is, why not ? People died while they sat on their hands & left the "Rescue" part of their title to everyone else :\
"Too risk-averse !?" Imagine if the senior firemen had adopted that attitude during the London Blitz - "no, you can't go into the Docks, the Germans might come back and drop some more bombs !" :mad:

27th Mar 2018, 20:37
There have been conflicting 'justifications' emerging, from 'the bomb had not been reported to have gone off' so they declared an exclusion zone - to 'a gunman at large'.

Although two fire crews were stationed close enough to the Arena to hear the explosion, they were sent to a rendezvous point three miles away amid fears that there was a marauding terror attack and they would not be safe,

Who was the incident commander?

Rail Engineer
27th Mar 2018, 21:15
The emergency services still come under the auspices of Health & Safety legislation like any other employer so it is not as cut and dried as you suggest.

That said from the very little I have heard it does seem like the usual cock-up, with first response being sent to an RDV some 3 miles away. Amazingly this did not seem to have got picked up at the so called emergency exercise some 3 months previous.
In these sorts of organisations there is a dissolution of sole decision-making towards command groups.

Whilst like yourself I get frustrated when I read of seriously stupid decisions and protocols, the other side of the coin is that if you go down the route of targeting individuals making difficult choices, you will (a) soon run out of people willing/able to do that, and (b) create an atmosphere of complete risk aversion. We do however seem unable to learn from previous experiences partially because when I have known these de-briefings to take place everyone becomes very defensive, especially when the media and commentators will second-guess decision-making. One thing is for sure, as soon as you hear phrases praising the response, etc. from inside these organisations you know straight away that there was an unmitigated cock-up somewhere and the Chief is getting his defence in early:ok:

27th Mar 2018, 21:22
“We are very much a learning organisation. We are not seeking to go down a discipline route.” My question is, why not ?

Because today it is a "lessons will be learned" that we hear after every single incident/crime/mistake.... it has become a mantra to avoid people taking responsibility.

Curious Pax
27th Mar 2018, 21:30
The fundamental problem seems to have been that there was a belief that there was a marauding shooter following the bomb, as there were also reports of shots fired. The Fire Chief seems to have followed the national protocol, hence the long delay in the fire brigade attending. Worth noting that there was no major fire, so the delay actually meant that the first aid trained firefighters weren’t there to assist in that respect. The Police also started to go down that route, but fortunately they had a senior guy present who could see what was happening and decided there wasn’t a shooter. Paramedics were also present as the police didn’t tell their chiefs about the phantom shooter!

Worth considering what the result would have been if there actually had been a shooter present - dead paramedics and police most likely.

The major question is why it took 2 hours to decide that the firefighters could go in - half an hour would have been more reasonable as a large number of armed police were on site by then.

the Chief is getting his defence in early he’s a she, but wasn’t in charge at the time - the guy who was took early retirement.

27th Mar 2018, 21:33
wasn’t in charge at the time - the guy who was took early retirement.

with his pension intact.

28th Mar 2018, 00:48
There's a natural instinct to look for `heads to roll' in situations like this.
I think it comes down to a question of blame culture versus just culture.
As a previous poster commented, blame cultures result in risk aversion, cover-ups and no-one learning.
It's a little surprising that people on a pilots forum, who should have knowledge of CRM and root cause analysis are advocating a blame type outcome.
Sure - losing your job where there's gross dereliction of duty is an appropriate sanction.
To what degree were innocent mistakes made?
Was gross incompetence involved?
Was there any malice?
All questions that need asking...

off watch
28th Mar 2018, 07:37
tartare - good points but IMHO the problem with just culture is that it seems to have become a mechanism for protecting those at the top from answering for their misdeeds. It brings to mind Sir Humphrey's comment to Jim Hacker : "the Official Secrets Act is not to protect secrets, it's to protect Ministers" & judging by the lack of prosecutions for corporate manslaughter, just culture is working well !

Curious Pax
28th Mar 2018, 08:44
with his pension intact.

Although things could certainly have been done better, given that he was following nationally agreed protocols why should he lose his pension? Listened to an interview earlier with the local Fire Brigades Union rep, and given the history of pretty major animosity between the union and management, it was telling that he refused to pick out the fire chief for blame.

28th Mar 2018, 09:03
Reading the Kerslake Report, it seems there was a whole host of contributing factors and I would place GMP higher up the responsibility ladder. On the one hand, they declared a shooting incident. They then told the fire service to go to holding point which was within a sterile area into which the fire service could not go in the case of a shooting attack. So the fire service decided to assemble at another, nearby, fire station. The nearest fire station to the Arena was about half a mile from the incident and this too was within the danger area in case of a shooting incident. Fire engines from that station were also mobilised to the same station as the initial crews. They were puzzled by the arrival of the ambulance service arriving at their station as they were leaving. The police were slow to advise other groups of the assessment of the incident not to include terrorist shooting. So the fire service were acting within their guidelines.
When the Chief Fire Officer got involved, he had discussions with the man in charge of the ambulances who explained what was needed of them. This resulted in his overriding the fire officer in charge of the incident who had decided special rescue teams should be deployed and instructing the dispatch of "bog standard" crews to the scene. The ambulance service person had basically wanted stretchers and the labour to handle them so the Fire Chief was probably right to get the standard crews to the scene immediately.
Interestingly, the report makes no comment on the effect of the delay to the fire service arrival on the welfare of the casualties. This has been delegated to the coroner. So, despite the ridiculous amount of time it took for the fire service to arrive, we still have no idea if this made the situation worse or not in terms of casualties.
Not mentioned too much in the media was the role of British Transport Police. (The Arena is built above Victoria station). Having heard the blast, they were on scene literally within seconds. They were doing what they could, without regard for their personal safety, until a GMP Inspector arrived on scene and took control from the BTP sergeant who had been running things up until that time and events (in my opinion) took a turn for the worse.
There is form for this kind of cock up. 25 years ago, my brother was one of the firemen on scene at the bombing in Warrington. They could see that one kid was dead but the second was alive, although seriously injured. My brother was physically prevented by the police from rescuing the injured boy, on the grounds there might be a second bomb. To this day he holds a grudge over that decision.

Rail Engineer
28th Mar 2018, 18:47
I think what most people want is accountability from those higher up the ladder who set the Corporate Culture within which an organisation operates.

I can name series of Companies where the "public" stance was the usual "Safety uber alles" but within the organisation absolute priority was set on the achievement of financial performance and production and lo and behold anyone who affected that through the application of good safety management. Whilst financial performance was a key measurable, safety was not. The clear and ever present working atmosphere reflected production above all else, and there was the clear understanding that management expected short-cuts to be taken. Of course when something happened the senior managers were quick to produce the various process and procedures that should have been followed, but try to follow these pre-accident and you were not there for long.

Only recently I heard of a statement being made that "programme is king and meeting production targets is paramount" - this by a very senior manager.

It is very easy to demonstrate an organisations commitment to safety, and especially easy to identify the controlling mind of an individual or a Board as any good Safety Manager will tell you. The problem is the HSE which is peopled by career Civil Servants and led by those who do not have the strength of character to start implementing Prosecutions of large Companies. Start at the MD and work down and you will soon see a rapid turn-round. Unfortunately the judicial system is also to blame with professionals continually harping on about how difficult everything is rather than setting up a system that does allow those at the top to be sanctioned. Whilst every Company has a culture, this is the result of one or more of a small group in control who set the environment right at the top.