However much planning and training goes into preparing for a major incident, there are likely to be procedural failures that lead to a significant degradation of service delivery, either because of the impact of the external event or failures in internal management controls, according to David Rubens.
On May 22, 2017, a suicide bomber detonated a device just outside the Manchester Arena, killing 22 people, many of them children attending an Ariana Grande concert. is was a high-impact incident that placed all of the emergency management networks, including emergency services, hospitals, transport managers, city mangers and civic leaders among others, under immense pressure.
However, it is also exactly the sort of attack that must be considered as a core strategic capability for any organisation operating in today’s threat environment. The Kerslake Arena Review into the response of the emergency services to the incident makes it clear that much of what was achieved across all aspects of the emergency response was e ective and appropriate. Indeed, many members of the emergency services went over and above the call of duty. ey responded to the incident, cared for the casualties and ensured the safety and wellbeing of all those caught up in the immediate event, and those a ected in secondary ways, either through their relationships with actual and potential victims, or by being caught up in the natural disruption that followed.
Real-world test
As the Lord Kerslake points out, despite the fact that the Greater Manchester Resilience Forum had carried out many multi-agency planning and emergency response exercises, none of those involved had ever encountered anything like the events of May 22; this was a real-world test of the plans and assumptions in a way that can never be replicated in training exercises, however realistic they might be.
Multiple multi-agency exercises had been organised previously – in fact, one had been carried out only a few months before the attack. is meant that most of the emergency response agencies at the scene were able to work together with the con dence that repeated joint exercising brings. is was clear in the way that decisions were made at a time when they did not t into ‘accepted procedures’, but were felt to be the most appropriate action in the speci c, and often chaotic, circumstances. One example was the decision to establish the Casualty Clearing Station on the station concourse and to allow emergency sta and members of the public to remain in the foyer, notwithstanding its designation at the time as a ‘hot’ zone. ese were vitally important judgements that signi cantly in uenced the course of events. However, the root causes of major critical failures in the response operation were not unexpected and could have been predicted and prepared for as part of the basic principles of multi-agency major event response. ey are the same issues that are highlighted in the executive summaries of every post-event review and report, whatever the speci c details of the incidents involved.
In the simplest terms, these are the challenges associated with communication and integration – information exchange, joint decision-making and the ability to create a common operating picture between all of the responding agencies, both horizontally on a multi-agency framework, and hierarchically through the various command levels of Gold, Silver, Bronze. As an example, here follow excerpts from a number of different reports, which could probably be cut and pasted in their entirety and dropped into any emergency response post-action review and be equally relevant. I have excluded the names of the incident or countries involved.
“I heard this refrain again and again from (…) emergency planners: excellent work within individual agencies, but still a lack of government-wide disaster response planning. Interagency co-ordination is still weak, and in most cases the government’s disaster response plans are woefully short of detail. Most agencies are unfamiliar with the disaster response plans and capabilities of other agencies, impeding e orts to develop well-coordinated plans. Underlying all of this is the (…) government system, which does not appear to encourage rapid decision-making or interagency co-ordination.”
“In essence, there is concern that the regional disaster prevention plans that have been created to satisfy those involved in local government will be useless when put into action. (Speci c programmes) are just that, overproduced systems that cannot be easily operated or revised. Ironically, these de ciencies are obvious to the governments that paid for them.”
And: “The preparation and response to (…) shows that we are still an analogue government in a digital age. We must recognise that we are woefully incapable of storing, moving and accessing information, especially in times of crisis. Many of the problems we have identi ed can be categorised as ‘information gaps’ – or at least problems with information-related implications, or failure to act decisively because information was sketchy at best. … One would think that we could share information by now. But (…) again proved that we can’t.”
The two major failures in the Manchester bombing response both involved communications. In the words of the report: “The Greater Manchester Fire and Rescue Service (GMFRS) did not arrive at the scene and therefore played no meaningful role in the response to the attack for nearly two hours.”
Information gaps
The other communication failure involved the Casualty Bureau, which should have been set up as a point of contact and centralised information-sharing for people seeking information on the missing, injured or dead. is had been outsourced to a private company – Vodafone – under the National Mutual Aid Telephony system. In the words of the review, it was: “A complete failure.” is a ected both the ability of local families to contact the helpline, and integration of the Manchester system into the wider national framework, which was supposed to give the option of increased capacity in this sort of situation.
One additional point highlighted in the Kerslake Review involved the fundamental issue of multi-agency response and collaboration. Given the increase in locally radicalised home-grown terrorists creating high-impact attacks, using either weapons or vehicles, it is to be expected that the response planning would be at the heart of modern policing and major city management. is was the case in Manchester, which had a wellpractised framework in place – Operation Plato – the multi-agency response to a marauding rearm attack.
However, as the report states: “There was not a shared communication across the agencies of the declaration of Operation Plato … nor was there a shared understanding of its implications.”
Although the circumstances were di erent, the use of Operation Kratos that underpinned the killing of Charles de Menezes in London in 2005 shows remarkably similar issues in terms of confusion at the highest level of leadership, a lack of understanding about the implications of the operation and, as always, breakdown in communication. The report on that incident by the Independent Police Complaints Commission stated: “The main and central issue in this tragedy is whether the level of identi cation was properly communicated from the surveillance team …” The significance of taking decisions under the extreme pressure of command is also underlined in that particular report.
Responding to what is perceived to be a credible threat, whether in terms of a suicide bomber approaching a target in London during a period of highest national alert, or to a terrorist attack in a concert venue, puts every aspect of the system under pressure. However, this cannot be used as an excuse for failure, especially when the causes are already recognised as those points that are most likely to fail, and which would have the greatest impact on the ability of all responding agencies to act quickly and e ectively. While there is no desire to apportion blame, there is the need to recognise responsibility, as I am sure responders at every level of those agencies would acknowledge.
Communications and information transfer are at the heart of any multi-agency response, and it is the failure to manage those issues, under the intense stress of an actual response environment, that is almost always the root cause of operational failures. It is not enough to expect that things will go well, or as planned. In fact, the signi cant points at the heart of the responses to both the Manchester bombing and the Charles de Menezes shooting were how well the relevant agencies were able to adapt and respond to highly unstable situations, which were evolving and mutating on a minute-by-minute basis, for which they often had only partial, unclear or unveri ed information.
The ability to manage the transfer of complex information, under pressure, between multiple stakeholders, within the confusion of an actual crisis, is the foundation of effective response. Without this, it is impossible to deliver a cohesive, integrated multi-agency response.
The tragedy is that the lessons that need to be learned are written in blood. Minutes after the south tower collapsed at the World Trade Center in 2001, police helicopters hovered near the remaining tower to check its condition. “About 15 oors down from the top, it looks like it’s glowing red, the pilot of one helicopter radioed at 10:07 hrs.”
Seconds later, another pilot reported: ‘’I don’t think this has too much longer to go. I would evacuate all people within the area of that second building.’’
Those clear warnings were transmitted 21 minutes before the building fell; o cials say they were relayed to police o cers, most of whom managed to escape. Yet most re ghters never heard those warnings, or earlier orders to get out. eir radio system failed frequently that morning and was not linked to the police system. Police and re commanders guiding the rescue e orts did not talk to one another during the crisis.
Three-hundred-and-forty-three re ghters died in the twin towers. anks to the warning given over the police radio system, ‘only’ 60 police officers died.
Responders cannot a ect the incident itself, but they can take responsibility for preparing to manage the response in the best manner available.
As Rittel and Webber say, in their Tenth Law of Wicked Problems: “The planner has no right to be wrong.”
