In the summer of 1985, Eastwood & Partners installed two additional radial fences on the West Terrace. One radial fence extended from the mouth of the central tunnel to the perimeter fence, dividing the existing centre pen into what became Pen 3 and Pen 4. The second fence was installed parallel to an existing one, to create a 2m-wide corridor, referred to as Pen 5. This was for police use.
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Figure 2E: Digital reconstruction of the West Terrace layout in 1985, following the installation of two further radial fences (Source: R2S)
The evidence tends to suggest that Eastwood & Partners installed these as part of a general review of the layout of the Leppings Lane end and arrangements for segregation of supporters, initiated at the request of SYP.
In his report, Mr Cutlack made clear that, following the installation of these additional fences, the capacity of the West Terrace should have been recalculated based on the revised capacity of the individual pens, rather than considered as a whole. He calculated that the changes that created Pen 5 reduced the combined capacity of Pen 3 and Pen 4 by approximately 26.5m2, meaning that capacity should therefore have been reduced by a further 143.
He also highlighted that the installation of the radial fences should have resulted in a requirement for amendments to be made to the existing Safety Certificate.
On 11 April 1981, Hillsborough Stadium hosted the FA Cup Semi-Final between Tottenham Hotspur and Wolverhampton Wanderers. The game was attended by over 50,000 spectators.
Just after kick-off, a crushing incident took place on the West Terrace near the PCB. SWFC received reports that 38 people sustained injuries. SJA treated 30 supporters on site for minor injuries. Eight people were taken to hospital; three had broken limbs and two required stitches.
Following the match, SYP held an internal debrief, where senior SYP officers expressed concerns about the layout of the Leppings Lane terraces (the West Terrace and North West Terrace). Assistant Chief Constable Robert Goslin felt that, to assist with crowd control, the terraces required more divisions into separate pens, so that the supporters were not in such a solid mass. He also suggested that the permitted capacity of 10,100 for the two terraces was too high.
SYP followed this up with SWFC. Chief Superintendent Robin Herold (Ch Supt Herold), who had been the match commander for the 1981 FA Cup Semi-Final, had a meeting with Eric England, the Secretary of SWFC at the time. He explained SYP's concerns and the proposal that the terrace should be divided into pens. According to Ch Supt Herold’s notes, Mr England disagreed with the view that the capacity was too high and suggested that, instead of fixed fences, portable barriers could be used to assist with crowd control.
SYP persisted, and the then Chief Constable wrote to the SWFC Chairman, reiterating SYP’s concerns and recommending that the issues should be discussed with the local authority.
The OWP visited Hillsborough Stadium on 8 June 1981. Meeting minutes recorded that SWFC, together with SYP, were considering revising arrangements on the West Terrace. By early September, Dr Eastwood had been instructed by SWFC to arrange the installation of two fences on the West Terrace, to divide it into three approximately equal sections, each with its own entrance. This would allow parts of the terrace to be used by supporters of SWFC at home league games, with a smaller area allocated to away supporters, separated by the fences.
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Figure 2C: 3D model of the West Terrace layout in 1981, following the installation of two radial fences (Source: Operation Resolve, based on image produced by Return 2 Scene LTD (R2S))
There was to be a gate at the top of each fence, which could be either locked shut or secured against the back wall, allowing people to move between pens. The latter option would only be considered if the whole terrace was allocated to supporters of the same team.
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Figure 2D: Example of gates in radial fence (Source: Dennis Bond, SYP)
According to Dr Eastwood and an SYCFS officer who regularly attended the OWP, if the gates were open, this would be under police control. SYP officers have disputed this and said they had no responsibility for managing the gates.
The plan was approved by the local authority on 14 September 1981, and the fences were installed in October and November that year. Subsequent documents indicate that SYP was largely happy with the new arrangements.
Following a change to the terrace such as this, the capacity should have been formally reassessed. There is no evidence that it was.
SYP had been instrumental in getting Hillsborough Stadium designated, so that it required a Safety Certificate. SYP was then part of the Officer Working Party (OWP), a multi-agency group responsible for advising the local authority on safety matters related to the stadium. SYCFS and later the Area Health Authority were also part of this group.
In this role, various SYP officers attended regular OWP meetings to discuss safety issues. At one of these meetings, on 15 August 1979, it was agreed that the Safety Certificate should be issued to SWFC, subject to identified ground alterations; SYP was involved in the decision-making process.
The OWP also conducted stadium inspections twice a year. SYP officers attended these too. In 1987, the OWP changed its name to become the Safety of Sports Grounds Advisory Group (SSGAG); SYP remained a member.
SWFC was not in Division 1 at the time. However, because Hillsborough Stadium was used regularly for matches like FA Cup semi-finals, which attracted crowds of over 30,000, the then Chief Constable of SYP believed the stadium should be required to have a Safety Certificate. He wrote to the Home Office to request that Hillsborough Stadium should be designated. In 1978, it was, so SWFC had to obtain a Safety Certificate.
The application form was submitted in September 1978; the capacity of the stadium was given as 54,950.
SWFC had by this time appointed local engineering firm Eastwood & Partners as structural advisers and to help the club meet its duties under the SSGA 1975.
The director of Eastwood & Partners, Dr Wilfred Eastwood, reviewed the layout of the stadium and assessed the capacity against the standards in the Green Guide 1976. In early 1979, he calculated, under a strict interpretation of the Green Guide, the capacity of 54,950 was too high. In a letter to SWFC, he explained that if the club made certain improvements, like upgrading some crush barriers, the capacity could stay above 50,000. He calculated maximum permitted capacities for each area of the stadium, based on his interpretation of the Green Guide; for the West Terrace, the maximum permitted was 7,200.
After work was done to upgrade the crush barriers as Dr Eastwood had recommended, Hillsborough Stadium was granted a Safety Certificate in December 1979. On the Certificate, the total stadium capacity was set at 50,174 and the maximum permitted capacity of the West Terrace at 7,200.
As part of his work for the Goldring Inquests, engineering expert Mr Cutlack made his own calculations of the maximum permitted capacities for each area of the stadium as it was in 1980, following the Green Guide 1976. He concluded that most of Dr Eastwood’s figures were too high and that the maximum capacity of the West Terrace at that time should have been 4,518.
In this calculation, Mr Cutlack included the gates in the perimeter fence at the front of the terrace as part of the emergency exit provision. However, he also noted that it was not wholly clear whether those gates would be deemed suitable as emergency exits under the Green Guide 1976. They were narrow and had been designed primarily to allow police officers into the terrace rather than to allow supporters out. If these gates were not included, he calculated that the permitted capacity should have been 3,089.
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Figure 2B: View of perimeter gate and perimeter fence from Pen 3 (Source: SYP)
In short, this meant that from 1979 onwards, there were many more supporters allowed on the West Terrace than should have been, according to the safety guidelines of the day.
In 1989, stadium safety was based on the SSGA 1975 and the Guide to Safety at Sports Grounds, an official government publication widely known as the ‘Green Guide’ due to its green cover. Both had been introduced following the 1971 disaster at Ibrox Park, the stadium of Glasgow Rangers, in which 66 spectators were killed. The report into the disaster recommended a new process of certifying and inspecting football grounds. It also set out some proposed standards for clubs and licensing authorities to follow.
The Green Guide was first published in 1973. It provided detailed guidance on numerous aspects of stadium design and layout, such as how many exits were needed for each area, the use of crush barriers, particularly on terraces, and the construction of stairways. It also explained how to calculate the safe capacity of each area of the ground. It was, and remains, guidance and there is no legal requirement to adhere to it.
In 1976, and again in 1986, the Green Guide was updated, to include additional guidance and clarification. The 1986 version was produced soon after the publication of ‘The Final Report of the Committee of Inquiry into Crowd Safety and Control at Sports Grounds 1985’. This inquiry had been set up following two incidents at football matches on the same day, 11 May 1985: a fatal fire at Bradford City’s stadium, in which 56 people died, and a riot at a match between Birmingham City and Leeds United, in which a 15-year-old boy died. Following the two incidents, Justice Oliver Popplewell, a senior judge, was appointed by the then Home Secretary to undertake an inquiry into the operation of the SSGA 1975 and make recommendations to improve both crowd safety and crowd control. The Final Report is often referred to as the Popplewell Report.
Drawing on recommendations in the Popplewell Report, the Green Guide 1986 included some significant changes, such as:
a requirement for football clubs to have a designated safety officer “of sufficient status and authority effectively to take responsibility for safety at the ground”
additional guidance on the use of turnstiles for spectators entering a ground, including an observation that the maximum number of supporters that could enter through a single turnstile each hour was unlikely to exceed 750
a new chapter on crowd control, which had a specific reference to the need for clubs to work with the police to counter potential disorder
The Green Guide 1986 was the version in force at the time of the disaster.
The SSGA 1975 introduced a requirement for designated professional sports grounds to obtain a Safety Certificate. These were granted by local authorities, who were required to set terms and conditions to “secure reasonable safety” at the stadium. Local authorities were then responsible for checking whether the terms and conditions of the Safety Certificate were being met, and for deciding whether any condition of the Safety Certificate needed to be amended in response to changes at the ground.
Any stadium with capacity over 10,000 could be designated as needing a Safety Certificate, but in practice the requirement was initially just applied to the grounds used for Football League Division 1 (the equivalent of the modern-day Premier League) and those regarded as international football stadiums.
In 1989, Hillsborough Stadium was one of the largest football grounds in England. It hosted World Cup matches in 1966 and had been used several times during the 1980s for major games such as FA Cup semi-finals, including in 1987 and 1988. The 1988 Semi-Final was between Liverpool and Nottingham Forest; SYP, the FA and SWFC all perceived it to have been a success.
Like most football stadia in 1989, Hillsborough Stadium had a mix of seated areas (called stands) and standing areas (known as terraces). Tickets for terraces were generally cheaper. At the east end of the ground, known as the Penistone Road end, there was a large terrace named the Spion Kop. This was the ‘home’ end, normally used by SWFC supporters. At the opposite end of the ground, known as the Leppings Lane end, there was a smaller terrace, referred to as the West Terrace, below the West Stand.
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Figure 2A: Map of Hillsborough Stadium as it was in 1989 (Source: SYP Archive)
Despite its pre-eminent status, there had been various safety incidents at the ground, with supporters experiencing crushing at the Leppings Lane entrance and on the West Terrace. The most severe of these incidents had been at the 1981 FA Cup Semi-Final, where a crush on the West Terrace resulted in numerous injuries and several supporters receiving hospital treatment. However, in the aftermath of the Hillsborough disaster, supporters of different clubs described (including in evidence to the Taylor Inquiry) having experienced uncomfortable overcrowding in the pens of the West Terrace on other occasions, including at both the 1987 and 1988 FA Cup Semi-Finals.
Together, these incidents raise questions about the suitability of Hillsborough Stadium to host major matches and whether it met the safety standards of the day.
Operation Resolve investigated these issues, with a particular focus on what role the police played in any discussions and decisions about the stadium layout.
Under the terms of reference for the managed investigation, Operation Resolve investigated: Issues relating to the stadium, including any role played by the police in:
a) suitability and choice of the stadium to host the event b) the planning and decision making in relation to the ground’s design, alterations and final layout, including the siting and condition of barriers, fences, and gates within the fences c) the design and layout of the pens
What was found?
• The Safety Certificate issued to Hillsborough Stadium in 1979 was based on incorrect calculations about the safe capacity of each area of the stadium. This meant that more people were permitted in some areas of the ground than should have been. On the West Terrace, the permitted capacity was 7,200 but the engineering expert appointed to the Goldring Inquests calculated that, applying a strict interpretation of the guidance at the time, it should have been no more than 4,518 when first set in 1979—and possibly as low as 3,089.
• When changes were made which further reduced the amount of space for spectators on the West Terrace, no steps were taken to reassess the safe capacity of the terrace, either by SWFC or SCC which issued the Safety Certificate for Hillsborough Stadium. Nor was capacity formally reviewed in response to changes in safety requirements for sports grounds during the 1980s.
• Following crushing incidents at previous FA Cup semi-finals at Hillsborough Stadium in the early 1980s, SYP officers proposed changes should be made to the layout of the West Terrace. These were implemented, splitting it into separate pens, which would also allow home and away supporters to share the terrace at relevant SWFC matches.
• SYP officers subsequently proposed significant changes to the Leppings Lane entrance to the stadium, to help segregate rival supporters at that end. The proposed changes were rejected as too expensive; though some changes were eventually made to this area of the stadium as an indirect result, these were very different from what SYP had suggested. This demonstrates an awareness among the police and other organisations that some aspects of the stadium layout presented potential risks to supporters.
• Despite this awareness, recognised risks were not managed with due care. For example, SYP officers requested that a crush barrier near the main entrance of the centre pens of the West Terrace should be removed, so that supporters did not congregate there. Engineering experts raised concerns that this could affect barriers lower down the terrace, but the barrier was removed, on the condition that SYP would keep the area near the entrance clear of spectators. However, there was no mention of this in police planning for the 1988 or 1989 Semi-Finals.
Significant new evidence
The most significant new evidence in relation to stadium safety was the three reports produced by Mr Cutlack, who was instructed as an independent civil engineering expert to the Goldring Inquests.
These showed, among other matters, that the capacity calculations used when SWFC first applied for a Safety Certificate were too high. They also included detailed analysis of key issues such as the causes of a crush barrier breaking on the day of the disaster.
The third report was commissioned by Operation Resolve to address issues that had arisen during its investigation and had not been considered in Mr Cutlack’s first two reports.
The IOPC is required by law to produce an investigation report for each complaint or conduct matter it investigates. These reports are designed to allow the IOPC decision maker to reach a view on appropriate outcomes and, with the decision maker’s additional input, to inform the relevant police force or police and crime commissioner of the IOPC opinions and decisions In the Hillsborough investigations, there are 161 such reports; several conduct reports covered multiple conduct matters, for example where a group of officers were under investigation for the same issue. Complainants and the officers under investigation have been informed of the outcomes, as have those identified as interested persons in any of the individual investigations.
However, none of these reports, on its own, can address the wider scope of the IOPC and Operation Resolve investigations, or respond to the full terms of reference for these investigations. This report therefore fills this gap. As well as explaining the outcomes of complaints and conduct matters, it summarises what the investigations found in relation to unresolved queries around the disaster. It also gives an overview of topics related to police conduct that have not been addressed by previous inquiries or investigations, such as the work of WMP in the aftermath of the disaster.
Notes on language and terminology
All statements and accounts are cited verbatim in this report. In some cases, they include spelling or typographical errors, which are reflected in the quotations.
Unless specifically stated, all police officers are referred to by the rank they held at the time of the disaster. Similarly, if an officer’s name has subsequently changed, they are referred to by the name they used at the time of the disaster.
During the course of this investigation, the IOPC was established, replacing the IPCC. The IOPC took on responsibility for any ongoing IPCC investigations. For clarity, throughout this report, all references to the independent investigation into police conduct in the aftermath of the disaster refer to the actions of the IOPC rather than the IPCC, even where those actions took place before the IOPC was established.
