The next planning meeting took place on 29 March. By this time, Ch Supt Mole had moved to become divisional commander of B Division, based in Barnsley. He stated that, after the first planning meeting, he had no further involvement in the planning for the 1989 Semi-Final.
Instead, the meeting was chaired by Ch Supt Duckenfield and involved the three members of the F Division planning team. The purpose of the meeting was to review the F Division Operational Order. Ch Supt Duckenfield has repeatedly said they went through it page by page; he asked a few questions and suggested some minor amendments but was largely content to approve it.
At the Goldring Inquests, he was asked if he had raised any questions about any incidents in the stadium’s history that he should have been made aware of. He replied that, as a new commander, he would have asked questions, but 26 years on he could no longer recall the specifics. He said he was not told anything about the history of the ground that caused him any concern.
He also stated that he was not alerted to any particular issues that had occurred at the 1988 Semi-Final.
On 20 March 1989, the FA announced that Hillsborough Stadium had been selected as the venue for the FA Cup Semi-Final between Liverpool and Nottingham Forest on 15 April. This was a repeat of the previous year’s semi-final.
SYP officers have repeatedly stated that the planning of the police operation for the 1989 FA Cup Semi-Final was based on the plans for the 1988 FA Cup Semi-Final, which was viewed within SYP, SWFC and the FA as having been a success. The grounds for this are not wholly clear, but they appear to have been that there was no serious disorder and that the match had adhered to its intended schedule.
However, the HIP Report identified that at the 1988 match “at least 62 people experienced crushing in the central pens, some sustaining injuries such as bruised ribs.” There had also been a small pitch invasion at the end of the game.
It is not clear whether the overcrowding at the 1988 Semi-Final or the resulting injuries were recognised by any authorities before Hillsborough Stadium was selected to host the 1989 Semi-Final. It appears that the fact that supporters had been injured was not covered during debriefs following the 1988 Semi-Final and the evidence indicates that the police planning team was unaware that there had been crush injuries. The pitch invasion, however, was known.
The planning process for the 1989 game largely followed the approach used in 1988. This consisted of some planning meetings involving representatives from most of the different organisations who would be part of the match day operation, and the development of Operational Orders.
There were three planning meetings in total, on 22 March, 29 March and 10 April. However, in a change from the process used in 1988, there was no meeting between SYP and SWFC in 1989. It is not clear why such a meeting was not arranged, when it would have provided an opportunity for all the relevant parties to discuss issues and review plans.
There were also three Operational Orders, each prepared by a different division of SYP.
F Division was responsible for policing the area where Hillsborough Stadium was located. The F Division Operational Order was the main one for the match and involved the most officers.
D Division was responsible for policing Sheffield city centre, including the main railway station. The D Division Operational Order covered operations beginning the night before the match.
Road Traffic Division was responsible for road safety and traffic flow on roads in South Yorkshire. It had no responsibility for roads in other forces’ jurisdictions, which covered the main part of the journey from either Liverpool or Nottingham to Sheffield.
For F Division, Ch Supt Mole appointed a planning team of three officers: Supt Murray, who was his regular deputy match commander at league matches, Chief Inspector David Beal (Ch Insp Beal) and Inspector Steven Sewell (Insp Sewell). The latter two both had considerable experience in planning police operations for matches at the stadium.
In his 1989 account, Supt Murray recalled meeting with Ch Supt Mole on 20 March to start the process. He said that “as this was a repeat of the same fixture the previous year, which had passed without serious incident we decided to base the order on the previous year's event.”
However, Supt Murray also said he was “asked by Chief Superintendent Mole to aim for a manpower reduction on 1988 of 10% in the interest of most effective and efficient utilisation of resources as it was to my knowledge that the previous year, some officers had been under employed.”
In the same account, Supt Murray said that following the 1988 game, he had identified a number of areas where he considered arrangements could be improved. None of these referred to overcrowding. Supt Murray did, however, refer to reinforcing security on the perimeter track at the end of the game to prevent a pitch invasion as occurred in 1988, and instructing officers in the West Stand to be particularly vigilant about preventing spectators from climbing into that stand from the terraces below.
A planning meeting was arranged for 22 March 1989 at Hammerton Road Police Station. The meeting was chaired by Ch Supt Mole and attended by the core planning team plus representatives of other organisations involved in the match, such as British Rail, local public transport providers and the Highways Authority of the County Council. Representatives of SYP’s D Division and Road Traffic Division also attended the meeting. No one from SWFC was present.
Supt Greenwood and Supt Marshall were both there; both had been sector commanders at the 1988 game and were selected by Ch Supt Mole to serve as sector commanders again for the 1989 Semi-Final. Ch Supt Duckenfield also attended, having been appointed as chief superintendent of F Division, taking effect from 27 March 1989. This meant he would be in post for the 1989 Semi-Final and would serve as match commander. According to his own accounts, and those of others present, he did not contribute to the meeting.
No minutes or other notes have been found for this meeting. Notes were first sought in 1989, shortly after the disaster, by SYP colleagues and then by WMP, but could not be located. Operation Resolve has also examined all available documentation but has not found anything relevant. The details of the planning meeting are therefore taken from the accounts of those present.
The overarching impression is that the meeting largely confirmed the intention to repeat arrangements from the previous year, with just a few changes, such as around traffic operations.
Police Sergeant Kenneth Jones (PS Jones) was one of the officers responsible for producing the D Division Operational Order. He commented that “The tone of the meeting from memory was that the F order and the D order would be based on the previous year.” However, he said that he and his colleague wrote the D Division Operational Order from scratch.
PS Jones also said that at the meeting on 22 March 1989, he arranged for further meetings with South Yorkshire Transport (SYT), British Transport Police (BTP), British Rail and the SYP Road Traffic Division. These meetings did not include the F Division planning team, but he did liaise with Insp Sewell in respect of the unloading points for the SYT buses.
Under the terms of reference for the managed investigation, Operation Resolve investigated: Planning and preparation for the match by the police, including organisational and individual decision making in relation to:
a) the resourcing of the event b) any role played by the police in allocation of areas within the ground to the visiting teams’ supporters c) the arrangements for the policing of the match, including arrangements for the arrival of supporters and their management outside the stadium d) the arrangements (or lack of) for precise monitoring of the crowd numbers and their safety within the pens at the Leppings Lane end
What was found?
• Though SYP officers have repeatedly insisted that their planning for the 1989 Semi-Final was broadly the same as for the 1988 Semi-Final involving the same teams, there were several important differences, including changes in key personnel. No allowances were made for these changes.
• For the 1989 Semi-Final, there was a 14% reduction in the number of officers on duty compared to the previous year. In the area where Liverpool supporters would arrive, there were 21% fewer officers on duty. SYP had intended to reduce the number of officers on duty by just 10%.
• A significant change made by SWFC to entrance arrangements for the terraces at the Leppings Lane end meant that all 10,100 Liverpool supporters who had standing tickets had to enter through just seven turnstiles. For these spectators to get in on time, each of the turnstiles would have had to operate continuously at maximum speed for almost two hours. It is not clear whether any SYP senior officers understood the potential consequences of this change.
• There were various gaps and inconsistencies in the key planning documents developed by SYP, known as Operational Orders. A major gap was a total absence of contingency plans with clear tactics to address known risks that had occurred at previous matches, including crushing on the West Terrace. Another was around responsibility for monitoring capacity on the West Terrace to prevent such crushing occurring.
• The three SYP divisions involved in the police operation all developed their own Operational Order without working together. They were approved by senior officers in each division, without looking at the other Orders. This resulted in a lack of coordination. Some accounts suggest that the Force Control Room was supposed to provide a coordinating role, but this was not documented anywhere. Beyond that, SYP relied solely on briefing meetings led by the match commander to bring the different divisions’ activities together.
• The replacement of the highly experienced match commander Ch Supt Mole was poorly timed. It was a direct result of the decision to move Ch Supt Mole from the role of divisional commander for F Division and to replace him with the newly promoted Ch Supt Duckenfield. There was an unwritten policy that the divisional commander would be match commander at Hillsborough Stadium.
• There is no definitive explanation for the decision and no evidence that Ch Supt Duckenfield’s appointment as divisional commander was inappropriate or conducted improperly. However, it meant that someone who had never previously commanded a match at Hillsborough Stadium was given responsibility for a major game, with just a few weeks’ notice.
Significant new evidence
The Operational Orders and police planning for the 1989 FA Cup Semi-Final have been examined by a range of previous investigations and inquiries. In this investigation, Operation Resolve was able to draw on the views of Douglas Hopkins, a former Metropolitan Police chief superintendent with a wealth of experience commanding football matches in the 1980s and 1990s. Mr Hopkins was appointed by the Goldring Inquests as an expert witness on the policing standards of the day. He also gave evidence at the criminal trials of Ch Supt Duckenfield and Mr Mackrell.
SYP was the primary driving force behind SWFC's initial application for a Safety Certificate under the SSGA 1975. It was then involved, as part of the OWP (and later the SSGAG), in discussions around the requirements of the Safety Certificate before it was issued.
The evidence shows that SYP officers continued to be involved in discussions around safety and stadium design. Following a crushing incident at the 1981 FA Cup Semi-Final, SYP expressed to SWFC the view that the capacity at the Leppings Lane end was too high. It also proposed the introduction of radial fences to divide the terrace into separate pens to assist with crowd control. The fences were introduced, but the capacity was not reviewed.
SYP was also instrumental in the installation of further fences in 1985 and the removal of parts of barrier 144, in 1986.
While these changes were proposed by SYP, they were then planned by SWFC and particularly Eastwood & Partners. The plans were considered by the OWP—of which SYP was a member—and agreed. The involvement of SYP within this process appears to have been appropriate and in keeping with expectations of the time.
Mr Cutlack observed that the removal of barrier 144 had a detrimental effect on safety. However, he commented that this should have been raised by the engineers and did not criticise SYP for suggesting it.
Both Eastwood & Partners and the SYCC principal surveyor have said that SYP offered to monitor the entrance to the pens from the central tunnel, as part of securing agreement for the changes to barrier 144. SYP officers have said they did not agree to any such duties, and police planning documents make no reference to any officers being allocated to this task.
SYP was also closely involved in a further proposal to redesign the Leppings Lane turnstile area. Mr Cutlack identified that the resulting plans, if implemented, could have averted the disaster or at least reduced its severity. However, the plans were deemed too expensive, and a less extensive change was made, which did not increase turnstile numbers and resulted in fewer turnstiles being available for entrance to the West Terrace.
Considered as a whole, the evidence gives the impression that SYP had an interest in the stadium layout, insofar as it affected the force’s ability to police matches effectively.
This also appears to have been the primary factor in SYP’s insistence that it would only agree to Hillsborough Stadium hosting the 1989 FA Cup Semi-Final if the same arrangements were used as in the previous year—despite the request from Liverpool Football Club to change the allocation of ends.
Questions about the safety of the stadium are crucial not only to understanding the causes of the disaster, but also to investigating the actions of the police and other organisations. In simple terms, if the stadium was not safe, this could indicate other parties—notably SWFC—were also at fault. Set against that, the police were responsible for managing the safety of spectators attending football matches at a stadium. This meant that if officers felt any aspect of the ground was unsafe, the police had a responsibility to raise concerns to the club and other partners, and to mitigate any perceived risks to supporters.
Evidence shows that the licensing authorities—first SYCC, then SCC—did not insist on a review of the Safety Certificate in response to changes to the stadium layout or incidents of crushing.
However, the core responsibility for ensuring the Safety Certificate was up to date rested with SWFC. Over the decade after the Certificate was issued, SWFC authorised a series of significant changes to the design and layout of the stadium and in July 1986, asked Eastwood & Partners to review the current Safety Certificate and advise the club of any alterations to the terms and conditions it considered appropriate. Despite this, the Safety Certificate was not updated, and the capacities of the different areas were not reviewed, except in the case of the Spion Kop, where capacity was increased after an application from Eastwood & Partners and SWFC.
Operation Resolve investigated both SWFC and Eastwood & Partners in relation to their responsibilities under the HSWA 1974 and the SSGA 1975. However, because neither organisation exists as the same legal entity it was at the time of the disaster, it was not possible to launch meaningful legal proceedings against either. In the case of SWFC, the company was still in existence but had no registered directors; Operation Resolve ensured it was kept active for sufficient time to explore these issues.
Although proceedings could not be considered in respect of any organisation, they could in respect of individuals. Over the course of its investigation, Operation Resolve identified a range of evidence that indicated Mr Mackrell may have failed to fulfil his duties as SWFC’s ‘responsible officer’ under the SSGA 1975 and as safety officer as defined in the Green Guide.
Following the investigation by Operation Resolve, and consideration by the CPS, Mr Mackrell was charged with two offences under the SSGA 1975. These charges related to breaches of the Safety Certificate for Hillsborough Stadium alleged to have been committed by SWFC while he was the responsible officer. These charges were in addition to a separate charge against him under the HSWA 1974, which is examined in chapter 3.
During the trial of Ch Supt Duckenfield and Mr Mackrell, jurors were directed by the judge that it was not appropriate to proceed with the charges under the SSGA 1975 due to insufficient evidence.
The evidence clearly indicates that the choice of the stadium to host the 1989 Semi-Final was made by the FA. The choice was based on geographical location and the perceived suitability of the stadium. Hillsborough Stadium had been used to host an FA Cup Semi-Final in both the previous two years, and these were viewed as having been successful by the FA, SWFC and SYP.
When the FA selected Hillsborough Stadium as the venue for the 1989 FA Cup Semi-Final, none of the authorities raised any objections or concerns.
SYP did have some input into the decision. When Hillsborough Stadium was proposed by the FA as a possible venue for a Semi-Final between Liverpool and Nottingham Forest, Mr Mackrell contacted Ch Supt Mole to ask if SYP would be willing to police the match. Ch Supt Mole made it clear that SYP would only agree if the same fundamental arrangements for the allocation of areas of the stadium were applied as had been used at the 1988 Semi-Final between the same teams. This was to facilitate the segregation of opposing supporters.
This meant that the Liverpool supporters would be allocated the West Terrace, North West Terrace, West Stand and North Stand, reflecting their likely routes to the ground. However, it also meant that Liverpool would receive fewer tickets overall than Nottingham Forest, despite having higher average crowds, and that all Liverpool supporters would be required to enter the ground through the turnstiles at the Leppings Lane end.
The then Secretary of Liverpool Football Club, Peter Robinson, asked the FA if it could change this allocation of ends so that more tickets would be available to Liverpool supporters. SYP refused and would not agree to policing the game if the arrangement was changed. This was accepted by the FA. Nottingham Forest supporters were allocated 27,754 tickets for the match, including 21,000 for the Spion Kop terrace. Liverpool supporters were allocated 23,542 tickets, including 10,100 for standing areas (7,200 on the West Terrace and 2,900 on the North West Terrace).
The number of standing tickets allocated to Liverpool supporters matched that on the Safety Certificate, but as has been made clear, the permitted capacity of the West Terrace was based on flawed calculations. It should have been reassessed and potentially reduced once the additional fences were installed.
Although Hillsborough Stadium possessed a Safety Certificate, it was identified as early as the Taylor Inquiry, and has since been confirmed in Mr Cutlack's reports, that there were various ways in which the ground in 1989 did not adhere to the recommended standards of the Green Guide 1986. For example:
there were not enough turnstiles at the Leppings Lane end for the number of spectators
the fact that Pens 3 and 4 had a shared entrance and exit
there were some areas of Pens 3 and 4 where the distance to the nearest crush barrier was more than recommended
some of the barriers were the wrong height—including one of the barriers higher up the terrace than the barrier that collapsed, which meant during the crush in the pens the collapsed barrier was subjected to a pressure greater than it had been designed to withstand
the emergency exits from Pens 3 and 4 were not suitable—the central tunnel was too steep and the gates in the perimeter fence at the front were too narrow
the permitted capacity for Pens 3 and 4 was far higher than it should have been
Despite these factors, and the fact that there had been previous crushes on the West Terrace, Operation Resolve has found no evidence that any party felt that Hillsborough Stadium was unsafe when it was considered as a venue for the 1989 FA Cup Semi-Final.
The various alterations to Hillsborough Stadium should have resulted in a review of the Safety Certificate and its terms and conditions, but did not. However, from 1986, work began to review the conditions of the Safety Certificate, both by SCC and, separately, Eastwood & Partners on behalf of SWFC.
However, by the time of the 1989 Semi-Final, this had only resulted in revised draft conditions being presented for consideration by the SSGAG. The revised version contained the same capacity figures as the original Safety Certificate, with the exception of the capacity for the Spion Kop, which had been revised upwards to 21,000 following work to extend it. SWFC and Eastwood & Partners had requested this upward revision, which increased the overall capacity of the stadium from 50,174 in the original Safety Certificate, to over 54,000.
In 1987, SWFC specifically asked Eastwood & Partners' advice as to the capacity of the West Terrace in light of all of the alterations that had taken place over the years. Eastwood & Partners advised that there was no need to change the capacity of 10,100.
In June 1986, Insp Calvert sent the newly appointed SYP match commander, Chief Superintendent Brian Mole (Ch Supt Mole) a summary of officers' suggestions for improving policing at Hillsborough Stadium. One issue he raised was that some of the crush barriers on the West Terrace caused congestion as supporters entered the centre pens from the central tunnel. He raised the concern that similar problems could occur with getting into the tunnel if an emergency evacuation was needed.
The primary cause of concern was barrier 144, a 7.625m-wide barrier consisting of three parts, located directly in front of the central tunnel. In evidence to the Taylor Inquiry in 1989, Insp Calvert explained that “the barrier was right across the entrance to the tunnel and the fans got to the barrier and stopped and we would have a build-up right back up the tunnel, fans would not move out and we could not control what was happening.”
He and some colleagues felt that the West Terrace would be safer if the crush barrier was removed, or at least partially removed. After discussion with senior officers, it was agreed to propose this at the next OWP meeting, where after initial reservations by some members, it was agreed to remove parts of barrier 144.
In a statement from 1990, the surveyor from South Yorkshire County Council (SYCC), who was part of the OWP, recalled this and said he had agreed with the proposal. However, he noted two key points. Firstly, he understood that the police would be present near the tunnel entrance and would work to keep the area clear of supporters. Secondly, he suggested marking out a ‘sterile area’ in front of the central tunnel mouth that should be kept clear of spectators at all times.
Two parts of the barrier were removed as proposed and yellow markings painted on the floor to mark the sterile area. These markings are just visible either side of the radial fence in figure 2H, which was taken after the disaster. However, no evidence has been found that either SYP or SWFC managed the sterile area at the 1989 FA Cup Semi-Final or took steps to prevent supporters standing there.
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Figure 2H: The location of barrier 144 and the central tunnel, April 1989 (Source: Philip Rich, SYP)
In his first report, Mr Cutlack commented: “Clearly, it was intended that the removal of part of barrier 144 was to have a beneficial effect on safety however in my opinion the reverse was true.” He explained that “The removal of this barrier created an un-obstructed path for a crowd surge in the tunnel” and added: “In my opinion EP [Eastwood & Partners] should have resisted this alteration and advised the Club and the Police of the likely implications of removing Barrier 144.”
On the day of the disaster, a crush barrier in Pen 3 collapsed. This has been identified as one of the key moments in the disaster. The evidence does not suggest that the removal of barrier 144 had any direct effect on the barrier that collapsed.
In his report, Mr Cutlack explained that during the crush, barrier 124A was subjected to a pressure greater than it had been designed to withstand, as a result of three factors:
crowd density
the depth of the crowd behind the barrier
the fact that barrier 136 (higher up the terrace) was substantially lower than recommended, resulting in the crowd behind this barrier exerting a greater forward pressure
However, he did not believe that the removal of barrier 144 could have had any impact on barrier 124A, because the additional pressure on barrier 124A came from an area outside of where barrier 144 had been.
Around this same period, there was also discussion between SYP and SWFC about changing the turnstile configuration at the Leppings Lane end. This occurred after SWFC returned to the top division and had larger numbers of away supporters at its games. SYP found it harder to keep these away supporters segregated from the home supporters accessing the Leppings Lane turnstiles. Figure 2F shows the layout at the time, which required barriers to separate opposing supporters.
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Figure 2F: Drawing of Leppings Lane entrance layout as it was in 1985 (Source: Eastwood & Partners)
Inspector Clive Calvert (Insp Calvert), who regularly policed the Leppings Lane end in this period, proposed that the whole of the Leppings Lane turnstiles, which were then in a crescent shape, should be demolished and replaced with new ones parallel to and near the rear of the stand. These new turnstiles would then offer direct access to individual pens and to the stands—meaning opposing supporters could be separated earlier. They would also have separate toilets and food and drink facilities, to avoid potential conflict. Senior officers agreed that this proposal should be discussed with SWFC, and the main match commander at the time wrote to the SWFC Secretary, Richard Chester, setting out SYP’s suggestions.
Mr Chester discussed these with Dr Eastwood, and they agreed an alternative proposal, which would require less work but still offer complete segregation of opposing supporters. It involved adding six new turnstiles but not changing the entire layout.
This was discussed further at an OWP meeting, and SYP accepted the proposals, subject to a few additional recommendations. The design was revised and by the end of April a clear plan was in place, as shown in figure 2G. This would have resulted in 30 turnstiles rather than the 23 which existed at the time. Each block of turnstiles was also clearly aligned with a specific area of the stadium; for example, on the far left, turnstiles 28 to 30 would have offered access only to the south pen of the West Terrace.
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Figure 2G: Drawing of proposed modification to Leppings Lane entrance (Source: Eastwood & Partners)
In his first report, Mr Cutlack commented that if this plan had been implemented “it is quite possible that the events of 15th April 1989 would not have occurred with the same consequence.” As well as having more turnstiles available, which would have made a crush outside less likely, he noted that the plan would have enabled better use to be made of turnstile count data. Because the banks of turnstiles would have been directly linked to specific areas, the data would have shown the numbers of spectators that had been admitted into each area. When an area reached capacity, the associated turnstiles would simply have been closed.
SWFC asked Dr Eastwood to provide an estimated cost for the work. At a board meeting on 2 May 1985, SWFC directors rejected the proposal as too expensive. A few days later, the Bradford fire occurred (see paragraph 2.8) in a wooden stand. Even before the investigation was complete, football clubs realised that they would need to fund fire safety improvements; SWFC was no exception.
There was further discussion between Eastwood & Partners and SWFC, and in August 1985, a revised plan was implemented. This involved no increase to the number of turnstiles but allocated each bank of turnstiles to a specific area of the stadium, to assist with segregation. Under this plan, there were seven turnstiles allocated to the terraces, eight to the North Stand and six to the West Stand.
Mr Cutlack commented that these alterations “resulted in it being more likely that over-crowding would occur outside the turnstiles because fewer turnstiles were allocated to the West Terrace.” He added: “This was reasonably foreseeable by any competent party.”
Once again, the changes to the turnstile layout should have resulted in a review of the Safety Certificate; they did not.
