Chapter 2: The 'moment' of

¶2.2.1 Part 1 of this Report establishes the recent historical context to the 1989 Semi-Final at Hillsborough, coincidentally a repeat of the previous year's match between Liverpool and Nottingham Forest.

¶2.2.2 The strong assertion made in previous reports and analyses that the period from the near tragedy of 1981 on the Leppings Lane terrace to the 1989 disaster was infected by institutional complacency regarding crowd safety is affirmed by the documents disclosed to the Panel and reviewed in the previous chapter.

¶2.2.3 The decision by the Football Association (FA) to hire Hillsborough Stadium for a semi-final for a third consecutive year was, in itself, a demonstration of confidence in the facility, its management and its policing. Further, it confirmed that in the professional judgements of all agencies concerned the stadium and its operation was once again 'fit for purpose' following a five-year absence from the FA's roster of semi-final venues.

¶2.2.4 Issues of concern, not least the chilled relationship between Sheffield Wednesday Football Club (SWFC) and South Yorkshire Police (SYP) but also negotiations about stadium safety and alterations, had not been made public.

¶2.2.5 Relying on limited documentary disclosure, the previous chapter reveals the focuses of these concerns. Significantly, given the controversy about safety, stewarding and policing after the ill-fated 1981 Semi-Final, the not dissimilar problems that occurred in 1987 and 1988 apparently were not debriefed and nor were they recorded.

¶2.2.6 In retrospect, as the previous chapter demonstrates, taken alongside the near tragedy of 1981, the 1987 and 1988 events provided, at minimum, a clear warning of potential dangers on the concourse outside the Leppings Lane end, at the turnstiles, in the tunnel approach to the central pens and on terraces confined by perimeter and radial fences.

¶2.2.7 Despite this, the FA had been reassured by SWFC and by SYP that the previous semi-finals had been successful, had passed without problems, and that the 1989 Semi- Final could operate as a rerun of the 1988 match. This was reinforced when it transpired that the same two clubs were involved.

¶2.2.8 Yet there was one significant difference regarding policing. Chief Superintendent Brian Mole, Hillsborough's most senior and experienced match commander, was transferred from the local police division in highly controversial circumstances.1 He was replaced by Chief Superintendent David Duckenfield 21 days before the Semi-Final. No further information on this sequence of events has been made available to the Panel but, as this chapter shows, it was a significant development. Based on the documents disclosed to the Panel, what follows considers the immediate context, circumstances and aftermath of the disaster.

¶The 1989 FA Cup Semi-Final 2.2.9 According to Graham Mackrell, the SWFC Secretary, there was no inter-agency pre-match briefing before the 1989 Semi-Final. His understanding was that SYP 'felt one was not necessary as the game involved effectively an action reply [sic] of the year before'.2

¶2.2.10 Mr Mackrell's recollection conflicts with SYP's liaison officer, Inspector Steven Sewell, who recalled a planning meeting held on 22 March 1989 attended by 'various people' concerned 'with the police operation'. However, neither the South Yorkshire Metropolitan Ambulance Service nor the Fire Service, was invited.3

¶2.2.11 The notes of this meeting could not be traced when requested by Counsel for SYP.4 According to C/Supt Mole, while there was no meeting with the FA the 1988 arrangements were confirmed for 1989 by telephone.5

¶2.2.12 The Match Commander in 1989 was C/Supt Duckenfield. As in 1988, SYP's Assistant Chief Constable for Operations, Walter Jackson, assumed overall control of planning and operational policing on the day.

¶2.2.13 Interviewed by West Midlands Police (WMP) for a report to the Director of Public Prosecutions (DPP), he stated that as Match Commander C/Supt Mole's 'kind of community policing' strategy was to try 'to get the same … people at the same place all the time, and so he did that and he used a lot of his, community bobbies, so that they were at the same place, would identify the people concerned, so that if there were any particular problems … they could identify them quickly'. ACC Jackson stated that 'it was good practice, and ... we always shared it with everyone else'.6

¶2.2.14 As stated above, C/Supt Duckenfield replaced C/Supt Mole 21 days before the match. According to ACC Jackson, C/Supt Mole was not asked to police the match. C/Supt Duckenfield was an experienced divisional commander who would be supported by C/Supt Mole's established team.

¶2.2.15 However, C/Supt Duckenfield had not worked at Hillsborough for ten years.7 Because the change of command happened within a month of the Semi-Final, C/Supt Mole initiated the planning with C/Supt Duckenfield involved from the first meeting.

Phil Scraton (2009) Hillsborough: The Truth Edinburgh: Mainstream, pp18-20. 2. Statement of Graham Mackrell, 19 May 1989, SYP000038670001, p79. 3. Inspector Sewell's evidence to the Taylor Inquiry, SYP000123550001, p5. 4. Letter from ACC Anderson, SYP, to Hammond Suddards, 5 May 1989, SYP000097360001, p2. 5. Note of internal SYP meeting to discuss 'Proof of Evidence' for the Taylor Inquiry, 26 April 1989, SYP000097190001, p4. 6. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p61. 7. Final submission to the Hillsborough Inquiry on Behalf of the Treasury Counsel, SYP000098180001, p20.

¶2.2.16 The detailed planning was processed by the same SYP team as 1988 overseen by Superintendent Bernard Murray who, as second-in-command, liaised with C/Supt Duckenfield. Reflecting on C/Supt Duckenfield's new role, ACC Jackson considered that the 'open and frank policy' which he operated in SYP would have allowed C/Supt Duckenfield to make known his reservations about policing the match.8 2.2.17 During his interview for the eventual criminal investigation into the disaster, Supt Murray observed that C/Supt Duckenfield and C/Supt Mole exhibited contrasting leadership styles. Whereas C/Supt Mole operated on the ground and was mobile within the stadium, remaining in radio contact with the Police Control Room, Supt Murray stated that C/Supt Duckenfield viewed his role as supervising the policing of the stadium from the Control Room.9

¶Pre-match briefings 2.2.18 C/Supt Duckenfield briefed senior officers the day before the match, his notes emphasising public order and crowd safety. They contained no reference to crowd safety issues from the previous year. He emphasised that as it was an all-ticket match, 'if supporters do not have a ticket then whatever they say they will not be allowed into the ground' as 'safety limits' had to be protected.10 2.2.19 He noted that the 'stadium has been divided to ensure maximum segregation and to reduce any possibility of public disorder'. As it would be 'full to capacity' and some officers 'may never have experienced a football match of this nature' the priority was 'to ensure the safety of spectators and you must make sure you know the escape routes and that you are fully conversant with your responsibilities should a crisis arise'. He stated: 'I cannot stress too highly the word "Safety"'. 2.2.20 Superintendent Roger Greenwood was Ground Commander inside the stadium and raised the issue of overcrowding, specifically because there was concern to avoid a situation in which Liverpool fans who gained tickets for the Spion Kop would be transferred to the Leppings Lane terrace, thus repeating the events of 1981. 2.2.21 He briefed Inspectors under his command not to transfer Liverpool supporters from the Spion Kop to the Leppings Lane terrace, contrary to the instructions in the Operational Order. His briefing concentrated on public order problems: 'the question of supporters from the Leppings Lane terrace being hauled up by fellow supporters into the West Stand [seated area] at half time thus creating over capacity in the West Stand'.11 2.2.22 Further, given the experience of the 1988 Semi-Final, 'it was quite foreseeable that there would be a large element of Liverpool supporters who by whatsoever means would be purchasing tickets for the Spion Kop'. This 'problem had been evident last year and … cordoning Police officers had come under threat to personal safety'. 2.2.23 He advised that 'generally speaking if things are going well for Liverpool supporters crowd management should be reasonably well achieved, however should things in any way not go well [with] them then they had proved extremely difficult to contain and moods would easily change'.

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p66. 9. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp53-54. 10. Chief Superintendent Duckenfield's briefing notes for the 1989 FA Cup Semi-Final, 14 April 1989, SYP000038820001, pp318-323. 11. Notes of Superintendent Greenwood's briefing on 14 April 1989, document dated 20 April 1989, SYP000010690001, pp2-3.

Chapter 2 The 'moment' of 1989 — 89

¶2.2.24 Reflecting on an incident at a Sheffield Wednesday v Liverpool league match, Sheffield Wednesday supporters had been transferred to the Leppings Lane terrace where 'Liverpool supporters went wild attempting to scale the fencing in an attempt to get to the Sheffield Wednesday supporters. It was necessary for some officers to draw truncheons to contain the Liverpool supporters'.

¶2.2.25 Interviewed by WMP for a report to the DPP a year after the disaster, Supt Greenwood stated that from experience he expected crowd distribution to be monitored by officers in the Police Control Box 'visually and with screens'.12 His recollection that at the briefings he made specific references to 1981 was confirmed by SYP officers Inspector Gordon Sykes and Inspector Graham Delaney.13

¶2.2.26 Superintendent Roger Marshall was Ground Commander outside the Leppings Lane end of the stadium. His briefing focused on public order rather than safety. While C/Supt Duckenfield had, as stated above, included safety in his briefing Supt Marshall's mindset was influenced by the events of 1988.

¶2.2.27 Interviewed a year after Hillsborough by WMP for a report to the DPP, Supt Marshall recorded his 'fairly jaundiced view of football supporters', noting 'incidents that had taken place in 1988 ... that I found disturbing and distasteful, for instance there was a fight and a stabbing which took place in Hillsborough Park ... and there was some shoplifting which took place down in the precinct and generally the reputation of, of Liverpool fans left a lot to be desired in my view'.14

¶2.2.28 Focusing on alcohol and disorder, Supt Marshall stated he was aware of the late arrival of Liverpool fans but understood it within the context that 'one associates football matches with, with heavy drinking and that was precisely what was taking place'.15

¶2.2.29 He took no action to encourage fans to move quickly into the stadium because he considered that this would have had a deleterious effect on their mood and behaviour. He considered that crowd congestion in the concourse outside the Leppings Lane turnstiles was due to non-ticket holders and poor intelligence from Merseyside Police.16

¶The Operational Order 2.2.30 The 1989 Operational Order replicated the 1988 Order. Given the format, wording, postings and spelling errors it was a redraft with few changes. The most significant difference was a 19 per cent reduction in manpower and the exchange of roles between Supt Marshall and Supt Greenwood (in 1988 Supt Marshall had been Ground Commander and Supt Greenwood had been responsible for the police operation outside the stadium in Leppings Lane).17

West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, p22. 13. Statement of Inspector Gordon Sykes, 18 July 1990, SYP000038800001, pp248-250. See also statement of Inspector

¶Graham Delaney, SYP000038800001, p334. 14. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p31. 15. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p45.

¶SYP000038880001, pp55-56. 17. Document giving comparison of Operational Orders at Hillsborough Football Ground, SYP000027020001, p3.

¶2.2.31 Supt Marshall policed a semi-final only in 1988 and previously earlier than 1981. Supt Greenwood had more recent experience. According to Supt Marshall there was no reason for the change in operational roles between 1988 and 1989 other than 'variety'.18

¶2.2.32 The reduction in police personnel was concentrated in the Leppings Lane area of the stadium and had 'a direct affect [sic] on sector 2 who's [sic] responsibility was the Policing of the Liverpool supporters'.19 The reduction was three inspectors, five sergeants and 58 constables.

¶2.2.33 Some operational changes reflected concerns about a minor post-match pitch invasion in 1988. Additional officers were allocated to the perimeter track at the end of the match and instructions were given to stop fans climbing the perimeter fence, ensuring the gates in the perimeter fence remained locked. The 1989 Order stated that 'these gates will only be opened if a specific message to evacuate is given on the public address system'.

¶2.2.34 Police officers were positioned on the track in front of each perimeter fence gate. The Operational Order instructed: 'No-one is to be allowed access to the track from the terraces without consent of a Senior Officer except to receive medical attention'.

¶2.2.35 In 1987 and 1988 the word 'No-one' was underlined. In 1989 the entire sentence was in capitals and underlined. Despite the wording, C/Supt Mole stated that during his time as match commander he had expected individual officers to use their own initiative in situations of distress.

¶2.2.36 However, C/Supt Mole considered that use of personal initiative could lead to a further problem, 'because there is a tendency, if you open gates – and we have found that with the Kop – that to let a couple of people out because of some reason; they may have lost daddies at the other pen; that a lot of people then think they want to come as well, so the message is to clear it with Control before you actually open the gate because you can create a problem in isolation that that Officer is not aware of'.20

¶2.2.37 The Operational Order also specified that perimeter fence gates could be opened only after a coded message had been announced via the public address system. Thus officers were not expected to work on their own initiative.

¶2.2.38 Further, neither the Operational Order nor the briefings alerted officers to the possibility of crushing. In the final submission to Lord Justice Taylor made by the Fire Service it was affirmed that 'Chief Superintendent Duckenfield had concluded, in the light of the discussions and information he had, that the pens on the Leppings Lane terraces did not present a major problem. The probability of crushing was not specifically mentioned in any briefings'.21

¶2.2.39 While the 'Operational Orders emphasized the need to prevent spectators gaining access to the pitch ... the function of the perimeter fence gates in providing a means of escape in certain eventualities, particularly crushing, was not referred to'. Consequently, in the pre-match briefing at the stadium on the day, and in earlier briefings, SYP officers 'on the ground do not appear to have been made aware of the dangers of crushing in the pens particularly if they became overcrowded'. 18. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, p26. 19. Document giving comparison of Operational Orders at Hillsborough Football Ground, SYP000027020001, pp9-10. 20. Transcript of Chief Superintendent Mole's evidence to Lord Justice Taylor, day 7, 24 May 1989, SWF000002030001, pp68-69. 21. Final submission of South Yorkshire Fire Service and Civil Defence Authority to Lord Justice Taylor,

¶SYP000098170001, p17.

¶2.2.40 Finally, the boundaries between Supt Greenwood's responsibilities as Ground Commander and Supt Marshall's responsibilities outside the Leppings Lane turnstiles – and the communication between both senior officers – remained unclear and did not form part of C/Supt Duckenfield's briefings.22

¶The mindset 2.2.41 In its submission to the Taylor Inquiry, SYP claimed that '1988 intelligence stated that when Liverpool played at Tottenham, the Stadium was filled to capacity, 2,000 Liverpool fans were locked out and ran riot outside the ground, stealing from shops and causing public annoyance'.23 2.2.42 While no other evidence has been provided to support this claim, SYP stated that it influenced the 1988 Operational Order. Consequently, 'the formulation of Serials included officers giving special attention to shopping areas, to counter such eventualities. This contingency was repeated in the 1989 Order'. 2.2.43 The submission described how manpower levels were determined by Force intelligence and experience while noting, 'it is not possible to form contingencies for unprecedented changes in behavioural attitudes' thus suggesting that the only variable in crowd management was fan behaviour. 2.2.44 In 1989 officers were not assigned specifically to the tunnel entrance on the inner concourse but SYP, in its submission to the Taylor Inquiry, explained how 'the Operational Order has inbuilt flexibility and perceived problems which result in the request for redeployment of manpower can be facilitated via Ground Control, dependant [sic] upon the developing situation. To this end there were 7 Serials consisting of 7 Sergeants and 72 Constables in the immediate vicinity of the Leppings Lane turnstiles and West Stand'. 2.2.45 The minor pitch invasion in 1988 also influenced the mindset for 1989. It was 'drummed into all officers that access to the pitch must not be permitted except in the most exceptional circumstances', leading 'to the failure to react quickly enough to the emergency that in fact arose'.24 2.2.46 Police Constable Peter Smith and Police Constable David Illingworth were deployed on the perimeter track supervising the gates into central pens 3 and 4 respectively. The gates were not to be opened without permission given by a supervisory officer, other than to allow injured persons onto the track to receive medical attention. PC Smith's experience in 1988 influenced his expectations for 1989:

¶The 1988 … Semi Final between the same teams had taken place with myself and

¶Police Constable ILLINGWORTH on the perimeter track. That year the terraces were filled well prior to the kick off. We had a constant job asking people to get off the top of the perimeter fence. I noticed that a large number of fans were worse for drink and

¶I suffered much abuse from them consisting of the usual verbal and spitting.

¶At the conclusion of the game the gates from the terraces to the pitch both opened by bodily pressure and by fans reaching through the fencing and releasing the gates.

¶The wire meshing on the perimeter fence was also ripped out by the fans to gain access to the track. Others simply climbed over the fence and dropped onto the track. Others had climbed over during the match and were either escorted from the track or returned when approached by Police Officers.

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp71-77. 23. South Yorkshire Police submission to Lord Justice Taylor, Part IV: Policing at Hillsborough, SYP000096730001, pp7-23. 24. Treasury Council submission to Lord Justice Taylor, SYP000098180001, p19.

¶One fan who re-scaled the fence to return, was later treated for an ankle injury. Having

¶Policed that match and other matches involving Liverpool over the last two years, I had no doubt of what my duties would entail in 1989.25 2.2.47 There had been some friction between supporters at the 1988 match. Supt Greenwood recalled that police officers had drawn truncheons to control the situation. Thus he 'anticipated that such a situation was likely to occur at the 1989 semi-final'.26 2.2.48 According to SYP, there were six significant changes between 1988 and 1989: reduction in overall manpower levels; improvement in the ticket identification system; use of a portable video camera for evidence gathering; attention paid to off-licences as well as licensed premises; abandonment of a spotter plane; and redeployment of coach reception officers to stand-by duties in Leppings Lane and Penistone Road North.27 2.2.49 In 1987 ten 'football special' trains had been used, reduced to three in 1988 and only one for Liverpool supporters in 1989. Transport arrangements were not within the control of SYP.28 C/Supt Mole considered that it was easier to maintain control when fans arrived by train. 2.2.50 In 1989 Liverpool supporters arrived by special train at Wadsley Bridge station and were walked to and from the ground by police officers. Liverpool supporters who arrived at Midland station, allocated to Nottingham trains, were segregated from Nottingham Forest fans and bussed to the ground under police supervision.29

¶15 April 1989 2.2.51 The Police Control Room log book for 15 April 1989 began at 8am but there was no entry beyond 2.21pm.30 Consequently information about much of what happened at the time of the disaster is derived from statements, interviews conducted by WMP for the criminal investigation and evidence presented to the Taylor Inquiry. 2.2.52 Supt Murray and C/Supt Duckenfield arrived at the Police Control Box at approximately 1.50pm. ACC Jackson arrived soon after 2pm. He remarked that more Nottingham Forest fans appeared to be in evidence than Liverpool fans. He left the Control Box at approximately 2.15pm and took his seat in the Directors' Box at 2.35pm.31 Supt Murray stated that he was also aware that more Nottingham Forest fans than Liverpool fans were inside the stadium.32 2.2.53 Leppings Lane was closed to traffic when large numbers of fans began to arrive. This had not happened in 1988.33 While Supt Murray and C/Supt Duckenfield exchanged comments about the possibility of delaying the kick-off, Supt Murray was confident that the crowd would pass through the turnstiles in time.

Statement of PC Peter Smith, 29 April 1989, SYP000038810001, pp189-190. 26. Statement of Inspector Roger Greenwood, 3 May 1989, SYP000038790001, p117. 27. South Yorkshire Police submission to Lord Justice Taylor, Part IV: Policing at Hillsborough, SYP000096730001, p49. 28. Minutes of meeting with Counsel, 26 April 1989, SYP000096360001, p65. 29. Appendix to a report by British Transport Police re. arrangement and experiences at 1989 FA Cup Semi-Final at

¶Hillsborough, 10 April 1989, SYP000097420001, pp10-11. 30. Extract from Control Room log book, 15 April 1989, SYP000121610001, pp21-25. 31. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp152-157. 32. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp66-68.

¶pp79-80.

¶2.2.54 As Ground Commander, Supt Greenwood was in radio contact with the Control Box and was positioned close to the players' tunnel. According to Supt Murray, Supt Greenwood could have made contact quickly with the referee.34 At 2.54pm a request to delay kick-off was made to the Control Box by Police Constable Michael Buxton. Without conferring with C/Supt Duckenfield or Supt Murray, Sergeant Michael Goddard, whose Control Box role was to operate the radios, immediately replied that it was too late as a team was on the pitch.

¶2.2.55 He believed that C/Supt Duckenfield and Supt Murray had heard the message and was under the impression that C/Supt Duckenfield had decided already not to postpone the kick-off. This was not because of any comments made in the Control Box but the assumption that 'if a game is going to be delayed it will be delayed before the teams come out'.35 The 1987 delay had been sanctioned before the teams left the dressing rooms.

¶2.2.56 It was PS Goddard's impression that if C/Supt Duckenfield was considering a delay he would have contacted FA officials rather than remaining in the Control Box. PS Goddard's understanding of the policy was that should there be 'a particular reason such as a motorway blockage or fog for people to be late it would be delayed, but if they just turned up late it wouldn't'.36 This interpretation contrasted markedly with the position of the previous Match Commander, C/Supt Mole.37

¶2.2.57 At 2.40pm Mr Mackrell and Glen Kirton from the FA stood on the perimeter track by the players' tunnel. They recognised there was a substantial number of fans still to enter the stadium. Mr Kirton queried whether the police required a delay. Mr Mackrell said they did not, since 'pulling back the kick-off produced all sorts of organisational problems at the end of the game'.38

¶The build-up to kick-off 2.2.58 Supt Marshall stated that at 2pm he was on the outer concourse on Leppings Lane and all was calm. The build-up began approximately 20 minutes later. Soon after he discussed with Inspector Sykes the large number of fans 'spilling off the pavements into Leppings Lane'. He closed the road to traffic but estimated that there was sufficient time before kick-off to process the increasingly dense crowd.39

¶2.2.59 In a statement a year later to WMP for the criminal investigation he commented, 'it did not cross my mind' to suggest delaying the kick-off to C/Supt Duckenfield. He had been influenced by C/Supt Duckenfield's policy on late arrivals and considered that any delay 'was a matter for Control'. It was a 'question for Mr Murray and Mr Duckenfield, having regard to the intelligence which ... they could have … obtained or had received from other people'.

¶2.2.60 Supt Marshall considered that the police lost control of the crowd outside the stadium at approximately 2.44pm.40 He recalled standing on a parapet to view the tightly 34. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, p90. 35. Sergeant Goddard's evidence to Lord Justice Taylor, HOM000026040001, p42. 36. This was a question put to PS Goddard to which he replied in the affirmative. It was put to him by Mr Phillips before

¶Lord Justice Taylor, HOM000026040001, p42. 37. See Chief Superintendent Mole's understanding of the grounds for delaying kick-off, relating to his experience in

¶1987, in Chapter 1. 38. Statement of Glen Kirton, Head of External Affairs at the Football Association, 17 May 1989, SYP000038700001, p151. 39. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp60-71.

¶SYP000038880001, p102.

¶packed crowd at the approach to the turnstiles. This moment was caught on CCTV. He was unable to make direct contact with the Control Box, and he changed channels to contact Hammerton Road Police Station to pass a message to the Control Box. 2.2.61 On reflection he considered that more officers or better organisation would not have helped as he estimated six to eight thousand people in the crush.41 The situation at the turnstiles became severe, he claimed, because there had been a failure in intelligence and the police resources available were inadequate to respond effectively. 2.2.62 It is evident from the disclosed documents that the situation in the Control Box after 2.35pm became chaotic. There were constant incoming calls and radio messages, the radio system failed and police reinforcements were sent to Leppings Lane under the wrong assumption that there was crowd disorder. 2.2.63 Yet the main focus remained on the Spion Kop where trouble was anticipated because officers expected Liverpool fans to gain entry among Nottingham Forest fans. Supt Murray was unclear in his recollection of the precise time, but by 2.45pm he stated that he was aware of a serious crowd problem on the Leppings Lane terrace and responded to subsequent radio requests for reinforcements.42

¶Opening the exit gates 2.2.64 A low, gated metal fence separated the outer concourse at the turnstiles and the street approach along Leppings Lane. In 1988, all but one of these gates leading from the road into the outer concourse were closed, whereas in 1989 all but one were open.43 2.2.65 Video coverage from 1988 showed these gates on the outer concourse closed from 11am. A 1989 video showed that, in this instance, they were not closed until an attempt was made once congestion was recognised.44 ACC Jackson was unable to explain the difference in approach but blamed a small element of the crowd who had been drinking and were anxious to gain entry into the stadium.45 2.2.66 As congestion built to dangerous levels, Supt Marshall radioed an urgent request for stadium exit gates, close to the turnstiles, to be opened to allow fans into the ground. In his message he stated that there was a real possibility of fatalities if relief was not immediate. 2.2.67 In his WMP interview for the criminal investigation, Supt Marshall stated that as he was unaware that the exit gates were identified as A, B and C he had not named the gate that should be opened. He acknowledged that there were other means to identify each gate. He stated that he had no information about the crowd inside the stadium and assumed, '[t]here must be nobody on the terrace cause there's all these people here trying to get in'.46 2.2.68 Supt Marshall considered he had no option to direct fans elsewhere as they 'wouldn't have gone ... this is the problem that people seem to so desperately to fail to appreciate that there were thousands and thousands of people, many of whom had far too

West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp107-110. 42. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, p112. 43. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp88-89. 44. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp91-92. 45. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp102-103.

¶SYP000038880001, p74.

¶much to drink ... elements of people who hadn't got tickets ... that it's eight minutes away from kick-off and I'm gonna be in that ground come hell or high water...'.47 2.2.69 Having requested the opening of the exit gates, Supt Marshall stated that it did not occur to him to inform Supt Greenwood of his actions.48 He assumed there was considerable space on the terraces. After the gates were opened, the pressure was relieved, the crowd outside was under control and fans continued to use the turnstiles.

¶2.2.70 In the Police Control Box Supt Murray recalled a brief delay before C/Supt Duckenfield authorised opening the exit gates. Supt Murray was unsure which gates had been opened and later stated: 'I thought [the fans] would come into the ground and I thought they would be absorbed by the concourse'.49

¶2.2.71 The WMP report to the DPP questioned whether C/Supt Duckenfield had sufficient knowledge of the stadium's geography and signage to appreciate the consequences of opening Gate C, particularly the impact on the already full central pens. The WMP investigation team also questioned whether C/Supt Duckenfield understood his instruction to 'open the gates' related to Gate C only or to Gates A and B as well.50

¶2.2.72 At the time the gates were opened, Supt Murray was aware the pens were not evenly filled. Yet he stated that it did not occur to him to attempt to redistribute fans. In his 1990 interview with WMP for the criminal investigation he stated that he considered this would have been a dangerous strategy as the numbers were so high. Further, closing the tunnel entrance to the packed central pens did not cross his mind.

¶2.2.73 On reflection Supt Murray considered that a line of officers across the mouth of the tunnel would not have been effective given the volume of fans who had entered through Gate C. He judged it would have caused a further build-up that would have broken the police line.

¶Consequences of opening the gates 2.2.74 At the time Supt Murray was concerned about the consequences of opening Gate A with large numbers of fans rushing into the North Stand seats. Expecting problems, police officers were despatched to that area. His action anticipated the impact of opening Gate A, but failed to consider the consequences of opening Gate C.51 PC Smith recalled looking through a glass window in Gate A at approximately 2.50pm and noticing numerous fans crushed and in great distress.52 Sergeant Wright claimed that he requested Club stewards to open the gate to relieve the pressure but the stewards refused.

¶2.2.75 Near Gate B Inspector John Bennett was on a turnstile roof assisting distressed fans over the wall and into the stadium to escape the crush outside. A number of these fans had lost shoes and clothing. Stewards also refused to open Gate B. Eventually a steward unlocked and opened the gate for approximately one minute. This relieved the crush.

West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp113-114. 48. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp119-129. 49. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp117-135. 50. WMP report to the DPP, Part VII, SYP000038850001, p69.

¶pp137-146. 52. Recollection of PC Brown, 19 April 1989, SYP000096810001, pp4-6.

¶2.2.76 There remains some discrepancy about who opened Gate B. According to PC Smith, he and another officer opened the gate, not a Club steward. Then a steward helped him to replace the bolts when the gate was closed.53 Police Constable Michael Craighill noted that prior to the gate being opened, the metal began buckling inwards due to the pressure of the crush outside.54

¶2.2.77 By 2.45pm the tunnel was three-quarters full of fans attempting to descend into the central pens. No police officers were evident near the tunnel entrance.55 Video evidence shows that when Gate C, directly opposite the tunnel, was opened 'the spectators almost universally are moving towards the tunnel entrance to the terraces and there is virtually no movement nor any activity by anyone to direct these same spectators to the south side of the west stand'.56

¶After the crush 2.2.78 Supt Murray later reflected that, in the Control Box, he did not make the connection between the opening of the exit gates and the emerging problems in the central pens.57 As fans tried to climb from the overfull pens he went down to the pitch to attempt to stop the match.

¶2.2.79 Once he became aware that Supt Greenwood was contacting the referee to stop play, Supt Murray returned to the Control Box. He did not speak to anyone on the pitch nor did he go to the pens to investigate.

¶2.2.80 Meanwhile, Supt Greenwood was unaware of the problems outside the turnstiles. Realising that there was a crush in the pens likely to result in serious injuries, he gesticulated and shouted to the crowd to move back up the terrace steps. Given the density of the crowd, this was not possible.

¶2.2.81 Supt Greenwood waved to the Control Box to stop the match and ran to the referee. He stated that he 'took this action unilaterally, having received no response from the Control Box'.58 He returned to the pens to assist with rescue and evacuation.

¶2.2.82 An urgent radio message requested all available officers to move inside the stadium. Supt Marshall assumed there had been a pitch invasion and entered through Gate C. At this point fans were retreating from the terrace through the tunnel. Many were injured and it became increasingly evident to Supt Marshall that there could be fatalities.59

¶2.2.83 On Supt Murray's arrival back at the Control Box, he was instructed by C/Supt Duckenfield to return to the pitch and to try to clear fans from the goal area. There he found fans seriously injured, possibly dead, and realised he was not carrying a radio.60

Recollection of PC Smith, 19 April 1989, SYP000096810001, pp13-14. 54. Recollection of PC Craighill, 19 April 1989, SYP000096810001, pp9-11. 55. Recollection of PC Smith, 19 April 1989, SYP000096810001, p13. 56. Overview of video evidence provided by Deputy Chief Constable P Hayes, 18 April 1989, SYP000096810001, pp56-59. 57. West Midlands Police interview with Superintendent Murray for report to the DPP, 25 June 1990, SYP000038900001, pp169-176. 58. West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, pp29-30. 59. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp128-129.

¶pp179-192.

¶Supt Murray then contacted various officers and gave them directions. Utilising another officer's radio, he called for 'a fleet of ambulances'.

¶2.2.84 ACC Jackson had been watching the match from a seat in the Directors' Box located above the players' tunnel. He stated that he had not seen fans being moved from the central pens before kick-off. Shortly after kick-off he became aware of fans on the pitch behind the goal.

¶2.2.85 He considered three possibilities – crowd disorder, Nottingham Forest fans at the wrong end or a pitch invasion. He realised it was a serious problem when fans were on the pitch and he went to the Control Box. He was unclear at that point whether the match had been stopped or was continuing.61

¶2.2.86 On reaching the Control Box, ACC Jackson noted an air of 'concern and puzzlement as to what, what was going on'. He and C/Supt Duckenfield had a 'a short conversation about the possibility of a pitch invasion'. Nothing was said about the opening of the exit gates.

¶2.2.87 ACC Jackson then went to consult Supt Greenwood and other officers. He understood from Supt Greenwood that he was dealing with 'a crushing incident'. On a brief walk around the stadium ACC Jackson did not visit pens 3 and 4 before returning to the Control Box where, as he later described, the atmosphere was 'hyped up quite considerably, and lots of things were happening'. He 'considered that [he] was in command of a major, a major, developing major incident'.

¶2.2.88 When ACC Jackson had arrived on the pitch, Supt Greenwood assumed that, as the senior officer at the match, he would organise the necessary support and with those in the Control Box being aware of the seriousness of the situation, he would take control. Supt Greenwood, however, felt 'as if I was dealing with the disaster alone'.62

¶2.2.89 Supt Marshall stated later that he was shocked by what happened and had been unable to direct an ambulance into the stadium due to the crowds. He organised approximately 30 officers to assist with casualties and 'established three areas on the access to the South Stand, one for the walking wounded and one for the seriously injured, and one for the dead'.63 He allocated a police officer to remain with each body to establish continuity of identity. According to Supt Marshall, he took charge of the rescue operation without receiving direction from the Police Control Box.

¶2.2.90 On ACC Jackson's return to the Control Box, Graham Kelly, FA Chief Executive, and Graham Mackrell, SWFC Secretary, were present. At that stage, ACC Jackson 'didn't say much ... because basically I was ... concerned with what was happening down there [on the pitch]'.64 Mr Mackrell later recalled, when he visited the Control Box 'no reference was made at any stage to the gate having been opened, and it was clearly an urgent situation where I did not wish to interfere with the Police operations'.65

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp158-180. 62. West Midlands Police interview with Superintendent Greenwood for report to the DPP, 29 June 1990,

¶SYP000038920001, pp29-30. 63. West Midlands Police interview with Superintendent Roger Marshall for report to the DPP, 19 June 1990,

¶SYP000038880001, pp130-135. 64. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p182. 65. Written statement of Mr Mackrell to Lord Justice Taylor, 26 June 1989, SYP000096840001, p419.

¶2.2.91 ACC Jackson recalled C/Supt Duckenfield saying 'something to the effect that the gates had been stormed'.66 In the context of the rescue operation 'it seemed unimportant'. Mr Kelly also referred back to the discussion:

¶The Police in the Control Box were apparently under the impression that a gate or gates had been forced. They told me so and showed me a picture which purported to represent this. They said that the match would have to be abandoned because there had been fatalities. They did not know how many. The Police Commander

¶[C/Supt Duckenfield] was present in the Control Box together with the Assistant Chief

¶Constable, Mr Jackson … We were told that when the gate had been forced there had been an in-rush of Liverpool supporters.67

¶2.2.92 At approximately 3.30pm ACC Jackson and C/Supt Duckenfield went to the SWFC boardroom to meet FA and SWFC officials. The discussion there focused on abandoning the match, when this should be announced to the crowd still in the stadium, and on the injured fans. When ACC Jackson entered the meeting, 'running through my mind was still the fact that the gates had been stormed'. Nothing was said in the meeting to alter that perception.68

¶2.2.93 ACC Jackson was eager to evacuate all the injured from the stadium before the crowds dispersed. Despite ACC Jackson's reluctance to air such a message, the Liverpool manager, Kenny Dalglish, made the announcement using the public address system.

¶2.2.94 Soon after, ACC Jackson spoke with Detective Chief Superintendent Terence Addis, Head of CID at Hammerton Road Police Station, who arrived at the Control Box at approximately 3.50pm. He was unable to enter due to 'a fireman stuck in the door' and was directed to take charge of the temporary mortuary in the gymnasium and assume responsibility for the immediate SYP investigation of the events.

¶2.2.95 According to ACC Jackson, Det C/Supt Addis 'went to set things in motion [and] to set up the HOLMES [computer system] to appoint an officer to that, to get the Coroner down to tell him what we were doing and what arrangements did he think we should make et cetera'.

¶2.2.96 Just after 4pm, Supt Marshall met C/Supt Duckenfield, ACC Jackson and Supt Murray in the Control Box. According to Supt Marshall, 'all of them' were 'in a state of shock'.69 Supt Marshall explained to ACC Jackson that officers had been overwhelmed by the crowd outside and he had opened the gates. ACC Jackson was 'surprised', since he was still under the impression that the gates had been forced.70 Given 'the circumstances … the pressure that we were working under … the trauma of the event and all the rest of it', he did not feel it necessary to question C/Supt Duckenfield about the contradiction. ACC Jackson's assessment of C/Supt Duckenfield was that he did a 'superb job', describing him as 'calm, cool, collected and he was good with his staff, and we worked well together in the box'.

¶2.2.97 Former Match Commander C/Supt Mole arrived at the stadium having heard a request on the radio for additional support at Hillsborough. At around 4.45pm he was briefed by ACC Jackson who then left Hillsborough with Supt Murray and

West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, p184. 67. Statement of Graham Kelly, Chief Executive of the FA, HOM000001380001, p6. 68. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp170-225.

¶SYP000038880001, p135. 70. West Midlands Police interview with ACC Jackson for report to the DPP, 28 June 1990, SYP000038910001, pp188-230.

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¶C/Supt Duckenfield to brief the Chief Constable and his Deputy at headquarters and to prepare for a press conference. C/Supt Mole was appointed the Incident Commander.

The SYP decision to replace the experienced match commander, Chief Superintendent Brian Mole, and appoint Chief Superintendent David Duckenfield who had minimal experience of policing at Hillsborough, just weeks before an FA Cup semi-final, has been previously criticised. None of the documents disclosed to the Panel indicated the rationale behind this decision.
A planning meeting attended by both senior officers was held less than a month before the match. The documents disclosed to the Panel give no explanation for the non-attendance of the South Yorkshire Metropolitan Ambulance Service and the Fire Service at this meeting.
Chief Superintendent Duckenfield held a briefing for senior officers on the day before the match. At that meeting he emphasised the importance of crowd safety. Briefings held by other senior officers, however, focused on potential crowd disorder, alcohol consumption, ticketless fans and the difficulties of managing Liverpool supporters. From the documents disclosed to the Panel, it is apparent that the collective policing mindset prioritised crowd control over crowd safety.
This mindset, directed particularly towards Liverpool fans, was clearly evident in SYP's submission to the Taylor Inquiry.
As previously known, the SYP 1989 Operational Order was derived, with a few alterations, from the 1988 Order and gave no indication of the crowd management problems experienced in 1988.
The SYP Operational Order concentrated primarily on the control and regulation of the crowd with no appropriate reference to crowd safety, crushing or evacuation of the stands/terraces.
From the documents disclosed to the Panel, the management roles and responsibilities of senior SYP officers were unclear, particularly the lines of communication, decision-making and information exchange between those responsible for policing outside the stadium and the ground commander inside the stadium.
There was clear evidence in the build-up to the match, both inside and outside the stadium, that turnstiles serving the Leppings Lane terrace could not process the required number of fans in time for the kick-off. Yet the growing danger was ignored. When the request to delay the kick-off eventually was made, it was considered too late as the teams were on the pitch.
For a considerable period inside the Police Control Box it was clear from the near view of the central pens below, and the CCTV coverage of the turnstiles and pens, that serious problems of overcrowding were occurring at the turnstiles and in the pens. Senior police officers' decision-making was hampered by poor communications, a malfunctioning radio system and the design of the Control Box.
Superintendent Roger Marshall was responsible for policing outside the stadium at the Leppings Lane end. As the crush at the turnstiles became severe he requested the opening of exit gates to allow fans into the stadium and relieve crowd pressure. He had no knowledge of the uneven distribution of fans on the Leppings Lane terrace. Similarly, the ground commander inside the stadium, Chief Superintendent Roger Greenwood, had no knowledge of the extreme situation developing outside the stadium. • The overview of both sites was the Control Box, with CCTV monitors and a near view of the central pens. Chief Superintendent Duckenfield acceded to Superintendent Marshall's request and authorised the opening of Gate C. Despite a clear view from the Control

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¶Box and CCTV monitors, neither Chief Superintendent Duckenfield nor his assistant, the experienced Superintendent Bernard Murray, anticipated the impact on the already packed central pens of fans descending the tunnel directly opposite Gate C. • On opening Gate C there was no instruction given to the SYP officers inside the stadium to manage the flow and direction of the incoming crowd. • From the documents provided to the Panel it is clear that the crush at the Leppings Lane turnstiles outside the stadium was not caused by fans arriving 'late' for the kick-off. The turnstiles were inadequate to process the crowd safely, and the rate of entry insufficient to prevent a dangerous build-up of people outside the ground.