It can be argued that emergencies come in two broad types. Those that are a result of what can now be predicted fairly accurately, such as major weather-related events and their consequences (flooding); and those that are a result of a complete surprise. Major road, rail, ship and air disasters are good examples as are large-scale fires or chemical explosions. Despite their relative infrequency the catalogue of past events can always serve as a start point for planning a response.

The response to so-called rising tide events, such as flooding or the aftermath of major winds, can be anticipated and appropriate Strategic Control Group (SCG) measures put in place. Major events like the London Olympics also benefit from the slow-burn of decision-making ahead of the events. Senior, experienced commanders can bring their knowledge to the planning problems to try and manage and anticipate risks and ensure events go off safely. But does this mean this traditional hierarchical model provides a one-size-fits-all solution?

Manchester Arena Inquiry

Terrorism is an extreme form of a complete surprise. The evidence emerging from the Manchester Arena Inquiry shows the stresses and strains this placed on the emergency services as they struggled to sift through the rapidly moving palette of information trying to build situational awareness. While headline writers readily find criticism in their superficial analysis of the emergency services’ response to attacks, they are not the ones faced with potentially life-threatening decisions if they place their staff in harm’s way.

Irrespective of your point of view on the response, and there is a spectrum of opinion (some informed, some based on rumour and conjecture), the simple fact is the first half an hour after an attack has occurred is bound to be confusing. It is a simple fact that spending time trying to form a detailed picture of the situation is nugatory effort. Information is arriving sporadically from reliable and unreliable sources, which is bound to confuse and create alternative forms of reality.

But the one place where real knowledge exists is at the scene. This is where first-hand people from the emergency services are seeing what is going on. They are removed entirely from the wider fiction that is inevitably building up as mainstream media and (arguably more problematic) social media goes into overdrive. Those people are up front and personal with the situation and those best placed to make decisions as to how the response should evolve.

It is possible to argue that in no-notice events command structures need to be turned on their head. The initial response should be determined by the lowest level of commanders at the scene. The historical position that only people of seniority can take command and issue orders needs to be challenged. Whoever is at the scene needs to take responsibility for the response. This view is underscored by a detailed analysis of the evidence given to the Manchester Arena Inquiry; specifically, the focus of questioning of witnesses about the decision not to hold a SCG until nearly six hours after Salman Abedi exploded his improvised device.

While Sir John Saunders will make his own mind up about the decision-making around the holding of what we can call a formal SCG, there is little doubt that those commanders who did assemble to be involved at a strategic level of command did hold informal ‘huddles’ and discussions as events unfolded. There is no suggestion in any of the evidence that this in any way held up the response on the ground.

Strategic Control Group Purpose

If this is the case, what is the point of the SCG? Everyone knows what the strategic commanders first priorities are going to be: save lives, reassure the public and then devise a plan for getting back too normal with the minimum of impact. Every exercise that is held in the counter-terrorism field has seen an almost direct copy of these priorities.

Given this situation, it is reasonable to ask the question, so what did the SCG do during the Manchester Arena incident that had a material impact on the outcome? Aside from the order given by the Chief Fire Officer of the Greater Manchester Fire and Rescue Service (GMFRS) to deploy assets into the Arena in the early hours of the morning – countermanding what had gone before – there is little evidence to date that suggests the SCG had any impact other than (rightly) to start to focus upon the victims and their families by, for example, starting a casualty bureau. So, if the SCG had no impact on the events on the ground, why even bother to have them involved?

It is a simple fact that it always takes time for an SCG to form. Senior officers have to be mobilised. Keeping them posted on the emerging (confusing, dynamic) picture wastes the time of people involved at the coal face of the incident. Why not revise the model and adopt a different approach?

Declare that at the strategic level there is nothing that can be done of relevance to the initial response, where the ‘Golden Hour’ governs whose lives can be saved. Just issuing a pre-determined strategy, the contents of which are known to everyone anyway, is hardly commanding a situation. If anything, it is a hinderance, getting in the way of a timely and effective response.

Now of course there will be those who say that strategic commanders are the ones who are paid to make decisions. They are the ones who will carry the can if things go wrong. With a senior position, the argument goes, comes responsibility. But not if the central point of saving lives, which is what the public wants, is not achieved because people are having to move information around to allow strategic commanders to have situational awareness. Cut all that out and give responsibility to those on the ground. By being in the job they have shown their determination to save lives. Let them get on with it.

Cognitive Bias

Now of course that means they need to be trained to deal with the command situations and dilemmas they will face. Dealing day-to-day with routine law enforcement matters; the majority of fires and medical emergencies is not a grounding for decision-making in the middle of a terrorist attack. Many decisions in the mundane parts of life are readily taken by stereotyping the situation – a classic cognitive bias of humans. Paramedics rely on it all the time and it saves lives every single day.

But in a terrorist situation stereotyping is a cognitive bias that commanders should be aware of and seek to control. Where instinct cuts through cognitive bias to make a commander think again; even a relatively inexperienced commander can step back for a moment and ask their colleagues if they also have concerns. While in past articles we have pointed out the dangers of groupthink, it is still good practice to ask colleagues in the immediate vicinity if they feel in danger. Everyone should know they can speak up and on scene commanders should listen to anyone who has tangible concerns.

We can illustrate all of this from the confused situation that occurred at the Arena in the immediate aftermath of the attack. Reports of a second bomber, the possibility Salman Abedi left behind another device working on a timer to detonate when the emergency services response was in full swing, all added to the dilemmas faced by the command team. The suggestion that an active shooter was also in the vicinity did not help. This confusion arose because shrapnel dispersed by the bomb impacting the body created a signature injury that someone thought were bullet wounds. An easy mistake to make in that prevailing situation.

Throughout the confusion and reading all the testimony delivered by the end of January, one thing becomes clear. Those that were in the room where the bomb was detonated did not hear gunfire. None of the reactions on the CCTV that have been shown suggests anyone was reacting to the presence of an active shooter. Indeed, firearms officers were present at the scene in just over ten minutes after the bomb detonated. If anyone had been shooting, they would have run towards and neutralised the threat.

Operation Plato Flaw

Another point raised in cross examination of witnesses is the rapid decision to call Operation Plato at the scene. The police commander that did this had no other choice. There should have been an alternative; something that allowed him, from the scene, not to imply that there was an active shooter in the area. It is being said that the problems that occurred created a situation where command failed.

While Sir John Saunders will deliberate on that it is possible to suggest a much wider malaise – a total failure of imagination in senior command positions in the emergency services to think through alternatives to Operation Plato. Once it was called it was inevitable that everyone would believe an active shooter was present. The fact that no one tending to the most seriously injured heard any shots should have been the clearest indicator that no such threat existed.

It is not difficult to imagine how the remote parts of the command structure started to imagine that a marauding terrorist firearms attack was occurring. They had several international examples from which to base that analysis. Therein lies the danger of stereotyping and of groupthink. What this creates is a command disconnect between the situational assessment on the scene and that existing in the remote parts of the command system.

Correcting Command Disconnect

It is clear that the current approach to command, which is well founded for rising tide and events where planning timetables allow detailed consideration from senior experienced commanders, does not provide the best response in the aftermath of a terrorist attack.

This is important for one single reason: it is apparent that we fail to learn our lessons. Detailed questions are not asked. The preference is for the continuation of the status quo. When it comes to optimising our response to terrorist attacks that is not a sustainable rationale. If recent events tell us anything it is that we need to probe lessons learnt in depth and then absorb them into the culture and approach of organisations.

The Fire Knowledge Network believes this to be true and has established training programmes to provide this kind of detailed examination of detailed lessons that can be drawn from major incidents, irrespective of their characteristics and outcomes (see opposite). We believe that by taking part in these training sessions the Fire and Rescue Service people will learn first-hand from a forensic examination of the lessons that can be learnt. The series of articles, of which this is one, provide a demonstration of this kind of analysis.