Three examples to demonstrate that it takes something disastrous to occur, for things to change.

 Disasters are, by their very nature, horrific. The United Kingdom, for all of its development and technology, appears to have a pattern with these awful events. The basic premise is that complacency and a number of routine failings combine occasionally to contribute to a shocking catastrophe. After the catastrophe, the people are angry and the authorities themselves horrified, whilst, in certain circumstances, they hurriedly cover-up their basic failings. Either way, complacency and to an extent, ‘efficiency’ and monetary savings are blown open and exposed for what they are: dangers to public safety. However, once the storm dies down, are the lessons learned? I believe not – but the cycle continues.

I present to you three examples of preventable disasters which I believe illustrate the cycle of disaster creation which exists in the UK.

The Bradford City Fire – 11th May 1985 (Information sourced from the Popplewell Inquiry unless stated otherwise)

Having won the Third Division in the 1984 -1985 season, on 11th May Bradford City was to play their final game of the season, against Lincoln City, at home, in effect a celebration of the club’s promotion to the Second Division. The match was to take place at Bradford’s grounds, Valley Parade, with the main stand of the stadium, with capacity for 2,000 spectators, having been built in 1908. The stand was constructed from wood, with a canopy also of wood, coated in felt and also was built on a slope, which meant that a considerable volume of empty space existed beneath it – between 9 and 30 inches.  Due to the construction of the stand, its age and a lack of proper rubbish disposal, over the years in the void space beneath the stand a thick layer of detritus had built up – with rubbish within being dated as old as 1968, with the litter being potentially 12 inches deep. The gaps in the stand were too so wide that one fan reported, earlier in the year, having lost a football scarf which he had dropped and which fell through to beneath the stand.

On the day of the match, in front of a crowd of 11,000, Bradford City were presented with the trophy for the Third Division and Bradford’s manager was awarded ‘Manager of the Year’, in the presence of the Vice-President of the Football League, the Deputy Lord Mayor of Bradford and dignitaries from Bradford’s twin cities in Germany and Belgium. Play commenced at 3 o’clock but as half-time approached no-one had scored, but it didn’t matter for Bradford City – they had already won the Division. Five minutes before half-time however, John Helm, the commentator for the match for Yorkshire TV, spotted a small blaze at the end of the main stand – three rows from the back. Witnesses reported that they could smell tobacco burning as well as that of plastic – the fire had been started by a cigarette falling between the inches wide gaps in the stands and had ignited the decades of detritus which was layers thick beneath the dangerously combustible stands which were packed with spectators.

Aware of the small fire, which at first seemed nothing but a minor incident, a Mr Bennett of Row I, two rows in front, went to find a fire extinguisher – however due to the threat of their misuse by hooligans, no fire extinguishers were available in the stand, only at the club house. It is worth noting however, that due to the nature of the fire, effectively an inferno which spread in a void beneath the stand, due to inaccessibility, even available fire extinguishers would have made little difference. Despite this, it serves to illustrate the manifold failings and complacency which defined the disaster.

By 3:44pm, flames were clearly visible and within two minutes, by 3:46pm, practically the entire stand was in flames – approximately six minutes since the fire was first noticed. As the stand was engulfed, spectators fled onto the pitch, assisted by the Police, who with other spectators, clambered back into the stands to help people escape. Those who could not escape onto the pitch were forced to try to leave the stand by the exits to the street, South Parade. However, many of the turnstiles of the stand could not be used as exits and doors leading out of the grounds were locked and unmanned by stewards, who were untrained in fire-safety and evacuation. A majority of the causalities of the day died trying to escape the stand, only to find their exit locked or otherwise inaccessible.

In the short time it took for the stand to be engulfed with flames, 56 people, 54 Bradford City  and 2 Lincoln supporters, had died and 265 people had been injured. The entire, tragic case was caught on film, which can be viewed below, although, discretion is advised due to the nature of the incident:

The tragedy however, it was concluded in the Popplewell Report, commissioned by the Home Office, that the disaster was wholly avoidable and that a litany of errors had punctuated the management of the stadium and of the incident itself. Aside from the failings to clear litter from beneath the stand, the lack of fire extinguishers and the lack of exit access from the turnstiles of the stand, There were failings in the lack of access to the pubic address system for the Police to order an evacuation; the Police, despite their commendable work with helping fans, had no formal training in evacuation procedures; no Police radio control at the grounds; lack of easy access for emergency vehicles due to the non-connection of South Parade and Burlington Street; and a lack of adequate fire hydrants within the radius of the stadium which could be used to fight such a ferocious blaze such as the one at which the fire service arrived.

Two additional points however are damning. The first is the existence of the Guide to Safety at Sports Grounds (Football) 1976 known as the ‘Green Guide’ which was produced by the Home Office and Scotland Office. Contained therein are a number of suggestions which, the Popplewell Inquiry plainly states, had they been followed, would have prevented the disaster:

  • “One of the potential causes of fire in football grounds arises from the accumulation of waste paper… and other combustible materials which are dropped by spectators. Every effort should be made to reduce this hazard… combustible waste [should be] cleared as quickly as practicable…” (Para. 10.6 Housekeeping)
  • “Every stand should be provided with sufficient exits to allow for the orderly evacuation from the stand of all spectators likely to be accommodated.” (Para. 8.2)
  • “While the public are in the ground an adequate number of staff should be maintained to cover entrances, exits and other strategic points.” (Para, 10.7.2 Emergency Procedure and Staff Training)

The second is the correspondence between various authorities which had expressed concern at the condition of the stand prior to the fire. In June 1984 Superintendent Briggs of the West Yorkshire Metropolitan Police had written to a Mr Newman, the Secretary of the Club, a letter titled ‘Dangerous Grandstand’ expressing his concern that the stand was a hazard to public health, after he witnessed part of the stand break off having been hit by a ball. The Club, which had been in financial difficulties, was managed to avoid additional expenditure, but by January 1985 approval had been given for work to take place on the stand which was due to start on 13th May 1985, two days after the disaster.

Furthermore, the correspondence  between the Club and the then local authority, the West Yorkshire Metropolitan County Council (WYMCC), also shows clear knowledge that the stand was a hazard. In a letter of 11th July 1984, WYMCC informs the Club that: “the existing felt roof covering and the areas of decayed boarding resulting, consequently creates an unacceptable crowd safety hazard and should be rectified as soon as possible.” On the 18th July, a week later, the letter was resent with an additional letter which explained the WYMCC’s view on how Bradford City should alter their ground to meet with future regulation under the Safety of Sports Ground Act 1975, which mentioned the unsuitability of the grandstand, stating: “The timber construction is a fire hazard and in particular, there is a build-up of combustible materials in the voids beneath the seats. A carelessly discarded cigarette could give rise to a fire risk.” It would be a discarded cigarette which caused the fire.

The Popplewell Inquiry’s recommendations lead to the prohibition of new wooden stands, banned smoking in stadiums and lead to the renovation of many stands which could be deemed a fire hazard. Since then, the British Football League has never had a similar incident of such severity, but to do so, it took the deaths of 56 to bring the country up to speed with its own regulations. The cycle continues with the disaster at Hillsborough.

The Hillsborough Disaster – 15th April 1989 (Information sourced from Hillsborough Independent Panel Report unless stated otherwise)

For practically anyone in the UK, the term ‘Hillsborough’ is enough to identify the shocking compendium of events, failures, missed opportunities, lies and cover-ups which have come to define a tragic episode in British sport and a tarred the reputation of certain journalists, newspapers and the South Yorkshire Police (SYP).

The incident has its roots in a match played between Wolverhampton Wanderers and Tottenham Hotspur in 1981, for the semi-final of the FA Cup. Hillsborough was the home ground of Sheffield Wednesday and had been chosen for the match as a neutral venue, with a capacity for 54,000 spectators, with a mixture of standing terraces and seating. Safety inspections in 1978 found that the stadium was found not be following regulations under the Safety of Sports Grounds Act 1975 and the Green Guide. For the West Stand of the ground, entrance was only possible through Leppings Lane, with access to the standing terraces limited to a single tunnel which lead beneath the stand into the pens of the terraces. Before the 1981 game there was considerable congestion at the turnstiles and in the outer concourse and to relieve the outer pressure the SYP and stewards for Sheffield Wednesday Football Club (SWFC) open Gate C, an exit gate, to allow fans in. This caused a serious crush on the terraces, which narrowly avoided causing fatalities.

Plan of the Hillsborough Stadium – the claustrophobic nature of the Leppings Lane entrance and the limited access to the West Stand terraces should be noted (Source: Taylor Report)

Following the incident, in which blame was either SWFC’s, according to SYP, or SYP’s according to SWFC, work took place at the Leppings Lane entrance including the installation of lateral fences into the terraces, with only a small gate at the top of each fence allowing for horizontal movement along the terrace – previously installed fences along the front of the terraces had been installed to prevent pitch invasions. Recommendations that there would be monitoring of the distributions of fans into the new central pens were not adhered to, due to costs for SWFC. Despite later crushes at FA Cups finals, details of the terraces and the effects of the terrace gates were not discussed and figures for the safe capacity of the stadium were not revised, despite advice from safety engineers.

Plan of the West Terrace of the West Stand – the fences added which divide the pens and the pre-1979 barriers would prove lethal (Source: Taylor Report)

The FA Cup semi-final returned to Hillsborough in 1989, between Liverpool FC and Nottingham Forest. Over 50,000 fans had travelled to Sheffield for the event, which the authorities knew would be an important and large event. Before the event however, the stage was set for a mismanagement of catastrophic proportions. Inexplicably SYP replaced, three weeks before the match, their experienced match commander, Chief Superintendent Brian Mole, with the inexperienced Chief Superintendent David Duckenfield. A planning meeting with senior officers less than a month before the event was not attended by the South Yorkshire Metropolitan Ambulance Service nor by the Fire Service and briefings the day before for officers were framed in the mindset of crowd control rather than safety, with the match’s operational orders being effectively unchanged since 1988, despite crowd safety issues during the match and had no references to the role of the Police in overcrowding or crushes nor surrounding the bottleneck on the street of Leppings Lane and how it could be managed.

On the day of the match, the Leppings Lane entrance and its 23 turnstiles were responsible for the entrance into the stadium of 24,000 fans, 10,100 of which were due to be located in the standing terraces at the base of the West Stand. The central pens in the terrace, with capacities of around 1,000 each were the first to fill up and the gates at the head of the pens could be closed to prevent further intake but, due to the lack of modern accurate monitoring, this was at the discretion of guesswork and no-one knew how many fans were in each pen at anytime.

As the start-time of the match approached, the a severe crowd had built up at the Leppings Lane turnstiles and in the street behind – the Police, responsible for crowd safety, had taken no steps to stagger, filter or otherwise manage the thousands of fans which had to enter through the 23 turnstiles. A dangerous crush began to develop by the turnstiles and David Duckenfield, the Match Commander, in the Police Control Box which had CCTV footage of Leppings Lane and the turnstiles, received word from the Police Officer in charge of the outside crowd, Superintendent Roger Marshall, that unless exit gates were opened to help allow the crowd in, there would be fatalities. Duckenfield gave the order to open Gate C. 2,000 fans entered through the open gate and streamed towards the first entrance they could see to the terrace, the tunnel which lead to the already packed pens of 3 and 4. No stewards were present at either end of the tunnel.

Duckenfield refused a request at 2:54pm for kick-off to be suspended, citing that it was too late, and thus kick-off started at 3pm By this time the pens were fatally full, holding twice their intended capacity. Police did not open the perimeter gates to allow fans onto the pitch. Duckenfield, despite having a clear view of the crush and the underused side pens believed the Liverpool fans were attempting to invade the pitch. He gave no orders to close the tunnel to prevent additional people streaming into the pens. The Police officers at first believed the frenetic movement of people scrambling out of the pens was a pitch invasion and attempted to prevent it. During this time, the fatalities occurred as fans, caught between thousands of additional fans entering, the immovable perimeter fences and the dividing fences between the pens, began to suffer from asphyxia, literally being suffocated by the pressure in the pens. 96 fans would be killed as a result, with an additional 766 injured, with thousands reportedly suffering from the psychological effects of the incident.

Once it became clear that fatalities were occurring, the Police Officers at the fence, fans and 30 attending members of the St. John’s Ambulance began, in vain, administering first aid. For 45 minutes however, there was no official co-ordination between the emergency services – neither SYP nor South Yorkshire Metropolitan Ambulance Service (SYMAS) fully activated their crisis procedures, with senior ambulance officials failing to mobilise ground teams and dispatch site paramedics to the incident until after the fatalities had occurred. Only two major hospitals enacted their major incident mechanisms and both were due to the initiative of the staff, rather than through formal communications with the Police or SYMAS. Had a major incident be declared, Sheffield’s hospitals would have deployed teams with resuscitation equipment and the Fire Service would have brought heavy equipment to extricate fans from the pens. This did not occur, save at 3:50pm, when a team from the Royal Hallamshire Hospital, one of the hospitals alerted, brought resuscitation equipment the gymnasium, by now the de facto triage and mortuary for the disaster.

In a major incident, it was agreed that ambulances would wait by the entrance of the gymnasium, whilst Casualty Clearing Point Officer would send medical teams with the critically injured to the ambulances for transportation to local hospitals. This did not occur – ambulance crews at the gymnasium once new ambulances began to arrive, left their vehicles and ran across the pitch and, without co-ordination from superiors, had to deliver or oversee first aid themselves. Police officers and Liverpool supporters, due to the lack of stretchers, were forced to tear advertising hoardings away from the stand and use them to transport the injured, dead and dying to the gymnasium. The first ambulance eventually got to the stand across the pitch at 3:17pm – too late for the dead.

The entire incident, as with Bradford City, was captured on film. Again, viewer discretion, due to the nature of the event, is advised:

As also with Bradford City, the event was entirely preventable – the events preceding punctuated with errors, from the lack of training or planning between the emergency services, the lack of lessons learned from the 1981 crush, the appointment of the green David Duckenfield to a oversee the match and the lack of investment by Sheffield Wednesday in improving the stadium. Numerous failings on the day, each potentially minor in their own right, all contributed to the disaster, from the lack of Police officers at the tunnel and in the pens to direct fans, the lack of recognition as to the severity of the event by the ambulance services and the fatal decision to open Gate C.

Even worse, recommendations which had been made obvious after Bradford City, such as the manning of gates and exits during matches and the instruction of Police officers in evacuation procedures were ignored and the comment on the fact that the existence of perimeter fences at Valley Parade would have caused significantly higher casualties and therefore grounds with such fences should have sufficient exits for evacuations. That most important of recommendations fell on deaf ears and subsequently 96 had to die for the Taylor Report, the Inquiry following Hillsborough, to implement changes such as removing lateral fences and perimeter fences, as well as requiring Premier League clubs to provide only seats for fans. Lessons were learned, after they weren’t after Bradford and the entire event was even further marred with a Police cover-up, which may be covered at length in another article and the reaction of The Sun newspaper, which, in what is frankly one of the most disgusting and vile front pages ever published in British media, under the headline ‘THE TRUTH’ claimed that Liverpool fans, who had helped ferry the wounded and attempt CPR, were said to have picked the pockets of the dead; urinated on corpses; assaulted Policemen and paramedics and verbally abused, in a sexual manner, the body of a dead girl. The claims were lies and ever since Merseyside has boycotted the paper, but the full story is, again, not to be discussed at length now.

This year, criminal charges have been brought against six individuals, including Duckenfield for the manslaughter of 95 – 28 years after Hillsborough took place. Hillsborough has almost been bookended and since, it seemed, that disasters of such a scale had finally been designed out. Nothing of the sort could occur in 2017, of such magnitude – until it did.

The Grenfell Tower Fire – 14th June 2017

‘Grenfell’, I can say with certainty, will be seared into my generations collective memory, in the same way as Hillsborough did for those of the 1980’s. I cannot write with such detail on the disaster, for the inquiry has not yet been even started as of yet, let alone concluded, but some things we know for certain – primarily, as with Bradford and Hillsborough, the disaster should never have happened and yet it did, to the shame of those involved.

For all intents and purposes, Grenfell should have been in a prime position to avoid disaster. Built in 1974, Grenfell Tower was situated in the richest borough in the UK , owned by the local authority, Kensington & Chelsea Council (KCC), through the Kensington & Chelsea Tenant Management Organisation (KCTMO) and contained 120 flats with a mix of private and social-housing. The tower had recently undergone a multi-million pound redevelopment, in which, among other changes, new cladding and new windows were to be installed to improve ventilation, insulation and noise reduction. The work was undertaken, as has become common-place in recent years in a concerted move to reduce local government involvement in projects of this type, by a chain of private contractors and sub-contractors employed by KCTMO. A newsletter circulated by KCTMO to Grenfell residents of May 2016, stated that “The smoke detection systems have been upgraded and extended.” whilst also reiterating the ‘stay-put’ policy which was agreed upon with the Fire Brigade – a common policy in tower blocks where, as flats should be protected from the spread of fire, it is safer for residents to stay in their flats and wait for the Fire Brigade to extinguish the fire, rather than trying to evacuate. For all intents and purposes, Grenfell was safe. After all, how could anything go wrong in a refurbished tower-block, in the richest borough, of the richest city, of one of the richest countries on Earth?

At 00:54am BST on 14th June 2017, London Fire Brigade (LFB) logged an emergency call. The call detailed that there was a fire in an apartment block on Latimer Road. LFB dispatched 40 fire engine to the building and by 1:14am the Metropolitan Police would be called to the scene. At first, witnesses claim, the fire, which was later identified to have started due to a fridge-freezer exploding, seemed controllable, until the cladding on the outside of the building, which had been installed as part of the redevelopment in 2016, caught alight. From just being confined to a single flat on the 4th floor, within as little as half an hour, one of the flanks of the building was completely ablaze, with the fire, by 4:30am, having practically burned through the entirety of the block. 

Footage of the fire, as with Hillsborough and Bradford City, can be seen below, with discretion, again, advised:

The human cost was and, due to casualty figures being subject to revision as of 10th July 2017, will continue to be horrific. Police have so far identified at least 80 victims, with the final toll likely not being known until the end of the year – due to the heat of the fire, the only remains left for identification are not readily identifiable.

And yet, as with Bradford and Hillsborough, the disaster was entirely avoidable, was identifiable in the build-up and was punctuated with failings during the actual response, despite the hard-work of the individual fire-fighters and everyday heroes.

In 2009, in Southwark, a fire killed six at the Lakanal House tower-block and an inquest blamed the fatal incident on a combination of botched renovation work which allowed for the fire to spread quickly and in unusual ways, a failure by Southwark Council to properly evaluate the flats for fire safety, the stay-put policy of the block and confusion in the immediate fire-fighting operation. At the time, Lakanal House was the worst apartment block fire in the UK and it was touted as the wake-up call to enact stricter building regulations and better fire prevention and protection mechanisms. Lessons however, were not learned with regards to Grenfell.

In the plans for the redevelopment of Grenfell Tower, zinc panels with a fire-retardant core were originally proposed to be used for new cladding, but under monetary pressures, these were replaced with aluminium cladding with flammable plastic filler, which saved the Council an estimated £293,000. These panels were known not have the same fire resistance as the zinc cladding. Furthermore, glass reinforced concrete panels, with the highest fire resistance rating of A1, were used on the lowest block, where no-one lived and would have cost an estimated £1 million to cover the block in its entirety. These panels are often used for luxury flats but seemingly KCC did not investigate using them for Grenfell Tower. When questioned on the usage of flammable cladding, Chancellor Phillip Hammond suggested that the cladding used was in fact illegal in the UK. Since 2009, it has been said that four Ministers within the Department for Communities and Local Government received information that fire regulations were not up-to-scratch; dropped a review into fire regulations in 2013 and warnings which were sent to the All-Party Parliamentary Fire Safety and Rescue Group fell on deaf ears. In an immediate survey of towers following Grenfell, at least 75 across the country were found to be at risk of fire.

Aside from the failings to install inflammable cladding, Grenfell Tower was woefully ill-equipped with regards to fire prevention infrastructure. In 2013, following the Lakanal fire, the Government wrote to each local authority to encourage the introduction of sprinkler systems in tower-blocks. This would have added just 2% extra costs to the regeneration at Grenfell, according to the British Sprinkler Association. Added to the lack of active fire suppression measures, residents claimed the refurbishment work had lead to fire exits being blocked and gas pipes being exposed in communal areas. One Councillor, Judith Blakeman, who sat on KCTMO’s board raised 19 complaints by residents as to the safety of the building and was repeatedly told that the refurbishment had met fire safety standards – she was, she claims, treated “like a nuisance.” The tower was a fire hazard and the KCC and KCTMO had willingly chosen, out of monetary pressure, to make it so and yet the ‘stay-put’ policy had stayed in place, meaning that many residents did not leave the block and therefore likely died on the understanding that their flats would be safe.

It would also be prudent to establish that KCC was not short of cash however: as of March 2017 the Council has monetary reserves of £274 million; in 2014 it gave a £100 rebate to the highest tax band due and in 2015, as housing budgets were cut, paid out £5 million to established Opera Holland Park – funding an opera, whilst an extra £300,000 may have prevented the deaths of over 80 residents. The inequality of the borough runs deeper, and information thereof can be found here.

Investigations by the BBC following the incident also found there were failings with the LFB’s response. An aerial appliance, effectively an engine with a ladder which could reach the storey at which the fire started, did not arrive at the tower until 1:32am, by which time the fire was rapidly spreading across the cladding. Water pressure had to be increased by calling Thames Water, meaning that the fires inside the block could not be readily fought and there was a lack of extended breathing apparatus for the fire fighters which limited their ability to reach the top floors of the building. This has readily called into question the former Mayor of London, Boris Johnson, decisions to close 10 fire stations and reduce fire engines by 27 in the city, as well as wider Government policy which has seen a reduction of 10,000 fire fighters since 2010, resulting in an increase by 15% of fire deaths in 2015/2016.

It is almost certain that in the same way that Bradford and Hillsborough were found uncover the lecherous and apathetic practices of high-ranking Police and football authorities, so to will Grenfell but for local authorities and the Govenrnment. The cycle has continued but hopefully, finally, we may end it.

Thank you for reading this week’s article. I understand that the subject matter is far darker and serious than has been previously covered but it illustrates, I believe, an important point in the circumstances which seemingly always lead up to such disasters.

I would like to leave you with a video I found whilst researching Hillsborough. The Hillsborough Justice Campaign has been campaigning for 28 years to uncover the truth surrounding Hillsborough and the city of Liverpool has been behind them all the way, fighting against corruption in South Yorkshire Police and the lies of The Sun. In 2016, at a vigil, Sky News recorded the people of the city singing the Club’s anthem, ‘You’ll never walk alone’ and frankly, it is one of the most stirring videos I’ve every seen. Please give it a watch and be inspired by the determination of Liverpool for justice after all these years.