# The Hillsborough Stadium Disaster Interim Report/Part 1

PART I - WHAT HAPPENED AT HILLSBOROUGH?
CHAPTER 1
THE GROUND AND PRE-MATCH ARRANGEMENTS
Fixing The Venue
21. On 20 March 1989, the Football Association (the FA) requested that their Cup semi-final between Liverpool and Nottingham Forest be held on 15 April at Hillsborough Football Stadium. The corresponding semi-final between the same two teams had been held there in April 1988. The arrangements had been successful in the view both of the police and of the host club. Sheffield Wednesday (the Club) were therefore willing to accommodate the 1989 match. South Yorkshire Constabulary were prepared to police it but only if the ticketing arrangements were the same as those for 1988. Otherwise, the FA would have to look elsewhere. Those arrangements did not please Liverpool or its supporters either in 1988 or 1989. They thought the ticket allocation was unfair for reasons to be explained later. Reluctantly, however, the police requirement was accepted and the match was fixed for 15 April at Hillsborough.
The Ground
22. The Hillsborough Stadium is some 2½ miles to the north-west of central Sheffield in the district of Owlerton. The ground was opened in 1899 on what was then a greenfield site by the river Don. The pitch lies roughly east to west. A plan of the ground and its immediate environs is at Appendix 1.
23. The west end, with which this Inquiry is principally concerned, is known as the Leppings Lane end. The east end abuts on Penistone Road, the A 61. To the south is the river Don and to the north a residential street, Vere Road, which runs between Leppings Lane and Penistone Road North.
24. Alongside the river is a private roadway giving access to the south stand, to the Directors' and players' entrances, and to the administrative block under the stand. The roadway gives both vehicular and pedestrian access between Penistone Road and Leppings Lane, but there are gates which can shut it off at each end. There is some car parking along this roadway principally for Directors, players and employees of the Club. The south stand dates from 1914 and is the oldest at the ground. It is all seating with places for 8,800. 5,500 of those are roofed over and 3,300 are uncovered.
25. The north stand is also all seating and accommodates about 9,700. Behind it is a gymnasium or sports hall. There are also a first aid room and police room close by.
26. The east end is all terracing and is known as the Spion Kop. It was enlarged and roofed over in 1986 and now accommodates some 21,000 standing spectators. There are crush barriers in the Kop running parallel to the goal line but no dividing fences to prevent free movement from side to side.
27. At the west or Leppings Lane end of the ground there is terracing close to the pitch. Behind it is the west stand which provides covered seating and was built in 1965 for World Cup matches, some of which were held at Hillsborough in 1966. The covered stand accommodates 4,456 seated spectators. The terracing in front of it extends higher in the corners between the stands and its total capacity was stated to be 10,100. At both the Kop end and the west end access to the pitch is barred by perimeter fencing. The fencing is about eight feet high mounted upon the low wall at the foot of the terracing. At the top of the fencing the wire returns back at a sharp angle for some 15 inches to make it difficult for anyone to climb over towards the pitch. There are gates at intervals along the perimeter fencing to afford access between terrace and pitch. These gates are less than a metre wide and were designed to be opened only from the pitch side for police purposes or in an emergency. They are marked and numbered on the plan Appendix 1.
28. Unlike the Kop end, the west terracing has not only crush barriers parallel with the goal line but radial fences at right angles to it, dividing the area into pens. This division was begun after an FA Cup semi-final in 1981 when crushing occurred due to overcrowding and gates had to be opened. It proceeded in stages, the final arrangement being shown on the plan Appendix 1. The first section of the west terracing moving south to north contains gates 1 and 2 and is known as pens 1 and 2 although in fact constituting only one pen. Next is pen 3 with one gate; next pen 4 with one gate; pen 5, which is extremely narrow, was intended as a sterile area to divide pen 4 from pen 6. This was to isolate home and away fans on occasions when both might be accommodated on the west terracing in separate pens. Finally there is pen 7 at the north-west corner. Pens 5,6 and 7 each have a perimeter gate. At the back of the pens, under the front of the west stand, there is a gate in ​each radial fence. When those gates are open, the back row of the terracing is intended to permit access from pen to pen along the whole west side. In practice, when substantial numbers are present, those gateways are not readily visible or accessible. The present layout of the pens, fences, crush barriers and gates has resulted from a series of piecemeal changes. The nature and effect of those changes must be considered later.
The Turnstiles
29. Because of the housing in Vere Road there is no access from the north side of the ground. Along Penistone Road North there are some 46 turnstiles which usually give access both to the Kop and to the east end of the north stand. They are marked 43 to 88 inclusive on the plan. The 12 numbered 77 to 88 are designed to feed the north stand but were not used for that purpose on 15 April in order to segregate supporters of the two teams as appears later. Two of them, 77 and 78, were however used for access to the Kop.
30. At the south side of the ground there were 24 turnstiles (numbered 19 to 42 on the plan). Those numbered 37 to 42 led to the Kop and the rest to the south stand.
31. In summary, the south and east sides of the ground accommodated some 29,800 whose access on the day was through 60 turnstiles.
32. The other two sides of the ground, north and west, with a capacity of 24,256 were fed solely from the Leppings Lane entrance where there were only 23 turnstiles.
Travel to the Ground
33. Most supporters were expected to come by road although rail transport was available. Nottingham supporters travelling by train would arrive at the main line Sheffield Midland Station whence they would be directed and escorted northwards by the police. They would arrive at the ground along Penistone Road. Nottingham supporters travelling by coach, mini-bus or car would approach Sheffield from the south mainly on the M1. Again their arrival at the ground would predominantly be via Penistone Road or Merries Road.
34. Liverpool supporters travelling by normal rail service would arrive at Sheffield Midland Station just like their Nottingham counterparts. The police aimed to segregate the rival fans and put them into separate coaches. Liverpool fans could alternatively travel by special train to Wadsley Bridge, a British Rail station catering solely for football supporters and situated to the north of the ground. A police escort was available to conduct them on foot to the Leppings Lane entrance. Those coming from Liverpool by road would approach Sheffield either via the M62 and down the M1 from the north or across the Pennines from the north west. All such routes would bring them to the ground via one or other limb of Leppings Lane as shown on Appendix 1. Broadly, therefore, arrivals from Liverpool would be from the north and west; arrivals from Nottingham would be from the south and east.
Allocation of Places and Tickets
35. Experience in recent years has produced a policy of segregation to prevent trouble between supporters of rival teams. The need for this policy to be maintained was endorsed and emphasised by the Popplewell Report following the Bradford City disaster in 1985. Accordingly, before the 1988 semi-final the police decided that sections of the Hillsborough Stadium should be allocated so as to achieve efficient segregation of Liverpool and Nottingham Forest fans. The section to be granted to each was determined by the direction whence each predominantly approached. Thus, Liverpool were allotted the north and west sides of the ground for which access was from Leppings Lane. Nottingham Forest were allotted the south and east sides with access from Penistone Road.
36. The effect of the decision was that for this all-ticket Cup Tie, Liverpool were allotted only 24,256 places as against 29,800 for Nottingham Forest. This, although average attendance of supporters at home matches was substantially higher at Liverpool than at Nottingham. Moreover, with standing tickets at £6 and seats at £12, Nottingham Forest had 21,000 standing places compared with Liverpool's 10,100. So, Liverpool's allocation was more expensive as well as smaller. Understandably, Liverpool were aggrieved by the allocation of places and tickets. They sought with some support from the host club and the FA to have it changed in 1988, but the police were adamant. To switch ends would, in their opinion, have involved rival supporters crossing each other's paths when approaching the ground thereby frustrating attempts at segregation and creating a risk of disorder. In 1989, when the same plan was proposed, Liverpool again challenged it. The police, however, maintained their view, adding that those who had attended in 1988 would be familiar with the arrangements and that any change would lead to confusion.
​Access from Leppings Lane
37. As the plan Appendix 1 shows, the approach to the west turnstiles is across a narrow neck or forecourt at a bend in Leppings Lane where, coming from the north, it turns to the south-west and crosses a bridge over the river Don. Parking areas for the Liverpool supporters had been arranged north and west of the ground. They were therefore expected to arrive on foot along both limbs of Leppings Lane and would converge on the forecourt at the bend. In an arc across that forecourt is a line of railings with six sets of double gates. Inside those perimeter gates is the short approach to the turnstiles. As shown in the photographs Appendix 2, the latter are in two sections divided by a fence. The northern section consists of turnstiles 1 to 16. Numbers 1 to 10 gave access to the north stand. Thus there were 10 turnstiles for the 9,700 with north stand seats. Their tickets were marked "Entrance A" and were colour-coded brown. Turnstiles 1 to 10 correspondingly had the letter A above them and brown boards on the wall.
38. Turnstiles 11 to 16 were for those with seats in the west stand. Thus 4,456 were served by six turnstiles. They were the next block to the right of those marked A. However, instead of these turnstiles and the west stand tickets being marked B as might alphabetically have been expected, they were marked C. Their colour-code on tickets and boards was red.
39. On the other side of the dividing fence in the approach area, there were only seven turnstiles to serve 10,100 with tickets for the west terracing. Those seven turnstiles were labelled A to G. This was because there had originally been 18 turnstiles at Leppings Lane and the sequential numbering continued from 19 upwards on the south side of the ground. When the number at Leppings Lane was brought up to 23 the present arrangements of 1 to 1-6, A to G and then 19 upwards was adopted to avoid re-numbering all round the ground. However, above the lettering A to G was a large letter B. "Entrance B" also appeared on tickets for the west terrace. Thus, the three blocks of turnstiles encountered by a ticket holder at the Leppings Lane end read from left to right A, C, B. The colour-code for west terrace tickets and the boards beside turnstiles A to G was mauve. To the right of turnstile G is a tubular steel barrier to divide the queue for that turnstile from the roadway to the south stand.
Inside the Leppings Lane Turnstiles
40. Turnstiles 1 to 10 gave access to a passageway leading to the north stand. There is an exit gate (marked A on Appendix 1) between turnstile 1 and the adjacent housing.
41. Inside turnstiles 1 to 16 is a concourse leading to pens 6 and 7 and the steps to the west stand. There is a wall dividing this area from that inside turnstiles A to G. It had been built to segregate home and away fans at a time when the Club intended they should share the west terrace. That idea was not pursued but the wall remained. There was, however, a gateway in the wall which did permit access between the two areas. An exit gate (marked B on Appendix 1) was provided from the area inside turnstiles 11 to 16.
42. Finally, anyone using turnstiles A to G entered a concourse bounded on the left by the wall just mentioned and on the right by the wall of the private roadway coming from the south stand to Leppings Lane. There was an exit gate in the latter wall (marked C on Appendix 1) just inside turnstile G.
43. All three exit gates, A, B and C, were of concertina design. They could be opened only from the inside and were not intended for entry of spectators into the ground.
44. Those entering through turnstiles A to G had three options once inside the ground. They could by moving to the right go round the south end of the west stand and gain entry into pens 1 and 2. They could go through the gap in the dividing wall towards the concourse behind turnstiles 11 to 16 and then round the north end of the west stand into pens 6 or 7. However, there were no conspicuous signs inviting them to take either of those courses. The obvious way in was straight ahead of the turnstiles where a tunnel under the middle of the west stand gave access to pens 3 and 4. Above its entrance in large letters was the word "Standing" and a large letter "B". Thus B ticket holders were drawn towards the tunnel.
45. The length of the tunnel is some 23 metres. It rises slightly at first then levels off but finally descends towards the terraces at a gradient of 1 in 6. As it emerges onto the terrace, the way ahead is bisected by the radial fence between pen 3 on the right and pen 4 on the left. A short spur of brick wall projects forward from each side of the tunnel at its mouth. Those emerging are thus guided straight forward rather than to either side. The photograph at Appendix 3 shows the west stand and terraces.
46. As with the layout on the terraces, the configuration of the Leppings Lane turnstiles and the areas inside them was effected by a series of piecemeal changes. Again, it will be necessary to analyse their resultant effect.
​Policing Arrangements
47. At the 1988 semi-final, policing had been under the control of Chief Superintendent Mole, then Commander of F Division within whose area Hillsborough lies. He was still in post on 20 March 1989 when the FA broached the 1989 semi-final, but he was due to hand over command of F Division on 27 March to Superintendent Duckenfield on the latter's promotion to Chief Superintendent. Both were present at an initial meeting on 22 March, but on 27 March Mr Mole bowed out and Mr Duckenfield took over. Under him were Sector Commanders, all Superintendents with much experience of policing football matches at Hillsborough and elsewhere. In particular, Superintendent Marshall was in charge of the area outside the Leppings Lane entrance and the approaches to it. Superintendent Greenwood was in command inside the ground, but this included the area between the turnstiles and the perimeter fence. They thereby swapped roles from the previous year. Under Mr Duckenfield's overall command were some 801 officers and men on duty at the ground plus traffic officers and others from D Division to deal with the influx of supporters into the city centre. In all, therefore, some 1,122 police were deployed for this match amounting to about 38 per cent of the total South Yorkshire force. Included in the mounted section of 34 were officers from Liverpool and Nottingham to assist respectively in marshalling their home supporters. The total at the ground was divided into serials consisting usually of eight to ten Constables plus a Sergeant and an Inspector. The serials were posted to duties at various stations in and around the ground in three phases: before, during and after the match. All of this was provided for in an Operational Order which followed closely the Order drawn up for the 1988 semi-final and took into account the force's "Standing Instructions for the Policing of Football Grounds". The Order described the duties of each serial at each phase. It was supplemented by oral briefings before and on the day of the match.
Sheffield Wednesday's Arrangements
48. The Club provided 376 stewards, gatemen and turnstile operators for duty on 15 April. The stewards were briefed as to their duties on the morning of the match by police Inspectors and were allocated round the ground. They wore yellow tabards. The Club's control room, situated below the south stand, could communicate by VHF radio with the stewards. Closed circuit television was installed by the Club with screens in their control room showing all the turnstiles round the ground. A computerised counting system was incorporated in the turnstiles. This flashed onto a screen in the Club control room the running total of spectators passing through the turnstiles section by section. Thus, at the Leppings Lane end, there would be separate running totals for turnstiles 1 to 10 (north stand), turnstiles 11 to 16 (west stand), and turnstiles A to G (west terraces). When the total for any section was within 15 per cent of its permitted capacity a warning pulse showed on the screen. For the west terracing that warning would occur when the numbers were within 15 per cent of the total terrace capacity of 10,100. What the system could not do was monitor the distribution of fans on the terracing, pen by pen. It could give no warning therefore if one pen was full beyond its safe capacity.
Police Communications
49. The nerve centre for police control is the control room or box situated at the south-west corner of the ground between the south stand and pen 1 of the west terracing. The box is elevated and reached by a number of steps. It has windows commanding views across the pitch and straight along the line of the west perimeter fence. The box is very small and has seats for only three officers. Superintendent Murray was in control of it and was advisor to Mr Duckenfield as he had been to Mr Mole the year before. Next to him sat Sergeant Goddard who operated the radios. The third seat was for Police Constable Ryan who operated the telephone and public address systems. At the back of the box stood Police Constable Bichard who was in control of the police closed circuit television system operated by a row of consoles on a bench in front of him and behind the three seated officers.
50. There were five television screens showing views of five roving cameras fixed at high points on the stands and directed both inside and outside the ground. There was also a master screen which flicked in rotation from one camera view to another and which made a video recording. The cameras have a zoom facility to close in on any point of interest. Specifically, there were good camera views of the west terracing, of the Leppings Lane turnstiles and beyond them of Leppings Lane itself.
CHAPTER 2 15th APRIL: THE BUILD-UP TO 2.30pm
Early Arrivals
54. 15 April 1989 was a warm sunny spring Saturday. The match was a sell-out, so 54,000 ticket holders were expected. Others would come without tickets hoping to acquire them or even to gain access otherwise. The following account concentrates, as did the evidence, on the western approaches and the Liverpool supporters since the disaster occurred at their end. They began to arrive in the Hillsborough area quite early in small numbers. Some brought cans of beer with them and were seen drinking as they walked; others took advantage of the weather and sat about on walls and open spaces. When the public houses opened, many resorted there, drinking inside or spilling out into the sunshine. Leppings Lane and its environs comprise a mixed shopping and residential area. Local residents saw groups of Liverpool supporters keen to find a public house or off-licence. Many were asking for tickets or "spares". There were a few touts selling them at inflated prices. From an early stage, some of the fans were using private gardens and yards to urinate. As the morning wore on, numbers increased. Requests for tickets and trespass to urinate also increased. Still the prevailing mood was one of carnival, good humour and expectation.
Public Houses
55. There were some 74 shops with off-licences in and around Sheffield. In general, they opened at 8 am. Liverpool supporters did visit them but the evidence did not suggest a great amount of alcoholic drink was bought there.
56. Opening time at public houses was in general 11 am. Some remained closed all day. Of the others, some 72, mostly in the city, were frequented by local patrons only. Some 23 public houses, however, served over a hundred Liverpool supporters each. Another 51 served more than 20 each. Little trouble was reported, but many supporters drank enough to affect their mood. At first excitement: later frustration.
The Gathering Crowd
57. Towards the end of the morning, fans gathered on and around the bridge near the Leppings Lane entrance. They seemed reluctant to enter the ground early. All turnstiles were open at 12 noon and one or two as early as 11.30 am. Some 53 police had been deployed to operate outside the turnstiles and in the Leppings Lane area. They enquired at random whether fans had tickets. Those who had not were advised to go away; nevertheless, many returned more than once. Those who had tickets were guided in the right direction. The police tried to persuade them to enter the ground early. Officers, male and female, had been posted outside each turnstile with the duty of searching entrants for weapons, drink or drugs. Once through the turnstile, an entrant was liable to be searched again by one of a serial of officers positioned just inside.
58. At about 12 noon Chief Inspector Creaser asked Superintendent Murray whether the pens on the west terrace were to be filled one by one successively, but was told that they should all be available from the start and the fans should find their own level.
59. By 2 pm it was apparent to those inside the ground and those monitoring events in the police and Club control rooms that the number of Nottingham fans in their places greatly outnumbered those from Liverpool. The Kop and the south stand were filling up steadily, but the north and west stands were half empty. It was noted about that time that the turnstile figures showed only 12,000 had entered as against 20,000 at the same time the previous year. On the west terraces, although pens 3 and 4 were filling, the wing pens 1,2,6 and 7 were nearly empty. At 2.15 pm a Tannoy message asked fans in pens 3 and 4 to move forward and make room for others.
60. There had been three special trains from Liverpool in 1988. This time, there was only one. It arrived early, just before 2 pm, at Wadsley Bridge station. The 350 passengers were met by both mounted and foot police officers who escorted them in a crocodile down Leppings Lane. They were orderly and passed through the turnstiles into the ground by about 2.20 pm without incident.
61. By this time the police Traffic Division reported that the Liverpool routes were clear, so the majority of Liverpool fans were in the Sheffield area. The numbers converging on the Leppings Lane entrance were increasing rapidly. Between the perimeter gates and the turnstiles the crowd became congested. There was no longer a separate queue at each turnstile but a single phalanx filling the whole approach area. The foot officers outside the turnstiles were no longer able to search everyone and had difficulty in searching even selectively. ​Mounted officers in and outside the turnstile area were having difficulty manoeuvring in such a dense crowd. The police were beset by fans bemused by the ticket and turnstile labelling asking for directions. Many had been drinking but up to and just after 2.30 pm the mood remained good.
62. Superintendent Marshall was on foot amongst the crowd. He became anxious about the numbers coming down Leppings Lane and spilling out onto the roadway where buses and cars were moving. At 2.17 pm he radioed to control to have motor traffic in Leppings Lane stopped. This was eventually done at about 2.30 pm. Up to this time, despite the large mass outside the turnstiles and the numbers still approaching, there was still no panic in the crowd; no perception of crisis by the police. In the control room Mr Murray, who could see Leppings Lane on the video, advised Mr Duckenfield that they would get everyone in by 3 pm. Mr Duckenfield reaffirmed to him the policy about a delayed kick-off. It would be ordered only if there was some major external factor such as fog on the Pennines or delay on the motorway: not if spectators merely turned up late even in large numbers.
CHAPTER 3 THE CRISIS AT THE TURNSTILES
63. In the 20 minutes from 2.30 pm to 2.50 pm there were crucial developments both inside and outside the ground. In pens 3 and 4 there was a steady increase in pressure as more fans came through the tunnel to the favoured area behind the goal. By 2.50 pm these pens were already full to a degree which caused serious discomfort to many well used to enduring pressure on terraces. The numbers at that time were clearly in excess of the maximum density stated by the Home Office Guide to Safety at Sports Grounds (1986 Edn) (the Green Guide) i.e. 54 persons per 10 square metres. (Although the Green Guide has no statutory or legal force, it is the only official advice available about safety at sports grounds.) In the wing pens 1, 2, 6 and 7, there was still ample room and bare patches of concrete were visible.
64. Meanwhile, the crowd grew at the Leppings Lane entrance. As more arrived at the back the crush at the front grew worse. Entry to the turnstiles became more difficult. Their efficiency was impaired and their rate reduced. Arrivals at the back exceeded deliveries through the turnstiles, so the build-up increased. The foot officers outside were unable to function and in danger themselves so they went through the turnstiles and out again through gate C where they did what they could to relieve pressure by the tubular barrier. The mounted officers were surrounded by the dense mass of people and became ineffective. Superintendent Marshall was in the midst of the turmoil. He extricated himself and stood on a parapet of the bridge to get a clear view. A drunken fan tried to push him off: a beer can was thrown at a mounted officer. But these were isolated acts by individuals; the menace came from the massive numbers single-mindedly determined to be in for the kick-off with time running out. At the back of the crowd fans were frustrated by the lack of progress as 3 o'clock approached. Some, mostly young men who had been drinking, tried to push and force their way forward. At the front, people were jammed together and against the turnstile walls. Some panicked as the pressure intensified. Some youngsters and women were fainting and in distress. They were helped out through the tubular barrier by turnstile G or were passed over the turnstiles elsewhere. Fans climbed up and over the turnstile building or on to the dividing fence. This was to escape the crush rather than to gain free entry since most of them had tickets.
65. At 2.44 pm Mr Marshall radioed for reinforcements, for the Tannoy to request the crowd to stop pushing and for a vehicle with loudspeaker equipment to come and request the same. Unhappily, at about 2.40 pm, radio communication on channel 25 became defective. For a period of two or three minutes the control room lost contact. A communications officer came promptly and switched to the standby station. With the use of a handset at control, contact was restored. Despite this hiatus, two of Mr Marshall's requests were received. The Tannoy was used but with little effect. Reinforcements, including mounted officers from Penistone Road, were sent. The third request, for a Landrover, was received direct by its driver PC Buxton who arrived at 2.46 pm and urged the crowd by loudspeaker not to push. This was no more effective than the Tannoy. The mounted officers besieged near the turnstiles came outside the perimeter gates. An attempt was made to shut them against the crowd outside, to enable the throng inside to be dispersed or at least thinned through the turnstiles. The pressure from without, however, opened the gates again. Mounted officers, now reinforced to greater numbers, formed a cordon across the elbow of Leppings Lane from the sweet shop to the bridge, again with the object of reducing pressure inside the gates. They were successful in this for some minutes despite desperate individuals forcing their way under or between the horses. However, this exercise was overtaken by a more dramatic relief of the pressure.
"Open the Gates"
66. Between 2.40 pm and 2.45 pm the crowd inside and outside the turnstile approach had swelled to over 5,000. At the head of the phalanx conditions had become intolerable. Those who got through were short of breath and sweating profusely. Many complained to police officers on the concourse inside the turnstiles and asked them in forceful terms to do something. Exit gates A and B were being shaken. It was clear the crowd could not pass through the turnstiles by 3 pm. Police Constable Buxton radioed from the Landrover to control asking that kick-off be postponed. The suggestion was acknowledged but rejected.
67. Superintendent Marshall realised the crowd had become unmanageable. Although loth to do so, since it was contrary to basic police strategy, he decided to request the exit gates be opened to relieve the pressure. Otherwise, he feared fatalities would occur. Other senior officers outside the ground agreed. At 2.47 pm he radioed control to permit the gates to be opened. At 2.48 pm, whilst Mr Duckenfield was considering the request, gate C opened to eject a youth who had climbed in with no ticket. Immediately, fans outside took advantage and about 150 managed to get in before a mounted officer enabled the gate to be closed again. Mr Marshall repeated his request. Still no response from control. He repeated it a third time, adding that if the ​gates were not opened someone was going to be killed. In the control room, Mr Duckenfield had not made a decision. Mr Murray asked him "Are you going to open the gates?". Mr Duckenfield gave the order and Sgt Goddard radioed to Mr Marshall "Open the gates". Neither the Club control room nor any police officers inside the turnstiles were told of this order before or after it was given or of any action it would require.
68. At 2.52 pm, gate C was opened wide. Fans behind turnstiles A to G and from the concourse beyond came round to flow through it in large numbers.
69. About two minutes later the pressure outside gate A led Sgt Higgins to radio, despite the gateman's objection, for it to be opened. If it was not, he said, "It'll go and someone will get killed". Permission was given, but this time reserve serials were alerted to monitor the inrush towards the north stand. Gate B was also briefly opened against the gateman's wishes and about 200 of those pressed at turnstiles A to G gained entry to their left.
70. The largest entry, however, was through gate C. In the five minutes it was open about 2,000 fans passed through it steadily at a fast walk. Some may have had tickets for the stands. No doubt some had no tickets at all. The majority had tickets for the terraces. Of these, some found their way either right to pens 1 and 2 or left through the dividing wall to 6 and 7. But a large proportion headed straight for the tunnel in front of them.
CHAPTER 4 THE DISASTER
71.71. The initial influx through gate C, augmented by entrants via the turnstiles, came through the tunnel with great momentum. Fans spoke of being swept through, feet off the ground. The 1 in 6 gradient accelerated their progress. Upon reaching the crowded pens, some wished to go back but were unable to do so. The new arrivals found themselves pushed forward and the pressure became intense. At 2.54 pm, shortly after this influx began, the teams came onto the pitch. As usual, this was greeted by a surge forward. Many were now acutely uncomfortable and some were in distress. The mass seethed about but voluntary movement by any individual was difficult; hands down could not be raised and some fans found it hard to breathe. Still the flow continued through the tunnel causing further surges forward. There were shouts for help and for the gates to be opened to the pitch. Police officers on the perimeter track did not immediately react. In the deafening noise from chanting and shouting they did not at first recognise the problem. Realisation came at different moments to different officers in different places.
72. Gate 3 sprang open under the intense pressure from within. An officer quickly closed it. Shortly afterwards, it sprang again; officers tried to shut it. Those seeking to escape were urged and pushed back. Gate 4 was opened by a policeman who noticed the crushing. People began to spill out through it and were directed to the wing pens where there was still ample room. Meanwhile, gate 4 was closed again and then re-opened. At gate 3, a Constable, now alive to the crisis, followed strictly his written orders and radioed for permission to open that gate. Receiving no reply, he took it upon himself to open it.
73. Just before 3 pm, the match kicked off. At the same time, gate C, which had been closed at 2.57 pm, was reopened and a steady trickle continued to enter through the tunnel.
74. To escape the crush, fans began climbing the radial fences out of pens 3 and 4 into pens 2 and 5. Others tried to get over the front perimeter fence but were at first turned back by police who feared a pitch invasion. Near the front, fans, mostly youngsters, were weakened to the point of collapse and in some instances death but they were held upright by pressure all round. Further back, most were so preoccupied with the pain of being pressed against barriers and with breathing problems that they saw nothing of the game. But at the rear there were many who, although cramped, were watching the football unaware of the distress at the front.
75. At 3.04 pm, Beardsley for Liverpool struck the crossbar at the Kop end. There was a roar from the Liverpool fans and at the same time a powerful surge forwards in pen 3. The several surges which occurred after the influx from gate C carried the pressure down the pens towards the pitch. The force became such as to twist and break two spans of a crush barrier towards the front of pen 3. The evidence does not establish with certainty when this happened. Probably it was triggered by the surge at 3.04 pm. But I am sure it occurred after the influx from gate C so greatly increased the pressure in the pen. When the barrier broke those whom it had supported were projected towards the perimeter fence. Many fell and the involuntary rush of those behind pressed them down. The crushing force was transmitted and dispersed so that all along the front of pen 3 fans were pressed hard up against the low wall and the wire mesh of the fence above it.
76. In pen 4 no barrier broke. Nevertheless those at the front were crushed against wall and fence. Further back, two barriers were bowed and some individuals succumbed to the pressure around them.
77. Surges on terraces are common. Usually, they go forward, then recede. Here, with the weight of numbers, there was no receding. The pressure stayed and for those crushed breathless by it, standing or prone, life was ebbing away. If no relief came in four minutes there would be irreversible brain damage; if longer, death.
78. In the control room no-one noticed the overcrowding or anything amiss in pens 3 and 4 until the first fans spilt out onto the perimeter track just before kick-off. Then, the officers in command assumed that there was an attempted pitch invasion. They called up reserve serials waiting in the gymnasium and all available officers elsewhere to go to the pitch. A request was made to HQ for dog handlers.
79. Superintendent Greenwood, the Ground Commander, was by the players' tunnel at the kick-off. He noticed fans on the track and went to the west end behind the goal. As he approached, he did not think the pens overcrowded until he was very close and saw those pressed against the fence. Even then, he thought the situation "retrievable" if those higher up the pen relieved the pressure. He climbed on the wall below the fence and signalled with both hands to those behind to move back. Other officers joined him. It was impossible. Those fans who would have wished to comply were powerless to do so. Behind them, there were still many ​unaware of the crisis, watching the game. The football continued to joyous shouting and singing round the rest of the ground while those crushed and trapped slowly expired.
80. When Mr Greenwood's signals to move back proved fruitless, he tried to radio for the match to be stopped. At first, his message was not received by control, so he signalled with his arms towards the control box. Mr Duckenfield sent Mr Murray down from the box to have the match stopped via the linesman, the agreed emergency drill. Before he could do so, Mr Greenwood ran over the pitch to the referee who stopped the game. It was 5½ minutes past 3.
CHAPTER 5 THE AFTERMATH
Rescue Attempts
81. From 3 o'clock, gates 3 and 4 had been open and remained so. At first, fans had walked or staggered out winded and faint. But the final surge at 3.04 pm, and the struggle to reach the open gates, caused a horrendous blockage of bodies. The dead, the dying and the desperate became interwoven in the sump at the front of the pens, especially by the gates. Those with strength left clambered over others submerged in the human heap and tried to climb out over the fence. They were now helped by police and other fans who hauled them up and over. Numbers of fans were climbing over the radial fences into adjacent pens. At the back, many were hauled up into the west stand to relieve the pressure.
82. The steps from the sump at gateways 3 and 4 were so congested with bodies live and dead that each had to be prised from the pile by the police. Initially, no officer took effective charge. A number of individual officers and fans worked frantically to free those trapped but the gateways were so narrow that only two or three could get at the entwined bodies Willing hands got in one another's way. More officers arrived from the gymnasium and elsewhere in the ground. Many used their own initiative to help those laid out on the pitch, to assist in getting others over the fencing and to comfort the distressed. But some stood in groups near the perimeter fence not knowing what to do. They had been summoned in response to what was thought to be a threat to public order. What they found was a horrific scene of carnage and some young officers were shocked into impotence by what they saw.
83. It was truly gruesome. The victims were blue, cyanotic, incontinent; their mouths open, vomiting; their eyes staring. A pile of dead bodies lay and grew outside gate 3. Extending further and further on to the pitch, the injured were laid down and attempts made to revive them. More and more walking survivors flooded out on to the pitch as the players left. The scene was emotive and chaotic as well as gruesome. As the enormity of the disaster was realised, many of the fans milling about were bitter and hostile to the police, blaming them for what had happened. Officers were confronted, abused, spat upon and even assaulted. A small number of hysterical fans had to be subdued.
84. Adding to the chaos, a number of press photographers dodged about among rescue workers apparently avid to secure photographs at point blank range of those dying through the wire mesh and those laid on the pitch. Angry fans sought to assault them. Police had to intervene.
85. At about 3.12 pm, Chief Superintendent Nesbit, Commander of the Traffic Division, arrived on the pitch. He took charge at gate 3 and organised a chain of officers to simplify and expedite the extraction of casualties from the pen. In the absence of any mechanical means, police and fans together pulled and worked at the wire mesh with their bare hands and their feet to breach the fencing. They succeeded in both pens, enabling officers to get in and fans to be got out.
86. By now, some officers of their own initiative went round from the pitch to the tunnel where they met other officers from the turnstiles and the west stand. Together, they tried to persuade fans at the rear of the pens to go back through the tunnel. Some complied, but many resisted, wishing to stand their ground. Casualties were brought out through the tunnel, and as the pressure in the pens was relieved, officers were able to get further in and bring out more casualties, dead and alive. They were laid on the ground in the concourse outside the tunnel and attempts were made to revive them.
First Aid
87. The St John Ambulance Brigade had some 30 personnel posted round the ground for the match - 25 adults and 5 junior cadets, They were quickly on the scene when the first casualties emerged and sought to revive them. Their Divisional Superintendent, Mr Wells, tried unsuccessfully to help those pressed against the fencing by feeding oxygen to them through the mesh until they could be got out.
88. Dr Purcell, Sheffield Wednesday's doctor, came from his seat in the south stand and attempted resuscitation. Assisted by a male nurse from the crowd, he moved from patient to patient doing what he could, but in most cases it was too late.
89. At 3.13 pm a St John's ambulance came onto the pitch at the north-east corner and drove to the perimeter fence close to gate 3. There was no call for doctors and nurses on the public address system until nearly 3.30 pm. Nevertheless, as the minutes ticked past, some of them came onto the pitch to help of their ​own accord when they saw the casualties and the ambulance and realised the gravity of the situation. Many fans also worked prodigiously in attempts to revive the dead and the dying, in some cases their own relatives and friends. Artificial respiration, mouth to mouth respiration and cardiac massage were applied by the skilled and the unskilled but usually in vain. Those capable of survival mostly came round of their own accord. The rest were mostly doomed before they could be brought out and treated.
90. There was an urgent need to get casualties off the pitch and to hospital. There were six stretchers in the first aid room and three in the St John's ambulance. They were quickly brought into use. Then the fans improvised by tearing down the hoardings around the edge of the pitch and against the stands so that lengths of board could be used as stretchers. Improvising in this way, parties of fans and police ran repeatedly the length of the pitch bearing casualties to the north-east corner. A number were dead on arrival there.
In the Control Room
91. Mr Duckenfield stayed in the control room. Chief Inspector McRobbie was there in civilian clothes as an observer. Mr Duckenfield sent him down to the track to tell a policewoman at gate 1 to admit those displaced from the centre pens. Mr Duckenfield did not realise there were injuries until he saw someone laid on the pitch. Even then, he did not realise the nature of the problem or its scale.
92. Mr Murray returned from his attempt to stop the match and Mr Duckenfield sent him down again to clear the pitch and assess the situation. A message was broadcast requesting fans to clear the pitch. This was because Mr Duckenfield could not from the control room see clearly what was happening for the milling and increasing numbers.
93. The Assistant Chief Constable (Operations), Mr Jackson, had attended the match in civilian clothes as a guest of the Club. He came from his seat in the south stand to ask what had happened. Mr Duckenfield was unable to say; he did not tell Mr Jackson that the exit gates had been opened on his authority. Mr Jackson went down to the pitch to discover the situation.
94. At 3.06 pm Mr Duckenfield, still primarily concerned about public order, caused a message to be sent to Headquarters asking for Operation Support. That was a call for all available additional police resources to come to the ground to strengthen the police presence.
95. Mr Jackson was told by Mr Greenwood that there were casualties and returned immediately to control to make sure emergency services were alerted. Meanwhile, Mr Murray had seen the plight of those behind the fence. He radioed to control that a fleet of ambulances was required. He also asked for a Tannoy broadcast to those in the pens to move back but there is no clear evidence that it was made.
96. Only when Mr Duckenfield received the request for a fleet of ambulances did he realise the nature and gravity of the situation. Then, supported by Mr Jackson, he caused messages to be sent converting Operation Support into calls for the Major Disaster Plan.
No Information
97. Apart from the message to clear the pitch and the belated call for medical assistance about 3.30 pm, no information or advice was broadcast on the public address system. Mr Duckenfield feared that the crowd might turn hostile or might all attempt to leave together thereby hampering the emergency services if they were given information about what had happened. The result was that apart from those close enough at the west end to see the terrible truth for themselves, the majority of the crowd were left in ignorance. Many, especially Nottingham supporters in the Kop, still thought there had been a pitch invasion or other misbehaviour by Liverpool fans. They continued singing and chanting incongruously. This infuriated some Liverpool fans who were already distraught. A few began to run towards the Kop end. The police feared violence might result on top of the existing disaster. Accordingly, they deployed a large number of officers to form a line across the width of the pitch at the Kop end and advance up to the halfway line sweeping any Liverpool fans back as they moved. There the line stood as an insurance against disorder but doing nothing. Other officers were posted to the perimeter track facing the north stand for the same purpose. To those distressed and distraught who wanted urgent action, this large contingent of passive officers was seen as an affront. Feelings against the police intensified.
Misinformation
98. At about 3.15 pm, Mr Graham Kelly, Chief Executive of the FA, Mr Kirton also of the FA and Mr Graham Mackrell, Secretary of Sheffield Wednesday, went to the control room for information. Mr Duckenfield told them he thought there were fatalities and the game was likely to be abandoned. He also said a ​gate had been forced and there had been an inrush of Liverpool supporters. He pointed to one of the television screens focussed on gate C by the Leppings Lane turnstiles and said "That's the gate that's been forced: there's been an inrush". Inevitably Mr Kelly was interviewed a little later live on television. He spoke of the two stories concerning the gate - the fans' account that the police had opened it, the police assertion that the fans had forced their way in.
99. About 3.30 pm there was a further meeting in the Club's boardroom. Mr Duckenfield went there and met Mr Kelly, the referee and representatives of the three clubs. ACC Jackson was also there. Mr Duckenfield indicated the match was likely to be abandoned although no firm ruling was given. He added that he did not want people to know it was to be abandoned lest the dispersing crowd hamper the emergency operations.
Public Announcements
100. Later the managers of the two teams were asked to go to the control room. They were invited there to make a public announcement to calm the crowd. Mr Kenny Dalglish agreed to do so. He told the crowd that there were problems and asked them to assist the police and those rendering first aid. He asked for calm and his message was well received. It was then 3.56 pm. At 4.10 pm it was announced that the match was abandoned for that day. Again that message was received calmly by the crowd most of whom behaved responsibly as they dispersed.
Fire Brigade
101. Meanwhile the emergency services had been in action. At about 3.10 pm a request came from the perimeter fence to control for bolt croppers to cut the wire mesh. Sergeant Goddard contacted the police garage close by without success. At 3.13 pm, PC Bichard requested Headquarters to call the fire service to bring hydraulic cutting equipment to the Leppings Lane entrance.
102. There was no arrangement for a fire officer to be present during the match. However, the Major Disaster Plan required all emergency services to be alerted. After 'phone messages which must be described later, fire appliances arrived at both Leppings Lane and Penistone Road at 3.22 pm. At both entrances their arrival surprised police who were uninformed as to why they had been called or where they should go.
103. At Leppings Lane a police Inspector told Station Officer Swain "I don't really think we need you". Another police officer then asked for more resuscitators as people were dying so Mr Swain radioed for ten fire appliances. Each carries oxygen and resuscitation equipment.
104. At the Kop end, Leading Fireman Housley arrived with an emergency tender and Station Officer Fletcher in another appliance, each with a crew. The emergency tender came along the roadway by the south stand but owing to its height was unable to proceed further. It therefore backed out and went to the Leppings Lane entrance losing some eight minutes. From there, Mr Housley and his crew went onto the pitch with resuscitation equipment. They rendered help there and later at the gymnasium. Mr Fletcher and his men ran along behind the south stand carrying cutting equipment and oxygen cylinders. When they arrived at the fence, the cutting equipment was not required as by then the last of the dead and injured were being removed from the pens. Mr Fletcher set up a casualty clearing area under the police box and firemen assisted in carrying victims as well as rendering first aid on the pitch.
South Yorkshire Metropolitan Ambulance Service (SYMAS)
105. Before 1986 there had been no SYMAS representative routinely present at Hillsborough matches. The Club was content, as indeed are many other clubs, to rely upon the St John's Ambulance Brigade and a 999 call if necessary. From 1986 onwards, after representations, the Club provided two seats in the south stand for SYMAS staff at League matches. At one stage it was suggested they would be best placed in the north stand close to the gymnasium which had been designated as the casualty centre in the event of a major incident. The south stand seats were allotted as they placed the SYMAS staff closer to the players' tunnel should a player be injured. These seats were, however, not available at Cup semi-finals. SYMAS representatives nevertheless attended at the semi-finals by arrangement with the police in 1988 and again in 1989. The SYMAS officers stood on the ramp leading to the pitch at the north-east corner. They had one ambulance outside the ground and one on standby.
106. On 15 April 1989, Officers Higgins and Eason were at the ground with an ambulance and crew. They noticed fans on the track and went to the Leppings Lane end whilst the game was still in progress. They began to attend to casualties. Meanwhile, at 2.59 pm, there had been a call from Police Constable Waugh at police ​Headquarters to the Hillsborough police control asking if ambulances were required. This was on the instruction of Chief Inspector Edmundson who had heard over the radio, as had Police Constable Waugh himself, crowd noise and snatches of speech from Hillsborough suggesting distress and possible injuries. The reply from the control box was: no reports of injuries but keep standing by. At 3.07 pm after hearing from the ground that there might be injuries, police Headquarters notified SYMAS that ambulances might be required. Then, seconds later, Mr Murray's request for a fleet of ambulances was relayed to SYMAS. They reacted at once. Ambulances began to arrive at the Leppings Lane entrance at 3.13 pm and at the Penistone Road entrance at 3.17 pm. In all, some 42 ambulances attended, 31 of them from SYMAS and 11 from neighbouring authorities. By 4.30 pm, they had conveyed some 172 casualties to the Northern General Hospital and the Royal Hallamshire Hospital.
Gymnasium
107. The gymnasium had been in use for serving meals to the police. When the Major Disaster Plan was ordered, it was cleared and divided into two. One end became a temporary mortuary; the other was used as a casualty clearing area for the injured. As the stretchers, designed and improvised, brought in more and more casualties, the scene was initially and inevitably chaotic and harrowing. There was intense distress amongst the injured and bereaved; relatives were reluctant to be parted from the dead and sought to revive them. There were people looking for missing friends and relations; there were recriminations, there were scuffles. Some of those involved were the worse for drink. Doctors and nurses had followed the casualties in from the pitch and sought to attend the injured as best they could in the adverse circumstances. Those in most urgent need of hospital treatment were taken to ambulances as they arrived, triage being employed to determine priorities. Doctors were requested by the police to examine each person thought to be deceased to confirm and certify death. A police Constable was detailed to attend and guard each of the dead and a photograph of each was taken by a police photographer so that relatives coming to identify bodies could be spared the ordeal of searching amongst all who had died.
The Dead and the Injured
108. Of the 95 who died, the evidence suggests that at least 16 and probably 21 came through gate C after it opened at 2.52 pm. That is established by the statements of relatives and friends who came through with them but survived.
109. By commendable hard work, a team of pathologists headed by Professor Usher completed post-mortem examinations on all the deceased within 48 hours. They found that 88 of the victims were male and seven female. Thirty-eight were under 20 years of age, 39 were between 20 and 29 years and only three were over 50. In virtually every case the cause of death was crush asphyxia due to compression of the chest wall against other bodies or fixed structures so as to prevent inhalation. In all but nine cases that was the sole cause. In one, pressure on the chest had been so great as to rupture the aorta; in six cases there were also injuries to the head, neck or chest; in the remaining two cases, natural disease was a contributory factor. In 18 cases bones were fractured. Thirteen of those were rib fractures. However, one was a fractured femur, one a fractured radius and the remaining three involved fractures of bones or cartilages round the voice box. These injuries suggest the victims may have been trodden while on the ground.
110. Blood samples were taken from the dead. No alcohol was found in any of the females. Of the males, 51 had no more than 10 milligrams per cent in their blood which is negligible; 15 had over 80 milligrams per cent and six over 120 milligrams per cent.
111. Although the great majority of those who died were in pen 3, at least five were in pen 4. Most deaths occurred at the front of the pens but there were a few fatalities further back.
112. In all, some 730 people complained of being injured inside the ground and 36 outside it. Of the 730, about 30% are thought to have entered through gate C after 2.52 pm. The largest category of injury was bruising, especially to the ribs and chest.
CHAPTER 6 SPECIFIC INCIDENTS
113. I have given my findings as to the basic factual background and the main sequence of events in narrative form. There was very little conflict as to the principal events save as to some timings and numbers. Indeed, the consistency of the evidence has been a remarkable feature of this Inquiry. The experiences of most witnesses were unforgettable and no doubt the early hearing helped to preserve accurate memory. Also, the existence of timed videos and photographs and of logged and taped messages provided reliable checks by which to prompt and test witness recollection. Accordingly, I have not for the most part burdened the narrative with citations from the evidence of individual witnesses.
114. However, there were several instances of detailed evidence and assertions being highlighted by the media in dramatic and emotive terms during the hearing. Since some of those much-publicised incidents gave rise to unfair criticism, they ought to be the subject of specific findings. I have therefore dealt with them individually at Appendix 6.