# The Hillsborough Stadium Disaster Interim Report/Part 2

PART II - WHY DID IT HAPPEN?
"Events of the magnitude of Hillsborough don't usually happen just for one single reason, nor is it usually possible to pin the blame on one single scapegoat... ... Disasters happen because a whole series of mistakes, misjudgments and mischances happen to come together in a deadly combination."
Dr John Habgood, Archbishop of York, preaching at the Hillsborough Memorial Service on 23 April 1989.
115. This disaster was the worst in the history of British football. It happened because pens 3 and 4 became grossly overcrowded. They were uncomfortably overcrowded by 2.50 pm at least to a degree which required that they should be closed to further arrivals. Even the numbers coming through the turnstiles in the last 10 minutes would have increased the pressure beyond danger point and there would have been injuries if not fatalities. As it was, the influx through gate C after 2.52 pm so increased the pressure in the two pens as to cause fatal crushing.
116. The overcrowding up to 2.52 pm was due to a number of factors which can be considered broadly under three heads.
117. The crushing and fatalities after 2.52 pm must be considered under a number of headings.
CHAPTER 7 THE LAYOUT AT THE LEPPINGS LANE END
118. I have already observed that the layout of the turnstile area, of the terraces and of the concourse between them was the result of piecemeal changes. A brief history of these changes is now necessary.
The History
119. Before 1965, the Leppings Lane end consisted entirely of terracing like the Kop. In that year, the west stand was built and the terraces remaining in front of it were truncated to their present depth, front to back. As to width, they consisted of a single standing area with no dividing fences. During the early 1970's, hooliganism and pitch invasions made it necessary to prevent access to the playing area and the perimeter fences were therefore erected in 1977.
120.120. Section 1 of the Safety of Sports Grounds Act 1975 empowered the Secretary of State to designate a sports stadium having, in his opinion, accommodation for more than 10,000 as a stadium requiring a certificate from the local authority. Hillsborough was so designated with effect from 1 January 1979 by SI 1978/1091. In anticipation of that date, Sheffield Wednesday instructed Eastwood and Partners, a firm of consulting engineers, to act on their behalf especially in their dealings with the local authority. Dr Eastwood, the principal of the firm, is a highly experienced civil and structural engineer and has advised several major football clubs. He recommended that a number of additional crush barriers should be added since those already in place were insufficient to comply with the Green Guide (1976 edition). That work was approved and carried out during 1979.
121. The relevant local authority at the time was the South Yorkshire County Council. It set up an Officer Working Party consisting of representatives of the police, the fire service, its own building surveyor's division and its own legal and administration department. The Working Party made inspections and consulted with the Club and Dr Eastwood. A Safety Certificate was issued on 21 December 1979 for an indefinite period. It has remained in force ever since and has not been amended.
122. Schedule 3 of the certificate sets out the maximum crowd capacity for various areas in the ground. The figure for the west terrace is 7,200 and for the north-west terrace 2,900. These figures were intended to be in accordance with the Green Guide (1976). Paragraph 15.4 provided for a maximum "packing density" of between 54 and 27 persons per 10 square metres depending on the condition of the terrace. Dr Eastwood had calculated 8,000 for the west terrace on the basis of 54 per 10 square metres. He thought this a justified starting figure in view of his improved system of barriers. However, he reduced it to 7,200 because there were no gangways on the terrace and he did not think it feasible to provide any. So, the total figure for the Leppings Lane terraces was and is 10,100.
The 1981 Semi-Final
123. As already mentioned, there was crushing at the Cup semi-final in 1981. The match was between Tottenham Hotspur and Wolverhampton Wanderers. The police debriefing minutes after the incident prophetically refer,
   "to the late arrival of a large number of spectators who were still waiting to enter the Leppings Lane enclosure when the match started. The flash point occurred when Tottenham scored" (at the Kop end) "after only three minutes. The spectators just entering pushed forward to see what was happening and caused a crush, which resulted in the injuries".
124. Those being crushed called for the perimeter gates to be opened onto the track. There was no immediate reaction, according to Mr Vaux who was there, but fortunately a police Inspector gave instructions and the gates were then opened. About 250 came out onto the track. There were broken arms, legs and ribs and 38 were treated either in hospital or by the St John Ambulance Brigade. It is clear from the documents (a) that the turnstile readings showed the capacity figure of 10,100 had been exceeded by over 400 (b) that the police shut off further access to the terraces because of crushing, and (c) the police view after the event was that the capacity figure of 10,100 in the Safety Certificate was too high. This latter view was communicated to the Club by the Chief Superintendent then in command of F Division but it was not pursued.
​Three Pens
125.125. After this incident in April 1981 the police requested that the terrace should be divided into sections. The object was to improve crowd control by reducing sideways movement. Division would enable more even distribution to be effected when there was a capacity crowd. It would also enable the west end to be used for both home and away supporters who could be segregated in separate pens, if necessary with an empty pen between them.
126. This proposal was agreed by the Club and the Officer Working Party and was approved by the local authority. Two radial fences were accordingly fitted in November 1981. They are the fence now separating pens 2 and 3 and that now separating 5 and 6. The result was to divide the whole terrace into three pens. Access from the concourse to the middle pen was through the tunnel and to the wing pens round the sides of the west stand. Dr Eastwood suggested and illustrated an altered layout which would have provided separate access through separate banks of turnstiles to the north stand, to each end of the west stand, and to each of the three pens. Whilst the main object of this was segregation, such a layout would have enabled each of those areas to be monitored numerically via the turnstiles so as to ensure its maximum capacity was not exceeded. The plan was not adopted. The maximum capacity for the new centre pen was calculated at 2,200, but no alteration was made to the Safety Certificate so to limit it nor was there any means mechanically of counting the numbers going into that pen.
The 1985 Changes
127. By 1985, Sheffield Wednesday had been promoted to the First Division and was drawing larger crowds. The improvement of the Leppings Lane end was raised again by the Club and Dr Eastwood prepared a number of drawings. These illustrated various schemes for achieving segregation by providing more turnstiles in separate banks and divisions of the concourse. The police wanted further divisions of the terrace itself, again to improve control and segregation. There was much discussion of these schemes which included suggestions of 29 and even 34 turnstiles in total. In the result, the following alterations were carried out in 1985.
New Radial Fences
128. On the terraces, two more radial fences were fitted. One divided the existing central pen into the present pens 3 and 4. Gates were fitted at the mouth of the tunnel to enable each of those pens to be closed off. The second fence was placed in the new pen 4 so as to create the narrow pen 5 intended to be a sterile area. Until those two fences were added there existed only perimeter gates 1,2,4,5 and 6. The creation of pen 3 required a new gate 3 to be fitted which was done.
Barriers
129. The lines of the new radial fences ran across existing crush barriers so that without modification those barriers would have run through the fencing. The police considered the barriers would be used by fans as convenient mounting points to scale the new fences, thereby defeating their object. They therefore wished spans to be removed from the barriers. Had their wishes been met in full the result would have been an unimpeded run in pen 3 from the mouth of the tunnel down the south side of the new fence to the perimeter. Dr Eastwood dug his heels in against that proposal which he rightly regarded as dangerous. He did however agree to some modification to the middle row of barriers in the newly created pen 3, chiefly to facilitate access. Likewise in the new pen 5, The 1985 modifications to the pens are shown on the plan Appendix 4.
The Turnstiles and Concourse
130. At the entrance, modification but no increase in number was made at the turnstiles. The bank 1 to 16 was divided from A to G by the metal fence now in place and that division was projected across the concourse inside the turnstiles in the form of a brick wall. A personnel gate was provided for access through that wall but was enlarged to its present size at the request of the police. Those alterations were made in the interests of segregation. The more elaborate divisions which Dr Eastwood had suggested, giving separate access to each sub-division of the accommodation, were not pursued for financial reasons. In May 1985 the Bradford disaster occurred. The south stand at Hillsborough had wooden decking and the Club realised it would have to undertake expensive remedial works there. The cantilever roof of the same stand was also discovered to require expensive repairs.
131. In fact, shortly after the new dividing fence and wall had been built at the Leppings Lane entrance and concourse, the Club, by agreement with Chief Superintendent Mole, ceased to accommodate home supporters at the Leppings Lane end. There was therefore no longer any need for segregation at that end, but the wall remained.
​132. Also in 1985, electronic counting equipment was installed at all turnstiles. This conveyed the running count for each bank of turnstiles, for example A to G, to a television screen in the Club control room where the figures were displayed. In 1986, an electronic eye was installed in each turnstile booth to catch and record anyone who climbed over the turnstile.
Barrier 144
133. In June 1986, the police requested that the crush barrier nearest to the tunnel at the entrance to pens 3 and 4 should be removed to assist the flow of fans into the pens. They found it caused obstruction because it was in a good viewing position and spectators liked to stand against it in numbers thereby blocking access by others further into the pens. The police also suggested it might hamper effective evacuation through the tunnel especially in an emergency. Dr Eastwood considered the pros and cons of this proposal and accepted the police view. The Officer Working Party approved the proposal at a meeting on 7 August 1986 on site. Authority was given then and there by Mr Bownes on behalf of the Sheffield City Council which had taken over responsibility for the Safety Certificate from South Yorkshire County Council on 1 April 1986. Two spans of the barrier were therefore removed, leaving only one span in pen 4 as shown on Appendix 4.
Effects of the Layout
134. The result of these changes was to divide the terrace into a number of small areas without providing any computerised or mechanical means of limiting entry numerically into any one area if all areas were open for choice. Before the fences and pens had divided the terrace, the overall figure of 10,100 could be monitored via the turnstiles and in theory the crowd could even itself out laterally. Even then, it was not possible strictly to ensure compliance with Schedule 3 Part 1 of the Safety Certificate which prescribed a maximum of 2,900 for the north-west terrace and 7,200 for the west terrace. Paragraph 3 of Schedule 2 of the Safety Certificate provides:
   "The number of spectators admitted to the Stadium and to the several areas of spectator accommodation within the Stadium shall not exceed the figures specified in Part 1 of Schedule 3".
The Club had to rely upon visual monitoring.
135. The situation became worse however with the division of the west terrace into pens. Not only were there more and smaller discrete areas but some were likely to attract more than their appropriate share of the 10,100 total. It is well recognised that the area behind the goal is very popular. Moreover, the position of the tunnel vis-a-vis the turnstiles A to G, its labelling and the absence of signposts advertising the wing pens would draw to it those with terrace tickets. It was therefore highly likely that pens 3 and 4 would fill to capacity and indeed exceed it unless preventive steps were taken. Had Dr Eastwood's plan for separate turnstile access to separate sections with separate toilet and refreshment facilities been implemented, total computerised control could have been kept.
CHAPTER 8 LACK OF FIXED CAPACITIES FOR THE PENS
136. In 1981, when the terrace was divided into three areas, Dr Eastwood gave the Club the figure of 2,200 capacity for the centre pen. He based this on the Green Guide, making such allowances as he thought right. No doubt the numbers could have been counted in via the turnstiles if only that pen was in use or if such pens as were in use were filled sequentially, but not otherwise.
137.137. After the 1985 changes, Dr Eastwood did not himself give any figures for the new pens 3 and 4. Someone on his staff however split the figure 2,200 into 1,200 for pen 3 and 1,000 for pen 4. Those figures did not even take account of the fact that pen 5 had been carved out of pen 4 which was bound to have a reducing effect on capacity. Nevertheless, the figures of 1,200 and 1,000 were put on a drawing emanating from Eastwood and Partners and the figures have been notionally regarded since as applicable by the Club and the police. They are in fact too high.
138.138. Dr Nicholson, at the Research and Laboratory Services Division of the Health and Safety Executive, has calculated that the figures for pens 3 and 4 respectively would be 1,015 and 1,036 if the strength and spacing of the crush barriers had complied with the Green Guide. But they did not.
Departures from the Green Guide
139. In pen 3, four out of five gaps in the lines of crush barriers do not conform with paragraph 115 of the Green Guide (1986). In pen 4, nine out of ten do not conform. In particular, the spans taken out of the barriers in pen 3 in 1985 left gaps well in excess of the maximum of 1.4 metres prescribed. One gap was 57% wider than the Green Guide maximum. Moreover, that gap was in direct diagonal line from the mouth of the tunnel to the barrier which collapsed. Dr Eastwood justified these larger gaps by the absence of gangways. Fans had to be able to get in and out and standard gaps tended to get blocked up. The effect of his reasoning was that the absence of gangways, recognised as having a safety function, led to the sacrifice of a second safety feature, namely gaps of strictly limited width.
140. Again, the removal of barrier 144 was bound, as Dr Eastwood conceded, to affect capacity. In fact it did more, as I shall indicate later.
141. Capacity should also have taken account of two further departures from the Green Guide. If, as was the case, the perimeter gates were not regarded as exits, some 40% of those in pens 3 and 4 were more than 12 metres from an exit (and there was no gangway) contrary to the aim of paragraph 96. Four out of five of the crush barriers in pen 3 and six out of nine in pen 4 were below the height prescribed in paragraph 110. These were the old barriers which had been repaired and plated where their bases had corroded and fresh concrete had been applied, raising the level of the steps. The point is not academic since, in the event, many fans were bent painfully over barriers under great pressure.
142. Dr Nicholson calculated that when all relevant factors regarding the configuration and the Green Guide are taken into account, the maximum capacity for pen 3 should have been 822 and for pen 4, 871.
Safety Certificate
143. Whatever should have been the maximum capacities for pens 3 and 4, the fact is that no figures at all in respect of them were put into the Safety Certificate. Despite all the changes in layout of the fences and barriers, the two figures, 2,900 for the north-west terrace and 7,200 for the west terrace, have remained as the only maxima with which the Club has to comply.
144. Section 2(1) of the Safety of Sports Grounds Act 1975 provides (so far as is relevant):
   "A Safety Certificate shall contain such terms and conditions as the local authority consider necessary or expedient to secure reasonable safety at the stadium when it is in use..."
Section 2(2) provided (so far as is relevant):
   "Without prejudice to sub-section (1) above, a Safety Certificate
   (a) shall specify the maximum number of spectators to be admitted to the stadium;
   (b) may specify the maximum number to be admitted to different parts of it;
   (c) shall include terms and conditions-
   ... (iii) as to the number, strength and situation of any crush barriers."
145.145. It is clear that when the certificate was first issued the South Yorkshire County Council went further than simply to fix the maximum numbers for the whole Stadium. They prescribed figures for each part of the ground not merely by the four points of the compass but by specified sections.
146. Section 8(1) of the 1975 Act requires the holder of the certificate before carrying out any proposals to alter or extend the stadium or any of its installations while a Safety Certificate is in operation to give notice of those proposals to the local authority. That obligation is specifically repeated in Sheffield Wednesday's certificate at Schedule 2 Paragraph 5(2). The Club complied with the requirement. Having received notice of the alterations to the pens and the barriers, the local authority ought, in my view, to have amended the Safety Certificate accordingly. They did not do so.
Why was the Safety Certificate not Amended?
147. Although Dr Eastwood acknowledged that the various changes to the layout would have had an effect on capacity, he did not take active steps to see that appropriate amendments were made. He says he mentioned from time to time that the alterations would have an effect on capacity and that he did not realise the Safety Certificate was not regularly updated. However, I find two memoranda in early 1987 highly significant. Dr Eastwood's assistant Mr Strange was concerned with queries from the FA as to Hillsborough's capacity for a semi-final. Mr Strange recorded these questions in a memorandum:-
   "Has any account been taken for alterations done on Leppings Lane over the last few seasons? Is the 10,200 or so figure still correct? I said that in my opinion it needs to be adjusted, better do it now than later."
148. Mr Strange's next memo (a few days later) records as follows:-
   "Dr Eastwood says leave the capacity at Leppings Lane end as it is, providing police have gates under West stand open so that people can distribute throughout the terrace evenly."
Although he says the last nine words do not report him accurately, Dr Eastwood accepts the rest of that message.
149. In my view the provisions as to capacity in the Safety Certificate ought to have been reviewed and altered. The unhappy situation is that the police believed even the overall figure of 10,100 to be too high as far back as 1981. That was reported to the Club but apparently not to Dr Eastwood. Meanwhile, that global figure had been rendered academic by the sub-division of the terrace which was not reflected in the Safety certificate at all. If proper maximum figures had been inserted in the certificate for each of the pens, the Club and the police might well have been prompted to find some means of limiting the numbers entering those pens other than by visual monitoring. This could have been done by implementing one of Dr Eastwood's plans for totally separate sections, turnstile to viewing area. It could have been done by insisting on sequential filling of pens at all matches; alternatively, by counting fans into each viewing area.
The City Council
150. That the Safety Certificate was not amended and individual capacities not reviewed cannot be laid solely at Dr Eastwood's door. He was, after all, consultant engineer to the Club and responsibility for the certificate was that of the local authority. When the South Yorkshire County Council handed over to the Sheffield City Council, the latter delegated all its powers and duties under the 1975 Act to its General Purposes Panel. Apparently, therefore, the decision-making body on behalf of the Council was that Panel, although two specific functions were delegated to the Head of Administration and Legal Department - the power to issue a prohibition under section 10 of the 1975 Act and the power of entry and search under section 11 of the Act.
151. In practice, Mr Bownes, the Council's Chief Licensing Officer in the Administration and Legal Department, bore the brunt of the Council's duties under the Act. ​152. The Officer Working Party was superseded by a Safety of Sports Grounds Advisory Group, but apart from the change of the name the system continued as before. Mr Bownes attended the inspections and meetings of the Advisory Group together with the representatives of the police, the fire service, the department of health and consumer services, and the building engineer's division of the Council. The latter was an engineer and ought therefore to have been alive to the same issues as Dr Eastwood.
153. The Advisory Group seems to have worked in a very informal manner. A short passage from Mr Bownes' evidence gives the flavour of it:-
   | "Q | Who was taking the lead in the working party as you understood it? |
   | A | That is a good question, sir. Leads were coming from several different directions really. |
   | Q | Who chaired it, if anyone? |
   | A | Nobody as such, sir. It was an inspectiqn rather than a meeting as I understand it. |
   | Q | Who decided what should be inspected? |
   | A | Effectively the group itself, sir, it seemed to me. There was also some input from the Club representative as to, if you like, an element of direction as to what should be looked at. |
   | Q | Apart from the inspections the working party met, presumably, or did they only meet on inspections? |
   | A | No, sir, I have referred to three previous meetings. |
   | Q | Who took the chair when it met? |
   | A | I suppose it could be said that I did, to some extent. |
   | Q | There is no point in having inspections unless you form conclusions as a result of that inspection, is there? |
   | A | That is correct. |
   | Q | There must presumably have been some meeting following the inspection at which you all sat down together and decided what, if anything, should be done. |
   | A | There was not, to my recollection, no. |
   | Q | How did you decide what should be done, if anything needed to be done? |
   | A | There were discussions on the site, particularly in relation to barrier 144, which took place at the time. |
   | Q | Nothing more than that and no record anywhere of any decisions that were made? |
   | A | No, sir." |
The decision to remove barrier 144 was assented to on behalf of the City Council by Mr Bownes. It was not referred to the General Purposes Panel. Whether Mr Bownes strictly had any power to assent to it is to say the least very doubtful. But he himself admits that he was ill-equipped to do so. He knew very little about football grounds. He had read the file passed on from South Yorkshire County Council and assumed all had been run satisfactorily by them.
154. It was recorded, however, in a report which Mr Bownes drafted that "the conditions (in the Safety Certificate) give some cause for concern as they appear to be inadequate or inappropriate in some areas". The report to the General Purposes Panel suggested that new Safety Certificate conditions should be drafted.
155. The task of revising the Safety Certificate was begun in June l986.In July 1987, a draft was sent to the fire service to which they replied in August. In September 1987, the Panel was informed that the redrafting was ​"progressing steadily" and should be submitted to the Panel in October. The final draft was not circulated until 30 March 1989,16 days before this disaster.
156. Meanwhile, the Safety Certificate has remained unamended since 1979. The enlargement of the Kop in 1986 increased its capacity to 21,000. Although this was known and agreed by the Council it had not been the subject of any change in the certificate which still showed the capacity of the Kop as 16,850. Mr Mackrell, Sheffield Wednesday's Secretary, raised the question of amendments to the Safety Certificate and in particular with regard to the Kop in April 1987 with Eastwood and Partners but nothing resulted.
157. Sheffield United Football Club was designated under the 1975 Act on 3 July 1984. A Safety Certificate was about to be issued by South Yorkshire County Council at the time it handed over to the Sheffield City Council on 1 April 1986. No certificate has yet been issued to Sheffield United.
158. The explanation given for these delays was pressure of work. Mr Bownes as Chief Licensing Officer was responsible for 32 other licensing systems when this one was added to his burden. He had a staff of only five. I fully accept that the addition of further statutory responsibilities to the already heavy workload of a local authority with curbs on its expenditure creates problems. But it is clear that the attention given to this important licensing function was woefully inadequate.
Summary
CHAPTER 9 LACK OF EFFECTIVE MONITORING OF THE TERRACES
160. Monitoring the spectators on the terraces so as to avoid overcrowding involves observing the numbers and their distribution in each area, making decisions as to when an area is "full", taking steps to close it off and moving spectators from one area to another, if necessary. It is a function beset by three problems. 1) Who should carry it out? 2) When is an area "full"? 3) Fear of hooliganism.
Who should Monitor the Terraces?
161. Should it be the host club via its stewards? Should it be the police? Should it be both? Or should it be by arrangement, depending upon the ground or section of the ground in question?
162. In principle, a football club which invites the public to a match on its premises for reward is responsible for securing safety at that event. The Green Guide (1986) provides:
   "23. The safety of the public inside the ground is the responsibility of those who stage the event and administer the ground in which it is held, ie the "management". This responsibility applies in both normal and emergency situations...
   195. ...there are five basic duties which stewards are called upon to carry out. These are:
The Interim Popplewell Report
163. There was considerable controversy in the course of the public inquiry held by Mr Justice Popplewell in 1985 as to the responsibility of the club and the police. In paragraph 3.6 of his interim report, Mr Justice Popplewell quoted from a report produced for the Minister of Housing and Local Government in 1969 as follows:
   "The responsibility for controlling crowd behaviour is divided between the police and the club operating the ground. The broad line of division being that police are responsible for movement of spectators in public thoroughfares and from public thoroughfares into the ground, while the club is responsible for the control of spectators once they are on the club's premises . .."
Mr Justice Popplewell said he did not quarrel with that view and went on to observe that in practice the police have to take charge and be responsible for controlling crowd behaviour. He then said (paragraph 3.8):
   "It follows, therefore, that as a matter of practice, while the physical safety of the building and the maintenance and good housekeeping of the ground must always be the responsibility of the club, the police have to take the de facto responsibility of organising the crowd, with all that entails, during the game ..."
Mr Justice Popplewell went on to instance evacuation of the ground as a procedure in which only the police could bear the responsibility of supervising the organisation of the crowd.
The Final Popplewell Report
164. He harked back to this subject in chapter 4 of his Final Report. There, he came down more firmly in favour of holding the club responsible for crowd safety. At paragraph 4.13 he said "Because, as a matter of ​practice, police officers have regularly attended in large numbers at football grounds, it has somehow been assumed by the clubs that the responsibility for control of what goes on inside the ground has passed from them to the police. A police presence is there to assist in the enforcement of law and order. Those responsible for organising a private function, however, have the primary and continuing obligation and responsibility to ensure reasonable safety for those who are invited on to their premises." Mr Justice Popplewell ended that section as follows: "It cannot be too strongly emphasised that it is upon the club, or the occupier of the ground who is putting on the function, that the primary and continuing obligation rests."
165. There remains, however, the question whether there are some grounds or parts of grounds where the club may need to rely upon the police (whom they pay to attend) to control filling of pens and monitoring them for overcrowding. In other words, whilst the duty in law to ensure safety rests upon the club, they may need, and by agreement be entitled, to employ the police to act as their agents in certain circumstances. This very difficult and grey area as to club and police responsibility will need to be reviewed in greater depth at stage two of this Inquiry.
Arrangements at Hillsborough
166. What is clear, however, is that de facto the police at Hillsborough had accepted responsibility for control of the pens at the Leppings Lane end. The evidence of the senior officers who had been concerned with policing at Hillsborough over the years was all one way on this point. Only Mr Duckenfield, who had not policed at Hillsborough for some 10 years prior to 15 April, took a different view.
167. Mr Lock is now security officer at Sheffield Wednesday and was formerly a police Superintendent at Hillsborough matches occupying Mr Murray's role. He claimed there had been a formal although unwritten agreement between the Club and the police in about 1982, whereby the police agreed to steward the Leppings Lane end of the ground. Such a formal agreement is denied by other senior officers and I do not accept that any formal agreement was reached. Nevertheless, a practice or arrangement did develop which was known and accepted by both Club and police. Its effect was that throughout the ground the stewards were responsible for manning exits and entrances, for controlling entry into the stands, for assisting spectators to their seats in the stands and for helping to control the exits after the match. They were also responsible at the Kop end on the terraces for keeping gangways clear and helping to control the crowd which usually consisted of home supporters. At the Leppings Lane end, however, there were no gangways on the terraces and the crowd consisted usually (and always since 1987) of away supporters. Mr Mole and other senior officers accepted that it would have been unreal and unreasonable to expect stewards to go onto those Leppings Lane terraces. They would not have been effective there; moreover, they could well have been in some danger from hostile away supporters. The police accepted, therefore, that the proper filling of the pens and monitoring them for overcrowding could and would not be carried out by stewards. Many stewards have tended to be either extremely young or somewhat elderly. They are paid only a modest sum (£9 at Hillsborough) and they are not suitable either by physique or by training to cope on a crowded terrace with no gangways.
Case for the South Yorkshire Police
168. Notwithstanding the overwhelming evidence from senior police as already mentioned and from the Club, Counsel for the South Yorkshire Police continued throughout the hearing to contend that the Club and not the police were responsible for filling and monitoring the pens and that this was well known to both parties. He maintained that the police were there essentially to secure and preserve law and order. Quite apart from the police evidence to the contrary at this Inquiry, the official stance of the South Yorkshire Police has not always been to that effect.
Harris -v- Sheffield United Football Club Limited
169. In March 1986, the South Yorkshire Police Authority obtained a judgement against Sheffield United Football Club for money due for police services provided at Sheffield United's matches. The defence had been, inter alia, that the police were not providing "special police services". They were doing no more than performing their normal police duties of securing and preserving law and order amongst a crowd. The police argument was that they had additional duties. In his judgement, Boreham J summarised the instructions for policing as providing for:"(a) the maintenance of enforcement of law and order; (b) the enforcement of the Club's ground regulations, many of which are concerned with law and order; (c) the safety and comfort of the spectators, officials and players." ​He referred to the argument of Counsel for the South Yorkshire Police as follows:-
   "Thirdly, here the police were not discharging their own duty to the public; they were in fact discharging the Club's duties to the spectators whom the Club invited to the ground. The Club chose to invite large numbers to their private premises; it was the Club's duty to provide for their safety, health and comfort. They could have employed a security firm as banks and others have to do to protect their interests; they chose to request the police to perform those duties knowing that the police expected payment. Fourthly, the police within the ground provided services which it was not within the scope of their public duty to perform. For instance, they assisted in crowd management and in the enforcement of such ground regulations as refused entry to those who tried to enter without paying or prohibited spectators encroaching on parts of the ground which their entry fee did not entitle them to enter. It may be, submits Mr Bentley, that the maintenance of law and order was the predominant aim but there were other services performed."
The learned Judge found:-
   "In addition to what may be called their law and order role the police were expected and did take part in crowd management, ensuring the safety of spectators, the enforcement of the Club's regulations and to be on hand to assist in the event of some emergencies such as fire or accidental injury."
Police Practice at the Leppings Lane End
170. At League matches at Hillsborough, the police practice was to decide in advance how many and which pens would be used. If a modest crowd was anticipated only one or two pens might be needed. It was better to confine the fans to limited spaces (a) to prevent them running about and (b) to reduce the number of police required. The practice was then to fill the pens one by one. This involved making a judgement as to when a pen was full. There would then be a police decision to close that pen and fill another. It was regarded as impractical and unsafe for police officers (just like stewards) to go onto the Leppings Lane terraces with away supporters. This meant that monitoring the numbers in any pen had to be done from vantage points outside it. Here, the police were much better placed than the stewards. There was a good view from the control box and the television screens there. There were officers on the perimeter track. No stewards were placed there because having both police and stewards interfered with the viewing. There were also police in the west stand who could look down on the pens. Intelligence from all these sources could give the police a good appreciation of the state of the terraces. When it was necessary to shut off access to the pens officers on the concourse could be informed by radio and could take the necessary steps.
"Find Their Own Level"
171. At Cup semi-finals, a different approach was adopted. All the pens were opened from the start and the policy was "to let the fans find their own level". This phrase was repeated again and again by police officers at the Inquiry. What it meant was that no specific direction was given to fans entering through the turnstiles. They were free to go wherever they wished on the terraces. If they became uncomfortable or wished for any other reason to move their position, then theoretically they could move elsewhere. In this way it was hoped that the fans on the terraces would level themselves out and that distribution would be achieved without police intervention. On these occasions, the gates at the top of the radial fences were locked in the open position. It was sought to argue, therefore, that there was freedom of movement from one pen to another enabling fans to "find their level".
172. This argument was bad both in theory and in practice. In theory, the whole object of the radial fences had been to achieve even distribution by directing fans into desired positions. To say then that they could move freely from one pen to another would defeat the object and enable fans to go from a less popular to a more popular area without inhibition. In practice this did not happen because the position and size of the gates was such that once a substantial number of spectators were in, the gates were unnoticeable and inaccessible especially to those towards the front who might have most need of them.
173. The same argument was deployed to suggest that individual maximum capacities for individual pens need not be assessed since the presence of the open radial gates still meant that the terrace was one area. In practice this simply was not so. The photograph at Appendix 5 taken from the north stand at 2.59 pm shows very clearly the congestion in pens 3 and 4 contrasted with the sparseness in pen 6. This gives the lie to the suggestion that the fans could, if uncomfortable, "find their own level".
174. The effect of this policy was that whereas at League matches the police had to make a positive decision when to close one pen and open another, at semi-finals, where overcrowding was much more likely, the police ​left it to the fans themselves to "find their own level". Effectively, they were left to monitor their own comfort and safety so as to avoid overcrowding. The police would only intervene when there was some overt sign that an area was "full".
When is an Area "Full"?
175. Over the years, spectators on terraces have come to accept conditions which are often very uncomfortable and not infrequently downright dangerous. They are subjected to buffeting and squeezing to get in and out of the terraces. They are packed tightly and exposed to surging and swaying during the match. They put up with these conditions because they are devoted to the game and because there is little they can do about them. They believe the discomfort will pass and nothing very untoward will happen. Usually that is the case and they are reassured by it. Most clubs have not, until very recently, consulted their supporters as to their grievances or suggestions. The practice has been to pack them in on the assumption that if they are prepared to put up with it the conditions must be tolerable. Although crowd figures at football grounds have been reduced in recent years, this has been due principally to the increased proportion of seating as against standing accommodation. Terraces have still been packed.
176. It is said that many fans enjoy these features of terrace viewing. Clearly close proximity, shared discomfort, weathering sways and surges together and chanting the same songs and slogans en masse do evoke good humour and have produced a spirit or cult of the terraces which many enjoy. Equally there are many who simply endure these things for the football, for a cheap ticket or indeed for the chance of getting in at all. And before Hillsborough most fans on the terraces, even if they enjoy the hurly-burly, had not realised the narrow margin of safety between an uncomfortable crush and a fatal one.
177. The Green Guide sought to improve safety and comfort by laying down criteria for maximum capacity, ie defining what is "full". The standard set was 54 persons per 10 square metres in favourable conditions but fewer, down to 27, in less favourable conditions. The tendency may have been to aim off too little from the higher figure for shortcomings in the layout. Certainly the figures considered appropriate in pens 3 and 4 at Hillsborough were too high, as already indicated.
178. Even taking the highest figure suggested in the Green Guide, the problem remained that those supposed to be monitoring pens visually had and have little idea of what 54 persons per 10 square metres look like. Mr Duckenfield's opinion was that when a pen was full to capacity, the spectators would be "shoulder to shoulder and chest to back". That view may derive from seeing the sort of density crowds regularly endure without injury resulting. But it is much more dense than the Green Guide maximum.
179. The South Yorkshire Fire Brigade provided the Inquiry with photographs of people standing in an area of 10 square metres at various densities of packing. Together with my Assessors and others, I took part in a similar experiment at the Health and Safety Executive's Sheffield laboratory. We stood in a room of measured area at densities of 54, 80 and 100 per 10 square metres. It was clear from the photographs and from our experiment that the maximum density set out in the Green Guide left considerably more room than those monitoring the terraces would have left before declaring an area "full".
180. The tendency has been to allow the pens to fill until the fans complain or show signs of discomfort. If the density at the front appeared less than at the back, the Tannoy would invite the fans to move forward to make room for more. The evidence before the Inquiry and many anecdotal letters I have received clearly show there have been frequent occasions when the packing on terraces, not only at Hillsborough, has caused discomfort and sometimes, for brief periods, fear. Usually the surge recedes, the sway returns, the pressure eases and the incident passes unrecorded.
181. After the crushing at the 1981 semi-final, Hillsborough was not chosen again by the FA until 1987. There was evidence that the central pens were uncomfortably overcrowded on that occasion and again at the 1988 Cup semi-final, although entry to the tunnel was blocked off by police shortly before kick-off in 1988 because the pens were deemed to be "full".
Fear of Hooliganism
182. Over the last few years, hooliganism at and associated with football matches has strongly influenced the strategy of the police. In their plans and management they have concentrated on averting or containing threats to public order. This is understandable and indeed commendable. But it has led to an imbalance between the need to quell a minority of troublemakers and the need to secure the safety and comfort of the majority. In the police Operational Order, the emphasis was upon prevention of disorder and in particular prevention of access to the field of play. There was no express requirement that officers on the perimeter track ​or in the west stand should keep watch for any possible overcrowding on the terraces. Indeed, the view was expressed in evidence that packing fans close together on the terraces assisted in controlling the unruly since the less room they had the less scope there was for misbehaviour.
Summary
183. Although the police had accepted defacto responsibility for monitoring the pens, their policy on the day was to leave fans to "find their own level" and to concentrate their own attention on possible disorder. Whilst in theory the police would intervene if a pen became "full", in practice they permitted the test of fullness to be what the fans would tolerate.
184. By 2.52 pm when gate C was opened, pens 3 and 4 were over-full even by this test. Many were uncomfortable. To allow any more into those pens was likely to cause injuries; to allow in a large stream was courting disaster.
CHAPTER 10 THE BUILD-UP AT THE TURNSTILES
185. The decision to open gate C, and subsequently gates A and B too, was forced on to the police by the crowd conditions which developed outside the turnstiles. The crush was so severe that injuries were being suffered and deaths were feared unless the pressure could be swiftly relieved. Why the crowd pressure had built to such intensity was one of the principal issues during the hearing. The suggested causes must be considered in turn.
The Physical Layout
186. I have already described and illustrated the approach to the turnstiles (Appendices 1 and 2). At Penistone Road and at many other grounds, turnstiles are in a straight line, adequately spaced and with a sufficient waiting area for queues to form. Not so at Leppings Lane. The building line, the bridge over the Don and the bend in the road, left a wedge-shaped approach to perimeter gates set in an arc, and across a short forecourt, to turnstiles also set in.an arc. The pairs of turnstiles were close together and the forecourt, especially as divided by the metal fence, provided little space for a waiting crowd.
The Number of Turnstiles 187. The decision to fill the whole of the north stand from the Leppings Lane end required the 23 turnstiles there to admit 24,256 spectators. Of those, the seven turnstiles (A to G) serving the terraces had to admit 10,100, ie an average of just under 1,450 through each turnstile. At the Penistone Road end, 29,800 were served by 60 turnstiles, or just under 500 per turnstile.
188. The Green Guide recognises (paragraph 47) that the rate at which spectators can pass through turnstiles depends on a variety of local circumstances but states "in general based on observation and experience, it is unlikely that the maximum notional rate per turnstile would exceed 750 per hour". Since the semi-final was an all ticket match requiring no cash transactions, the Club considered that a higher rate of about 1,000 per hour per turnstile could be expected. Even at this higher rate, which assumes the turnstiles working at maximum efficiency non-stop, it would have taken nearly 1 ft hours to admit all those with terrace tickets. At 750 per hour, it would have taken nearly two hours.
189. The Green Guide provides (paragraph 44):-
   "Turnstiles should be of such numbers as to admit spectators at a rate whereby no unduly large crowds are kept waiting for admission...".
190. The Officer Working Party had discussed in 1985 the need, and Dr Eastwood's various schemes, for improvement of the turnstile arrangements. The mathematics are elementary. Both the police and the Club should have realised that the Leppings Lane turnstiles and the waiting area outside them would be under strain to admit all the Liverpool supporters in time. Success depended on the spectators arriving at a steady rate from an early hour and upon the maximum turnstile rate being maintained. In fact neither of these requirements, which are inter-linked, was fulfilled. That they might not be so was in my view foreseeable.
The "Late" arrival of Liverpool Fans
191. Between 2.30 pm and 2.40 pm the crowd waiting for the turnstiles swelled to over 5,000 and became unmanageable. The case made for the police was that large numbers of Liverpool supporters arrived late; a high proportion of them were drunk and unco-operative; a high proportion had no tickets; all of them were hell-bent on getting in on time. They say this was unforeseeable and explains why they lost control.
192. Whether those who arrived between 2.30 pm and 2.40 pm were "late" was much debated. The ticket simply requested its holder "to take up [his] position 15 minutes before kick-off. That may have been intended to persuade those with stand tickets to take their seats, but it would not be unreasonable for a standing spectator to arrive at the turnstiles between 2.30 pm and 2.40 pm. Whether they were "late" or not, however, there was certainly a large concentration of Liverpool fans arriving at about 2.30 pm and after.
Traffic Delays
193. It is unlikely that traffic conditions had any significant effect on this. True, there were delays on the Liverpool traffic routes. There were roadworks on the M62 which was the recommended route. At various points the carriageway was reduced from four lanes or three lanes to two, but no serious delays were reported. ​On the M63 there were longer delays due to a contraflow and at its junction with the A560 there was heavy congestion due to volume of traffic. However, the Liverpool routes were clear by 2.20 pm and those witnesses who complained of delays en route had nevertheless managed to be in range of the ground in ample time.
Fine Weather and Drinking
194. The likeliest explanations for the sparse Liverpool attendance in the ground before 2.30 pm were four-fold - the warm weather, drinking, disinclination to enter the ground early and prolong the standing, and a tendency of Liverpool supporters to cut it fine.
195. The police emphasised that at the 1988 semi-final there was no comparable build-up of "late" arrivals. They claim, therefore, that they had no reason to foresee it in 1989. However, in 1988, although the weather was fine, it was 11 °F cooler than in 1989. 15 April was the sort of fine spring day which tempted fans to sit or stand about in the sun with a drink. If you had a ticket it would seem more pleasant and sensible to relax in that way than to enter the ground early and stand on the terrace for an extra hour. Pre-match entertainment in the ground had been advertised but did not take place. Even if it had, it may not have been an encouragement to many fans to enter so early.
Was Drunkenness a Major Factor in the Crisis at the Turnstiles?
196. Of those who arrived at 2.30 pm or after, very many had been drinking at public houses or had brought drink from home or an off-licence. I am satisfied on the evidence, however, that the great majority were not drunk nor even the worse for drink. The police witnesses varied on this. Some described a high proportion as drunk, as "lager-louts" or even as "animals". Others described a generally normal crowd with an unco-operative minority who had drunk too much. In my view some officers, seeking to rationalise their loss of control, overestimated the drunken element in the crowd. There certainly was such an element. There were youngsters influenced by drink and bravado pushing impatiently at the rear of the crowd thereby exacerbating the crush. But the more convincing police witnesses, including especially Detective Superintendent McKay and Chief Inspector Creaser as well as a number of responsible civilian witnesses, were in my view right in describing this element as a minority. Those witnesses attributed the crush to the sheer numbers of fans all anxious to gain entry. There was no criticism of the crowd by any of the witnesses in the period up to 2.30 pm or even 2.35 pm. What happened then was not a sudden deterioration in the mood or sobriety of those assembled there. No doubt those coming behind would have had more to drink and would have included the unruly minority. But the crisis developed because this very large crowd became packed into a confined turnstile area and its very density hampered its passage through the turnstiles.
197. Superintendent Marshall and other officers criticised the crowd as unco-operative because police exhortations to stop pushing and to ease back were not heeded. How could they be? In that crush most people had no control over their movements at all. Two incidents involving police horses illustrate the point. One horse was found afterwards to have cigarette burns on its rump. Clearly that was the despicable work of a hooligan whether in drink or not. However, there were also eyewitness accounts of a horse being physically lifted off its feet by the crowd. That occurred, as the police accepted, without malice or intent but as an involuntary consequence of crowd pressure which those by the horse's flanks could not resist any more than the horse itself.
Reduced Efficiency of the Turnstiles
198. The labelling of the turnstiles in the order A, C, B was confusing. A fan with a B ticket who went by mistake to the wrong side of the metal fence would have had the greatest difficulty in getting back and round to the correct side. The colour coding was inefficient because the coloured wooden panels were affixed to the turnstile walls so low that they were not easily visible through a crowd. The information on the ticket printed by Sheffield Wednesday Football Club was misleading and its layout unhelpful, as Mr Mackrell frankly conceded.
199. The result was that in the early stages, police officers were pestered by fans for help as to where they should go. Later, as the crowd became more dense, fans were presenting their tickets at the wrong turnstiles. There were also Liverpool supporters who had acquired tickets for the Kop end but sought entry at Leppings Lane. They caused delays in the turnstile operation when entry was refused and after a while the police instructed the operators to let them through. There was further delay because the crush made it difficult for fans to get into the turnstile entrances. Once there, the pressure from behind was such as, on occasions, to jam them in the doorway or against the paddle of the turnstile. Finally, there were fans without tickets who sought to enter by offering payment, by seeking to go over or under the paddle or by sliding through with a ticket holder. All of these activities slowed down the turnstile rate which at the worst period was only about 600 per hour per turnstile. The waiting crowd therefore expanded and as the minutes passed frustration grew. Visitors ​who had paid for tickets and travelled from afar realised they were making little forward progress. Frustration increased pressure and induced panic at the front. Determination to get into the match was intensified by determination to get out of the crush.
Were Fans Without Tickets a Major Factor in the Build-Up?
200. It has become a fact of football life that fans do turn up at all-ticket matches without tickets. It is not possible to give an accurate figure or even a reliable estimate of the number without tickets on 15 April. Police estimates varied from about 200 to about 2,000. There were certainly frequent requests for tickets or "spares" during the hours before the build-up. Many of those warned off by the police were seen to return to the area. Some were hanging about on the bridge. Again, however, the police witnesses who most impressed me did not consider the number of ticketless fans to be inordinately large. This accords with two other sources of evidence.
201. First, there was a wide range of witnesses who observed inside the ground that the Liverpool end was at a late stage well below capacity save for pens 3 and 4. The north stand still had many empty seats and the wing pens were sparse. The match being a sell-out, there were clearly many ticket holders to come and they could account for the large crowd still outside the turnstiles. Had the Liverpool accommodation been full by 2.40 pm, one could have inferred that most or much of the large crowd outside lacked tickets.
202. Secondly, such figures as are available from the Club's electronic monitoring system and from analyses by the HSE suggest that no great number entered without tickets. They show that the number who passed through turnstiles A to G plus those who entered through gate C roughly equalled the terrace capacity figure of 10,100 for which tickets had been sold. The Club's record showed 7,038 passed through turnstiles A to G. However, the counting mechanism on turnstile G was defective, so the HSE did a study using the video film and projecting figures from the other turnstiles. This gave an assessment of 7,494, with a maximum of 7,644 passing through A to G. Again, using the video, the HSE assessed the number who entered the ground whilst gate C was open at 2,240 with a maximum of 2,480. Accordingly, the HSE's best estimate of the total entering through gate C and turnstiles A to G was 9,734 with a maximum of 10,124.1 recognise that these can only be rough checks because, for example, some with terrace tickets were allowed through turnstiles 1 to 16 and there would be other similar factors which have not formed part of the assessment. Nevertheless, the figures do suggest that there was not a very significant body of ticketless fans in the crowd which built up.
The "Conspiracy" Theory
203. On behalf of South Yorkshire police, the theory was advanced that the "late" arrival of so many Liverpool supporters was planned to buck the system. The suggestion was that fans without tickets conspired to arrive late and create such trouble as would force the police to admit them to the match. The slender evidence upon which this theory rested came from two sources: overheard conversations in public houses and the antecedent history of Liverpool supporters at away matches.
204. One witness said he heard three Liverpool supporters saying, in effect, that they would manage to get in without tickets by causing trouble so that police would open a gate, and that they had done this before. Another witness heard two of a group of Liverpool supporters say they had no tickets, that they would go to the ground just before kick-off, that no-one would stop them getting in and that they had not been stopped yet. Statements were put in relating to two other small groups talking in similar terms.
Liverpool Supporters at Away Matches
205. The South Yorkshire police prepared a dossier of reports on the behaviour of Liverpool fans at away matches with the object of showing a pattern of troublesome behaviour by large numbers either without tickets or with forged tickets. Without setting out the whole history, it can be summarised as follows.
206. On three occasions Liverpool fans without tickets were allowed into all-ticket matches upon payment. (At Watford on 13 February 1988, 1,500 were admitted; at Southampton on 24 September 1988, 150 were admitted; at Southampton again on 12 December 1988, 750 were admitted.) At Norwich on 1 April 1989, Liverpool supporters arrived without tickets but 1,272 tickets had been returned and fans from both Liverpool and Norwich were allowed to buy them for cash. A similar situation occurred at Wimbledon on 13 May 1989. There were six other occasions from 1986 to date, including the Cup finals of 1986 and 1989, when numbers of Liverpool supporters turned up without tickets or otherwise behaved badly.
207. Four points must be noted, however. On none of the occasions when ticketless fans were admitted for payment was the match a sell-out. There was therefore room in the ground on each occasion. At a sell-out fans ​might not expect to be allowed in, even for payment. Secondly, no trouble of the kind alleged was encountered at the 1988 semi-final when Liverpool visited Hillsborough. Thirdly, Liverpool visited Hillsborough again in January 1989 without any trouble. Finally, no forged tickets were in use on 15 April apart from three crude photocopies.
No Conspiracy
208. I have already found that there was not an abnormally large number of fans without tickets on this occasion. With one or two exceptions, the police witnesses themselves did not subscribe to the "conspiracy" theory. I am satisfied that the large concentration at Leppings Lane from 2.30 pm to 2.50 pm did not arrive as a result of any concerted plan. There were, I accept, small groups without tickets who were willing to exploit any adventitious chance of getting into the ground. They, together with the minority who had drunk too much, certainly aggravated the problem faced by the police. But that main problem was simply one of large numbers packed into the small area outside the turnstiles.
The Police Operation at Leppings Lane
209. The Operational Order for 15 April followed closely that laid down for the 1988 semi-final. The emphasis was on maintaining law and order. Side roads were to be blocked off to prevent damage in residential areas. Pairs of officers were to patrol streets to prevent "clash of rival supporters". Officers were to watch public houses, shops and supermarkets "where looting could take place". Outside the turnstiles, officers were to ensure supporters entering did not have banners, weapons, missiles or alcohol.
210. Unfortunately, hooligan behaviour has made all these steps necessary. But the only written provision aimed at effecting controlled entry to the turnstiles was one enjoining officers "to ensure orderly queues are formed". There was no provision for controlling the entry of the crowd into the turnstile area.
211. As long ago as 1924, the Departmental Committee on Crowds stated:"The control of crowds should begin at a point some considerable distance from the entrance to the ground. The advantages of an arrangement of this kind are... in preventing congestion at the entrances to grounds." This was particularly important at Leppings Lane where the turnstile area was so small and awkwardly laid out. If a large crowd was permitted uncontrolled entry through the perimeter gates, the forming of queues at the turnstiles and control by officers, whether on foot or mounted, would become impracticable. Those waiting at the turnstiles would become a single growing mass. Once that happened, it would be difficult to retrieve the situation.
212. Whether steps were taken and what steps to avoid this happening was left to oral briefing and ad hoc instructions on the day.
Previous Experience
The senior police officers said it had never happened before so there was no reason to foresee it. In fact, the only two previous occasions when the Leppings Lane terraces had been used to fill the whole of the north and west sides of the ground were at the two semi-finals, in 1987 and 1988. In 1987, the match was on a Sunday, scheduled for 12 noon, and kick-off was postponed for a quarter of an hour because of late arrivals.
Policing in 1988 As to 1988, there was a very large and consistent body of evidence that, on the day, the police in Leppings Lane conducted an efficient filtering exercise designed to keep away those without tickets and control the flow of fans towards the ground. I do not believe that so many witnesses without either opportunity or reason to put their heads together could be mistaken about what they experienced on that occasion. Yet, the police maintain that no filtering exercise other than on a random basis was conducted in 1988 and that their policy and practice then were no different from those of 1989.
   | "Q | Were you aware of a build-up of numbers last year towards the latter stages at the turnstiles? |
   | A | Yes. . . There was a huge build-up around 10 minutes to 3 when many, many Liverpool supporters came at that time. They had been drinking, the ones that I saw and there was quite a sizeable crush built-up - sizeable queue. |
   | Q | Queue or crush? |
   | A | Compacted queue, built-up in the area by the turnstiles which I believe are marked A to G. That crowd reached back almost to the gates. It never got any bigger than that and the turnstiles operated relatively freely and they dealt with that crowd. Fans were still arriving at about 10 past 3 but by then the... |
   | Q | This crowd that you have described of the late arrivals at about 10 to - was it an orderly crowd? |
   | A | Oh no. No. The orderly crowd had gone in, and when I say they were not an orderly crowd, obviously mixed amongst those people were... |
   | Q | Of course, but taking it generally? |
   | A | But by and large they had taken a lot of drink on board and they were in such numbers that excluding them from the ground was completely out of the question. |
   | Q | Were they standing in an orderly queue or was there some pushing and shoving? |
   | A | There was a lot of pushing and shoving. There was an urgency to get into the ground. |
   | Q | But fortunately it does not appear to have been in nearly such numbers as this year. |
   | A | It wasn't." |
Police Intelligence in Advance
216. Apart from that experience in 1988, the tendency of Liverpool supporters to arrive late was not unknown. Witnesses said that they get through the turnstiles at their home ground, Anfield, quite quickly and tend therefore not to arrive early. Indeed, a general recent tendency to postpone arrival was noted by the Sheffield City Council Advisory Group, with police present, on 23 March 1988. The minute reads:-
   "As far as the turnstile question was concerned, a pattern has developed of people arriving some 15 minutes before the start of the game hoping to gain admission. This trend may be due to the banning of alcohol at sports grounds which could lead to people going elsewhere for refreshment prior to the football match. As the available turnstiles operated quite effectively for the majority of the time, and that the late arrival problem could perhaps only be dealt with by education of the spectators" (sic).
217. In so far as Liverpool supporters' behaviour at away matches may have been indicative of what police problems might arise on 15 April, most of the facts should have been available at the planning stage. As in other forces, South Yorkshire Police had a liaison officer whose job was to seek, receive and collate relevant information as to the visiting supporters. The Association of Chief Police Officers' Guide to Policing Football highlights the importance of such liaison:"It is important that the officer responsible for policing the match determines the pre-match planning in the light of the intelligence at hand. Whilst that intelligence can be obtained from a variety of sources, the prime source for football intelligence is the Police National Intelligence System which is based on the network of police liaison officers. Summaries completed by police officers of the home club force are forwarded to the visiting club's liaison officer making available intelligence about fans' behaviour at both home and away fixtures. This information will be collated and made available for future matches involving that club".
218. The FA had also laid down in a memorandum issued in the 1985/6 season measures to be adopted by the away club which included the following:-
   "It is the responsibility of the away club to advise the home club of the recent behaviour of their supporters at away matches, irrespective of whether the behaviour has resulted in disciplinary action by the Football Association or not".
219. It does not seem that information of this kind was passed to the Sheffield Wednesday Club or played ​any part in the South Yorkshire Police plans. Had the latter been informed of the history contained in the dossier and summarised above it may well have influenced police strategy in Leppings Lane.
220. There is presently a proposal that a national computer-based police football intelligence system should be set up to make the necessary information readily available.
Police Intelligence on the Day'
221. The unfilled space in the Liverpool areas inside the ground, the figures for entry available from the Club's computer and observations on the video screen should have enabled those in the control room to monitor the numbers arriving and still to arrive at Leppings Lane. Radio contact with mobile (Tango) patrols detailed to monitor licensed premises in the district could have indicated the numbers still to come. But at 2.30 pm when Mr Murray told Mr Duckenfield they would "get them all in by 3 o'clock" he seems not to have appreciated that in addition to those visible at the turnstiles there were many more still to come. Certainly, Mr Marshall outside the turnstiles was not told and could not otherwise have known that there were still many Liverpool ticket holders to arrive.
Mr Marshall and Mr Greenwood
222. The division of command between these two officers did not help. Mr Marshall was in charge of the serials outside the perimeter gates in the Leppings Lane area and in the roads beyond. In practice he operated inside and just outside the turnstile area. Mr Greenwood's area as Ground Commander extended from the pitch to the perimeter gates. He in fact stationed himself near the players' tunnel. He was wholly unaware of the growing problems at the turnstiles and was in no position to exercise control over his officers who were under pressure there. No-one in the control room thought to tell him.
Control Lost
223. In the result, the large concentration of arrivals from 2.30 pm to 2.40 pm pressed unrestrained into the turnstile area through the perimeter gates which were fully open. When that area was full, later arrivals swelled the crowd out to the forecourt and even into the road. As already recounted, the foot officers at the turnstiles became trapped and endangered and retired through the turnstiles. The mounted officers could not operate amidst such a dense crowd in a confined space. They came out of the turnstile area. There were then the belated attempts to close the perimeter gates and prevent more fans joining the mass until it had a chance to diminish through the turnstiles; still later the attempt to put a cordon of horses across the entrance.
224. Despite knowledge of the difficult layout, the very large number of fans to be got through so few turnstiles and the tendency of fans to arrive in the last half hour, no contingency plans were made to avoid a crush such as occurred. Even on the day, the need to close Leppings Lane to traffic before 2.30 pm and the other available intelligence already summarised, should have prompted those in command to take precautions against such a crush. If some of the perimeter gates had been closed and cordons of mounted and foot officers had been placed a little distance from those gates, the flow of fans into the turnstile area could have been controlled before that area became engulfed. It was the crush itself which produced the frustration and the panic and brought out the worst in those who had drunk too much. Earlier control of entry would have prevented the crush and maintained the good mood which had prevailed until 2.30 pm.
225. It should moreover have been obvious by 2.40 pm, if not earlier, that a large part of the crowd could not be admitted until well after 3 pm. Had a decision to postpone kick-off been made and announced much of the frustration and with it the impetus crushing the crowd would have been reduced. A combination of controlled filtering and a postponed kick-off would probably have obviated the need to open the gates.
Postponement of Kick-off
226. At various stages in his evidence, Mr Duckenfield gave three accounts of why he thought it too late to postpone kick-off. Once it was that one of the teams had already come onto the pitch. Then it was that a group of photographers at the tunnel had wrongly led him to think that the teams were coming out. Finally, he did not know why he thought the teams were coming out. They did not in fact come onto the pitch until 2.54 pm, two minutes after gate C was opened. Police Constable Buxton had asked for a postponement of kick-off before gate C was opened. It should not, however, have needed a police Constable in the thick of the crowd (and there were others of like mind) to think of postponing the kick-off. The need should have been clear in the control room.
227. The truth was that Mr Duckenfield applied inflexibly the policy he had discussed with Mr Murray. Kick-off would not be postponed unless there were some major cause for delayed arrivals eg a jam on the ​motorway or fog. I accept that the thinking behind this policy was not callous or punitive. If kick-off is postponed whenever a proportion of fans choose to leave the public houses late, the practice may grow and kick-off times would become meaningless. But, a commander must deal with the problem of the day. Faced with a situation which was becoming dangerous, crowd safety should have been his paramount consideration. Kick-off should have been delayed.
Summary
228. The layout of the turnstiles and the number they were required to serve left no margin of safety against an uneven flow of fans. Because police strategy in advance and on the day did not cater for it, the arrival of a large number of supporters between 2.30 pm and 2.40 pm created an unmanageable crush. The presence of a substantial minority of fans who had drunk too much aggravated that problem. Having lost control and rejected the option of postponing kick-off, the police were faced with a serious danger of deaths or injuries. They were left therefore with no alternative but to open the gates. Superintendent Marshall was right at that stage to ask for it and Mr Duckenfield was right to agree. But the possible effects of so dramatic a step required other action.
CHAPTER 11 THE BLUNDER ON OPENING THE GATES
229. The decision to order the opening of the gates was not accompanied or followed by any other order to deal with the consequences. When gate C was opened, a steady stream of about 2,000 fans poured through it over some five minutes. Clearly they were going to go into the ground somewhere and unless they were diverted their likeliest route was through the tunnel for reasons already given. No warning was issued from the control room that the gate was to be opened. Serials on the concourse were not alerted. Neither the Club control room nor the Chief Steward at the Leppings Lane end was warned. Not even Mr Greenwood, the Ground Commander, was informed. From 2.47 pm when Mr Marshall made his first request until 2.52 pm when Mr Duckenfield acceded to it, there were five minutes in which orders could have been given as to how the influx was to be absorbed. It was not done. In evidence, Mr Duckenfield began by saying that no officer made any wrong decision but he later conceded he had erred in this regard. He said he did not consider where the people would go when the gate opened. Even after it opened, when he could see the influx on the television screen, no order was given to steer the fans to the wing pens. Mr Duckenfield said it did not cross his mind to detail officers on the concourse to shut off the tunnel. Those officers could not have known from their position how full pens 3 and 4 were. That was a matter for the control room to monitor from its own observations and using intelligence from around the ground.
230. Since pens 3 and 4 were full by 2.50 pm, the tunnel should have been closed off whether gate C was to be opened or not. The exercise was a simple one and had been carried out in 1988. All that was necessary was for a few officers to act as a cordon at the entrance to the tunnel and divert fans elsewhere. Unfortunately, the 1988 closure seems to have been unknown to the senior officers on duty at the time. It did not figure in the debriefing notes. It therefore had no influence on the planning for 1989.
231. Planning apart, however, it should have been clear in the control room where there was a view of the pens and of the crowd at the turnstiles that the tunnel had to be closed. If orders had been given to that effect when gate C was opened, the fans could have been directed to the empty areas of the wings and this disaster could still have been avoided. Failure to give that order was a blunder of the first magnitude.
232. Significantly, when permission was given to open gate A, Mr Duckenfield did order serials to go to that part of the concourse to monitor the influx towards the north stand. He did this because he feared that if fans went to the north stand without tickets, they would not get seats and, there being no perimeter fences at the north side, they might invade the pitch. This illustrates again the preoccupation with avoiding pitch invasion as against safety and the risks of overcrowding. Because those entering through gate C could not get onto the pitch, it was not thought necessary to alert officers to monitor them. The possibility of overcrowding simply was not considered.
CHAPTER 12 THE BARRIERS IN PEN 3
Barrier 144
233. The removal of barrier 144 in 1986 should have reduced the notional capacity of pen 3 as already mentioned. But it did more. In the absence of barrier 144, the influx of fans after 2.52 pm met no retarding structure as it came into pen 3. The pressure created was free to push fans straight down by the radial fence to the lowest line of barriers. The pressure diagonally from the tunnel mouth down to barrier number 124a which collapsed was unbroken by any intervening barrier. 124a was also vulnerable to pressure straight down the pen through the gap in the barrier above it created in 1985.
234. Inspector Bullas, positioned in the west stand, described what he saw looking down on the pens around 3 pm.
   "... I saw from the direction of the tunnel a kind of movement down the terracing... the type of thing that you see on the nature programmes, the molten lead flowing down the side of the mountainside, the molten lava... a "river of people" ... going directly towards the pitch but there again spreading... out."
235. Dr Eastwood conceded in evidence that the removal of barrier 144 was likely to have contributed to the collapse of 124a. Later, he sought to resile from that answer, but I think his earlier admission was correct. It was argued that if barrier 144 had remained, the influx from gate C would have built up further back and the tragedy might have occurred in the tunnel or might have broken barrier 144 itself. This is speculative and I think unlikely. What remained of barrier 144 in pen 4 did not cause a build-up; nor did it collapse. But its remaining in position may well have accounted for no barrier further down pen 4 collapsing and for the lesser carnage in that pen.
When did Barrier 124a Fail?
236. Counsel for the South Yorkshire Police sought to argue that this barrier collapsed or may have collapsed at about 2.47 pm. His purpose was to suggest that the opening of gate C was not causally linked with the crushing and fatalities resulting from that collapse. I have already found that whilst the evidence does not permit the time of collapse to be fixed with certainty, it was after 2.52 pm. I now give my reasons:
the biggest group of witnesses was that which related the collapse to the surge following Beardsley's
Dr Eastwood's Testing of the Barriers
237. Two sections of barrier 124a in pen 3 collapsed as a result of the overcrowding. That collapse caused a number of deaths. Dr Eastwood and his staff had undertaken the periodical testing of crush barriers required by the Green Guide and by the Safety Certificate. Barrier 124a had been tested in July 1988 and passed.
238. The test had been carried out in accordance with Dr Eastwood's interpretation of Annex C to the Green Guide. That requires an evenly distributed force of 6.0kN/metre width to be applied for 3 five minute ​periods, the interval between applications to be as short as possible. A record has to be kept of the amount of deformation during each loading and of the percentage of recovery. If the recovery is less than 50% after the third application offeree, the barrier has failed the test. If recovery is between 50% and 75%, there must be a re-test. The question is: 50% or 75% of what? Is the recovery to be in relation to the position of the barrier before the first application offeree or before the third? If the former, a span of 124a recorded 53% at the 1988 test and should have been re-tested. If the latter, it recorded 100% and passed. Unfortunately the Green Guide is unclear as to the correct interpretation. Dr Eastwood took the latter view and so passed the barrier. He justified his interpretation in evidence. He said failure to recover to the original position could be due to a "shake-down" effect related to some giving in the ashes under the concrete or to some other extraneous factor rather than to any defect in the material of the barrier itself.
239. I think, after consulting Professor Maunder, that safety ought to have dictated recovery should be by reference to the position of the barrier before the first application of force. I accept, however, that the Green Guide is ambiguous and Dr Eastwood's interpretation is tenable. It has some support from the British Standards tests on steel structures. Clearly, however, for the future, the Green Guide should be clarified on this point.
Corrosion
240. Inspection of barrier 124a, and indeed other barriers at Hillsborough, by the HSE showed considerable corrosion of the metal at vulnerable points where water could accumulate. Dr Eastwood agreed that if a significant degree of corrosion was observed on visual inspection, a barrier should be condemned.
241. The Green Guide does not specifically refer to corrosion. Paragraph 39 provides, inter alia:
   "Crush barriers and balustrades should be examined for deformation or any other overt signs of weakness".
Paragraph 6 of Annex C provides:
   "If during any test, even though the barrier... satisfies the above loading requirements, doubt should arise for any reason (including such matters as cracking of the terracing or distortion of connections) as to the safety of the barrier... a detailed investigation should be carried out. Unless the results of this investigation remove the doubt as to safety of the barrier... (it) should be deemed to have failed the test".
242. Since corrosion is a likely cause of deterioration, a revision of the Green Guide should make specific reference to it.
Causation
243. Tests done by the HSE suggest that although barrier 124a passed the loading test in 1988 and probably would have been able to sustain a force which did not exceed the test load, it was unable to resist the load imposed upon it by reason of the numbers in pen 3, the excessive gap in the barrier higher up the pen and the absence of barrier 144. Corrosion probably played a part, but the effective cause of the collapse was the excessive and unanticipated pressure to which the barrier was exposed.
CHAPTER 13 THE CRUSHING NOT RECOGNISED
Observation from Control Room
244. As the stream from gate C flowed through the tunnel, the officers in the control room could be expected to keep a close watch on pens 3 and 4. They had a direct view of them from an elevated position through their window. Although they had no field-glasses, there was the zoom facility on the TV camera. The radio was by then working again and although reception was difficult due to crowd noise and possibly excessive air traffic on channel 25, attempts could have been made to alert officers on the perimeter track to watch for overcrowding and report their observations. In the event, pens 3 and 4 became more and more crowded, surges took place, fans were showing and signalling distress. None of this was seen or recognised in the control room.
Officers on the Track
245. The 20 officers detailed to the perimeter track were distributed round the pitch so that some five officers were at the west end. Their written instructions made no reference to the avoidance or detection of overcrowding. The same applied to the officers in the west stand. Mr Greenwood admitted that his oral briefings also contained no mention of monitoring the pens for overcrowding.
246. The Operational Order for 1988 had instructed officers to forbid anyone "access to the track from the terraces without the consent of a senior officer (except to receive medical attention)". At the end of the 1988 semi-final, there was a minor pitch invasion. Accordingly, that prohibition was emphasised in the 1989 Operational Order by being put into capital letters. The combination of no instructions as to overcrowding and a strong prohibition on opening the gates was likely to make police recognition of crushing slow and their response reluctant. Small wonder that the growing pressure and congestion between 2.50 pm and 2.59 pm went unheeded or certainly unremedied. Even when officers recognised there was a problem, the rule required consent of a senior officer before a gate could be opened.
247. "Senior officer" meant an officer of Inspector rank or higher. The Inspector in charge of the 20 officers on the track was Mr Darling. He stationed himself by the players' tunnel, the most central position for supervising his men. In evidence he said:
   "I would only take action if I thought crowding had got to such a stage that the fans were in danger. I'd then inform ground control and I would expect someone deployed to the back of the stand."
That underlines the inhibition against opening perimeter gates. So did the evidence of one Constable who said it had been so drummed into officers not to open the gates that when he saw distress in pen 4, he "debated" with himself before opening the gate, thinking: "If I'm wrong, I'm going to get a right bollocking for this." Naturally, one would hope that common sense and humanity would make some officers cut through the rules and open a gate if fans were clearly in distress.
248. This is what happened, but not until officers recognised the distress and even then not immediately. Hence, gates 3 and 4, having been opened, were shut again before they were finally opened and at first those seeking to climb out over the fence were pushed back. This reaction of the police did not go on for as long as some witnesses believed. They probably misinterpreted the hand movements from Mr Greenwood and others aimed at persuading fans to move back and relieve the pressure as attempts to stop those climbing out at the front.
249. Nevertheless, there was a period during which the failure to recognise the problem and the inhibition against tackling it caused vital time to be lost.
CHAPTER 14 THE RESPONSE OF THE POLICE
The Officers in Command
250. Even when realisation of the problem came to officers on the track, it was some minutes before it reached the control room. When spectators first appeared on the track, the immediate assumption in the control room was that a pitch invasion was threatened. This was unlikely at the beginning of a match. It became still less likely when those on the track made no move towards the pitch. Mr Motson, the BBC commentator, recognised and said, well before the match was stopped, that the trouble seemed to be overcrowding and not misbehaviour. Still, the assumption to the contrary persisted in the control room. Until Mr Murray radioed for a fleet of ambulances, about 3.06 pm, Mr Duckenfield continued to treat the incident as a threat to the pitch and to public order. The message calling up all available officers mentioned a pitch invasion. Operation Support was initiated and dog handlers were requested.
251. Until Chief Superintendent Nesbit arrived, there was no effective leadership either from control or on the pitch to harness and organise rescue efforts. No orders were given for officers to enter the tunnel and relieve pressure. Some officers did this on their own initiative. Apart from the Tannoy request to clear the pitch, no attempt was made to clear and mark off a casualty area where first-aid could be given without hindrance by fans and photographers milling about between the bodies. There was no co-ordination of the early provision of first-aid or of stretcher parties or of the rescue effort through gates 3 and 4. No request for help was broadcast to doctors and nurses in the crowd until about 3.29 pm when it was too late. Probably, there was little that could have been achieved in most cases however soon doctors had been summoned, but there were marginal cases where earlier attention might have made a difference.
252. The plight of those behind the fencing and the existence of injuries were known to officers at the scene from 3 pm. But the Major Disaster Plan was not started until 3.06 pm at earliest when the ambulance service was called. No request for cutting gear or for the fire brigade was made until 3.13 p.m. Again, it is unlikely that these services could have saved lives if they had been called promptly, but it is possible.
Police on the Pitch
253. Despite the initial lack of leadership, many officers did all they humanly could to rescue and revive the victims. Many supporters who gave evidence paid tribute to these efforts. It is also fair to say that the number of officers who could at first be usefully involved at the two open gates was necessarily limited.
254. Chief Superintendent Nesbit's action in deploying a line of officers across the middle of the pitch has already been mentioned. I can well understand the resentment it caused. However, the police assertion that a rush by some fans towards the Kop end raised fears of conflict are well borne out by the video tape. In my judgement, Chief Superintendent Nesbit was well justified in using some of the many officers called up pursuant to Operation Support to prevent possible violence. To have had open fighting in a ground where some 90 spectators already lay dead would have been an unthinkable and obscene development.
Fans on the Pitch
255. Many fans who escaped onto the pitch alive were in a state of collapse or close to it. Most of those who retained their strength strove magnificently to assist the victims. They helped pull them clear; they helped with first-aid; they helped carry the improvised stretchers.
256. There were fans, however, who were distraught, angry, drunk, or all three. Their conduct in abusing, assaulting and spitting at the police was disgraceful, the more so since earlier police failures had little to do with those officers now doing their best for the injured. In addition, there were abuse and assaults on ambulance men and firemen in the course of their rescue work. This was. probably because their similar uniforms caused them to be mistaken for police. However, although the abuse was widespread, the number of assaults and spittings was on the evidence comparatively small. In deploring them, one must recognise the uniquely horrifying experience which those responsible had just suffered and were still suffering.
False Reports
257. Before this Inquiry began, there were stories reported in the press, and said to have emanated from police officers present at the match, of "mass drunkenness". It was said that drunken fans urinated on the police while they were pulling the dead and injured out, that others had even urinated on the bodies of the dead and stolen their belongings. Not a single witness was called before the Inquiry to support any of those allegations although every opportunity was afforded for any of the represented parties to have any witness called whom they wished. As soon as the allegations I have mentioned were made in the press, Mr Peter Wright, Chief Constable of South Yorkshire, made a dignified statement dissociating himself from such grave and emotive calumnies. Those who made them, and those who disseminated them, would have done better to hold their peace.
CHAPTER 15 THE PERIMETER GATES WERE TOO SMALL
258. The perimeter gates in the pens were not designed as exits. They were intended to afford access by the police to cope with any local disorder or with an emergency. The kind of emergency contemplated was not massive crushing but, for example, the collapse or illness of an individual. Emergency evacuation of the pens had been considered by the Officer Working Party. Although fire risk was minimal since the terraces, west stand and tunnel were of concrete construction, the fire brigade were the principal arbiters of evacuation procedure. They aimed to be able to empty the pens in six minutes. The plan was to evacuate spectators via the tunnel. If for any reason that option became impracticable, eg due to a bomb threat, then the alternative route would be along the back of the terraces, through the gates in the radial fences and round the sides of the west stand. The fire brigade were satisfied that each of these routes would enable the pens to be evacuated in less than six minutes, without relying on the gates to the pitch. Those gates would also be available, but their use was excluded from the calculation of evacuation time.
259. The need to provide for speedy and large scale evacuation from the front of the pens to the pitch was not anticipated. The Green Guide (1986) provides as follows:
   "209. Access to the pitch must be made as difficult as possible in normal circumstances while at the same time ensuring that the police have effective access to the terraces for the purpose of crowd control and enabling the pitch to be used (where appropriate) in the event of serious emergency …
   214. … at some major soccer stadia, where restriction on crowd movement forms a necessary part of the safety measures, it may be necessary to have a fence which prevents access to the pitch in normal circumstances … but allows for access in emergency.
   215. For most major stadia, whether used for association football or other sports, the pitch perimeter fence will be required either to prevent access to the pitch as mentioned above, or at least to discourage attempts by spectators to enter the playing area. Gates or other access points (minimum width 1.1 metres) should nonetheless be provided for use in an emergency … Provision of such gates or access points is particularly important to allow full access to the playing area (or track) where it is likely to be used as a place of safety in an emergency. Such gates or access points should be properly stewarded and clearly marked so that immediate access to the playing area or perimeter track can be ensured".
260. Gate 3 was .82 metres in width; gate 4 was .79 metres in width. There were therefore clear departures from the Green Guide standard.
261. The Safety Certificate provided (by Schedule 2 Paragraph 24) as follows:
   The (club) shall arrange for the Stadium to be inspected by a suitably qualified Chartered Engineer … at least once each period of 12 months … and … shall as soon as possible after each inspection supply to the … Council a Certificate by the said Chartered Engineer as to the current compliance or non-compliance with … the appropriate provisions and recommendations of the (Green) Guide of all structural parts of the Stadium …
262. It was argued that there was no breach of the Safety Certificate since the Green Guide specifically provides for flexibility. However, in my view the Safety Certificate cannot and certainly should not be interpreted so liberally as in effect to leave such basic requirements as the size of exit gates to the total discretion of the club and its advisers. One of the matters for consideration at stage two of this inquiry will be whether, and in what respects, the Green Guide needs to be clarified and toughened.
263. Dr Eastwood explained the small width of the gates by reference to the dilemma facing the police. They wanted a gate sufficient for its intended purpose ie police access and small scale emergencies. On the other hand, they did not want a flood gate of such size as to endanger the prime principle of preventing pitch invasions. In the light of Hillsborough, this is perhaps the most poignant example of the difficulty of achieving a balance between stopping hooliganism and ensuring crowd safety.
264. Even if the width of gates 3 and 4 had complied with the present Green Guide standard, they would have been wholly inadequate to relieve pressure and release spectators swiftly on 15 April. Moreover, the Green Guide says nothing about the number of gates required for a pen of given size. Whilst the Club, ​Dr Eastwood, the Officer Working Party and the local authority can be criticised for failing strictly to conform to the Guide, the real failure was common to all those who have been responsible for considering safety on the terraces. The anxiety to protect the sanctity of the pitch has caused insufficient attention to be paid to the risk of a crush due to overcrowding. Certain it was, that once the crush occurred on 15 April gates 3 and 4 were wholly inadequate for rescue purposes.