Volume 2 of the Report of the Public Inquiry into the Attack on Manchester Arena on 22nd May 2017, focussing on Emergency Response, has been published. The Manchester Arena Inquiry report is a lengthy tome, with Part 1 coming in at 716 pages. I can only claim to have read the first half of the first volume, and did not manage to fit in more reading over the weekend!
This second blog on the report highlights some additional lessons that should be observed in Crisis Management and Incident Management planning.
It is evident that communications and the sharing of information has proved difficult throughout the response to the bombing, both between different organisations but even within the same organisation. As an example, officers not being aware that a Major Incident had been declared or that specific points had been identified as rendezvous points. At one point, the British Transport Police incident log recorded “still on hold with GMP”, despite the force being equipped with radios.
Communications during incident management will always be difficult. Just to take a simple example: when a call comes into to a Crisis Management Team, should all stop to listen so that all have the information despite the potential impact on the existing activity? Alternatively, does one person take the call and, if that is the case, how is that information then shared. Imagine this simple circumstance then extrapolated to communicating with other organisations, such as customers, suppliers, emergency services regulators and neighbours, as well as to staff and their families.
It is clear from the detail of the report that log-keeping has been a critical element in understanding the incident response and being able to identify an accurate timeline of communications and actions.
However, the report also highlights another aspect of log-keeping when it stated that one of the senior Police Officers ‘did not look at the GMP incident log. Had he done so, he would have seen that Inspector Smith was making repeated requests for paramedics in the City Room. Accordingly, this was not something that he was able to discuss with Annemarie Rooney when they spoke at 23:15.’
Effective log-keeping can assist with a better understanding of the situation, and is a critical element of any crisis management response.
The report highlights the importance of exercises, but also criticises the failure to actually implement and track the actions that have been identified as being required, stating ‘as there was no comprehensive system for monitoring exercises, it was difficult to understand how organisations could be sure that lessons were learned.1005 Sometimes lessons were not captured at all. Sometimes lessons were simply not recorded accurately.’
Additionally, the report highlights that ‘there was a failure to derive and embed learning adequately from some important exercises.’
LESSONS IDENTIFIED ARE NOT LESSONS LEARNED UNTIL CHANGES HAVE BEEN MADE, AND CHECKED TO ENSURE THAT THE CHANGES MEET THE REQUIREMENTS
It is critical that, following exercises, training and real incidents, any ‘glitches’ in the processes are correctly assessed, and root cause analysis completed. Following this, a number of actions may be identified, with each of these being allocated to individuals with responsibility for completion. Each of these actions should then be tracked to confirm completion.
Having implemented any changes, it is then important to conduct some form of review, whether by audit or exercise for example, to confirm that the changes have actually produced the required results.
Additionally, organisations must maintain records of who has attended training and exercises. The Arena report notes that ‘There was no comprehensive system for maintaining records of exercises or details of who attended.’ Without maintaining such records, no organisation can be confident that all staff have completed the relevant training, and that they are therefore equipped for their role.