Risk management Hillsborough Disaster

2.40 – 2.50pm

The police open up Gate C, which is intended as an exit. This caused a rush of supporters through the gate into the stadium.

3.00pm

Estimated number of fans in pen 3 was 3000, (capacity 2000, which was later reduced to 1600). The crush began.

3.06pm

Supporters started climbing steel fence and coming onto the park to avoid the crush. The match was abandoned. (Contrast.Org- 15/4/92)

2.1 Police control

In Taylor’s report which was the inquiry responsible for depicting the events of the day, and where they went wrong (which will be discussed in Taylor’s Report 3.1). Lord Justice Taylor attributed the main bulk of the responsibility on the ineffective Police control of the matter. He stated that the Hillsborough Disaster was mainly caused by the Police on the day by opening the secondary entrance to the Stadium, This in turn caused the massive influx of fans just before “kick off”. This order was given by Chief Superintendent David Duckenfield, who later admitted he “froze” (discussed in more detail in Prosecution 3.2). If the police had followed generally accepted procedures e.g. delaying kick off even although this was calculated to delay the game by 40 minutes (wikipedia 2000), this tragedy would have been prevented. With hind sight fans would be more than understanding if the game was delayed as it would have avoided the deaths of almost 100 supporters.

2.2 Communication

Another example of ineffective and lack of procedures at Hillsborough Stadium is the lack of communication between the Police that opened gate C, and the Stewards/Police that should have been blocking off a pen when the standing area is thought to be full. , This should have been recognised in the early stages of a simple Risk Management analysis as an essential procedure for crowd dynamics to run effectively.

The Hillsborough disaster would have been prevented if this communication had taken place. As the Leppings-end stand was still not at capacity, the crush was due to the concentration of fans in pen 3 and 4. If communication between the Police at the gate and Stewards at the entrance to the pen had occurred, fans would have been more evenly distributed. ( 15/04/1989)

2.3 Stadium design

The Hillsborough Stadium design has been blamed for the events that unfolded on the 15th of April 1989. Many individual factors could have been responsible for the crush. These are:

Low number of turnstiles

In a major sporting stadium, it is commonly known that to ensure an effective distribution of fans, a high number of turnstiles and exits are required to provide the stadium with effective crowd dynamics, e.g. avoid major bottle necks which can make a crowd difficult to control and can even end in crushes. An example of this is the Ibrox disaster which occurred in 1975 and 66 died. The Ibrox disaster should have spurred the Hillsborough management team to upgrade the stadium. The events of the Hillsborough crush unfolded after a build up of fans formed outside turnstiles A – G. With a larger number of turnstiles, this build up could have been spread more evenly. (MacLeary John 15/4/ 2004)

Ineffective and illegal crush barriers in place

In Taylor’s report discussed in section 3.1. It was uncovered that the crush barriers in the Hillsborough stadium were not up to regulation standards. These regulations and standards were stated in the Guide to Safety at Sports Grounds 1986. After the Taylor inquiry it was stated that due to the ignorance to health and safety the capacity of the pens in Leppings End should have been closer to 1600 instead of the 2000. (P F Heyes and J G Tattersall 11/89)

2.4 Ignorance to implement new procedures

An example of ineffective Risk Management is the passive learning displayed in the Hillsborough Risk Management Team (if a competent one actually existed). This can be observed through the ignorance to act even after complaints were placed prior to the tie by Liverpool FC, after Liverpool FC fans complained of a crush in a cup final in 1981. If this had been heeded, 96 Liverpool fans may still be alive. This act of ignorance by the Hillsborough Risk Management Team shows serious incompetence.

Another example of their ignorance is displayed below:

Fig 3

This figure portrays the increase in the severity of incidents at football stadiums from 1946 to 1989 in Britain. As has been discussed the Hillsborough Stadium design is in many ways lacking. If the Risk Management Team had been competent, the growing increase in severity of stadium incidents should have been the ultimate motivation to correct the flaws in the stadium and make new more effective procedures to deal with, or prevent, any incidents that did occur.

3. Introduction to the Impact of the Hillsborough disaster

The impact of the events that unfolded at the Hillsborough disaster was vast, due to it being a semi-final an important match, hundreds of thousands had turned on their TV expecting to see a footballing spectacle. Instead they witnessed the largest loss of life recorded at a British sporting ground. Nearly 100 people perished due to the crush. These events caused massive sympathy from all around the world. In the weeks that followed many signs of respect were shown by 6 minute silences, and over the upcoming months, many statues were erected as a sign of respect for the people that perished in the disaster. The major impacts of these events shall be discussed in the following section.

3.1 Lord Justice Taylor

Lord Justice Taylor was appointed to conduct two public inquiries. Firstly into the cause of the Hillsborough disaster, and secondly a general report in recommendations for sporting grounds. (Howard, Michael 17/12/96)

Taylor’s first report into the immediate cause of the Hillsborough disaster placed most of the blame, on the Police control of the matter. The ineffective control of the events that unfolded on the day of the semi final were inadequate, narrow minded and unacceptable.

The second report was for recommendations for sporting grounds. This commonly became known as the Taylor report and led to a general reform in the design of top stadiums all round the world. In this report it condemned the hooliganism barriers which were placed at most stadiums round the nation. These were all removed and most of the top stadiums were converted to all seating venues (BBC 15/4/1999). The Taylor report has been accredited for eliminating football crushes from British history. The Hillsborough disaster remains the last major football incident of Great Britain.  

3.2 Prosecution

In the days that followed the Taylor report, it was deemed that the actions of the senior Police official David Dunkenfield and his colleague Bernard Murray, who ordered gate C to be opened, was unacceptable and negligent. David Dunkenfield openly admitted if the Police control had acted more efficiently and followed pre-standing procedures, the Hillsborough disaster would have been prevented. He stated he “froze” due to his lack of experience with major games. David Dunkenfield was due to be tried, but the charges were dropped because of poor health. He went into early retirement on a full Police pension. The charges against Bernard Murry were also dropped, as it was deemed to be unfair to prosecute him without prosecuting his senior, who gave him the orders. (Wikipedia 2000)

4.  Risk Analysis

 As portrayed in this assignment, many things that Risk Assessment could have prevented have gone wrong and catalysed the death of 96 people. If effective Risk Management had been place these event would have been stopped and the black spot on British society known as the Hillsborough Disaster would have been prevented.

A simple Risk Management analysis would have identified key measures, which were either unsatisfactory or non existent. These are:

Lack of Police control/ procedure

Lord Justice Taylor identified the Police control of Hillsborough disaster as ineffective. In months or years leading up to the Hillsborough disaster, many disasters could have been prevented. If stadiums and sporting grounds had calibrated with Police to put in place, a general emergency plan which stated the measures that should be taken in the event of a crush / fire etc. If this document was produced, it would have prevented the improvisation of David Dunkenfield (e.g. opening Gate C) and in this example prevented this Hillsborough disaster.

More often and more vigorous Health and safety checks

If the Hillsborough Management Team had invested more time in checking that Hillsborough stadium was up to health and safety standards, it would have been identified that the stadium design naturally induced bottle necks due to a low number of turnstiles. Also it would have been observed the crush barriers were not up to standard in the Leppings-end Tier and would either require a reduction in the capacity, or these crush barriers being replaced.

5.0 Conclusion

In conclusion the Hillsborough disaster was preventable and in no way excusable. The justice system has failed the supporters by not prosecuting the persons at fault, these people were the police and the stadium management team. As supporters enter the stadium the expect to be cared for and watch the game in peace and due to this fact the Police and Management team owe the Fans duty of care. As shown on the 15th of April 1989 this duty was unfilled. Although this needless loss of life is heartbreaking, the improved measures for stadium designs, stated by Lord Justice Taylor in the months after the disaster have probably saved hundreds of lives.  

6.0 References

• Fig 1 - http://www.stadiumguide.com/hillsborough.htm&h=244&w=373&sz=29&hl=en&start=9&
• Fig 2 -
• Contrast.Org- 15/4/92 -
• Wiki 2000 -
• MacLeary John 15/4/ 2004 - Hillsborough disaster: 15 years on
• P F Heyes and J G Tattersall 11/89 - Examination of Crush Barriers from Pens 3 and 4
•  (15/04/1989),
• Fig 3 – http://www.crowddynamics.com/
• Howard, Micheal -
• BBC unknown author (15 /04 /1999) Hard lesson to learn -
• Wiki 2000 -

6.1 Bibliography

• Ground safety and public order: Hillsborough Stadium Disaster, report of Joint Working Party on Ground Safety and Public Order (Report/Joint Executive on Football Safety); Joint Working Party on Ground Safety and Public Order;  
• No Last Rights: The Denial of Justice and the Promotion of Myth in the Aftermath of the Hillsborough Disaster; Phil Scraton, Ann Jemphrey and Sheila Coleman ISBN O-904517-30-6
• Hillsborough: The Truth; Phil Scraton;  
• 'Death on the Terraces: The Contexts and Injustices of the 1989 Hillsborough Disaster' Phil Scraton in P. Darby eta al (eds) Soccer and Disaster: International Perspectives  
• Scrutiny of Evidence Relating to the Hillsborough Football Stadium Disaster (Command Paper); ;  
• Sports Stadia After Hillsborough: Seminar Papers; , ,  (Ed.);  
• The Day of the Hillsborough Disaster; Rogan Taylor (Ed.), Andrew Ward (Ed.), Tim Newburn (Ed.);  
• The Hillsborough Stadium Disaster,  : Inquiry by Lord Justice Taylor (Cm.: 765); ;  
• The Hillsborough Stadium Disaster: Inquiry Final Report (Command Paper); ;  
• Words of tribute: An anthology of 95 poems written after the Hillsborough tragedy,  ;