This is excerpted from The Green Beret Guide to Seven Great Disasters

“There was no organised response there at all… There was nobody in charge, no plan, no organisation at all… There was no resuscitation equipment there… The scene was just absolute chaos.” BBC Commentator Des Lynam

The Facts

On 15 April 1989 at Hillsborough Stadium in Sheffield, England, a crowd crush killed 96 people and injured 766 more.

1981: A crush occurred on the same end of the stadium, resulting in 38 injuries.

October 1988: Chief Superintendent Mole is ordered to be transferred on 27 March 1989.

22 March 1989: Planning for the FA Cup semi-final match was attended by Chief Superintendent Duckenfield, who was replacing Mole.

15 April 1989.

10:00 am: Chief Superintendent Duckenfield briefs his officers at the stadium. There are no records of what was briefed.

10:00 am to 2:00 pm: Fans begin arriving. There are 24,000 Liverpool fans and 29,800 Nottingham Forest fans.

2:15: Fans at the Leppings Lane gate increase beyond capacity to process. Entry is slowed down.

2:30: Duckenfield asks a fellow officer if the fans will be in place on time or if the kick-off can be delayed. He’s told all fans will be inside by the 3:00 pm kickoff.

2:37: The turnstiles are overwhelmed and some fans get stuck in them by the press of the crowd behind them.

2:47: Superintendent Marshall asks control if he can open exit gates to prevent injuries among those pressing the turnstiles. One gate is opened to throw out one fan, but one-hundred-and-fifty pour through.

2:50: Teams come on the field and the crowd responds. Those outside, trying to get in, can hear the crowd.

2:52: At the third request, CS Duckenfield order Gate C to be opened.

2:54: 2,000 more fans press in through.

2:54: PC Buxton radios control asking for the kickoff to be delayed, but is told it’s “too late”.

3:04: A ‘crush barrier’ in pen three breaks from the crowd pressing on it.

3:06: Injured and dead start to be carried away on advertising boards.

3:15: Duckenfield says the crowd got in through the gates, not that he had authorized the openings.

3:30-3:35: An appeal is made for doctors and nurses over the stadium speakers. The match is declared abandoned.

The Cascading Events

Cascade One

The venue was not up to safety standards.

To prevent problems between fans and players, many soccer stadiums were equipped with high steel fences between the stands and the fans. The terrace was a sloped place where there were no seats. Fans stood, packed together, to watch matches. The very nature of this invited trouble. 

In 1981 there was a ‘crush’ in the terrace. The after-action-report (AAR) said that there would have been fatalities if not for a swift reaction. It recommended that capacity be reduced to prevent a reoccurrence. The Sheffield Wednesday chairman responded: “Bollocks—no one would have been killed.” This, despite the fact that its safety certificate had lapsed in 1979.

Action was taken, but it was for the wrong reasons and was the wrong action. The terrace was divided into three sections, laterally. This, and later, changes, such as going from three to five sections, negated the stadium’s safety certificate, which was never renewed.

Several times over the years more fans than could be safely accommodated packed into the terrace. Several complaints were filed. Nothing was done.

Lesson

Safety standards must be enforced and updated.

This was a case where in response to a serious incident, changes were made that actually made the potential for disaster worse; in addition to invalidating safety certification. It’s obvious concern for safety wasn’t considered a priority.

Cascade Two

A minor prank led to a loss of key expertise.

A probationary police officer in the local division was handcuffed, stripped naked, and photographed by fellow officers as part of a hazing prank. When news leaks, four officers resign and seven more are disciplined. Chief Superintendent Mole, the man who was experienced in dealing with crowd control at the stadium is ordered to be transferred on 27 March 1989.

There is no substitute for experience for a complex task such as crowd control. His replacement had no experience with the stadium and crowds. A focus on a small incident led to dire consequences.

This is an example where an unrelated, minor event had unforeseen consequences.

When the game was awarded to this venue, during the planning on 22 March 1989 it was attended by Chief Superintendent Duckenfield, who was replacing Mole.

Lesson

Unintended consequences is often a factor in disasters.

The officers who pulled that prank could not have known that it would contribute greatly to the tragedy that would happen the following year. Also involved though, were the superiors who replaced the experienced Mole with the inexperienced Duckenfield. What’s intriguing, though, is that institutional knowledge about game day management for the police should have still existed on the force. Did Duckenfield avail himself of that expertise? From actions on that day, it does not appear so.

Cascade Three

Inadequate and inexpert planning, focused on the wrong problem.

With fans pouring in, a focus was on keeping the fans from the two teams separated not only in the stadium, but entering the stadium. The major concern was not overcrowding, but ‘hooliganism’ by rowdy fans. Even though Liverpool had more fans, the other team was allocated the larger seating area because there was a desire to keep the fans from crossing paths on their way to and into the stadium.

Entrances that the Liverpool fans would normally have used were blocked off to them. Because of this, fans began to pile up trying to enter the stadium. This led to pressure from behind which would be a direct cause of the disaster.

This was only exacerbated when the fans not yet in the stadium heard the roar of the crowd inside the stadium as the two teams took the field, aka pitch, to warm up. Fearing they were missing out, the entering fans pressed forward.

Worse, fans presenting tickets at the wrong turnstiles, due to the confusion, and those trying to get in without tickets, couldn’t turn away because of the crowd pressing up behind them.

The initial plan was to split up many of the incoming fans left and right around the West Stand to Pens 1, 2, 6 and 7.

Desiring to relieve the pressure, the police first opened up exit gate C. Then they opened Gates A and B. As you can see, this funneled fans toward the center tunnel under the West Stand, not toward the sides.

Police and stadium officials who normally monitored the tunnel and Pens 3 and 4 to avoid overcrowding were not present. Thus, people poured in through the tunnel.

Because of the lateral fences that had been installed, those already in 3 and 4 couldn’t move sideways into the adjacent pens.

Lesson

The primary concerns were about the behavior of fans, not crowd safety.

Any time a large group of people are gathered, there is a potential for disaster. Crowds act differently than individuals. It is incumbent on those responsible for a venue and crowd to design the venue and take steps to prevent disaster.

Excerpted from the Green Beret Preparation and Survival Guide:

Crowds act differently than individuals. What was a peaceful protest or event can quickly escalate. No matter what your role, even as an innocent bystander, it pays to be prepared. Also, you can unexpectedly become caught up in an incident while in transit from work, school or traveling.

This also applies to any crowded environment where things can get out of control: Sports events. Concerts. Movie theaters. Any time there is a crowd, there is a possibility for an incident that will get out of control. People have been killed and hurt at these events.

11 people were killed at a Who concert because of the crush for festival seating. 39 people were killed at a soccer match in Belgium while trying to escape a fight between fans. 96 people were killed at a soccer match in England when fans were channeled into too tight a space with no exit. Crowded night clubs have often been the scene of disasters. The Station fire in Rhode Island killed 100 people when pyrotechnics started a fire. Many died rushing for the same door and getting caught in the stampede.

Think about what would happen if a fire broke out or an active shooter occurred at any large event. Always know where the exits are. Have a plan to get out. Remember: people will instinctively go toward the way they came in. Find the emergency or other exits as soon as you enter any venue. Make sure you can find them in the dark and in a panicked crowd. If going with a group, make sure you have a rally point outside the venue to meet at, even if just in case someone loses their cell phone.

What was terrible for the victims of this disaster was that once they went into that tunnel, there was no way to back out.

Cascade Four

Bad Decision making.

Before things got out of control, an officer on the ground radioed a request that the start of the match be delayed twenty minutes as had been done years previously. This request was denied.

The speed of this disaster is rather amazing when you consider that in just a few minutes it went from rowdy to deadly. The funnel of fans entering the tunnel had no idea what lay ahead. Those already in Pens 3 and 4 were pressed forward by the weight of the humanity behind them. They were pushed against the fencing and each other.

Police inside the stadium ignored cries of distress from the increasingly packed crowd. The match started on time at 3:00 pm. This increased the desire of the fans in the tunnel and outside to get inside. This increased the pressure on those inside.

The goalie on that end of the field heard fans pleading for help, but there was no police response.

At 3:04, a section of the fence gave way.

The ground commander, ran to the referee and got the match halted at 3:05:30. But it was too late. Fans were mostly fending for themselves, being pulled to safety by those in the stands above or over the fence. A gate in the fence was forced open. Nevertheless, many died standing up, asphyxiated by the pressure of those around them.

The crowd spilled out onto the field, those that were alive, and some that were badly hurt or dying.

Even now, though, there was no coordinated or rushed response.

Lesson

Any crowd situation needs one individual in charge who is experienced both with the venue and crowd control.

Positive control must always be maintained.

The decision to open the exit gates alleviated one problem while causing a much worse one. One suspects that a person unfamiliar with crowds and the stadium design made the decision, since it channeled the crowd into the disaster.

That was undoubtedly a major contributor to the disaster. However, backtracking, a number of decisions got to that point: removing the former police commander without insuring that institutional knowledge was passed on. Was there an SOP how to handle crowds at the stadium? My research couldn’t uncover one. As you’ll see at the end, SOPs are critical in all organizations. They allow continuity in the face of changing personnel.

Cascade Five

Inadequate ambulance and emergency response.

Contingency planning is a staple of all organizations and events. Any large venue should have an SOP for mass casualty events.

There was a casualty reception point (CRP) designated at the entrance to a gymnasium, but this was outside of the stadium. Anyone injured was to be brought there. Getting them there fell to fellow fans.

There was a contingency for medical personnel and ambulances to actually enter the stadium, but it required an official declaration to be made by ‘those in charge’. Which never happened.

Lesson

Terrible planning, combined with a lack of initiative in the face of tragedy.

One of the best pieces of advice I’ve heard about acting in a disaster came from a bulldozer operator who saved a bunch of people in the Paradise, CA wildfire. He had no comms, was in a dire situation, and thought to himself “What would my boss order me to do?” Apparently, he had a good boss because the driver used the bulldozer to plow open an alternate route, allowing a number of people who would have perished to escape. He used his initiative in the face of disaster.

In a way, it was easier for him to do this since he was alone. Those medical personnel in the ambulances, outside, which eventually numbered 42, were in a quandary. Should they go in? Would the injured be brought to them?

Two made it onto the field. Some medical personnel left the holding area and moved to the field, but not all of them brought the necessary gear. Lives were lost in the critical moments after the tragedy when proper care and equipment might have made a difference.

Cascade Six

The police and authorities sought to blame the victims without assuming responsibility.

In terms of timeline, this happened as the Final Event was ongoing. I’m putting it here because it shows a continuation of a mindset that abdicated responsibility throughout.

The third ambulance that made it onto the field was sent there by an official as a PR attempt to sooth fears and reassure people. It was far too late.

The spin began immediately with the focus being to blame the fans as being drunken hooligans who had rioted and caused their own disaster.

Lesson

A blame game not only helps no one, it also indicates abdication of responsibility.

I put this one before the final event, even though it happened afterward because it shows the mindset of those in charge. To start blaming victims show those in charge didn’t take their responsibility seriously. They’re trying to shift responsibility.

It also means they weren’t willing to conduct an effective After-Action-Review which is one of the keys to preventing future disasters. It took twenty years and adamant refusal of acceptance of the official story of blaming the victims, before an accurate report on what happened came out.

Final Event

The fatal crush.

Fans entered the stadium through not only the turnstiles but the three open exit gates at what was described as ‘steadily at a fast walk’. Funneling into the tunnel, where they could not see what lay ahead, they formed a human wave of pressure. Those already in Pens 3 and 4 had nowhere to go  to relieve the pressure from behind.

During previous matches, police had monitored the entrance to the tunnel and redirected fans to the sides to avoid over-crowding. For some reason, on this day, there was no one monitoring the tunnel. Fans kept entering, well beyond capacity.

Adding to the pressure, the match started on time at 3:00, despite the requests by officers who were concerned to postpone the start. Those fans who could not yet see the pitch could hear the crowd reacting to the game and this increased their desire to get inside. It was a deadly match lit on a conflagration that was already pressured to deadly levels.

It took just a few minutes for people in Pens 3 and 4 to realized their predicament. They could not turn and go back out as the wave of people was still coming in

Some police at that end of the stadium became aware of fans trying to climb the barrier, but mistakenly thought they were trying to rush the pitch instead of save their lives. The slow response contributed greatly to the disaster. The goal keeper on that end heard fans begin to plead for help. At 3:04, only four minutes after the match began, a shot hit the goal bar. At that moment, one of the barriers in Pen 3 gave way, spilling fans out onto the field. It took a minute and a half before the ground commander realized what was really happening and had the referee stop the game. But there was no plan in place to release the pressure inside the Pens. Fans in the terrace above tried to help pull people up to them. More barriers gave way, but consider the force of people required to break through a barrier designed specifically to stop that very action?

By the time the pressure on those inside was reduced by those escaping it was too late for most victims. Many died standing up of compressive asphyxia from what is termed ‘crowd crush’.

Crowd crush can occur when the density of a crowd becomes greater than four people per square meter. At that point physics takes over as it gets progressively more crowded. When the crowd reached six to seven per square meter, people are so tightly packed together that they are no longer individuals. A shockwave can travel through these people like a wave through fluid.

If a single person falls, or more people push into the edge of the crowd, such as those still coming through the tunnel, it precipitates further crushing. People become unable to draw a breath.

It is often referred to as a ‘stampede’ but that is not only inaccurate but also insulting. Stampede implies people caught in it have a choice. They do not. And those on the periphery often have no idea what’s going on.

Situations we need to be aware with the potential for crowd crush are venues and areas where large crowds are trying to move in a certain direction to either reach a destination or to get away from a threat. Those at the rear push forward, not aware that those in the front have no place to go and are being crushed. It is estimated that a crush pressing against a fence can bend one designed to withstand 1,000 pounds of force.

One key to this is lack of visibility. In this case it was the entrance tunnel, where the entering crowd could not see ahead. Consider all venues in these terms.

Lesson

Responsibility rests with individuals, not crowds.

In retrospect, the prism of disaster experience, we can see that this catastrophe was inevitable. A confined space with one entrance where those coming in couldn’t see where they were going was ripe for disaster without strong, positive control.

From the lack of certification, the building of the pens, the fencing that stopped lateral movement, the lack of supervision on match day, poor decision-making, inadequate response and lack of accountability, this was almost an inevitable disaster except, as you can see with the rule of seven, at any point along the way it could have been prevented.

Individuals can’t be blamed once they’re in a crowd that is placed in an impossible situation.

It took until 2012 for an independent panel to determine that crowd safety was “compromised at every level.” It also, sadly, noted that perhaps 41 of the 96 who died might have been saved by a proper, swift emergency response.

Some lessons were learned and implemented. Standing pens were replaced with all-seating.

Blaming victims is never useful. Especially in a crowd environment.