| 1 Inaccurate situation awareness (SA) | Tactical meeting 1 |
British Transport Police 1: I'd get initially the same thing that it was a bus, a car not a bus
British Transport Police 2: It's one vehicle that's been collided with involving a train. There is no, it was described as a multiple RTC [road traffic collision] before, it's not, several vehicles now
British Transport Police 1: There are several vehicles involved that exact circumstances how that's come about I'm not aware
Police: Okay [name] do you know xxxx or was it unattended?
Ambulance: My [name] said the RTC involved 15 vehicles including a bus which had turned over but it didn't say that it was a school bus, it just said it was a bus
British Transport Police 2: I mean that's that's something that we got to get a grip of really, really quickly as to is it just a car on a crossing or it is something different and somebody left the scene. Again [name] and I as SIO [senior investigating officer] and SIM [senior incident manager] will be looking at that to determine obviously is there any potential culpability
| Lack of initial information available resulted in difficulties for Tactical to develop an understanding of risks present on the incident ground, including vehicles and hazardous materials, along with how sectors were connected. Much of this information was still unavailable to Tactical during the second meeting, despite Strategic already having access to these details, hindering the ability of Tactical to develop accurate SA. This lack of SA development prevented agencies from identifying what information they would need to update their assessment of risk, resulting in a key agency, the Gas Company, not being invited to earlier Tactical meetings. Tactical were therefore delayed in accessing this important risk information until the third meeting |
| 2 Inaccurate SA | Tactical meeting 2 |
Police: Sector 2 is just behind the xxx house this is a train carriage, which has overturned. In terms of that [name]?
Fire: We have a derailed carriage there umm several vehicles also involved umm 18 casualties that have been removed from that site, 4 casualties are still on scene and being rescued and at this moment in time 15 unconfirmed erm fatalities that is being confirmed at this moment in time and we also have a vehicle with 1 female is and she is being rescued as we speak
Environment Agency: Again sorry can I just check the vehicles that they're just cars is just to check are there are HGV's [heavy goods vehicles] or carrying certain chemicals
Police 2: I'll get that information for you
Police: Sector 3 is xxx café there we've got a railway carriage gone into a building that's roughly where the level crossing was that area
Fire: Okay umm this we've got a train and building we've got 40 casualties on the carriage and 7 confirmed fatalities. We had it confirmed by BTP that the electricity supplies have been isolated. At the moment in time we've got two USAR teams working on the collapsed structured and within the erm carriages to ensure that there are no other casualties in the buildings or the carriage
Police: And sector 4 is roughly this area here as you look at the map to the right of Jake's café which was the tower 2 casualties have been moved from the area by helicopter there's a HGV and a car crashed in and around that area is this it
Fire: Yeah at this moment there is no fire service activity going on in sector 4
Police: Well the number of fatalities in that area as well?
British Transport Police: Sorry I couldn't see the map. Are these all connected? I know we're dealing with positively connected link all these incidents are linked?
Fire: Yes this is all the result of the one incident
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| 3 Inaccurate SA | Tactical meeting 3 |
Gas: The medium pressure network has been closed down so we wouldn't be looking at further evacuation of the 500 meters at the moment. The low pressure is still connected. We're paying particular attention round the flats to verify if the flats did have gas in there but I must stress that there still is a danger of explosion within the low‐pressure network. We're taking readings but it's difficult for us to get near the site so we are trying to close sections off rather than going but that will take another hour two hours
Police: So [name] did you say that there is a danger of explosion?
Gas: There still is a danger because the low pressure network is still connected we could have pockets of gas in the buildings so it's still a danger and that must
Police: Right and what would your advice be around those particular buildings at this point?
Gas: If there's no life no life no bodies or no people in there stay away don't go near until we can isolate the gas
Police: And have you absolutely identified where those structures are and which of those buildings are you referring to?
Gas: Well that's what we are doing now but the problem is getting access to these buildings because it's chaos
Police: Cause what I've heard so far about it it's that it's our biggest risk so far I've heard during this meeting so as an urgent action I need you to go away and come back and liaise with NAME (G: Yeah) to establish exactly where those buildings are
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| 4 Inaccurate SA | Interviews |
I err responding initially to the scene, which is…that's what I would do in order to err to develop the best possible situational awareness that I could to make sure that I could get eyes on an err ensure that I was happy with the way that it was structured from a fire and rescue perspective and the tac commander, the tactical objectives were err appropriate and in keeping with what it was.
Well, the first informative message was err probably sent within about 2 or 3 minutes. Major incident make pumps ten and maybe err requested the search and rescue team. That is [poor], where is your methane message… You haven't said why, nothing. You know you've done nothing there in the way of sizing that incident up.
| Initially, Strategic Commanders had access to more detailed information regarding the incident than Tactical, due to the Fire Strategic Commander attending the incident in person, whereas Tactical were reliant on limited messages provided from the incident ground |
| 5 Articulation of Information | Strategic meeting 2 |
British Transport Police: And of course we talked about a casualty clearing station, initially that's where they're going to. Nothing more to add to that at the current time.
Police: Ok when you say in terms of casualty reception, what has something been set up in terms of?
British Transport Police: Which is I think one of our colleagues just updated to that effect
NHS England: I mentioned about a casualty clearing station but not in terms of survivors reception
10 minutes later…
Local Council: We are providing all the support we can to our partner agencies. We have set up a survivor reception center and a family and friends center (P: right that's been set up has it? Great) yes (P: and where that is?) [location name]
| Differences in the use of terminology created issues for agencies to understand when the information they had was of relevance to discussions, resulting in delays to sharing information and repetitive discussions |
| 6 Articulation of Information | Tactical meeting 2 | Police: Ok since an xxx an xxx to be drafted and agreed have an update of [name] and lieutenant [name] been completed (Police 2: they've done xxx ok thank you) and command in operations and resilience going forward to be looked at by all partners and that's on‐going in relations to xxx (Police 2: ok you can address that in the xxx ok thank you) and an update by the xxx coordination group to be drafted which is done (Police 2: yeah) and silver commander to link xxx in relation to outer cordon reliance issues which has been tasked in to our silver erm attendance at gold to be all level representation to be in regular contact with gold so that we are co‐located effective. RVP management and implications to traffic management to [location] road being communicated to our silver commander in term of logistics erm. At the next SCG all gold of mutual aid being requested and where from (Police 2: ok) that's starting to look like xxx and multi agencies to xxx an area to keep requests as a matter of priority xxx a policing perspective and the rest to be set up outside the main cordon in sector 4 in a hanger, I don't have a specific location at this time and gold commanders to ensure that strategic objectives are communicated through silver but on a transmission to bronze commanders so strategy turns into the right application (Police 2: right) being communicated through
| Failure to be concise and to filter information to ensure that it was of relevance across agencies created difficulties in interpreting messages and identifying relevant cues amongst less relevant |
| 7 Articulation of information | Tactical meeting 5 | British Transport Police: We looked at identifying any significant areas of significance in the investigation around the potential causation. We identified this in the meeting with the RAIB the ORR health and safety etc. My DI investigative bronze and the scene evidence recovery manager and we agreed and agreed protocols around the half barrier at xxx crossing the carriage in situ on the track erm the driver's cab which is the cab on the carriage that's on its side off the track the signal LL1234 the signal box at [location] the tread‐all which is I'm reliably informed is a device that's tripped by the train the train trips the device and that sort of trips across in to operate also the relay room this is the tread‐all talks to the relay room that triggers a crossing erm and these are the key areas that we've looked at. As to where anything that they're working effectively there are no faults and as to whether any significant causation factors those are all things that will take a little bit of time and a specialist from [agency name] will look at those. All of the exhibits processed in a place whereby we make sure the integrity continuity of exhibits and the xxx is in operation in respect of that around the body recovery I might be just slightly out of date now this is this was from the last meeting erm there's only one sector sector 2 which is the cab that the SIM team were really able to get into all the others were held up by through hazards and the fire service were had priority over all of those areas. Erm the sector 2–3 bodies were recovered at the last count leaving 18 bodies still to recover and there are also 3 bodies that have been in situ at the temporary body recovery area when the SIM team arrived there erm the fire service have now made the decision that in in these other sectors they're gonna have to actually dismantle the buildings that would take some considerable time probably a couple of days so it would be a while xxx erm on those those enquiries on‐going HM coroner fully updated
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| 8 Articulation of Information | Interviews |
There was almost a surge of information erm in the tactical meetings there was a room full of endless people giving information which everyone sits and listens to but ultimately you spend a long time listening and it wasn't necessarily of any value to me…I need to know my stuff so it was almost as if we needed two meetings.
I know you can go and argue that you all need to have a clear picture of everything that is going on but the reality of environment agencies considerations affecting the ambulance response in that acute phase is nil. Unless its gonna cause us a hazard in which case they need to put their hand up at the beginning and say look there's a real hazard here to x for your staff.
I think we were having a spot of bother earlier on during the day because the TCGs were going on too long and so by the time they'd finished all the communication and intelligence and everything we couldn't be late back to our strategic because at times he was going blind erm we weren't getting the information from the front because there was that much going on so therefore then you've got this delay
I think the fact that we spent so long in briefings made it difficult to spend time briefing downwards and upwards for me
TCGs were overrunning and they were over running so badly that there was no opportunity for him to come out and give me a briefing before going into the SCG so all the information that I'd got was either old, outdated and I couldn't get that information because the tactical coordinating group was going on too long.
I think erm different terminology, erm certainly I got there's a couple of things I'll have to brush up on myself, the acronyms used particularly around the investigation of the DVI [disaster victim identification] personally I would have to get to grips with…I think those are the things that hinder us.
| Delays to information sharing and repetitive discussions resulted in longer meetings, leading to overlaps between Strategic and Tactical meetings and preventing the exchange of information within teams across hierarchical levels |
| 9 Rationale | Strategic meeting 1 |
Fire: Based on previous incidents of this nature this is not something that's gonna get resolved quickly from our perspective. You're talking this will run into days and potentially into weeks, not least with the building collapse side of the incident. There are evidence of successful rescues being carried out 14 days after that and it may well take that long to get to err delayer the building to the point where we can say with certainty that we've accounted for everyone so just to make that clear that this is not going to be over quickly will it (P: yeah). Not necessarily going to impact on everyone's resources other than necessarily ours but just to make that point.
Police: Ok got that, I understand.
Ambulance: We also got a situation with a number of casualties, there are multi‐trauma cases, there are sever injuries which are likely to exceed the available capacity within the local [city name] area and the wider [county name] area. We are working to try and identify available trauma sites that can be used to potentially take some of the more serious casualties out due to the numbers involved, just to make you aware that we will advise as the day goes on.
| Providing a rationale for information being shared regarding the duration of the incident allowed other agencies to consider the implications of this in terms of their own resource management and to share similar details of how this would impact on managing casualties. Similarly, providing a rationale for why information was needed regarding school attendance enabled quick access to this information as agencies were able to understand what was needed and why |
| 10 Rationale | Tactical meeting 1 |
British Transport Police: I would want to know very, very quickly who basically hasn't turned up for school you know. I would wanna know school register who basically hasn't turned up because they may be some of our casualties you know and I would need to get a grip of that quickly.
Police: Ok can the local [council] take that away?
Local Council: Yeah, we'll do that.
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| 11 Rationale | Interviews |
In all seriousness that was really challenging, even to make people understand. Do you understand what it is I'm asking for?
We got to the point, mid‐afternoon when the police said to us look it's gonna take us a significant amount of time to be able to answer that question. Now at that point I said right that's fine… This operation will not be resolved in a matter of hours, this is days possibly weeks and you need to understand that and I explained to them what we were gonna do. Because that does then change completely the dynamic. Once the police are telling me I can't tell you, we just don't know, that's fine. That's all I need to know because now we will accept that it has to be dismantled brick by brick if necessary until we get it where we need to get to.
| Although ensuring that other agencies understand the relevance of information requests can be cognitively demanding, agencies recognized the importance of this for accessing information |
| 12 Roles and Procedures | Strategic meeting 3 |
Fire: Chair, just in relation to one further matter requiring urgent action I need to make a request to military colleagues [name] military aid to the civil authority CAT A request to the effect that I require is the movement of urban search and rescue teams and assets onto scene ‘cos they are physically unable to get on to err onto the site because of the limitation of the err as caused by the incident so wanted to just flag that up now ‘cos that is an immediate priority for us ok?
Royal Air Force: Ok, I'll enquire heavily into that because I think it's absolutely right it sounds right.
| Demonstrating a shared understanding of one another's roles and remits allowed quicker coordination, and prevented lengthy discussions on issues that were of less relevance to others within the wider multi‐agency meeting |
| 13 Roles and Procedures | Strategic meeting 3 |
Fire: Just on that point chair if I may what we can do is we do have existing protocols with BTP and RAIB [Rail Accident Investigation Bureau] from the USAR [Urban Search and Rescue] capability around firstly body recovery simultaneous with live rescue and also evidence recovery may be worth us now taking. I'll take an action to make sure that we are then enacting that because it will probably allow us to join some of that up a little bit better cos you are clearly being frustrated and doing what you need to do
British Transport Police: Well there's an understanding that your job takes priority clearly erm but it might just make it slicker if we do that
Fire: We'll take an action and we'll pick that up outside the meeting
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| 14 Roles and Procedures | Interviews |
We've got a shared understanding of each other's resources, principles and priorities and objectives so when we do come together erm… those kind of principles come together to make it an easier relationship, therefore you get more from it and you're better able to manage a scene because you can describe issues which are ongoing and you can have a consensus around decisions
But we've got a pretty good arrangement both through the [Local Resilience Forum], you know we know each partner and there's a lot of mutual respect between the organizations which is very healthy so in terms of my own planning, my own training I've worked with a lot of these guys…So err whilst I don't know all the players by name I'll work with them at some stage and that really helps
It was highlighted on the course about tactical fire they go on the scene or having that tactical in the tactical group which is the same rank as myself, helped an awful lot because we were told that they would send an advisor
| Category 1 agencies noted the value of prior experience of working with one another for facilitation coordination and exchange of information |