Manchester Arena Bombing 22 May 2017.


On 22 May 2017 a bomb exploded at the Manchester Arena where around 14,000 people were attending a concert. The blast kill 22 people and injuries over 100 more. This has prompted a number of inquiries to be held in order to learn lessons form these events.

I shall focus on two. The first was lead by a former senior civil servant Lord Robert Kerslake and the second by Sir John Saunders (a retired High Court Judge). It is the recommends from their reports that I shall analysis. The purpose of this analysis is to inform my research that looks to produce a methodology to judge the validity of inquiry recommendations. In this case validity is judged by the probability that they will produce the outcome desired with undue unintended consequences.

My comments on the Kerslake recommendations can be found here.

My comments on the Saunders recommendations can be found here.

In what I write on this subject, I do not mean for any of my comments to diminish the loss or trauma that befell those involved in these events. I see each of them as the innocent victims of an other's action. The hurt and loss they feel should never be underestimated but it does need to be put in context.

Last updated:  9 Nov 21


The aim of the Review was:

To undertake an Independent Review of Greater Manchester’s preparedness for
and response to the Manchester Arena terrorist attack. To advise the Mayor, in
the exercise of his Police and Crime Commissioner function, of those aspects of
the preparedness and response that were effective and those that may inform
future good practice, together with where necessary and appropriate to advise on
what steps might be taken to address any areas that may be strengthened or

The Objective of the inquiry was to:

Placing the experiences of those directly affected by the Manchester Arena
terrorist attack at the heart of the Review:

• To assess the preparedness of Greater Manchester for the Manchester Arena
terrorist attack, including multi-agency planning and capacity development.

• To explore the effectiveness of the working relationships, cooperation and
interoperability between all of the agencies involved during the response to the
Manchester Arena terrorist attack.

• To identify and share good practice to enhance future preparedness and any future response to a terrorist attack both within Greater Manchester and beyond.

• To identify any gaps or other opportunities to increase preparedness and
strengthen any future response to a terrorist attack in Greater Manchester and
propose actions to address these.

The Report.

The report was published on 27 March 2018. It made 50 recommendations.

I has analysed them against my Prefect World model (Part 2) to confirm that they do conform. My analysis should that it does.The results of my analysis can be found here. The diagram set out below shows the number of recommendation made to each part of the model.

In each recommendation I have highlighted the action needed (in green), to what (in blue) and the result desired (in yellow).

The numbers of the recommendations in each category is in red. The number that concern new protocols and procedures tops the list at 21. The next highest at 11 are measures that recommend further reviews: a lack of skills comes next at 10, with 4 requirements for new equipment. It is therefore possible to see that the main failing identified by Kerslake are in the areas of procedures and skills. However, there was little consideration as to why what was done was done (identifying slips, lapses and errors) but rather just identify them as mistakes. Therefore whether this will stop the same issues reoccurring is very questionable.

Do date not Part 2 Analysis has been carried out on these recommendations.

Last updated:  27 Nov 21



The Terms of Reference for the Saunders inquiry is quite extensive. The purpose set was:

To investigate how, and in what circumstances, twenty‑two people came to lose their
lives in the Attack at the Manchester Arena on 22nd May 2017 and to make any such
recommendations as may seem appropriate.

The scope includes:

  • Whether the Attack could have been prevented

  • The build up to the Attack

  • The Attack itself

  • The security arrangements within and outside the Arena

  • The emergency response to the bombing

  • The experiences of each person who died

  • The immediate cause and mechanism of each death, including whether any inadequacies in the emergency response contributed to individual deaths

The Term of Reference for the inquiry are extensive. Therefore, of immediate concern is whether the structure of the inquiry provides an adequate seat of understanding to make sense of what it hears.

In June 2021 Saunders produced the first Volume of his report. This covered the security of the arena. Part 8 provides the conclusions and recommendations:


So far I been unable to conduct Part 1 of my analysis. I have to admit that I found this section of the document hard to interpret: I am glad that it is not for me to implement. It is one of the most confusing documents that I have ever read. I provide an annotated copy of the text here. As you shall see, I am still a long way short of making sense of what is being recommended. In most inquiry reports the term 'recommendation is used as a trigger word. It is used to help the reader get to the nub of the issue. I have that, in the case of this report, the word is used in a much more haphazard manner. I find the chapter that contains the recommends poorly structure and needs extensive interpretation. There is therefore, in my view, a huge gap between what is intended and the action likely to be taken.


It will be interesting to watch how those concerned try to implement these measures: if the pattern of past experience is repeated, the focus will be on being seen to act as opposed to delivering enhanced security at an affordable cost.

Even at this stage I have real concerns that these recommendations will not deliver the enhance safe outcomes desired. To me they appear to be more on offering "Hail Marys" (clearly set within the Perfect World paradigm) rather than practical solutions. In particular I have concerns over:

  • MR1 and 2: these look to address the issue of complacency without showing any understanding of the mechanism the promote complacency.

  • MR3 that looks to ensure that systemic failure are not repeated. This will only happen in a Perfect World and so the report is setting up the system to fail through its unrealistic expectations.

  • MR4; "A Protect Duty ... should be enacted into law". This will only make it easier to allocate blame rather than protect people.

  • MR5 and 6 should be achievable in themselves however whether they will achieve the safety outcome desired is still open for debate.

  • MR7 should be achievable in itself however whether the benefits will outweigh the costs are open to debated.

  • MR8 proposed a licensing system be examined. Again the issue of cost/ benefits makes this proposal highly suspect.

  • MR9 once again seems to be more about making the allocation of blame easier rather than increasing public safety.

However, of more concern (and I presumed linked to MR6), are paragraphs 8.99 and 8.100. I hope that I have misunderstood these comments on risk assessments for I feel that the report is hoping to substitute process for experience: this is unlike to work for many reasons covered elsewhere in my work. As someone who has worked in this field, I know that the balance is already tilted heavily in favour of precaution. By removing likelihood we would remove an important consideration when prioritising effort. The report's comments therefore must be seen as being heavily weighted by hindsight (knowing that something occurred at this event) while ignoring the evidence that nothing has happened at many other similar events. In Paragraph 8.75 the reports also seems to propose a behemoth for the Security Industry Authority to parallel the HSE set up. I am therefore left asking the question as to whether the pain this bureaucracy will inflict on society will be balanced by the enhance safety it will provide.

All my comments above require greater explanation for them to be fully justified. That task is for another day.

After Note:

After a week of trying to assess the Saunders Recommendations, I have abandoned the task. The recommendations come more in the form of a narrative with its mixture of 'ought to's and 'need to's, and about 20 'I recommend's. I find the text to be too ambiguous in the directions it imparts. It leaves the reader in considerable doubts as to what exactly needs to be done. Too much interpretation is required for the ideas to be considered to have been communicated successfully. I can see a wide range of activity that would align with the Saunder's narrative but have considerable doubt that they will enhance the safety of the concert going public. It is unlikely that the package of measure would fair well if confronted by a rigourous cost-benefit analysis. I fear the subsequent effects of these recommendations.

Last updated: 16 Nov 21