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The Kerslake Inquiry into the Manchester Arena attack on 22 May 2017, found that overall the response of the emergency services had been very positive. However, there were some problems in some areas of the response, including the Casualty Bureau operation, after a systems failure at Vodafone.

To put this in context, at its height 641 people were reported missing by worried friends and families were reported missing.

Under nationally agreed arrangements since 2009 through the Home Office, the role is currently held by Vodafone, which is contracted to activate the necessary telephone support, to provide the host police service with a dedicated telephone number, through which all calls can be routed.

It also enables other police forces to stand up their Casualty Bureau and thereby assist the host police force with additional call-taking capacity throughout periods of high volume. The facility is referred to as the National Mutual Aid Telephony system (N-MAT).

In accordance with these arrangements, the GMP Casualty Bureau Manager attempted to activate the N-MAT facility but this was unsuccessful due to a problem with the technical infrastructure of the system – a single national telephone number could not be allocated for the incident, while the facility was not available for other police forces’ Casualty Bureaus to be called upon to assist with call taking.

As a consequence, GMP’s call-taking capacity was restricted for several hours to those staff physically located within its own Casualty Bureau. During this time, a local (0161) number with limited capacity was utilised in the absence of a national (0800) number. As the Review put it, there was a ‘catastrophic failure’ of the system.

Vodafone explained to the Review that two failures occurred:

  • The 0800 number allocated by the Home Office’s Police National Computer service team from the bank of numbers they had available had recently been used for another incident in another force, and the recorded message on that 0800 number had not been cleared by the Police National Computer and the other force when the incident closed. This meant the number allocated by the Police National Computer to GMP still carried the message from the previous force’s incident.
  • As one of the servers on the platform was at capacity, the greeting message could not be recorded over. If an 0800 number had been allocated with no prerecorded message, then the 0800 number could have been issued and would have routed calls correctly, albeit without a Manchester Arena specific greeting message.

On the night, the Casualty Bureau manager made immediate contact with Vodafone in an attempt to rectify the failure and to stress the urgency of having a fully functional Casualty Bureau in place.

The Review heard that the Vodafone representative had little knowledge of the Casualty Bureau arrangements and referred the Casualty Bureau manager to another company called Content Guru, to whom Vodafone had sub-contracted technical guardianship of the service. Again, the Review heard that the Content Guru representative had little

knowledge of the police requirement or the vital role the Casualty Bureau contributed to the response operation.

The Casualty Bureau manager was told by Content Guru that there had been a major failure of the server in place to deliver the Casualty Bureau capability.

The Review states:

“A total of eight servers were in place to enable the call taking workload to be spread evenly across them. When a new message is recorded, it is uploaded to each server to ensure consistency. In the event that any of the servers cannot load the new message the system rejects the attempt to upload the message to ensure all servers hold the same message for that incoming line. On 22nd May, one server was at capacity as its memory was full. This meant it was unable to accept the new message, leading to the message being rejected across all the servers and, effectively, leading to the service failure” (Page 139, para 5.49).

By 2.30 am on Tuesday 23 May, sufficient call takers had been mobilised and were in attendance at the GMP Casualty Bureau, located at Sedgley Park, to enable it to go live.

At this time, the call information received through the other points of ahghentry into GMP was being passed through to the Casualty Bureau team and being collated. However, as a result of the failure of the N-MAT system, it was still not possible to activate the usual national arrangements.

This provided significantly less capacity than would have been the case with the national arrangements. At that time, call taking was limited to the 20 operators physically based at Sedgley Park. Due to this limited capacity, the Review was informed that calls from the public would still have been received in other police control rooms across GMP.

The Review reports:

“…, it would appear that the fall-back solution in place in the event of critical server failure did not get activated due to the inability to amend the recorded message and technical difficulties with the server. This suggests there was an inadequate level of knowledge or expertise within Vodafone or its sub-contractor Content Guru.

“Since May 2017, the Home Office has been engaged with Vodafone to explore the reasons for the failure of the National Mutual Aid Telephony system on the night of the attack and to gain reassurance that no such failure will occur again in the future. The ( Review) Panel has also received written correspondence from Vodafone UK in which their Chief Executive Officer offers formal and personal apologies for the failure and for the impact on those affected by the attack, gives assurance that steps have been taken to avoid a repeat of this failure including migrating the service to a new platform with necessary fall-back, as well as ongoing and rigorous testing and monitoring of the system”(Page 140, para 5.54-55).

  • This is an extract of a full feature in Resilience magazine, the quarterly journal of the EPS. Free subscription to the magazine is one of the benefits of joining the EPS – to join
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