This article is the basis of a key-note address delivered by [email protected]               (353)833155657   that illustrates the consequences of differing leadership models.


To understand the Hillsborough Stadium Disaster of 1989 in the UK, when 96 people lost their lives and many more had their life-span and quality of life reduced, a good place to start would be the 1988 fixture. For as a matter of coincidence Liverpool and Nottingham Forest football clubs played each other in the semi-final of the F A Cup in both years. On the two occasions the game was fixed for the neutral Sheffield Wednesday Stadium in Hillsborough and in both matches Liverpool supporters were allocated the West End of the ground which was accessed through the Leppings’ Lane entrance.

         Typically in 1988 some Liverpool supporters with a ticket for the standing terrace, behind the goal, would travel by bus to the stadium. The Police would have stopped the vehicle somewhere on the Pennines and conducted a search for alcohol and any object, like a flagpole, that had the potential to be used as a weapon. This was the routine and fans were used to the ‘drill.’ They would have got to the ground in plenty of time and perhaps had a drink before the game. On the way to the turnstiles at the bottom of Leppings’ Lane the 23,000 Liverpool supporters would have encountered a number of Police cordons and barriers where their tickets would have been examined. These cordons had two roles; to make sure that only those with tickets progressed further and secondly to act as a ‘valve’ in that the Police could simply stop the progress of the fans if the lane became over-crowded and allow entry to resume once enough of the previous cohort had cleared the turnstiles. Leppings’ lane was recognised as a bottleneck for the large volume of supporters that passed through and it needed careful policing. There were recorded problems and ‘near misses’ in 1981 and again in 1986. 

Once through the 24 turnstiles the match goers’ first sight was a tunnel entrance under the stand with a steep one in six gradient amid the concrete rear of the structure which accommodated a seating area overhead and the standing terrace to the front at ground level. The sight of the green grass of the pitch, through this opening, must have been inviting after several hours of travel. Most fans made their way down this tunnel which led into pens 3 and 4 situated directly behind the goal. They were called pens for good reason as there was a high fence on three sides of this enclosure (the pitch fence was 14’) and apart from small gates leading onto the pitch and at the top of the sections; the only way out was back through the tunnel.

When sections 3 and 4 were deemed to be at a safe capacity the Police would close the tunnel and the subsequent arrivals would be directed to the other standing areas ‘1 and 2’ and ‘5 and 6’. In this way the standing areas were equally populated for the ‘all-ticket’ event. The closing of the tunnel became known as the ‘Freeman’ tactic as it was a Superintendent Freeman who first introduced the method of safely filling the terraces (he may well have prevented death and injury in previous years).                

The Police control room was also situated at the West end of the ground and the elevated cabin gave the occupants a clear unobstructed view of the terraces underneath while CCTV monitors covered other areas of the ground including Leppings’ Lane.

On the 15th of April 1989 a new Commander took charge of the game at a time when hierarchical leadership styles were the norm; everyone waited to be told what to do by someone of more senior rank. It would appear there were no ‘hand-over’ briefings regarding the policing of the match. In 1989 there were no cordons or barriers on the approach route to Leppings’ lane and the thoroughfare soon became dangerously overcrowded especially in the half hour preceding the kick-off. CCTV footage shows children being handed over the wall for their own safety as the crush outside the turnstiles intensified. Other patrons can be seen climbing onto walls and parapets to extricate themselves from the pressure of the crowd.  Senior Officers requested that the match kick off time be delayed (as was done in the 1987 game involving Leeds) because it was becoming obvious that a large number of supporters would not gain entry in time and would miss a portion of the first half. Subsequently witnesses recalled delays on the motorway due to roadworks and the turnstiles being unable to accommodate the late surge. Having failed to persuade the match Commander to delay the game the next request from the officers on duty at Leppings’ Lane was to authorise the opening of Gate ‘C’ a double concertina type gate beside the turnstiles. This ‘opening of the gate’ would have the effect of allowing large numbers of supporters to enter the ground without the necessity of having to produce their tickets. The request, to open the gates, was based on common sense and health and safety considerations. Allowing large numbers in would relieve the dangerous crush of bodies that had developed outside the entrance. The priority was to prevent injuries or worse and if a number of patrons entered without tickets it was a price worth paying. The fatal flaw in the plan was that the Freeman tactic had not been put into place and the tunnel entrance remained open.

The TV cameras scanning the terraces at 2-30pm showed that pens 3 and 4 were dangerously full and this should have been obvious to the naked eye in the Police control box. The footage shows supporters climbing over the fence into neighbouring pens, where there was ample space, because the crush was so uncomfortable in the central pens and this was a full half hour before kick-off.

Following the third request, permission to open gate ‘C’ was secured and about 2000 patrons entered the ground through it. They like the fans before them instinctively headed down the tunnel at a normal pace. This was not a charge of fans but it acted like a slow ‘human piston’ travelling down a cylinder and unwittingly creating unbearable pressure that caused the deaths and injuries at the front. It is now estimated that following the opening of gate ‘C’ the capacity of the pens 3 and 4 rose to six times its safe limit. One survivor explained how he was pinned so tightly that the glass ‘popped’ out of his wrist-watch. A barrier snapped in pen 3 to add to the carnage. There was now a panicked crowd trying desperately to gain access to the pitch to save themselves and attend to the injured. With only narrow gates leading out to the open space many got out over the top and the area behind the goals quickly filled up with supporters; some of whom could only lie on the grass and wait for help. Others were pulled up into the stand overhead using their scarves to complete the manoeuvre. At six minutes past three the referee called off the game on the direction of the police but the scale of the horror was only unfolding. Later Police and match goers can be seen trying to pull down a portion of the fence originally designed to keep patrons off the pitch. It is now considered best practice that in an emergency at a game the safest place for the patrons to be; is the pitch itself.

The injuries were such that an immediate response was required from para medics and that didn’t happen. The first responder was a solitary and voluntary St. John’s Ambulance. Eventually up to 42 South Yorkshire ambulances were parked outside the ground but only two of these ever made it on to the pitch. Leadership was shown by Liverpool supporters who tore down advertising hoarding to use as make-shift stretchers in order to convey the injured, the dead and the dying to these vehicles. At the second inquest 27 years later it was stated that a more immediate response had the potential to save up to half of those who perished. It’s a statement that can never be fully proven but there is no doubt that what was needed on the day was for the 42 ambulances to be parked on the pitch at the Leppings’ lane end where trained first-responders and equipment would be available to those that needed it. The ‘Critical incident’ call was made too late.

                            During all of this time the PA system remained silent.


Santa Fe   

         Ten years later, on the far side of the Atlantic, Captain David Marquet realised a lifetime’s ambition when he was given the Command of the USS Olympia, a Los Angeles Type Nuclear submarine. David got his orders as was the norm a year in advance and he spent the time studying plans of the Olympia and reports on its crew after which he felt he knew the vessel and its sailors “inside out.” He was in a very confident mood when he arrived in Pearl Harbour to take command but as in life things don’t always go according to plan in the US Navy. When David arrived at HQ he got the equivalent of “good news and bad.” Marquet was to command a nuclear submarine alright but it was not to be the Olympia. The Santa Fe a ”new generation” sub was ready to go to sea and had no Captain available so Capt. Marquet was given this command instead. This meant that he set off to captain a vessel he knew little or nothing about (they don’t come off an assembly line) with the added twist that the crew was the worst performing in the fleet as measured by Navy evaluators. David knew that change was necessary when he gave an order to proceed at “two thirds” ahead on battery power alone during a routine manoeuvre. The Navigator relayed the order to the Helmsman who appeared to comply with the request but his “body language” betrayed that something was not quite right. When David engaged with the Helmsman he was informed that there was in fact no “two thirds” calibration on that particular vessel; the “new generation subs.” had only “one third” or “full” ahead settings. Marquet had never encountered a vessel that did not have a two third setting and the new commander then asked the Navigator, the not unreasonable question, “If there is no two-thirds setting; why did you ask the helmsman to proceed at two-thirds?”; “Because you ordered me to; Sir. Those were my orders Sir” came the reply, which, to the Navigator, should have been perfectly acceptable.

A meeting of officers was called and the problems outlined. In summary the Commander pointed out that he had not had the time to study the vessel before taking command and the crew were, as is traditional, blindly following orders without giving them any thought. This was problematic in ”peace time” exercises never mind a battle situation. Urgent change was called for and following a lengthy discussion change was enacted.

It was agreed that the phrase ”Permission to Sir” would be replaced by ”I intend to Sir” for all ranks. This meant that every crew member took responsibility for his own actions. When the aforementioned Navigator declared that he “intended” to submerge; well; he had better be certain that all the hatches were closed. By asking for “permission” to submerge the responsibility lay with the Captain alone.

The word “they” was also outlawed. When the Santa Fe was unable to go to sea for a few days it was because the wrong part had been ordered but the Engineer in the new regime  couldn’t tell the Captain that “they” ordered the wrong part; it had to be “we” got it wrong.

What happened because of these changes was transformational with everyone on-board taking more responsibility. They were all trained in their own area of expertise and didn’t require orders to carry out every task. Subsequent appraisals of the crew revealed that they had gone from “worst to 1st.” in the US navy; the best performing crew since records had begun. Many of the officers were in time promoted to their own commands.



Consider for a moment if Marquet’s crew (under the ”I intend to regime”) were performing police duties at Hillsborough in 1989; what would have happened? I can confidently predict that they would, of their own volition, have created cordons at Leppings’ lane and checked that everyone was in possession of a ticket before proceeding further. An Inspector may have radioed the control room to advise superiors of his men’s intention to do this but in any case veterans of previous fixtures would not have had to be told. Similarly the tunnel would have been closed as soon as pens 3 and 4 were at a safe capacity.

In the case of a major emergency if Marquet’s men were operating the Ambulance service, that day, crews would have got their vehicles and equipment on the pitch to the area where they were needed as soon as the nature of the disaster revealed itself knowing that as first responders’ time was of the essence. They would have used the Public Address system to assist in the evacuation of pens 3 and 4 and to direct emergency services and they would have procured equipment to make openings in the perimeter fence.

Leadership would have been shown at all ranks.

When confronted with the horrific Bradford City fire in the Valley Parade ground in 1985 Police Officers acted with extreme courage in order to evacuate the stand. Many lives were saved because of the bravery and selflessness displayed; no one waited for orders as it was obvious what needed to be done.

Hillsborough was as much a victim of a hierarchical system that didn’t allow for leaders within the ranks to make “calls” as it was due to poor judgement by one Commander.