Police, security staff and the operators of Manchester Arena missed numerous opportunities to prevent the 2017 bombing, or significantly reduce the death toll, a public inquiry has found.
Months of hearings have laid out harrowing details of how Salman Abedi was able to lay in wait during an Ariana Grande concert, before detonating his homemade device as young fans flooded out to be collected by their loved ones.
The blast killed 22 victims, including children as young as eight, and injured hundreds more in the deadliest terror attack to strike Britain since the 2005 London bombings.
A report published on Thursday listed numerous failings, including the “inadequate” actions by security guards after a man raised concerns about Abedi because he feared he was a terrorist.
Sir John Saunders, chair of the inquiry, said that despite the 2015 attack at the Bataclan in Paris and “severe” national terror threat level at the time, no one responsible for security at the arena “believed it could happen to them”.
He said there were a “number of missed opportunities to alter the course of what happened”, adding: “Abedi should have been identified on 22 May 2017 as a threat by those responsible for the security of the arena and a disruptive intervention undertaken.
“Had that occurred, I consider it likely that Abedi would still have detonated his device, but the loss of life and injury is highly likely to have been less.”
Relatives of the 22 victims said they were “failed on every level”. Paul Hett, the father of 29-year-old Martyn Hett, said: “We entrusted the lives of our loved ones to organisations who we believed had a duty of care to protect them.
“This inquiry has rightly found that we were failed by them on every level.
“This atrocity should and could have been prevented, and 22 people would not have lost their lives.”
Sir John said the “most striking” missed opportunity was the attempt by Christopher Wild, who challenged Abedi about his bag, to raised concerns with security guard Mohammed Agha.
“Mr Wild’s behaviour was very responsible,” the report said. “He stated that he formed the view that Abedi might ‘let a bomb off’. That was sadly all too prescient and makes all the more distressing the fact that no effective steps were taken as a result of his efforts.”
The findings were published in the first of three reports from the inquiry. The 200-page document covers security arrangements at Manchester Arena and issues for large venues nationally.
The next part will consider the emergency response to the bombing, and whether any of the victims’ lives could have been saved, and the final volume will look at Abedi’s radicalisation and if the security services could have prevented his attack.
Abedi had been in Libya to visit family for around a month before the bombing, and returned to the UK on 18 May 2017.
Later that day, he conducted his first known hostile reconnaissance at the arena, which was followed by visits on the 21 May and afternoon of 22 May.
Sir John said that if arena operators SMG had expanded their security perimeter beyond the venue itself, to the surrounding area, Abedi’s activity may have been spotted and he would have been unable to enter the City Room without being searched.
On the night of the attack, he took a tram to Manchester Victoria station and was passed by police officers and security guards.
The report said that Abedi was “visibly weighed down” by the 30kg backpack containing the bomb, overdressed for a warm evening and wearing a hat – facts that should “have struck an appropriately trained person as being of potential significance”.
At around 8.50pm, Abedi spent 20 minutes in the City Room where he would later launch his attack, concealing himself in a CCTV blindspot that had not been addressed by SMG for several years.
“He had no doubt identified this area during his hostile reconnaissance,” Sir John concluded.
“Had the area been covered by CCTV so that there was no blindspot, it is likely that this behaviour would have been identified as suspicious.”
Abedi left the City Room for a short time but remained in the station complex and then returned at around 9.30pm, going immediately back to the blindspot.
British Transport Police (BTP) officers were supposed to be patrolling the area and had been instructed to stagger their breaks, and finish them by 9pm ahead of the end of the concert.
The report said officers “ignored the sensible instructions” to take “unjustifiably” long breaks, meaning that there were no police in public areas of the Victoria Exchange Complex while Abedi was there from 9.10pm and 9.33pm, and no officers in the City Room for half an hour before the bombing.
During the final hour before the bombing, the report said that two members of the public raised concerns about Abedi.
In the first incident, a woman working on an anti-bootlegging scheme targeting merchandise sellers told a BTP officer that Abedi was praying, but Sir John said it was “entirely understandable” that the officer did not take action.
In the second incident, Mr Wild approached a security guard employed by contractor Showsec at 10.15pm after challenging Abedi about his bag.
Mohammed Agha, who was 19 at the time, did not know of the CCTV blindspot and did not view Abedi as suspicious.
The report said he told Mr Wild not to worry and effectively “fobbed him off”. Mr Agha made “inadequate” efforts to flag down his supervisor or to pass on the report via a colleague who had a radio.
Mr Agha called over his colleague Kyle Lawler, then 18, who told the inquiry that he thought something was wrong but felt “conflicted about what to do [because] he was fearful of being branded a racist and would be in trouble if he got it wrong”.
The security guards did not communicate Mr Wild’s concerns to their supervisor or anyone else, and Mr Wild said that he would have spoken to police if an officer was present.
Sir John said that either police or security guards could have taken “action that could have saved lives” in the final 15 minutes before the doors into the City Room opened and fans started flooding out.
“No one knows what Abedi would have done had been confronted before 10.31pm,” the report said, but noted that only one of the 22 victims arrived in the City Room before 10.14pm.
“An approach by a police officer may have caused Abedi to leave the City Room or he may have detonated his device. In either case, it is likely that fewer people would have been killed.”
Sir John said that even if Abedi was not challenged, reports of a suspicious man with a rucksack could have caused event managers to prevent concert goers leaving through the City Room.
“None of the [alternative] possibilities is likely to have resulted in devastation of the magnitude caused by Abedi at 10.31pm,” he added.
“None of those directly concerned with security at the arena on 22 May 2017 considered it a realistic possibility that a terrorist attack would happen there.”
Sir John made nine recommendations that he will monitor, including for SMG to improve security at Manchester Arena, Showsec to address failings and for BTP to “address systematic failings to ensure they are not repeated”.
He set out a series of proposals for the government’s incoming “Protect Duty”, which will legally require large venues to implement protections against terror attacks following years of campaigning by the mother of victim Martyn Hett.