PART III - CONCLUSIONS
CHAPTER 16
BRIEF SUMMARY OF CAUSES
265. The immediate cause of the gross overcrowding and hence the disaster was the failure, when gate C was opened, to cut off access to the central pens which were already overfull.
266. They were already overfull because no safe maximum capacities had been laid down, no attempt was made to control entry to individual pens numerically and there was no effective visual monitoring of crowd density.
267. When the influx from gate C entered pen 3, the layout of the barriers there afforded less protection than it should and a barrier collapsed. Again, the lack of vigilant monitoring caused a sluggish reaction and response when the crush occurred. The small size and number of gates to the track retarded rescue efforts. So, in the initial stages, did lack of leadership.
268. The need to open gate C was due to dangerous congestion at the turnstiles. That occurred because, as both Club and police should have realised, the turnstile area could not easily cope with the large numbers demanded of it unless they arrived steadily over a lengthy period. The Operational Order and police tactics on the day failed to provide for controlling a concentrated arrival of large numbers should that occur in a short period. That it might so occur was foreseeable and it did. The presence of an unruly minority who had drunk too much aggravated the problem. So did the Club's confused and inadequate signs and ticketing.
