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Carabao Cup Incident Review Report

Full details of the review after an incident after our home game against Manchester City

14 December 2018

Following an incident after the Carabao Cup tie against Manchester City, a full independent review of events and safety systems on a match day was conducted by Oxfordshire County Council and members of the Safety Advisory Group.

A summary of the independent investigation, including recommendations, is set out below.

It reads:

‘The safety review of the EFL Cup tie with Manchester City Football Club on the 25th September 2018 has now been completed and the findings in summary are as follows:

Pedestrian congestion following the egress phase of the fixture was primarily caused by the timing and incorrect positioning of the away team coach to the front of the stadium ahead of the match being completed. This situation was not conducive to aid crowd flow through the immediate area.

The moving of the Manchester City team coach was completed without the authorisation or direction of the match day Safety Officer by the driver supported by a steward(s) on the ground. Upon discovery that the coach had been moved a decision to leave the coach in position was taken, as further movement at that time would have presented further potential dangerous issues to leaving supporters.

This was further hindered by the incorrect and unauthorised use of pedestrian barriers without the Safety Officer’s prior knowledge. The positioning of pedestrian barriers had an adverse effect on crowd flow around the stadium.

The pre-match procedures in relation to the parking and location of the team coach were not followed by Manchester City Football Club or enforced by the stewards supervising and overseeing the away team coach.

The pre-match planning did not identify the need to accommodate a coach of such significant size with the Manchester City [Van Hool] coach measuring approximately 46 feet; some 6 feet longer than an average coach.

Despite pre-match planning involving both football clubs, the Manchester City team coach parked in a location and position not suitable to allow maximum crowd flow in the area to the front of the stadium. It can be assumed in absence of other evidence and by the fact pre-match instructions were ignored that MCFC positioned their team coach to leave the ground via the shortest route to the team hotel at Sandford via the Hilton Hotel exit onto the Grenoble Road.

Oxford United steward(s) failed to manage the team coach location effectively in response to the new unplanned arrangements. There were no clear instructions given to stewards/staff to monitor crowd density.

CCTV cameras for certain areas of the front of the stadium were obscured by trees having an impact on the immediate assessment of the area.

The North Stand external segregation barrier hindered crowd dispersal as people looked for additional exit points. This had an adverse effect to the front of the stadium.

The Safety Officer deployed an immediate response with the Chief Steward and Oxford United staff attending the location but actions were limited once the coach was in location with supporters egressing the stadium.

VIP car parking did not aid the situation with vehicles waiting to move.

There was a lack of directional and venue information given to supporters by staff on the ground.

During the egress phase there were supporters from both teams wanting to see the away team exit the stadium and get onto the coach. This created a static crowd that hampered the moving crowd trying to pass and leave the ground. The review established that to the front of the stadium in the coach area there was a walking crowd density of 3 people per square metre with a cross flow and direction change. The immediate area around the coach reached up to 4 people per square metre within a static crowd for a very short period of time. These levels, whilst not deemed dangerous, can prove uncomfortable to those that have not experienced such crowd density and are less mobile.

Review recommendations:

  • CCTV: Repaired/replaced to ensure fit for purpose and any moveable items obscuring view to be removed.
  • Team coaches: Management procedures documented for all stages including new coach parking area. This will also be written into the safety certificate.
  • New VIP parking arrangements to be implemented and fully documented.
  • Staff to be trained or to receive refresher retraining.
  • Non OUFC Safety Team staff to consult the safety team before taking any action that may have an adverse effect on crowd safety.
  • Clearly defined roles and responsibilities to be set for car park stewards.
  • Crowd density to be monitored around the whole of the stadium with staff being trained to be competent in assessment. Written procedures to be created and staff to be competent to respond to overtly dense situations that may occur.
  • North Stand Segregation barrier use. Information of its operation to be given at every match where used. Information signs to be put up when it is in use.
  • Lighting assessment to be completed.
  • Assessment of trip/fall hazards to be completed; any found to be highlighted/managed appropriately.
  • Hand held public address (PA) speakers to be kept in an easily accessible location and stewards trained to use them along with a review of stadium PA operation and messages.
  • Information sharing and operational coordination between OUFC and Thames Valley Police is very good. However, detailed sharing of egress information would have assisted the response to issues/incidents such as this. It should be noted that crowd management inside and outside the Kassam is solely the responsibility of OUFC, but better information sharing can assist with supporter requests and need for information.

Measures taken already:

  • Team coach parking; drop off to the front of the stadium as normal and park adjacent to the loading bay area. The coach will not move from this location until loaded and ready to leave the ground. This will be permanently stewarded. The drop off location at the front of the stadium is still being examined further to ensure public safety.
  • Stewards: training/retraining being completed.
  • Incident response procedures being reviewed.
  • VIP car park: movement now restricted for immediate period following the end of specified activity.
  • Lighting assessment completed, lighting whilst satisfactory is being increased.
  • Trip/fall hazard assessment completed with some areas being highlighted.
  • No unauthorised use of pedestrian barriers without the Safety Officer’s prior knowledge.
  • Items obscuring CCTV have been removed.

This review has been completed by Oxfordshire County Council and its Safety Advisory Group colleagues, who all take public safety incredibly seriously as does Oxford United Football Club who have been transparent and assisted this review at every stage.

Oxfordshire County Council would also like to thank Oxford United Football Club supporters and the Supporters Trust who assisted this process with information and comments, all of which formed an invaluable part of this review.’

Oxford United Supporters are advised to note the following:

  • The Rapid Expansion System (gate at rear of North Stand) – this will continue to only be used when there is a risk to the safety of supporters due to potential crowd disorder. Use will be advertised via the twitter feed @OUFCOfficial in the lead up to a fixture and via PA announcements within the Stadium
  • Oxford United supporters using North and East Stands are advised, if travelling by private transport, to park to the east of the Stadium
  • Oxford United supporters using the South Stand are advised, if travelling by private transport, to park to either the west or east of the stadium. Turnstiles 1 – 5 are best placed for parking to the west whilst turnstiles 6 – 10 are closer to parking to the east of the Stadium
  • Oxford United supporters, on foot, passing the front (south) of the stadium after a fixture are advised to use the car park which will have no vehicle movement until the area is clear of pedestrian supporters
  • Oxford United supporters who need to pass the front (south) of the stadium after a fixture, from either side of the Stadium, are advised to keep left to avoid a cross flow of crowds (the area will be managed and monitored by staff)
  • Oxford United supporters are advised not to walk over kerbs within the stadium perimeter whilst entering or leaving to reduce the risk of incident.
  • Any supporter who requires assistance in exiting the stadium and getting to their private transport are advised to contact a Stand Manager or Supervisor who are identified by either an Orange and Yellow or Orange coloured jacket.

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