Analysis Killers were on the loose and, to quote Friday's Guardian, "terrible risks had to be balanced... it flowed from this that something might go terribly wrong." Except, as the Stockwell One report into the de Menezes shooting makes clear, that's not exactly what it flowed from, and given the systems in place on the day, "might" severely understates the position.
The report quite clearly gives the lie to Met Commissioner Sir Ian Blair's claim that the incident was an "isolated breach", and that there is "no evidence at all of systematic failure by the Metropolitan Police." On the contrary, the systems of command, control and communications used were as a matter of design virtually pre-programmed to fail, to the extent that the life of Jean Charles de Menezes was in severe peril from the moment he stepped into the street. His death was not an 'unfortunate accident' but a direct consequence of systemic failure of the Metropolitan Police systems and procedures deployed (in this instance) for the surveillance and interception of suspected suicide bombers.
It would be accurate for police to complain that the death of Jean Charles de Menezes was 'beyond our control', but how did this, and effectively the entire operation, get 'beyond our control'? The answer lies in the intersection of a number of systems and procedures, faulty ones, several of them virtually pre-programmed to fail. Here we examine how that happened.
The inability of police Airwave radios to operate on the underground will tend to be seized on as the operation's main communications problem, but actually it's of little consequence; practically all that was going to go wrong had already gone wrong by the time de Menezes passed through the ticket barriers, and when the firearms officers (CO19) went through, his fate was already sealed. From the logs, it appears that little more than a minute elapsed between the firearms team going underground and de Menezes' death.
Officers involved in the operation on the ground used two radio systems primarily, with Cougar radios for the surveillance team, and Airwave as the general issue communications system. The CO19 firearms team had Airwave but also had the ability to monitor the Cougar traffic, and mobile phones were also used (so Airwave's working well, then).
The most obvious problems don't stem directly from lack of interoperability and/or inadequacy of the communications systems, but from the way communications were structured. Information from the surveillance officers on the ground was - at least in theory - collated by a surveillance monitor referred to as "Pat" in the report, then passed on to the control room and Commander Cressida Dick. The investigation found no evidence of any of the surveillance officers positively identifying de Menezes as "Nettletip" (the police codename for Hussain Osman), yet officers in the control room claim that they had been given positive ID.
Dick says that Pat told her that surveillance believed it was Nettletip, while Pat claims no recollection of this. CO19 officers claim to recall hearing a surveillance transmission saying it was "definitely our man", while a surveillance log altered after the event said either "definitely our man" or definitely not our man". The latter may have been altered to correct an error in the log of a sighting by surveillance officer "Laurence", who had reported that it was not Nettletip.