The broken terror systems that killed de Menezes
A study in systemic failure
Says the report: "Despite the belief within Room 1600 that Nettletip had been identified it should be noted that every entry on the Surveillance Running Log refers to the person as being 'U/I male', meaning unidentified."
The report notes that the ground surveillance team all appeared to believe that they did not have a positive sighting, while the control room believed that they did. It looks very much as if faulty filtering and Chinese whispers effectively manufactured this situation, helped along by individual officer's fears of the consequences of making a mistake. This would tend to make them extremely cautious of saying that it definitely wasn't Nettletip, meaning the possibility that it was him was pretty well embedded in the system. These doubts would be filtered upwards, and the same fears would lead superior officers to give undue weight to a single claim of 'might be' over half a dozen of 'probably isn't'. The claims of CO19 that they heard "definitely" illustrate that direct monitoring in the control room isn't the answer either - nobody admits to saying that, and they may simply have missed the word "not".
Command and Control
The communications problems inherent in the way the Met was running multiple teams from a remote control room suggest a system that isn't actually fit for purpose as regards tracking and intercepting a suspect, rather than one that just didn't work well on the day. But the command and control systems come out badly too, sometimes for related reasons, but not always.
The report notes that Commander Dick viewed it as natural that she, as the senior officer, should be in charge of the operation, and that is no doubt how it works as a matter of course at the Met. But she was presiding over a system that was - as we've seen - incapable of passing timely, accurate and undistorted information to the control room, and which also failed in the other direction, over the interpretation of her 'stop' command to CO19, who claim to have thought it was a shoot to kill order. The initial deployment plan called for surveillance, CO12, to monitor those coming out of the building and for CO19 to detain them at a safe distance. CO19 wasn't however in place (as detailed by Lewis Page), so neither de Menezes nor any of the other people coming out of the building were stopped and questioned according to plan.
More autonomy on the ground, or better, command authority there, would quite possibly have resulted in a contingency plan kicking in. The other people leaving the building were presumably left alone because they were identified as definitely not Nettletip, and de Menezes would probably have been stopped and questioned (stop and question was the plan), rather than shot a short time later.
De Menezes was neither stopped nor ruled out as Nettletip because initially the officer watching the exit was unable to get a clear look at him (because he was having a pee). Arguably de Menezes' chances might have been better if at this juncture he'd been misidentified as Nettletip. Would they have let an identified terror suspect get on a bus, or would CO12 have intervened? It's a possibility - but he boarded the bus, his identity shrouded by doubt. The capability to make decisions on the ground was also decreased because the ground commander was with CO19, not in the vicinity of the monitored block of flats.
A word here about CO12's and CO19's roles. The CO12 officers were armed, but were only intended to stop a suspect in the last resort, on the basis that they did not have specialist training, while CO19 officers did. This differentiation wasn't specific to this operation, and can perhaps be seen as a further sign of institutionalised risk aversion in the police.