City of Utrecht Shooting incident 24 Oktoberplein

Utrecht’s crisis organisation made understandable decisions during the complex situation that arose on 18 March

Press release 10-12-2019 | The report entitled ‘A city in silence’ published today by the Institute for Safety, Security and Crisis Management (COT) explains that Utrecht’s crisis organisation adopted an active response to the complex situation that arose during the attack on 18 March 2019 and made understandable decisions at the time. This includes its decision to act on the basis of the scenario of ‘an attack with a possible terrorist motive’. The report expresses appreciation for the emergency services staff and members of the crisis organisation, who endeavoured to safeguard the interests of both the victims and society in general, despite the exceptionally difficult circumstances they faced.

On 18 March 2019, Utrecht was startled by an attack on random victims in the tram at 24 Oktoberplein. Almost immediately following the incident, the mayor, in consultation with the chief public prosecutor and the City of Utrecht’s senior police officials, pointed out the importance that lessons be learned from the incident. A learning evaluation of the actions of Utrecht’s crisis organisation was therefore carried out. The findings of this evaluation were published today.

Exceptionally difficult circumstances

The attack on 18 March triggered various circumstances that had not previously occurred in the Netherlands: the swift interpretation that a terrorist motive could not be ruled out, the declaration of the highest threat level (Level 5) and the advice that the entire population of the City of Utrecht should remain indoors. Having examined the context of these exceptionally difficult circumstances, the COT identified a number of lessons to be learned. These should prove valuable to all crisis organisations in the Netherlands.  Utrecht’s crisis organisation will also take the lessons identified during evaluations into account in its further preparations for crisis situations and in future actions. The vital points are as follows:

Advice to remain indoors

Issuing the advice to remain indoors was justified, in view of the information available at the time. As a learning point, the COT indicated that further information should be provided regarding the scope of the advice, its duration, and the reason that it is considered necessary. It is vital that clear communication be issued on the implications of certain measures. In future training courses, the crisis organisation will therefore devote greater attention to more explicitly defining the impact, the preconditions and the perspective for action in the event of far-reaching decisions.

Escalation to the highest threat level

The COT concluded that the move by the National Coordinator for Counterterrorism and Security (NCTV) in raising the threat level to 5 and the mayor’s advice to remain indoors appeared to all intents and purposes coherent. However, no specific measures have been identified as necessary as a consequence of escalation of the threat level. The NCTV – in cooperation with the Municipality of Utrecht and other municipal and regional crisis partners – will therefore take steps to clarify the significance, division of roles and communication associated with the declaration of threat level 5. The municipality is to examine the precautionary measures it might put in place in the event that the city should face an acute threat.

Involving social organisations

The COT has pointed out that seeking closer contact with social partners, such as transport companies, schools, care and welfare institutions, can have a beneficial effect in terms of managing the impact of an incident. And this applies both in the event of a crisis and when implementing precautionary measures for crises. After all, holding preparatory discussions concerning the relevant roles and responsibilities should render organisations more capable of preparing themselves for a crisis. This has prompted Utrecht’s crisis organisation to both further develop its relations with social organisations and to conclude agreements aimed at more adequately organising their input during an incident.

Joint impression of the situation

A recurring challenge faced in crisis situations is that of jointly establishing a clear impression of the circumstances. The COT concluded that, during the shooting incident, it had also proven difficult to establish an appropriate and swift means of sharing information with one another. With a view to improving this, the police at national level are examining the possibilities of establishing a continuous, up-to-date impression of the security status. Prompted by the evaluation, the municipality, the police and the public prosecution service are to improve the provision of information within the judicial chain. In addition, the municipality, the police and the Security Region will take steps to boost the mutual provision of information.

Evaluation of the NCTV and National Police

At national level, the Ministry of Justice and Security investigated the deployment of national partners during this crisis. The National Police Board also commissioned a review of the National Police’s actions. The Minister of Justice and Security submitted the findings of these evaluations today, together with a letter to the House of Representatives, which explains how the most important lessons are to be implemented.

Memorial site

The events of 18 March and the suffering inflicted on so many individuals made a deep impression on the people of Utrecht. Shortly after 18 March, residents of the city – and other parties involved – expressed the wish that a permanent site should be set up, where they might continue to express their sympathy and commemorate the victims in an appropriate manner.
A memorial site is therefore to be established at 24 Oktoberplein, which will offer citizens the opportunity to reflect on the events of 18 March. A place that offers scope to express both our grief and solidarity. The design of the site reflects the wave of disbelief and sorrow that engulfed the City of Utrecht following the tram attack. Construction of the memorial site is to commence early next year, and should be completed by 18 March.

Health survey

The substudy into the aftercare for emergency services staff and professionals has been completed. Its findings include the recommendation that attention be devoted to organising both collective and individual aftercare for the professionals involved. The Municipality of Utrecht has further professionalised the aftercare for employees in the meantime. The entire health survey is to be completed by mid-2020.

Further information

For the COT’s full report, the lessons learned, the council letter, the NCTV’s report and the substudy by the Utrecht Regional Health Service (GGD), please consult