An independent review, chaired by former Head of the Civil Service Lord Kerslake, illustrated how poor communications between the emergency agencies gave the Greater Manchester Fire and Rescue Service (GMFRS) conflicting information.
Firefighters were barred from responding quickly to the attack on 22 May a year ago after their bosses wrongly thought they were dealing with a marauding terror attack like those seen in Mumbai and Paris.
Emergency services arrive close to the Manchester Arena after the explosion.
A recent report found that poor communication about the status of the scene resulted in firefighters being kept away from the Manchester Arena bombing that killed 22 people last May for more than two hours.
Other parts of the emergency services' response to the attack weren't up to snuff, aside from their communication amongst each other.
Firefighters, some who heard the bomb go off and are trained in first-aid and terror scenarios, did not get permission to go to the scene until hours after the suicide bombing, despite the nearest fire station being half a mile away.
The fire crews "stuck to the rules" for a possible active terrorist - while paramedics were not kept away during the May 22 attack by Salman Abedi at an Ariana Grande concert, according to the Kerslake Report.More news: Smith, Warner & Bancroft to leave SA after ball-tampering scandal
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The report said there was no single reason or person behind the failure: "Rather, it was a combination of poor communication and poor procedures". "This can lead frontline responders to make judgments that might be right on paper but wrong in practice and this in part explains the fire service's mistakes".
Because the senior fire officer on duty that night could not get through on the phone to the police duty officer, the response of the fire service was "brought to the point of paralysis" to the "immense frustration on the firefighters" faces, ' the report states. He should, theoretically, have withdrawn all responders from the Arena foyer after initiating Operation Plato, the agreed operational response to a suspected Marauding Terrorist Firearms Attack.
The behaviour of some media has been criticised in the Kerslake Report.
Yet after deploying 106 armed response officers within an hour, as well as explosive-sensing sniffer dogs from GMP and other local forces, the officer decided that to ask paramedics and other first aiders to evacuate would have been "unconscionable". But it said lives were undoubtedly saved by a police duty inspector's decision to override protocol and let police and medics stay at the arena and treat the wounded, even though it was unclear whether more attacks would follow.
Dawn Docx, the interim chief fire officer of Greater Manchester Fire and Rescue Service said she apologised unreservedly for the failures in the previous leadership of the service at the time of last May's attack.
"She was speaking after the publication of a report by Lord Kerslake into the emergency services" handling of the attack in May previous year.
But he conceded that it was "quite extraordinary that [the fire service] did not pick up what was happening".