Time has not been kind to the law enforcement first responders in the Uvalde, TX, school shooting massacre. From initial (and brief) reports of uncommon bravery has come a steady torrent of criticism pertaining to failed leadership, flawed execution of established tactics, and an overall sense that the teachers and students of Robb Elementary were not well served. Second-guessing continues to prevail, recriminations are rampant, but the facts as they have developed are damning. Videos of law enforcement taking hand sanitizer from a dispenser in the middle of the siege certainly didn’t help matters. It is no surprise that the entirety of the Uvalde Central Independent School District (UCISD) was dismissed, and the chief of police fired, among other actions taken in the disaster’s wake.
For those of us in the fire service, we may say “But for the grace of God go I” and be thankful that this was not a fire event. We would not be serving our own collective public, however, if we did not take a critical look at the shortcomings of the Uvalde operation to see if there are lessons within it that can be learned by fire departments so that when “our Uvalde”—whatever that might be—comes up we are ready to perform as expected, as needed, and as trained.
Investigative report findings
The Texas House of Representatives Investigative Committee on the Robb Elementary Shooting issued a report in July, 2022, extensively detailing the “shortcomings and failures of the UCISD and of various agencies and officers of law enforcement.” While taking strides to make clear that it sought not to villainize law enforcement or somehow equate its failings with the evil of the school attacker, the committee did find “systemic failures and egregiously poor planning.” Pretty tough words, especially in the context of the massive loss of human life.
The committee, while not sparing any of the responders from what it considered to be a fair and objective analysis of an almost complete breakdown of the law enforcement response to the incident, did try to put its assessment into a language that could be helpful to not only law enforcement but all first responders. The fire service may not be the primary responder into a mass shooting or other criminal incident, but there are plenty of emergency situations to which the fire and rescue services are first-in, and responsible for establishing the operating culture and effectiveness of a rescue operation. Thus, the work of the committee should be seen as instructive to the fire service and all of those operating in emergency management.
“Transform[ing] chaos into order.” The committee’s chief complaint about the law enforcement response to Robb Elementary focused on the lack of any semblance of incident command. At the top of the incident command ladder is the establishment of an incident command post. “A command post could have transformed chaos into order including the deliberate assignment of tasks and the flow of information necessary to inform critical decision making.” The incident command post is not just window-dressing: it is an essential—maybe the essential component to compel and encourage cooperation among various agencies and promote the sharing of information by assuring that representatives of responding units are actually all together in one place.
The report tracks the breakdown of most communications of vital information to this singular mistake, and it is not hard to see how the committee came to this conclusion. “[N]o responder seized the initiative to establish an incident command post…[d]espite an obvious atmosphere of chaos.” No one, the investigation found, “approach[ed] the UCISD (Uvalde Central Independent School District) chief of police or anyone else perceived to be in command to point out the lack of and need for a command post…."
Critically, the lack of a command post and the organized information analysis that emanates from this nerve center of any incident prevented responders from appreciating that what was thought to be a barricade situation was actually an ongoing active shooter scenario.
The committee also reached back to previous incidents elsewhere to punctuate the point that establishing a command post should be done as early into an incident as possible. The Pulse nightclub in Orlando and the Marjory Stoneman Douglas High School in Parkland, FL, shooting responses were among several that the committee noted has having served as lessons on this issue. Establishment of the command post should be done immediately after arrival and initial size-up.
The prompt establishment of a command post is primary, but the location of an incident command post is almost as important. “An effective incident commander,” the report states [who, one would assume, would be in the command post, but we will get to that below], “located away from the drama unfolding inside the building would have realized that radios were mostly ineffective, and that responders need other lines of communications…,” among other things. Locating a command post too close to the action, to a running rig, to the staging area, all frustrate the purpose of having a command post. Look at it this way: the command post and those operating at it should assure a certain sterility of the environment, like in the cockpit of an aircraft, making sure we were receiving and disseminating critical reliable information in a timely manner without excess or unnecessary chatter or distraction.
Executing according to plan
If chaos is ensuing, executing according to plan is challenging no matter how often it may have been practiced. That does not mean that effective strategies and tactics should not be learned and practiced, but rather that order plus proficiency are two sides of the same coin. The committee found that the UCISD and its police “failed to implement their active shooter plan.” Strategies and tactics are to be trained to the point of reflex and instinct. Clearly that was not the case in Uvalde, as the committee found. The problem is oftentimes exacerbated, as it was in Texas, when mutual aid is not informed or knowledgeable of a plan of action, or that a plan has been disregarded. Initial incident coordination and a complete chain of command throughout the operating area are essential to getting all incoming units on the same page.
In the school district’s active shooter plan, this issue was addressed; however, it was not followed in this real-life incident, as the committee’s report noted, quoting the plan: “The school district’s police department was assigned the responsibility for ‘the Incident Command Center’ and for being ‘first on scene to prevent or stop an active shooter,’ while the policy assigned to other ‘local law enforcement and first responders’ the function and responsibility to ‘follow the direction of the ICS leader to ensure proper procedures are followed’ and to ‘accept assigned roles of ICS leader.’”
Complacency is always our enemy
The Uvalde school officials and responding officers, it was determined, had developed a complacency towards facility security and response to reported incidents. This was largely due to the high volume of so-called “bailout” cases of illegal immigrants on the run after having come over the nearby United States border. To school and police officials, bailouts represented a frequent occurrence but not a major risk; consequently, a constant state of readiness and consistent security of the facility were both compromised.
Thus, it took some time for administrators and officers to appreciate the fact that the school was or was about to be under mortal siege. Forty-seven lockdown events happened in the span of three months just prior to the shooting event, most of them from bailouts. While bailouts were seen as an important security issue, they did not generally result in an acute threat to those in the building. In fact, “[t]he series of bailout-related alerts led teachers and administrators to respond to all alerts with less urgency….” More critically, the report concluded that “when they heard the sound of an alert, many assumed that it was another bailout.” From there, the entire alert status of the school deteriorated, to the point where doors were “commonly left…unlocked” (the report citing that many doors did not have operating locks) or propped open, among other habits contrary to security policy. As it turned out, most doors were secured the day of the incident only when word-of-mouth messaging started to spread the news of an intruder on the school grounds.
Lessons for the fire service
If anything is to come from the senseless deaths in Uvalde, everyone in emergency services should mine the events that unfolded at Robb Elementary on May 24, 2022 for lessons. Again, while this was primarily a law enforcement event, it is clear that the fire service can glean some take-aways from the situation. The foremost obligation is to restore a trust in government that was lost that day and in the weeks and months thereafter. It is not only the loss of trust in government to perform essential services, but to convey an accurate depiction of those events and scrutinize where necessary. As you will recall, the narrative went from heroism to vilification of law enforcement in a New York minute, spreading distrust like a fast-moving cancer. We all have a duty to help restore the trust by doing our jobs competently, and allowing others to objectively scrutinize our work. If we do the work well, we should not have to worry about the after-action analysis.
There is also an acute need for the public to be able to trust the work of government in the after-action analysis phase of an event. Trust was the victim as the public narrative went from heroism to havoc, when it was determined that more than an hour passed without meaningful engagement by police. The public cannot be expected to understand the intricacies of strategies and tactics. Sometimes they just want to see action. In a court case in New York, a fire department was sued largely because the perception of those observing the operations of the fire department concluded that it was not moving fast enough to save a victim, who ultimately perished in that fire.
The public is not always in the mood, especially after a particularly horrific event like the Robb Elementary shooting, to sort out fact from fiction. They want to know, intuitively, that the first responder community has done all it can to respond to the incident. It is our responsibility to make sure as much as we can that all the relevant facts are “good” facts, and acknowledge when they are not so good. That means operating efficiently, effectively and professionally at all scenes and openly and honestly during after-action analysis.
“Transforming chaos into order.” That is our job. We may not confront chaos coming from a gunman, but we face chaos every day in multi-casualty incidents, multiple alarm fires, and other catastrophic events. Chaos can also come in smaller events as well; remember, chaos is sometimes in the eyes of the observer. Organized, unified incident command is our single best tool to assure we meet the mission of transforming chaos into order.
The events of Uvalde, of the Station Night Club fire in Rhode Island, the Bronx, NY, Twin Park fire that killed 17 civilians last year, and of so many other incidents are not isolated sets of occurrences. We don’t practice the task of transforming chaos into order only when chaos is upon us, but when we simulate chaos, when we walk through incidents from other jurisdictions when either chaos ensued unchecked or it was effectively managed and mitigated, and when we discuss in our training rooms or at the station kitchen table the possibility for chaos, and our response to it, at potential events down the road.
Recently, a young lieutenant in my fire department decided to take it upon himself to “organize” his troops when directed to investigate a fire alarm. He was commended for taking the initiative, especially given the nature of the structure. The commonplace fire alarm is exactly the time to have this conversation, and the chief in command, the lieutenant and the crew walked through the building’s construction, layout, alarm system and challenges it presented given that it had unique characteristics that could be troublesome in the event of a live incident.
Incident command is also not optional. If your plan of operation calls for a person—chief, line officer, senior firefighter—to be the incident commander, that is not a suggestion or an offer. It is a directive. And if that person is uncomfortable taking command, there should be an orderly transfer and assumption of command that is understood by everyone on the fireground and at dispatch. The following is rather stunning testimony from the now former chief of the school police department: "[W]hile you are in there, you don’t title yourself…I know our policy states you’re [the police chief] the incident commander. My approach and thought was responding as a police officer. And so, I didn’t title myself. But once I got in there and we took fire, back then, I realized, we needed some things….As far as …I’m talking about the command part…the people that went in, there was a big group of them outside that door. I have no idea who they were and how they walked in or anything. I kind of—I wasn’t given that direction….[Y]ou can always hope and pray that there’s an incident command post outside. I just didn’t have access to that. I didn’t know anything about that.”
“Hope and pray?” Stunning. As has been said many times before, hope is never a strategy.
How many of us have the discipline to establish—and stay—at the command post during an incident? How many of us have wandered? How many of us have been first to respond but did not transition to command or make certain that command was established? How many of us wanted to stay in the action than retreat to the seemingly distant confines of the command post? It is more than just words—establishing command—but acting in command.
Executing according to plan
Execution of a plan means knowing the plan, understanding the plan, having the plan so ingrained as to be second nature, and having practiced it to achieve the highest possible level of operational effectiveness and efficiency. I remember a water rescue call I commanded years ago, talking to the police chief at the command post, and discussing the ongoing operation. If the team knows, understands and has practiced the plan, command is overseeing that and not providing initial instruction as if the team has never conducted a water rescue before.
Of course, we cannot anticipate every possible situation, but we can instill a competence and confidence in our firefighters to adapt and innovate off of the original plan so that when such deviation occurs, it is deviating off of the same basic platform that everyone responding knows and understands.
Complacency is always our enemy
The number of repetitive calls, be they fire or EMS, make the fire service particularly susceptible to complacency. “Frequent fliers” are a reality of the business but don’t routinely constitute actual emergencies, and certainly not the kind that may well erupt into chaos.
Or can they? If in the profession long enough, most every member can recall at least one incident where they thought they were rolling into a routine alarm only to find smoke showing, people gesticulating wildly, dispatch informing of multiple calls and other manifestations that this alarm will be unlike the others. Fighting complacency and familiarity, and resisting the very human nature characteristic of being lulled into a false sense of security, may be the toughest challenge for the fire service and all emergency services. It is hard enough when civilians have become complacent; we do not have that luxury.
We have heard it before: approach each alarm as if it is a job until you know that it is not. Practice those things that would go into a major call when working the minor ones. Inform building managers and occupants that complacency is as much risk to them as to first responders; make them part of the mission.
The Uvalde shooting was a tragedy all by itself. Unfortunately, the response to it was also deeply troubling, as it has turned out. As an old boss of mine liked to say, "there is no lesson in the second kick of a mule." Let’s learn the lessons of this horrific situation before we repeat the mistakes again.