Emergency Response Lessons from the Uvalde School Shooting

I recently read through the Uvalde Texas Robb Elementary school shooting after-action review and watched the documentary Uvalde 365 Presents: Crisis of Command (on Hulu).I’ll start by summarizing the incident specifics and then offer commentary about them.

Summary

• The first on scene—who automatically becomes the Incident Commander per the universally recognized FEMA Incident Command System—did not perceive himself as the Incident Commander. As a result, there was confusion as to who was in charge (and, in effect, nobody was in charge).
• There was one active shooter, and 376 law enforcement personnel responded to the incident (more than were at the Alamo).
• The entire incident lasted 77 minutes.
• No incident command center was established.
• There was no communication mechanism among law enforcement within the building and from inside to outside the building. WiFi was spotty and radio coverage was incomplete. No alternative means of communication was established.
• Initial responders thought the shooter might have barricaded himself in a pair of adjoining and connected classrooms (Classrooms 111 and 112) they believed were empty despite the fact that early on in the incident, school administrators conveyed that both 111 and 112 were scheduled to be in use (there were students and teachers in the classrooms). The message did not get conveyed to or was not comprehended by the police.
• The door to Room 111 (where the shooter was located) was most likely not locked as the lock had been broken for some time.
• Nobody checked to see if both classroom doors were actually locked. The bulk of the delay in breaching the classrooms involved finding keys to unlock the doors, tools to force the doors open, and bulletproof shields to protect the team entering the rooms.
• Thirty minutes into the incident, 911 received a phone call from within Classroom 112. A student named Khloie Torres called, saying, “Send help for my teachers. They’re still alive but they’re shot.” She added, "Please hurry." The 911 operator asked how many people were still alive, and Khloie counted eight. She added, "My teacher is about to die" and "Come immediately. Room 112."

My Commentary

Incident CommandIn an emergency response situation, it is protocol to establish an Incident Command Center.The ideal location for a Command Center is out of harm’s way. In a post-earthquake scenario, for example, you don’t want your command center in a high risk zone. Part of the reason to be out of the danger zone is it’s very hard to comprehend what’s going on if you’re in harm’s way. Just developing and maintaining situational awareness is an extremely mentally demanding task.The purpose of the Command Center is so that all information flows into one place and gets disseminated from one place. When there’s a Command Center, people and information naturally flow to it. When one doesn’t exist, information and material get lost in the shuffle.The job of Incident Command is to receive information, comprehend the information to form a mental picture of the situation, and decide what needs to be done and by whom. In essence, the #1 job of the Incident Commander is to establish and maintain situational awareness. Every other responder has a job or task to do. These tasks tend to be very “micro”—get a radio, call in more resources, find the master key. There’s only one person in the entire incident whose sole job is comprehension of the situation and that’s the Incident Commander.

Since there was no effective incident command established, it’s not surprising that logistical coordination and communication were poor.

911 CallKhloie Torres made a textbook perfect call. From the perfect call, you want an accurate count of people involved (the number of patients) as this communicates the magnitude of the incident. Khloie did this right. You also want a specific request and a specific location. Khloie gave both.Ten-year-old Khloie Torres was the person who had the best situational awareness of the incident.Body cam footage from the two most senior law enforcement leaders on the scene showed them talking to 911 dispatch about Khloie’s call. Both law enforcement leaders later testified they didn’t remember much about the call.LogisticsOne of the problems that occurred was that ambulances that arrived early during the incident were blocked in by the vehicles used by the 376 law enforcement personnel. Nobody had established or pre-planned an ambulance loading area. Nobody had established a traffic flow pattern for inbound and medical response vehicles. Nobody had established a staging area for ambulances—a staging area is a secondary parking lot that doesn’t clutter up a scene. It is used to hold resources that will soon be needed but aren't needed yet Nobody had established traffic control at the perimeter to direct arriving responders to parking out of the way of anticipated medical evacuation needs.

Conclusion

Forty-seven minutes after Khloie Torres called 911, police finally breached Classroom 111 (which likely was not locked), and the shooter was killed.This tragic incident was a complete collapse and failure of the Incident Command System. Nearly everything that one is taught in Incident Command training was not done in this case.Uvalde School District Police Chief Pete Arredondo (who was supposed to be Incident Commander) later testified in regards to the establishment of a Command Center: “You can always hope and pray that there’s an incident command post outside. . . . I didn’t know anything about that.” There is no need to hope and pray for an Incident Command Center when you can simply set one up by following FEMA ICS protocols.One of our Bainbidge Prepares initiatives this year is to teach and develop a larger group of members that can competently command an incident if needed. Although Bainbridge Prepares would not be involved in an active shooter event (known as a “Criminal Mass Casualty Incident”) with a crime scene, we would potentially be involved in many other types of incidents with similar needs.Along those lines, we have an Incident Commander training exercise tonight, March 1: Incident Commander Mass Casualty Simulation Exercises, Wed March 1st (6:30 pm–8:00 pm) at Fire Station 21. RSVP here (to make sure we have enough handouts and to get a list of items to bring to class).