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When intentional acts of violence occur, it is understandable for people to wonder if the incident was preventable. For example, after a mass shooting killed 19 students and 2 teachers in Uvalde, Texas, on May 24, 2022, many were questioning the predictability of the gunman’s actions and the decision-making process of the responders. Examining critical elements of the actions taken before, during, and after the incident help to answer these questions.
The 2004 publication entitled “Predictable Surprises: The Disasters You Should Have Seen Coming and How to Prevent Them” by Max H. Bazerman and Michael D. Watkins defines a predictable surprise as “an event or set of events that take an individual or group by surprise, despite prior awareness of all the information necessary to anticipate the events and their consequences.” The authors summarize predictable surprises into six key elements:
- Leaders know the problem exists;
- Organizational members recognize the problem is getting worse over time;
- Fixing the problem will cause high costs or political angst;
- Addressing the predictable surprise will not reward any leader, which includes uncertain costs that may be much higher than they thought;
- Leaders fail to prepare because maintaining the status quo is the natural tendency; and
- A small vocal minority benefits from inaction and special interest groups that benefit from the status quo will fight hard to block reform.
Three simple illustrations of a predictable surprise are the failure of the Enron Corporation in 2001, the terrorist attack of September 11, 2001, and the COVID-19 pandemic that emerged in the U.S. in 2020.
The OODA Loop (Boyd’s Cycle) & the Brake Light Theory
The OODA Loop decision concept (observe, orient, decide, act) was created by U.S. Air Force Colonel John Boyd in the 1950s as a creative concept for training fighter pilots in the “art of war.” Boyd taught pilots that attacking the minds of their opponents leads to a greater understanding of human reaction time. His study of human reaction resulted in his pilots having a 10:1 kill ratio over the enemy. When someone drives a motor vehicle, they often unknowingly use the OODA Loop. The “Brake Light Theory” is a familiar example that illustrates this concept as a simple reaction time. Here is one example of this theory:
On a typical day just north of Tampa, Florida, cars on Interstate 75 fill all three lanes as far as the eye can see. Every driver is traveling around 77 mph trying to get somewhere important. Suddenly drivers begin to slam on the brakes. Vehicles in the right lane swerve to the right shoulder of the road while drivers in the left lane attempt to move to the left shoulder or median. Each driver’s decision in the next few seconds can be traumatizing and even deadly, resulting in a multi-vehicle accident involving damage and possible death for 50-100 vehicles and their occupants. Each driver must now decide what to do.
Consider this individual account of Jane Doe, who is traveling north in the center lane on her way to visit family when she notices the brake lights. She instinctively tries to slow down, but the car behind her approaches rapidly. Envisioning being hit from behind; she eases off the brake. Meanwhile, the vehicle’s brake lights continue to turn on and off in front of her. Focused on not hitting the car in front of her, Jane attempts to move into the left lane. However, the driver behind her does the same thing and, as a result, blocks her escape to the left. Finally, with the center lane coming to a dead stop, she forces her way into the right lane. A catastrophe was narrowly avoided.
Brief History of Mass-Shooting Situations in Schools and Response Training
One could argue that mass-shooting training and planning began in April 1999, after the massacre at Columbine High School. Columbine was a wake-up call where two young men killed 13 people. At Columbine, just 13 minutes after the first call, two students killed 12 other students and a teacher and wounded 23 other people. Next, they killed themselves. SWAT (Special Weapons and Tactics) teams took 47 minutes to enter the school, resulting in massive criticism of law enforcement.
Emergency leaders across the nation recognized that a new incident response approach was needed, including immediately using available officers and going toward the sound of the gunfire. The goal was to interdict the shooter or shooters and stop the incident. Lessons learned from Columbine led the U.S. Justice Department to help fund the Advanced Law Enforcement Rapid Response Training (ALERRT).
In a 2013 FBI Law Enforcement Bulletin, former senior FBI official Katherine Schweit cited statistics from a study of active-shooter events between 2000 and 2010: (1) 57% of mass-shooting incidents are still active when officers arrive on the scene; and (2) 75% of those incidents required law enforcement action to end the shooter threat. Both factors certainly apply to the Robb Elementary School shooting incident. She also cited a different 2012 study of 35 active-shooter incidents, which found that 37% of the incidents ended less than 5 minutes after they began, and 63% ended in less than 15 minutes. Neither of these factors applied to the Robb shooting.
Cameras have played a key role in post-Columbine response incidents (as seen in Uvalde) and can assist identification of the shooter.
Abject Failure at Robb Elementary School
The Bazerman and Watkins research helps to prove what the head of the Texas Department of Public Safety called an “abject failure“ at Robb Elementary in Uvalde, TX. Citizens across the U.S. and other nations watched as the disaster unfolded and were asking the following questions:
- How could this be happening?
- Who is in command of this operation?
- What happened to the emergency “active-shooter” response plan?
- What happened to the emergency response training learned from Columbine, Sandy Hook, or Parkland High School?
Using Bazerman and Watkins’ six critical elements of a disaster, consider the various school employees who testified to the Texas House of Representatives Investigative Committee on the Robb Elementary Shooting on the predictable versus nonpredictable components of the Uvalde, Texas school shooting:
- School district leaders decided not to fund School Resource Officers at all elementary schools.
- School staff and mid-level leaders testified the way things worked was normal and getting worse. Major concerns and problem areas comprised policies for locking doors, the Raptor Alert System, facilities and management, and maintenance of doors and keys.
- Fixing the problem would cause high costs and political questions.
- Addressing a predictable problem (such as an active shooter) called for a plan and training but was met with the increasing exposure in the school district to a phenomenon known as bailouts (in this context, it means illegal immigrants bailing out of vehicles and running from law enforcement).
- A lack of understanding or training in the National Incident Management System led to the designated Incident Commander (Uvalde Independent School District Active-Shooter Response Plan) not assuming command or appointing an incident commander.
- Failure to act caused severe communication problems, a lack of a recognizable strategy for the incident, or a lack of coordination of tactical operations. In addition, the response used was based on the belief that the incident was a “barricaded subject” and not an “active shooter.”
Additionally, the Uvalde school shooting contained many influencers. Questions could broadly include, “What were the real contributing problems?” Factoring in influencers such as gun control and mental health problems is obvious. Other influencers, such as local law enforcement capabilities, level of incident command system (ICS) training, and prior experience, also cloud the picture.
Now consider the school itself. Factors such as teacher and staff knowledge of the facility and staff training for emergencies at the school were obvious. Lax management practices and weak school security will also come into the probe.
The world is not as predictable as people sometimes think. Even with a bias and plenty of nay-sayers, the OODA Loop offers a framework to increase the art of decision-making (see Fig. 1). However, decisions involving extensive response delays or failure to act increase the potential for the incident to have a bad outcome and far-reaching consequences.
Fig. 1. John Boyd’s OODA Loop (Source: CC BY-SA 4.0).
The predictable surprise was supposed to show how everything going wrong was based on the apparent failures that would have been addressed before the incident occurred. The Uvalde case showed obvious failures based on the unused active-shooter response plan. A traumatic, life-threatening event was happening. However, rather than immediately implementing the active-shooter plan, there was confusion, failure to set up incident command, and a broken communication system (as portrayed in bodycam footage).
In addition to being a predictable surprise based on testimony provided by first responders, school district staff, and the principal of Robb Elementary School, the real surprise was the abject failure mentioned above. For example, Uvalde CISD Police Chief Arredondoz (who was designated incident commander under the active-shooter response plan) testified to the Texas House of Representatives Investigative Committee on the Robb Elementary Shooting Report 2022 (page 52) that he thought he was dealing with a barricaded subject situation and did not know that children and teachers had already been shot. The multiple failures that converged in this incident were the lack of leadership and implementation of an emergency operations plan, poor understanding of a common operating picture, and a lack of command presence.
7 Key Research Areas
Despite lessons learned from Columbine, Sandy Hook, and Parkland High School, it was shocking to see the cascading failures at Robb Elementary School. In the May 28, 2022, issue of the Wall Street Journal, columnist Peggy Noonan summed it up as, “We’re out of words because we’re out of thoughts because we said them all and spent them all after Columbine and Sandy Hook and Parkland.”
National importance, common sense, and sheer determination drive the efforts to stop the continuance of mass-shooting incidents across the nation. Each time an active shooter has attacked a school, leaders repeat the promise to study what happened, update the response plan, train first responders and find a quick way to stop the killer. Key research areas to consider include the impact that the following elements have on gun violence in the U.S.:
- School Safety
- The Second Amendment
- State and local laws
- Response operations
- Robb Elementary School
- Mental illness
- Federal politics
School Safety Impact
School officials in any district will promise to do everything they can to protect students from a mass shooting. The Uvalde Consolidated Independent School District made that promise too. The security budget had doubled in recent years. The school district formed its own police department and created threat assessment teams at each school. As required by state law, they wrote their own plan for dealing with an active shooter and built fences around each school. Uvalde also had software to monitor social media, a threat reporting system, and the requirement that all teachers lock their classroom doors. Despite all this preparation, an armed and distraught 18-year-old former student simply entered an unlocked door, continued down a hallway, and entered a classroom, where he would soon kill 21 people.
The Second Amendment Impact
The Second Amendment to the U.S. Constitution is a prime source of the major debate that constantly follows any gun discussion in the U.S. Studying the original debate beginning with the Federalist Papers helps explain why it took approximately ten years for the nation’s founders to approve the Constitution. The Second Amendment continues to be one of the most contentious political arguments in the country. Another significant source of debate over firearms involves state and local law.
State and Local Laws Impact
Within the past decade, a new phenomenon has been slowly developing in various locales nationwide – the concept of allowing (even encouraging) teachers or school employees to carry guns. This strategy has been the leading solution pushed by gun-rights advocates, who contend it gives the school a fighting chance in case of attack. According to the National Conference of State Legislatures, at least 30 states allow individuals other than law enforcement to carry weapons on school grounds. Examples of specific state laws that are impacting gun use in schools include:
- In Florida, 45 of the 74 districts have over 1,300 school staff members serving as armed guards. This move happened after the Douglas High School shooting in Parkland in 2018.
- Approximately 84 of the 1,200 Texas Association of School Boards districts allow designated staff members to carry firearms.
- Ohio recently made it easier for teachers to carry firearms in schools with a new bill that reduces the required amount of training needed.
- Massachusetts passed a bill on August 1, 2022, to change its state gun laws following a U.S. Supreme Court ruling that made it harder to limit access to firearms.
- Governor J.B. Pritzker, from Illinois, signed HB4383 into law on May 18, 2022. The bill bans the sale and possession of “ghost guns” (i.e., un-serialized, privately made firearms that cannot be traced by conventional means) statewide.
Response Operations Impact
Disaster operations can be described as simply left of boom or right of boom. The left of boom is the time before the incident, which involves managing the preparatory work to train, equip, and develop new policies. The right of boom is the time after the first shot is fired when leaders use their collective disaster knowledge to note what is working and what is not. At the Uvalde school shooting, delayed police entry was again a response gap despite the lessons learned from Columbine and Sandy Hook.
This article reviews the Uvalde school shooting findings to determine aspects of predictability and gaps in the decision-making process.
Robb Elementary School Impact
The Robb Elementary School’s impact on law, policy, planning, training, mental health research, and gun control started the day of the mass shooting. Like the past school shootings, the political fallout will be substantial at first and fade from the collective memory until the next shooting occurs. However, on June 8, 2022, the Department of Justice announced the next steps in its critical incident review by charging the department’s Office of Community Oriented Policing Services (COPS) to conduct a full review and supply a roadmap for community safety and engagement before, during, and after such incidents.
Mental Illness Impact
Searching for solutions, the American Psychological Association (APA) commissioned a 2013 report for a panel of experts to provide research-based recommendations on reducing gun violence incidents across the U.S. That APA report concluded the following:
- No single profile can reliably predict who will use a gun in a violent act.
- The most consistent and powerful predictor of future violence is a history of violent behavior.
- Psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, and other relevant contexts that aim to change gendered expectations.
- Although it is essential to recognize that most people suffering from a mental illness are not dangerous, for those at risk for violence due to mental illness, suicidal thoughts, or feelings of desperation, mental health treatment can often prevent gun violence.
- Prevention of violence occurs along a continuum that begins in early childhood with programs to help parents raise emotionally healthy children and ends with efforts to identify and intervene with troubled individuals who are threatening violence.
- Firearm prohibitions for high-risk groups – domestic violence offenders, persons convicted of violent misdemeanor crimes, and individuals with mental illness who have been adjudicated as a threat to themselves or others – have been shown to reduce violence.
Federal Politics Impact
Many investigations were launched in response to the mass shootings in 2022, including the school shooting in Uvalde, Texas. On June 25, 2022, the most extensive bipartisan gun-safety law in decades was enacted, making it easier to restrict criminals and people with mental illnesses from buying weapons. The bill addressed mental health – for example, adding juvenile adjudications and mental health records to the background check system. However, the bill does not address every issue that could have possibly influenced the outcome of the Uvalde and other mass shootings (e.g., bans on classes of firearms or types of magazines, universal licensing, raising of the age to buy a firearm, limits on firearm purchases, national tracking database).
The investigation of the Uvalde shooting will continue at the federal level, lawsuits are sure to follow, and the former police chief for the school district has been fired. Standard practice for active-shooter incidents is to respond quickly with the law enforcement officers on the scene, go to the sound of gunfire, and terminate the threat.
For first responders, Rob Wylie, in his May 22, 2022, article entitled “Rapid response: Five ways to be prepared for an MCI [mass casualty incident] in your community,” suggests that the key areas to study now are:
· Train with police to begin lifesaving measures as soon as possible,
· Rapid triage is the first order of business,
· Be good at the basics,
· Have the right tools, and
· Have and communicate a plan for exfiltrating the wounded.
For school and public safety agencies, encourage all community members (e.g., teachers, family members, co-workers, and friends) to speak up when they witness actions or discussions that indicate potential threats. Public safety messages and reporting mechanisms are two ways to promote awareness and possibly thwart future mass shootings.