Using a systems-based perspective to analyze the Uvalde school shooting response

Enhancing individual and organizational performance is founded upon full comprehension of the “how” and “why” performance did not meet expectations


Two preliminary Investigations have identified multiple errors contributing to the mass murder of 19 children and 2 adults at Robb Elementary School in Uvalde, Texas. [1,2]

While wounds are still healing and information continues to be released, another active shooter incident could occur tomorrow. Therefore, there is no reason to delay discussions about the reported errors and start considering what lessons can be identified.

One proven method for investigating and mitigating human error is found within human factors science.

Investigators search for evidences outside Robb Elementary School in Uvalde, Texas, Wednesday, May 25, 2022.
Investigators search for evidences outside Robb Elementary School in Uvalde, Texas, Wednesday, May 25, 2022. (AP Photo/Jae C. Hong, File)

What is human factors science?

Human factors practitioners review critical incidents from a “systems-based” perspective. This perspective takes into consideration that people are prone to error and that many latent factors contribute to that human error.

Latent factors can be but are not limited to:

  • Organizational: Culture, accountability, training, procedures and leadership
  • Supervisory: Failure to correct performance, plan operations, or lead adequately
  • Situational/environmental: Equipment, communication, stress and sense-making

These factors collectively influence individual and team performance.

This article reviews the Robb Elementary incident investigative reports [1,2] and the school surveillance videos [3]. The focus of the discussion is not all-inclusive and focuses only on some of the prominent errors (i.e., decision/sense-making), as well as the latent factors that may have influenced performance.

Individual/team errors and systems-based failures during the Ulvade response

The following video segments can be viewed here.

(11:30:14) After crashing his car and firing rounds outside the school, the suspect, wearing dark clothing, climbed a chain-link fence onto Robb Elementary School property.

Failure to engage outside the school: Early reports indicated that an officer outside the school saw a person dressed in black over 100 yards away. There is no indication the officer saw a firearm. The officer asked a supervisor for permission to fire moments before the person in black disappeared from his view. While there are many possible systems factors that could have influenced this officer asking for permission to shoot, reports provide information the officer in question was concerned about the backdrop and the distance of the shot. There were also questions as to whether the officers’ training adequately prepared him to make a long-distance shot. However, other factors including, but not limited to organizational culture and supervisory influences should be investigated.

One situational factor that cannot be ignored is that the officer’s decision not to shoot was made in a split second under tense, uncertain and rapidly evolving circumstances. These same factors are often presented as supporting the reasonableness of a shooting decision that is ultimately determined to be in error (i.e., mistake-of-fact shooting). The point here is the quality or reasonableness of the decision should be evaluated based on the factors that led to the decision, not the outcome of the decision. While our concerns about asking a supervisor for permission to use deadly force may remain, the most recent investigative report indicates the person dressed in black was presumed to be a school employee. Therefore, the decision to withhold the shot was correct.  

(11:33:00) The shooter enters the school through the exterior door leading to the west hallway. This same door was propped open by a teacher with a rock just minutes (11:27:14) prior. Although a teacher closed the door before the shooter entered, it remained unlocked. (11:33:32) The shooter made his way to an unlocked classroom (111) and fires an estimated 100 rounds in 3 minutes. These 100 rounds were fired before law enforcement entered the building.

Locked classroom door policy: The Uvalde school district had a policy requiring classroom doors “locked and closed at all times.” One of the reports states that had doors been locked, the shooter’s progress would have been slowed, allowing more time for staff and law enforcement to respond.

The investigative reports provide some shocking details about the school district’s organizational culture that likely influenced staff adherence to safety and security. The report presents a history of school staff failing to lock classroom doors and their overt attempts to avoid being caught not doing so by district police. More concerning is that the principal and assistant principal testified they were aware of the failure of teachers to abide by the locked door policy.  

From an organizational perspective, long-term non-adherence to the locked door policy may be a perfect example of “practical drift.” Practical drift occurs when people slowly deviate from policy compliance over time and is often based on the development of shortcuts for personal gain. These shortcuts, when not corrected, then become the normal operating procedure. In this case, a report identified the Robb Elementary School staff’s noncompliance with safety protocols as a “fatal” error.  

(11:35:55 – 11:36:03) Eleven police officers have entered the school and are in the West and South hallways near the shooter’s location. Officers immediately move to classrooms 111/112 and are fired upon. They retreat to cover positions and sporadic gunfire is heard over the next several minutes. Radio traffic can be heard (11:38:37) referencing the shooter being contained or barricaded. (11:38 – 12:50) Requests are made for assistance/equipment and additional a few shots are fired by the suspect. (12:21) U.S. Border patrol (BORTAC) officers move to the breach point of room 111/112. (12:50) An ad hoc team of law enforcement officers make entry and neutralize the suspect.

Failure to engage inside the school: The surveillance video shows officers move to the location of the active shooter almost immediately upon entering the school and then retreat after being fired upon. From here, there is a litany of problems that may have impacted decisions by first responders. These problems are presented by investigative reports as first responder requests for ballistic shields, breaching tools, master keys and additional personnel. However, the reports provide details showing these problems were not the primary factors leading to a failure to engage the suspect.

What does present as a major factor is the first responders’ erroneous perception that the situation changed from an active shooter to a barricaded subject. This perception should be evaluated through the lens of sense-making or the cognitive process by which people give meaning to their collective experiences. In this case, the first responders' sense-making was likely influenced – at least in part – by their training and the existing environmental/situation factors. The first responders reported they did not see injured victims, did not hear screams and noted that nearby classrooms were empty. Another factor reported by first responders was the overabundance of previous emergency response situations (“bailout situations) at the school. In any event, the reports indicate that a lack of coordinated information gathering and communication problems may have also influenced first responders’ perceptions of the incident.

Failure to establish command: The investigative reports indicate there was no established command and control for this incident. By policy, the school district police chief was the incident commander, but he was operating as a first responder. Whether he should have stepped back at some point and assumed an incident command role or whether someone else should have assumed that role in his stead is a major point of contention. Minus a central point of intelligence gathering and communication, law enforcement’s ability to make sense of an incident and establish a rapid response is greatly diminished. The organizational failure to establish incident command appears to be a major factor leading to further delays in neutralizing the suspect.

Whether or not command was established could be considered irrelevant to the delay in breaching room 111/112. A significant number of rounds were fired inside a school even as responders reportedly perceived the situation to have evolved to a barricaded subject. Even the BORTAC team waited about 30 minutes to breach after reportedly stacking at the entry to room 111/112. The reports are not clear as to the reason for this delay, but it appears the school district police chief was attempting to negotiate with the suspect before ultimately giving authorization a few minutes prior to entry.  

Lastly, there is a need to evaluate the type, duration and recurring nature of active shooter training provided to the school district chief and other first responders. While all school district officers in the state of Texas are mandated to receive active shooter training, it is unclear whether any particular provided training establishes proficiency or whether learning decay had any influence on performance. According to reports, the school district police chief received active shooter sometime between 2017 and 2020. The question is whether a single 8- or 16-hour class will result in the proficiency necessary to successfully complete complex tasks several years later.    

Final thoughts

“It is easier to perceive error than to find truth, for the former lies on the surface and is easily seen, while the latter lies in the depth, where few are willing to search for it” — Johnathan Wolfgang Von Goethe

Although emotionally satisfying, there is little benefit from playing the blame game. Focusing on an officer who momentarily looked at his phone (his wife was critically wounded in room 111) or the imperfect tactical movement in a hallway does not enhance future performance.

Enhancing individual and organizational performance is founded upon full comprehension of the “how” and “why” performance did not meet expectations, even if the review points back to systematic failures of the organization itself. The value of a human factors systems-based evaluation is to understand the complexity and overlapping nature of the many factors that influence adverse outcomes. Through such understanding, stakeholders can develop countermeasures intended to reduce error and mitigate the effect of error when it occurs. This is how resilient organizational systems – intent on preventing or mitigating adverse performance outcomes – are born [4].

In closing, one recurring theme within both investigative reports is the confusion that seemingly existed in differentiating between an active shooter and a barricaded suspect. Further investigation is warranted, but just as the mass murder at Columbine High School 23 years ago fundamentally changed law enforcement's response to active shooters, Robb Elementary may provide the foundation for another change. For example, the nomenclature of these events may be important. Instead of referring to these incidents as “active shooters” it may be better to refer to them to as a mass murder response. Policy and training would then emphasize immediate engagement and neutralization [5] of mass murder and attempted mass murder suspects regardless of whether a gun, a knife, a vehicle, or some other instrument is employed or whether there is a lull in active killing. This may eliminate ambiguity or confusion in similar situations. 

My appreciation to Dr. John Black of Aragon National for peer-reviewing this article.

NEXT: Breaking down the ALERRT report on the Uvalde school shooting response

References

1. Texas House of Representatives Investigative Committee on the Robb Elementary Shooting.

2. Robb Elementary School Attack Response Assessment and Recommendations.

3. Exclusive Uvalde video shows school shooting, police in hallway after shooter entered classroom.

4. Reason J. (2000). Human Error: Models and Management. British Medical Journal, 320 (7237), p. 768-770.

5. Neutralization not limited to the use of deadly force and represents a range of options intended to stop current or future killing by a suspect.

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