Robert Goplin's thesis
Chain of Events: Mitigating Active Shooters and Hostile Events
– Executive Summary –
Active shooter/hostile events (ASHE) cause major damage, significant injuries, or death so rapidly that responders may be overwhelmed. Responders must quickly identify the immediate needs, what decisions need to be made, and what actions to take during the initial phase of an ASHE to move the incident from a chaotic phase toward one of order. My observation of stalls, or brief pauses, in action by responders during an ASHE training exercise conducted in the summer of 2021 served as the inspiration for this study. During the exercise, I witnessed responders occasionally stall when they encountered something that should have prompted them to act. The stalls involved law enforcement, fire department, and emergency medical services (EMS) personnel and included situations in which agencies did not respond to the actions of other agencies.
This thesis answers the research question: What shared action points can law enforcement and fire rescue personnel identify, prior to an incident, to improve response coordination and collaboration? Shared action points are recognizable events that occur during an incident. Recognition of these events can enable responders to quickly act on them to establish, maintain, or build momentum.
Due to concurrent and sometimes conflicting response priorities, law enforcement and fire rescue interactions can be challenging during the initial phase of crises. Fire rescue responders coordinate their actions and work in teams to achieve established, common objectives set by a person attempting to consider all aspects of the incident. However, those objectives may not be known to law enforcement responders. By the same token, law enforcement responders work as individuals to accomplish objectives beneficial to the incident but not necessarily known to other police officers or fire rescue responders. For example, law enforcement needs to neutralize the shooter during an active shooter incident, while fire rescue responders prioritize lifesaving treatment and transport of victims. However, fire rescue personnel need coordination with, and assistance from, law enforcement to have access to victims. Groups of fire rescue personnel need to be escorted under the protection of groups of police officers to access victims. This course of action requires coordination between fire rescue and law enforcement and the formation of law enforcement groups rather than individual operators.
Responders must quickly identify the immediate needs, what decisions need to be made, and what actions to take during the initial phase of an ASHE to move the incident toward mitigation. No universally understood and shared factors exist between law enforcement and fire rescue responders to trigger action at an ASHE. Knowing what factors support and drive the responders’ actions during an ASHE could improve coordination and collaboration, especially early in the incident response. Shared action points between the disciplines would result in common and relevant priorities. Understanding how agencies can build on each other actions would help responders quickly establish common objectives to address the incident’s complex and possibly conflicting priorities. Ultimately, improved coordination through shared priorities and objectives should lead to improved victim outcomes.
- Research Phases and Findings
The research consisted of three phases. In the policy review and analysis phase, I analyzed the policies of three agencies that respond to ASHE incidents in the same county. The case analysis phase examined after-action reports (AAR) of four prominent ASHE responses that occurred in various locations throughout the United States to identify common occurrences that responders could recognize. In the focus group phase, I worked with six subject matter experts (SME) to validate my findings from the previous phases and to provide additional findings and conclusions. The research was conducted through the lens of Recognition Primed Decision Making (RPDM). The RPDM framework was used because it specifically related to decisions made under severe time constraints similar to those encountered during an ASHE.
- Policy Analysis
The objective of the policy analysis was to determine what actions in department policies could be considered shared action points. If actions found in a policy would or should cause additional action by another responder or agency, those actions were deemed a shared action point. Additionally, the analysis of current agency policies provided the opportunity to consider whether shared action points found in AARs should be written into policy if they were not already there.
I analyzed each policy to identify eight specific elements relevant to actions taken at an ASHE. As trends appeared during the analysis process, I categorized each policy directive based on the overall reason for the action using categories I developed. I analyzed each policy to determine if certain policy-directed actions could serve as shared action points that responders could be trained to recognize. Finally, I analyzed the interactions found in policy to understand how frequently and in what ways agencies are expected to interact during an ASHE.
- Policy Analysis Findings
The policy analysis found that several shared action points exist in agency policies. Moreover, individual agency policies call for action to be taken based on the actions of another agency. This finding indicates that agencies expect shared action points to be recognized and acted on. The expectation that shared action points are recognized and acted on demonstrates the importance of identifying them and communicating them to responders to ensure that critical on-scene interactions occur.
- Case Analysis
The objective of the case analysis was to identify possible shared action points that occur during an actual ASHE. Additionally, I sought to determine if those action points resulted in action by other agencies or responders that positively affected the incident. Identifying shared action points in an actual ASHE is important because they represent real occurrences rather than training events. Once identified, real circumstances that could serve as shared action points can be simulated in training environments to add realism, which may improve decision-making and decrease stall time. Finally, I looked for shared action points that occurred in several cases to find any identifiable trend. Shared action points that occurred in all or most of the cases should be a focal point of future training exercises.
I selected the four ASHEs analyzed for this research for specific reasons. I chose the shootings at the Inland Regional Center in San Bernardino, California; the Harvest Music Festival attack in Las Vegas, Nevada; the Pulse nightclub shooting in Orlando, Florida; and the Marjory Stoneman Douglas High School in Parkland, Florida, because of unique circumstances at each incident. Moreover, the extreme nature of the Harvest Music Festival shooting precipitated a significant policy and operational reaction from the three agencies whose policies were analyzed in this study.
I collected the seven data points from each case concerning the actions taken, who took them, the interactions that occurred, and the results of the actions taken. I hypothesized shared action points based on the actions reported and any corresponding actions that were taken, or because they were recommended in the report. Corresponding actions were also categorized by the person taking them and the response component. The results of the action were documented to the extent possible and categorized as either positive, neutral, or negative. I also analyzed the interactions occurring on scene to identify which agencies or people interacted.
Additionally, I analyzed the policy and case data to understand which response component was most affected by actions taken on an ASHE. I define the “response component” as one of three major response elements to achieve the objectives of the incident: strategy, tactics, and tasks. The data was also used to compare and contrast the effect of policy-directed actions and on-scene actions on response components.
- Case Analysis Findings
The case analysis found that shared action points similar to those found in policy occur during ASHE responses. Additionally, I found that if responders recognize the shared action points, they can take further action based on the actions of another agency. The interactions occurring at an ASHE are also important. Understanding where interactions occur will allow for increased understanding of whether actions by one agency or actor drive or influence actions by other agencies or actors. The case analysis also revealed that action taken by one agency or person often results in a corresponding action by someone else. Moreover, I found that when action is initiated by law enforcement during an ASHE, a positive outcome is likely. Finally, I found that an action chain consisting of shared action points exists, which may be useful to ASHE responders.
- Focus Group Sessions
To validate my research, I asked the SMEs to analyze my case and policy analysis findings and provide feedback as well as any additional findings. During this focus group discussion, SMEs participated in a brainstorming exercise to establish situations that responders should react to at an ASHE incident. In the exercise, focus group participants were asked to respond to the following questions: What stimulus at ASHE incidents should cause a reaction? and What stimulus at ASHE incidents should not cause a reaction?
Focus group SMEs also discussed the driving force concept described by the Advanced Law Enforcement Rapid Response Training Center (ALERRT) as it relates to RPDM. Focus group SMEs concluded that ALERRT’s driving forces are tightly linked to Klein’s RPDM theory. Based on the focus group’s discussion on driving force and its relationship to RPDM, SMEs posited that when a specific driving force is encountered, it engages the decision-making process by either causing a mental simulation or the recall of an analog as Klein discusses in RPDM theory.
In the focus group discussions, SMEs provided their feedback on my findings. SMEs participated in a second exercise where they were asked to provide expected responses from law enforcement officers and fire rescue/EMS to the stimulus that they provided in the first exercise. Finally, participants engaged in a Force Field analysis exercise to weigh the merits of incorporating RPDM concepts and findings discussed in the focus group in to agency training plans.
- Focus Group Findings
The focus group discussions gathered valuable insights from agency SMEs. The first focus group discussion generated a list of driving forces that SMEs would expect responders to react to. The second focus group discussion provided a prioritized list of actions that SMEs expected responders would take during an ASHE. Finally, SMEs provided their input on whether the findings of this research should be incorporated into agency training in a scored exercise.
- Synthesis of Findings
A key finding of this research is that the outcome of actions taken by an individual may serve as the next driving force during an ASHE response. The outcomes of each action create new “actionable intelligence,” which is how ALERRT describes a driving force. Following this logic, the outcome serves as the next driving force, but only if it is recognized as such. This process starts with the first driving force encountered and forms an action chain that flows through the incident until it breaks or the incident is mitigated. I refer to this process as the mitigation action chain or mitigation action chain.
- Development of a Conceptual Model
As a result of this research, I developed a conceptual model called the mitigation action chain. The mitigation action chain depends on responders recognizing and acting on driving forces encountered during an ASHE (Figure ES-1). In terms of this conceptual model, I refer to the process of recognizing and responding to each driving force as the ASHE recognition process. As this process plays out, it creats a new link in the mitigation action chain. Each individual link in the mitigation action chain is made up of driving forces, processing, actions, and outcomes. The links connect to each other to form the mitigation action chain, which moves the incident toward mitigation. Figure ES-2 shows an example of the mitigation action chain.
Figure ES-1. Mitigation Action Chain
Figure ES-1. Mitigation Action Chain (MAC) Development
The case analysis of the actions taken during actual ASHE responses demonstrated that responders do recognize those points and often respond appropriately to them. In many cases, the actions taken in response to a driving force generated an outcome that served as another driving force. Each of these driving forces and outcomes is a potential shared action point. Each iteration of driving force, processing, action, and outcome—where the outcome serves as a new driving force—causes another action. Every time the ASHE recognition process runs its course, it forms a new link in the mitigation action chain and sets a course toward mitigation of the incident. However, the chain is broken when an action is not taken in response to any single driving force. The fracture of this chain may either slow or completely stop the march toward mitigation.
If responders recognize that outcomes of certain actions provide the opportunity for another action, then each action functions as a shared action point. In turn, as the actions build new mitigation action chain links, they form the mitigation action chain, which leads to the mitigation of the incident. The process is not rigid or linear and may be messy and circuitous, like a chain that is not under tension. The chain may branch out in different directions, all eventually merging at mitigation. Regardless of how the chain forms, if it remains intact, it leads to mitigation. If stalls in decision-making time are reduced or eliminated, the time to mitigation will likely be shortened.
Shared action points are important to responders because they help build or maintain momentum during an ASHE. Shared action points are similar to the tactical benchmarks used in the fire service. Benchmarks serve as an indicator of progress and incident status to all firefighters on the scene. When the incident commander announces a benchmark over the radio, it signals a transition phase in the incident where different priorities develop and different actions are required. The critical element of benchmarking is the shared understanding of what they mean and what actions are expected in the new phase of the incident.
This research resulted in 26 shared action points, shown in Table ES-1, that may occur at an ASHE. It could be argued that some shared action points are more critical for positive outcomes than others. Because this research is specific to the agencies involved and not generalizable, researchers would need to establish their own shared action points based on their policies.
To improve response coordination and collaboration, these action points can be incorporated in a cross-discipline training plan that introduces the mitigation action chain conceptual model. The training plan would explain how shared action points can decrease stall time and improve incident outcomes. Training would also explain how the RPDM process, driving forces, and the mitigation action chain are related.
Table ES-1. Shared Action Points
|An ASHE incident has been dispatched|
|An ASHE incident is actually occurring|
|Shots fired by perpetrator|
|Viable victims are present|
|A need to increase coordination|
|Triage area is too close to the hot zone|
|Rescue/mobility is limited by some condition|
|Equipment is not working|
|Equipment is missing|
|A suspicious object or package is present|
|A suspected explosive device is present|
|A responder has critical information|
|A responder is wounded/injured|
|A role or function is already filled or completed|
|A role or function is not already filled or completed|
|A command role or function is not effective|
|Learning the perpetrator’s location or location changed|
|The perpetrator is neutralized|
|Shooting or other mechanism of wounding victims has stopped|
|The perpetrator is monitoring responder’s actions|
|Communication problems exist|
|Unprotected personnel are too close to the hot zone|
|Arriving at an ASHE incident|
|Transporting a patient to the hospital (LE officer)|
|Encountering a room of people hiding from perpetrator|
LE = law enforcement
Evaluating the criticality of each shared action point could be another area of future research. The findings of such evaluation might help responding agencies focus more intently on these critical points during training exercises. Additional future research could include conducting timed experiments to determine the effectiveness of shared action points during all phases of an ASHE incident.
ASHE responses are complex, chaotic events that require significant coordination between law enforcement and fire rescue responders to ensure the most positive outcome possible for victims. The ASHE recognition process will help responders recognize shared action points that allow responders to build on each other’s actions without delay. As responders act in response to driving forces, the mitigation action chain forms a path toward mitigation. Responders trained to recognize shared action points and seize the opportunities they present will likely increase effectiveness during ASHE responses and thereby increase the likelihood of victim survivability.
 The author defines the order phase of an incident as occurring when the situation has stabilized to the point that the harm occurring—either to people, property, or the environment—is not growing in magnitude or scope. For example, a fire inside a building is controlled by the fire department. It may not be extinguished, but it is not growing.
 Gary Klein and Beth Crandall, Recognition-Primed Decision Strategies (Alexandria, VA: Army Research Institute for the Behavioral and Social Sciences, 1996), 4, https://apps.dtic.mil/sti/citations/ADA309570.
 Advanced Law Enforcement Rapid Response Training and Federal Bureau of Investigation, ALERRT Train-the-Trainer: Active Shooter Response Level 1, Version 7.2 (San Marcos, TX: Texas State University, 2020), INST 4–3.
 Klein and Crandall, Recognition-Primed Decision Strategies, 2.
 Klein and Crandall, 3.
 Mind Tools Content Team, “Force Field Analysis: Analyzing the Pressures for and against Change,” Mind Tools, accessed May 29, 2022, http://www.mindtools.com/pages/article/newTED_06.htm.
 Advanced Law Enforcement Rapid Response Training and Federal Bureau of Investigation, ALERRT Train-the Trainer, INST 2–26.
 John Coleman, Incident Management for the Street-Smart Fire Officer (Saddle Brook, NJ: Fire Engineering, 1997), 298–99.