575-page DOJ report on Uvalde is a roadmap to make every school safer
This document is only twenty pages shorter than 9/11 Commission Report making this critical information inaccessible to busy school administrators who need it the most.
This report offers a roadmap for every superintendent, school principal, and police chief to use the observations and recommendations as a checklist to ensure the same failures won’t happen in their community (note: I’ve made that checklist for them).
The response to Robb Elementary was an abject failure by police to not enter a classroom and save children during a school shooting. That’s not new information.
What is new in the Department of Justice report is hundreds of findings that range from complacency to cowardness across the entire public safety enterprise in Uvalde and Southeast Texas. Many of these findings point to systemic failures from inattention and incompetent leadership that may be happening in police departments across the country.
In typical government fashion, this report is inaccessible to the people who need this information the most. Opening a 575-page PDF file will crash older computers and test the focus of any reader.
The document uses more than 125 different acronyms including IADLEST, NMVVRC, and MMHPI. Recommendations are written with jargon and references that don’t make sense to a school official (e.g., Recommendation 36.2: The UTRC should engage with the OVC-funded NMVVRC Resiliency Center Director Forum network).
If I was a school official, I would read each recommendation and figure out what it means in plain language. If the same problem could happen at my school, I would highlight it and assign someone to fix the issue. With an encyclopedia length PDF file, that’s not possible.
To help solve this problem, I’ve created a spreadsheet with separate rows for each of the 273 observations and recommendations. While this is a lengthy process, I’m also adding plain language translations for each of the recommendations.
I added additional columns to help a school official and police chief review the findings, self-assess capabilities, and assign corrective actions.
Unlike a huge PDF file, spreadsheet rows can be sorted, moved, or copied. If there are ten corrective actions that should be assigned to the city’s emergency manager, those tasks can be sorted and cut/pasted into an email.
If you would like an editable version (or to help with the translation process) of this spreadsheet, please email k12ssdb@gmail.com.
Summary & Structure of the report
The officers in Uvalde didn’t just fail to enter the classroom, the entire public safety system failed at hundreds of other smaller tasks before, during, and after the shooting. No response is perfect but when hundreds of things go wrong, the entire system crumbles.
Here are examples of simple actions that failed because of lack of training, poor planning, inattention, and incompetence:
Gunshot victims were loaded onto a school bus without being checked for injuries.
Without a command structure to organize responding officers, hundreds of police cars blocked the roads and made it impossible for ambulances to get to the school.
Official Uvalde social media accounts posted messages that said all students were safe and the shooter was in custody prior to police entering the classroom.
Parents who waited for hours at the reunification center were told another bus of children was on the way. This bus never arrived because they were unknowingly the parents of children who were killed or hospitalized.
Red Cross was never given a list of contact info for victims’ families so that they could connect families with services.
Officers without specialized training gave death notices to parents while an FBI team of trauma experts was available and unused.
Memorial items were removed and disposed of without notifying families or informing the community about plans for a permanent memorial site.
Officers who were inside the school were sent to an outdated crisis debriefing program that has been shown to cause psychological harm and reinforce trauma.
Each one of these failures could happen after any school shooting if the officers, emergency responders, and school officials involved haven’t planned, trained, and prepared for a major incident.
This report offers a roadmap for every superintendent, school principal, and police chief to use the recommendations and findings as a checklist to ensure the same failure wouldn’t happen in his or her community. I’ve created a spreadsheet with separate rows for each of the 273 observations and recommendations.
The DOJ report is organized into findings and recommendations for seven topics areas (chapter 1 is a summary of the incident):
Chapter 2. Tactics and Equipment: Examines tactical approaches and availability of special tools and equipment during the critical 77 minutes between the arrival of first responders on scene through the classroom entry and killing of the shooter.
Chapter 3. Leadership, Incident Command, and Coordination: Examines the leadership, incident command, decision-making, and coordination actions that took place across responding agencies and law enforcement leaders.
Chapter 4. Post-Incident Response and Investigation: Assesses the establishment of post-incident investigative command and activities, victim identification, and crime scene management, as well as administrative investigations and after-action reviews.
Chapter 5. Public Communications During and Following the Crisis: Examines communications activities and approaches with and between government entities (including law enforcement) and the general public, family members, professional media, social media, and others.
Chapter 6. Trauma and Support Services: Analyzes support and resources provided to survivors, victims, responders, and other stakeholders.
Chapter 7. School Safety and Security: Documents the school safety planning and assesses the security apparatus of the Uvalde Consolidated Independent School District (UCISD).
Chapter 8. Pre-Incident Planning and Preparation: Assesses the training, agreements, and procedures for law enforcement, other first responder agencies, and other relevant stakeholders in the critical areas of active shooter response, incident command, emergency management, and other significant areas.
Important note from the DOJ press conference
At the end of the press conference to unveil the report, Attorney General Merrick Garland was asked “what are the most important findings?”
A.G. Garland responded that the DOJ’s top recommendations are:
Active shooter training for police
Establishing an onsite incident commander
Emergency radios need to be interoperable
These three recommendations are a more shocking sign of systemic failure than anything in the 575-page PDF.
Active shooter training for civilians has been common (or mandated) in schools and workplaces since 2008…more than 15 years ago. Columbine—which allegedly “changed everything for how police respond to schools”—was 25 years ago. How are police officers not being trained for an active shooter situation that is widely understood by regular people to be an ever-present threat requiring rapid response?
Establishing an “incident commander” during an emergency response has been a common practice for fire departments since portable radios became standard in the early 1970s. One of the recommendations from the 9/11 Commission Report was to establish a standard “Incident Command System” that would be used by every police and fire department in the country. Since the mid-2000s, a condition of federal grant funding to state/local police and fire departments is that all personnel are trained in the Incident Command System (known as ICS and NIMS—national incident management system). The federal government offers free online ICS training sessions that take less than an hour to complete. If hundreds of officers who responded to Robb Elementary were all lacking this basic training—which has been standard for 20 years—there is both a leadership and compliance issue that needs to be investigated.
At the World Trade Center, emergency responders from different agencies couldn’t communicate. 343 firefighters continued to climb the stairs because they couldn’t hear radio messages to evacuate. A recommendation of the 9/11 Commission Report was making all public safety radios interoperable and we have spent billions of tax dollars to do that for every police and fire department in the country. Another note, radio failures were at the center of the Parkland SRO’s legal defense. I wrote this article about Parkland and the problems with the radios systems used by most police and fire departments.
Solutions
This report shows there are hundreds of small things that can go wrong before, during, and after a school shooting. When they all go wrong, there is a catastrophic failure. Fixing these small problems before an attack happens is a task that needs to start today in every community across the country.
David Riedman is the creator of the K-12 School Shooting Database and a national expert on school shootings. Listen to my recent interviews on Freakonomics Radio, New England Journal of Medicine, and Iowa Public Radio the day after the Perry High shooting.
Thank you so much for your comprehensive and considered analysis of the DOJ Report on the Uvalde school shooting. This travesty could obviously have been so much less tragic with competent response, in contrast to the incredibly incompent response. Of course, such incompetency re firearm safety happens everywhere, from poor political response from our legislators re firearm safety to ignoring the precursor signs that we saw in the Lewiston shootings regarding Mr. Card and the New Hampshire Hospital shooting and killing of a police officer by Mr. Madore. I authored an Op-Ed re those shootings entitled “When will we ever learn?” No matter all the knowledge we have about firearm shootings, the obstacles to making progress seem always to be elusive given the power of the opposition to making thechanges that are needed.
Nevertheless, I am so impressed by your work on school shootings.
Leonard Korn MD
Chair, Subcommittee on Violence as a Public Health Issue, New Hampshire Medical Society