Near Miss Reports: What schools can learn from the zero fatality goal in aviation
Near Miss Reports: What schools can learn from the zero fatality goal in aviation
When airplanes almost crash, an investigation and report is mandated by the FAA. At schools when a mass shooting almost happens, little or no info is shared.
A plane full of passengers dying in a crash was the accepted norm every year from the beginning of commercial aviation in 1914 until the 1990s. Everything changed when the federal government and airlines got serious about safety and set a goal for zero commercial airline deaths each year. Commercial aviation is now safer than driving a car. A major factor in reducing deaths was studying accidents that happened, and collecting data on crashes that almost happened…known as near miss reporting.
A near miss in aviation is an incident that could've caused physical injury or property loss but didn't. When a near miss happens in an airplane, a report needs to be filed with the FAA within seven days so that other pilots are aware of what happened. Creating a culture that prioritizes safety above all else means that mistakes are not kept secret, they are documented and openly shared across the aviation industry.
Unlike aviation, the federal government has not made safety a top priority at schools. When a near miss happens on campus, the government fails to collect, analyze, and share this information. For example, a student with a handgun and 50 rounds of ammo walked into the principal’s office and fired a shot striking the principal in his arm. As he pulled the trigger a second time, the gun jammed. When the shooter fumbled with the weapon, two quick thinking staff members tackled him. Nobody else was hurt and the principal survived his injuries.
This is not a fictional scenario. It happened at Harrisburg High School in South Dakota in 2015. (Full report at the end)
Had you ever heard about this near miss school shooting? There are many lessons to learn from it. For example, the teenage shooter had just transferred to the school from out of state and was having a hard time adjusting. A major life stressor can lead to a crisis where a teen thinks that violence is their only option after cries for help aren’t heard.
Defining Near Misses at Schools
From collecting data on sixty years of school shootings, I’ve seen a wide array of different circumstances. Based on these real-world incidents, I’ve adapted the aviation definition of near miss to include shootings at schools that had the potential to be much worse. A near miss can be an incident without injuries or deaths. It can also be a shooting with victims killed or injured that had the potential to be much worse.
A “mass shooting” with 4 or more victims is the common threshold for a school shooting to get national media attention. A shooter with hundreds of rounds of ammunition who intends to harm many students but “only” wounds 2 victims is a near miss.
Here are some factors that go into classifying an incident as a near miss:
Intent/plan: Shooter had a detailed plan, maps, hitlist, or manifesto showing the intent to harm more students than were shot during the incident.
Multiple weapons: Shooter was armed with multiple guns demonstrating an intent to cause harm. While a teen might carry a handgun for self-defense, a teen with multiple weapons is probably committing a planned attack.
Amount of ammo: Shooter had dozens, hundreds, or even thousands of rounds of ammunition showing a capability to cause many deaths and injuries.
Number of shots fired: Shooter fired many shots but most of them missed the targets (literally a near miss). Example: 240 shots were fired at the Edmund Burke School in Washington, DC but only 4 people were wounded.
Gun malfunctioned: Shooter was attempting to shoot students, but the gun jammed.
Early intervention: Shooter was in the process of shooting (or attempting to fire) when staff, students, or bystanders intervened and stopped the attack before multiple victims were killed or wounded.
From studying school shootings back to 1966, I’ve gathered data on 381 near misses.
Near Miss Reports for Subscribers
Near miss reporting is mandatory for aviation and part of the reason there hasn’t been a fatal airline crash in the United States in more than a decade. In school safety, this is the first public compilation of near miss reports that will be published.
School Shooting Near Miss Reports for subscribers will include:
Date, time, school info, and diagrams of location (if applicable)
Incident summary
Near miss factors
Worst case scenario
Analysis of what went right and wrong
Alignment to trends with other averted and actual attacks
Lessons learned to apply to preventing future school shootings
School: Harrisburg High School
Harrisburg, South Dakota
1,478 students (suburb of Sioux Falls with pop. 6,700)
US News performance score 45/100
86% white, 6% of students on free lunch, 1:14 teacher to student
Large multi-building connected campus with 4 primary points of entry and dozens of exterior doors
Date: September 30, 2015
Time: 10:00am (during morning classes)
Summary: Student walked into the principal's office with a handgun and 50 rounds of ammo. He fired a shot striking the principal in his arm and when he pulled the trigger a second time, the gun jammed. As he fumbled with the malfunctioning weapon, two other staff members tackled him. After the shooting, school officials said the student needed help and they failed him. The teenage shooter had no history of violence, showed remorse in court, and was diagnosed with major depressive disorder. Prior to the shooting, he transferred to the school from out-of-state and had trouble adjusting to the new school. He was sentenced to mental health treatment and long-term probation rather than prison. As an adult, the shooter later broke the terms of his probation and was sentenced to 10 years in prison for domestic violence.
Near Miss Factors: 50 rounds of ammo; weapons malfunction; early intervention by staff
Worst case scenario: If the gun didn’t jam, the shooter had enough ammo to kill the principal, shoot other staff members and/or students, and then commit suicide.
What went right: Staff members took quick action to subdue and disarm the shooter.
What went wrong: School staff and the shooter’s parents failed to identify the warning signs of a teen in crisis (major stressor from moving and not adjusting to new school), failed to identify symptoms of major depressive disorder, failed to limit a 15-year-old’s access to a handgun, and failed to implement a security plan to prevent a student from bringing a gun onto campus or to keep an armed student from walking into the principal’s office.
Alignment to other attacks: Same pattern as most planned attacks at schools since 1966:
Teenage male student
Crisis from trauma or major stressor
Too young to purchase a handgun from a store
Handgun is accessible and unsecured in the shooter’s home
Teen is depressed and/or suicidal
Lessons learned:
Need crisis intervention program to identify and assist student in crisis
Parents and relatives need to secure firearms in their homes
Communication between school officials and parents to identify mental health issues
School staff need to monitor students following major stressors such as new students who have just transferred into the school from a different community
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.