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An examination of the law enforcement response to active shooter incidents in U.S. cities: findings and implications for improving future response efforts

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An examination of the law enforcement response to active shooter incidents in U.S. cities: findings and implications for improving future response efforts

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Content AN EXAMINATION OF THE LAW ENFORCEMENT RESPONSE TO ACTIVE
SHOOTER INCIDENTS IN U.S. CITIES: FINDINGS AND IMPLICATIONS FOR
IMPROVING FUTURE RESPONSE EFFORTS
by
Travis Norton
A Dissertation Presented to the
FACULTY OF THE USC SOL PRICE SCHOOL OF PUBLIC POLICY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF POLICY, PLANNING AND DEVELOPMENT
August 2024
Copyright 2024 Travis Norton

ii
Table of Contents
List of Tables ....................................................................................................................v
List of Figures ..................................................................................................................vi
Abstract........................................................................................................................... vii
Chapter 1: Introduction .................................................................................................... 1
Active Shooter Terminology and Current Response Protocols............................. 2
Chapter 2: Literature Review ........................................................................................... 8
Active Shooters – A Historical Perspective........................................................... 8
Active Shooter Literature .................................................................................... 23
ASIs and Systems Theory .................................................................................. 24
Complex Systems Theory................................................................................... 26
Initial Police Response Phase Challenges ......................................................... 27
The Incident Command System.......................................................................... 28
Chaos Theory...................................................................................................... 32
Uncertainty and Novelty...................................................................................... 39
Normal Accident Theory...................................................................................... 41
Purpose of the Study and Applications for Advancement................................... 42
Audience of the Study......................................................................................... 42
Chapter 3: Research Methods....................................................................................... 43
Research Questions ........................................................................................... 43
Approach............................................................................................................. 44
Worldview............................................................................................................ 44
Chapter 4: Data Reporting and Analysis ....................................................................... 57
After-Action Reports[2] ......................................................................................... 58
Uncertainty and the Incident Command System................................................. 60

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Thematic Analysis Summary............................................................................... 60
Response Difficulties Caused by IC Challenges................................................. 61
Specific Incident Command Challenges from AARs........................................... 62
Interviews of Law Enforcement Involved in ASI.................................................. 69
Specific Communication Challenges .................................................................. 76
Inappropriate Self-Deployment ........................................................................... 82
Thematic Analysis Summary............................................................................... 96
Unified Command Challenges ............................................................................ 99
Novelty .............................................................................................................. 109
Chapter 5: Discussion.................................................................................................. 122
Research Question #1: What Are the Known and Unrevealed Primary LE
Challenges for LE Supervisors That Contribute to Chaos and Uncertainty
During ASIs?..................................................................................................... 122
Research Question 2: How Do Response Challenges Due to Uncertainty or
Chaos Affect the Police Response to ASIs?..................................................... 124
Research Question 3: What Changes Can Be Made to the LE Response
System to Improve ASI Future Response Efforts and Reduce Uncertainty
and Chaos?....................................................................................................... 124
Recommendations for Practice......................................................................... 124
Policy Recommendations ................................................................................. 132
Recommendations for Future Research ........................................................... 141
Conclusion ........................................................................................................ 142
References .................................................................................................................. 143
Appendices .................................................................................................................. 161
Appendix A: Interview Script ............................................................................. 155
Appendix B: Other AARs .................................................................................. 160

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v
List of Tables
Table 1: AARs to Be Analyzed (in Order of Date of Incident)........................................ 46
Table 2: Joint Command vs. Unified Command (Heal, 2020) ..................................... 102
Table 3: Stakeholder Characteristics Around the Development of Active Shooter
Response Legislation .................................................................................................. 136

vi
List of Figures
Figure 1: Active Shooter Incidents 2018-2022................................................................. 2
Figure 2: System Theory Applied to First Responders During an ASI........................... 26
Figure 3: Command Staff Interference With the Incident Commander........................ 120
Figure 4: Initial Police Response Network Model ........................................................ 130
Figure 5: ICS Hierarchical Network Hybrid Model ....................................................... 131
Figure 6: Logic Model for Creating Active Shooter Incident Response
Recommendations....................................................................................................... 137
Figure 7: Swiss Cheese Model of Active Shooter Response Challenges ................... 141

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Abstract
The Columbine active shooter tragedy on April 20, 1999, fundamentally changed
the police response system. Despite these changes, law enforcement (LE) response
challenges are a serious concern and can put lives at risk. These response challenges
include incident command, indiscriminate parking, inappropriate self-deployment,
communications, and unified command. These difficulties contribute to uncertainty and
chaos during the response. Researchers have yet to investigate the active shooter
police response system and the complications that arise during the response. To
address this research gap, this study examined the quality of the initial LE response,
which is the crucial decision-making point in determining the number of lives lost and
saved. The study examines qualitative interview data and archival after-action review
data to (a) identify essential factors leading to ASI injury and death, conceptualized as
uncertainty and chaos, and (b) develop recommendations to help inform policy and ASI
training. Qualitative interview data revealed response complications not listed in the
archival after-action reviews. This qualitative interview data includes the lack of
command decision-making training, incident commanders facing life and death
decisions, difficulties helping innocent victims when the adversary targeted police, and
friction when executive command staff were present. The study concludes with
numerous recommendations to address response challenges and inform future
response efforts.

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Chapter 1: Introduction
On October 1, 2017, at approximately 10:05 PM, the most devastating mass
shooting event in U.S. history began on the last day of the Route 91 Harvest Festival in
Las Vegas, Nevada. The shooter, who rented a room on the 32nd floor of the Mandalay
Bay Hotel overlooking the Las Vegas Village concert venue, commenced shooting into
a crowd of approximately 20,000 concertgoers. For 11 minutes, the shooter fired 1,057
rounds at concertgoers, down the hallway at a security guard who was struck in the leg,
and at fuel tanks that connect to McCarran International Airport. For those 11 minutes,
chaos ensued at the concert venue. The Las Vegas Metropolitan Police Department
(LVMPD) officers working at the concert and concert attendees were initially confused
about whether the gunfire was fireworks (LVMPD, 2018, p. 25). However, as the firing
continued, many concertgoers began to understand what was occurring and fled.
Once LVMPD officers identified the active gunfire, they experienced uncertainty
and had difficulty determining the source of the gunfire, initially believing the shooter
might be inside the concert venue. An LVMPD detective utilized binoculars to locate the
shooter and broadcasted the information on the police radio. Responding officers
formed teams to locate the shooter, with one team locating him just as the shooting had
stopped. Ultimately, a special weapons and tactics (SWAT) officer used explosives to
breach the door to the shooter’s hotel room (Federal Emergency Management Agency
[FEMA], 2018). Inside the room, the team of officers found the shooter dead from a
self-inflicted gunshot wound to the head.
As a result of this incident, 59 people died, including the shooter, more than 850
people were injured, and over 400 were struck by gunfire (FEMA, 2018). While this was

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the deadliest active shooter incident (ASI) in U.S. history, it was only one of 30 incidents
in 2017. In that year, 138 people were killed, and 591 were wounded (Federal Bureau
of Investigation [FBI], 2018). The number of people killed and wounded was
exceptionally high in 2017 due to the mass shooting at the Harvest 91 Festival and the
First Baptist Church in Sutherland Springs, Texas. However, the number of active
shooter incidents (ASIs) has proliferated over the past 20 years, and ASIs pose a
severe threat to the safety of the U.S. population. While ASIs decreased by 18%
between 2021 and 2022, they increased by 66.7% from 2018 to 2022 (U.S. Department
of Justice, 2023).
Figure 1
Active Shooter Incidents 2018-2022
Note. Reprinted from U.S. Department of Justice, 2023
Active Shooter Terminology and Current Response Protocols
Although the term “active shooter” has become part of the public’s lexicon, it has
disparate meanings depending on the audience. Academic researchers have used the

3
terms “mass murder,” “mass shooting,” “autogenic massacres,” and “rampage shooting”
to refer to ASIs (Bowers et al., 2010; Fox & Levin, 2005; Mullen, 2004; Palermo, 2007).
Some of these incidents do not involve a firearm but a stabbing instrument, a vehicle, or
a bomb. The variety of weapons used adds to the confusion because these events do
not always involve an “active shooter,” as the widely used term indicates. Martaindale
and Blair (2019) highlighted these variations and suggested “active attacks.” While this
reference might add some clarity, the requirement is that the incident is “active.”
Incidents generally last 5 minutes or less (FBI, 2014), indicating that the term is
marginally helpful for law enforcement, who must respond within this short time frame.
Frazzano and Snyder (2014) also identified the inadequacy of the term “active shooter,”
stating that it does not convey to first responders and the public the multiple types of
attacks they might encounter. While they suggested the term “hybrid targeted violence,”
this term also does not clearly describe the wide variety of characteristics in such
incidents.
Further complicating the matter are incidents when a suspect barricades with
injured hostages, as occurred in the Pulse Nightclub attack in Orlando, FL, and at Robb
Elementary in Uvalde, TX. The term “active shooter” does not fit these circumstances.
At Robb Elementary specifically, once the shooter stopped actively shooting and was
inside a classroom with access to victims, responding officers stated he was barricaded.
During the incident, references to a “barricaded” or “contained” subject were transmitted
at least 26 times in person and via phone, radio, and text message (U.S. Department of
Justice [U.S. DOJ], 2023). The use of the terms “barricaded” and “contained” added
confusion to the response as more officers arrived on the scene with “a fundamentally

4
different understanding of the situation” (U.S. DOJ, 2023, p. 96). The U.S. DOJ Robb
Elementary after-action review (AAR) attempts to clarify these specific circumstances by
stating,
“An active shooter rarely ceases to be an active shooter and always remains an
active shooter so long as the shooter has access to victims. Active shooter
response protocols indicate that an active shooter’s past actions and reasonably
assumed imminent actions, along with the presence of victims, all determine
what actions law enforcement should take.” (U.S. DOJ, 2023, p. 92)
The widely accepted definition of an active shooter among local, state, and
federal law enforcement comes from the U.S. Department of Homeland Security (DHS),
which DHS defines an active shooter as “an individual actively engaged in killing or
attempting to kill people in a confined and populated area” (FBI, 2014, p. 1). Multiple
U.S. government agencies use this definition, including the FBI, the White House, the
U.S. Department of Education, and FEMA. While federal agencies widely accept this
definition, local responders who handle these incidents may have distinct experiences
leading to different definitions. Police response tactics vary for these different incidents
at the local level, and the variation in terminology could contribute to friction in the
response.
Distilling ASIs to one national standard may be impractical as there are wide
variations in definitions and terminology by scale (local, state, federal) and perspective
(academic, first responder, policy maker). However, standard definitions and
terminology are essential because they help first responders mitigate ambiguity during
their response. Standard definitions also align with the Incident Command System

5
(ICS) requirement that responders use common terminology during critical incidents
(FEMA, 2006). The National Incident Management System cites common terminology
as being needed to ensure efficient and clear communications among responders
during a crisis (FEMA, 2006).
The primary public safety responders to ASIs are local law enforcement (LE)
officers. The current response protocol strategy begins with the Stop the Killing Phase,
followed by the Stop the Dying Phase (Martaindale & Blair, 2019). This strategy was
created after the Columbine High School ASI in 1999 when LE officers implemented a
contain-and-wait strategy. Using this strategy, LE officers did not intervene in the
shooting but waited outside the school until SWAT teams arrived. The strategy was
ultimately discarded because of the loss of life (Mijares & McCarthy, 2015).
Columbine was a watershed event for police response protocols. After that
incident, SWAT members trained officers nationwide to form four- to five-person teams
to enter buildings and address active shooters. SWAT team members are subject
matter experts in entry and movement into structures and are suited to train officers in
these team-based tactics (Martaindale & Blair, 2019). These tactics evolved into soloofficer responses because officers rarely arrive at an active shooter incident together.
Waiting for more officers to arrive to form a team may allow an active shooter(s) access
to more victims (Martaindale & Blair, 2019). This time lag and the risk of additional
injuries and/or deaths caused ASI police tactics to move to solo-officer response when
practical.
Once the police have neutralized or taken an active shooter into custody, there is
a critical need to assist the injured and dying, which is when the Stop the Dying Phase

6
begins. Getting fire and emergency medical services (EMS) personnel to victims is
difficult when a scene is not secure. This response challenge led to officers being
trained in emergency medical care and creating different models of getting medical
personnel to the wounded. One of these models involves officers escorting teams of
fire and EMS (rescue task force) into the “warm zone,” where there is no active threat,
to treat the injured (Martaindale & Blaire, 2019, p. 249). In this model, police officers act
as security for fire and EMS personnel while they treat and transport the injured to a
higher level of care (Martaindale & Blair, 2019).
Most active shooter training has focused on training the initial responding officers
in the Stop the Killing and Stop the Dying Phases. Much less has been done to train
arriving police supervisors to lead and manage ASIs. Numerous ASI AARs confirm this
training gap by listing incident command challenges, including the absence of an
identifiable incident commander (Straub et al, 2017; U.S. Department of Justice, 2024;
Ventura County Sheriff’s Office, 2021). There are also response challenges with
integrating with fire/EMS and establishing unified command. As an instance, during the
Pulse Nightclub attack on June 12, 2016, the Orlando Fire Department (OFD) were not
in the unified command center and not aware of command decisions (Straub et al.,
2017).
As mentioned, police officers are generally the first public safety representatives
to respond to an ASI. Despite improvements in response training and tactics since the
Columbine incident, there remain LE response system challenges, including police
incident command problems, unified command issues, indiscriminate parking,
inappropriate self-deployment, and communication difficulties (Braziel et al., 2015;

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Braziel et al., 2016; Broward County Aviation Department, 2017; Connecticut State
Police, 2018; Lindsey, 2014; Police Foundation, 2015; Straub et al., 2017).
The aforementioned response challenges contribute to uncertainty and chaos
during the response. However, researchers have yet to investigate the ASI police
response system and the problems that arise during the response. To address this gap
in the research, this dissertation focuses on the initial ASI response phase. The study
examined the quality of the initial LE response, which is a short period within the context
of an ASI and may be the crucial decision-making point in determining the number of
lives lost and saved. The LE response to non-ASIs was purposely excluded from this
study. Instead, this dissertation centers on conflicts that involve an adversary and, as
such, carry unique challenges to LE responders (Heal, 2012).
The study analyzed qualitative interview and archival data to (a) identify
important factors leading to ASI injury and death, conceptualized as uncertainty and
chaos, and (b) develop recommendations to help inform policy and ASI training. The
remainder of this dissertation provides an overview of terminology and current
protocols, a review of the literature on current response to ASIs, the study design to
collect and analyze archival and interview data, the findings from the qualitative case
study analysis, and a summary of the most important findings and recommendations
stemming from this analysis.

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Chapter 2: Literature Review
Examining the initial LE response to an active shooter requires exploring several
bodies of literature inside and outside the active shooter domain. This study first
required studying the history of ASIs to demonstrate that contemporary police
responders face circumstances similar to those faced in the past. Next, this chapter
examines the current police response system, followed by the complex systems theory
and its relevance in the police emergency response system. The chapter briefly
examines the applicability of the Incident Command System (ICS) in the initial ASI
response phase. The concepts explored in this chapter include chaos theory,
uncertainty, and novelty. These topics will lay the groundwork for their impact on the LE
response system. The final category of relevant literature is the role of Perrow’s (1984)
normal accident theory in the LE response system.
Active Shooters – A Historical Perspective
Former U.S. Marine Corps General John Mattis (2020) stated that “history
teaches us that we face nothing new under the sun” (p. 42). While his statement’s
context concerns the historical study of war, it is no less applicable to understanding the
history of ASIs in the U.S. U.S. history is replete with examples of active shooters
dating to the Winfield, Kansas, attack at an outdoor concert that killed nine and injured
dozens on August 13, 1903 (Weinman, 2016). The Winfield, Kansas, attack and other
historical instances of ASIs show that LE responders face the same challenges today as
in the early 1900s. To improve the LE response to ASI, which is the overarching goal of
this work, an analysis of significant historical ASIs will be presented to highlight the
similarities to present-day ASIs.

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Winfield, Kansas – Active Shooter – August 13, 1903
Gilbert Twigg is arguably the first active shooter in the history of the U.S. Twigg
moved to Kansas with his uncle around 1888, worked as a miller, and met a local
woman. Twigg eventually proposed but broke off the engagement shortly after she
accepted. The broken engagement changed something in Twigg, who enlisted in the
U.S. Army 2 years later, where his marksmanship earned him a promotion to corporal
(Lyons, 2020). He did not see combat during his first several years but re-enlisted and
went to the Philippines, where there was a conflict between The Philippine Islands and
the U.S. over independence. While there, Twigg began to show signs of post-traumatic
stress disorder, which was not understood at the time (Lyons, 2020).
After being honorably discharged from the Army, Twigg failed to get his old job
back and could not find other employment, possibly because of his mental state (Lyons,
2020). Ultimately, he went to a hardware store and purchased a shotgun, a .32 caliber
handgun, and over 100 rounds of ammunition. Over the next several days, he practiced
his firearms skills. Almost two weeks after purchasing the firearms, Twigg placed them
in a wagon he pulled to Main Street and Ninth Ave. Near this area, a group of
approximately 1,000 to 5,000 people gathered for an outdoor concert by a military band
(Weinman, 2016). A group of boys saw Twigg coming up the alley, surveying the crowd
and holding his shotgun. Several minutes later, he dropped to one knee, pointed the
shotgun, and yelled, “I’ll kill every one of you” (Weinman, 2016, para. 7). Twigg began
firing as the crowd panicked. His first round hit a horse. Three men were hit exiting a
building, and the gunfire also struck another group of three women and a teenage boy.

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The local paper, The Chronicle, later wrote that Twigg was using military skirmish
line tactics by firing and retreating backward. The paper also said that Twigg fired low,
as the Army trained him to do (Lyons, 2020). Toward the end of the incident, Twigg
returned to his wagon in the alley. There, he shot himself in the head with the .32
caliber pistol, killing himself. The entire incident lasted 10 minutes, and eight people
died (Lyons, 2020).
Twigg left a manifesto where he wrote, “You should let this be a lesson to you in
the future,” toward the end of the document (Lyons, 2020, para. 8). Undoubtedly, it is
an ominous lesson for later generations of LE responders. In this historical ASI, the
tragic incident can be compared to present-day ASI statistics published by the FBI to
elucidate similarities to present-day ASIs. In a review of ASIs from 2000-2019, 96% of
ASIs were committed by lone male shooters. Also, 119 of those shooters committed
suicide, while 50 of the 345 total ASIs occurred in an open space, both of which
occurred in this case.
South Pasadena, California - School Shooting - May 6, 1940
What is considered the first active shooter incident at a school occurred on May
6, 1940. A disgruntled high school principal shot and killed the district business
manager and two teachers in South Pasadena, California (Williams, 2017). The
disgruntled 38-year-old high school principal, Verlin Spencer, was distraught over being
fired over frequent quarrels with his coworkers. Spencer was abrasive to his coworkers,
believed that teacher cliques were planning against him, and believed that two of his
victims were leading the coterie (Bovsun, 2020). Spencer was known to be an expert

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marksman with a .22 caliber Colt Woodsman semi-automatic pistol, which he carried in
his vehicle and practiced with at a local shooting range (Rasmussen, 1997).
Spencer was enraged over being fired and demanded a hearing with the school
board, which was granted. On the day of the hearing, Spencer left his sleeping wife at
home, drove to a local bank to have his last will and testament notarized, and then
drove to the school administration building for the hearing (Plummer, 2014). Spencer
arrived at the administrative building with his .22 caliber Colt Woodsman pistol and 50
rounds of ammunition. He and three other administrators went into the second-floor
board room. The three administrators were Superintendent George Bush, high school
principal John Alman, and school business manager Will Speer. While several hundred
boys were outside taking a gym class, Dorothea Talbert, the superintendent’s secretary,
heard Spencer become loud and irate several minutes into the meeting (Bovsun, 2020).
Gunfire then erupted from the board room, and Spencer shot and killed all three school
administrators. Spencer then ran across the hallway to the office of Superintendent
Bush. Talbert, who was frozen at her desk when Spencer entered, managed to duck as
he fired at her. The bullet did not kill her but left her paralyzed; she was the only person
to survive the attack (Rasmussen, 1997).
Spencer walked outside to his vehicle, which had a dead battery. He enlisted the
help of two unsuspecting high school students to jumpstart his vehicle. They obliged,
and Spencer drove two blocks to the junior high school (Rasmussen, 1997). Once
there, he located printing teacher Verner Vanderlip. Spencer stuck a gun in his ribs and
escorted him to a basement storage room, where a struggle ensued. During the
struggle, Spencer shot and killed Vanderlip. Next, he went to the other side of the

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school campus and entered a classroom where he shot and killed art teacher Ruth
Sturgeon. She died three days later. Spencer then started for his vehicle, but someone
saw him, causing him to run towards the cafeteria. Three South Pasadena Police
officers, each armed with shotguns, arrived and confronted him. Before they could
shoot, Spencer shot himself in the chest but did not die (Plummer, 2014).
Spencer stood trial and was sentenced to 30 years in prison, which he served in
San Quentin (Rasmussen, 1997). Ultimately, he was paroled in 1970 and died in
Hawaii.
This incident also resulted in the suspect attempting suicide. In this incident, the
attempt occurred when LE confronted the shooter. Spencer also targeted two different
locations, which is a challenge for responding LE because the suspect is mobile.
Camden, New Jersey ASI – 1949
Nine years after the South Pasadena ASI, Howard Unruh murdered 13 people
and wounded three others, including women and children, in 20 minutes in Camden,
New Jersey. This ASI became known as the Walk of Death and only ended after Unruh
ran out of ammunition for his pistol and police officers arrested him outside his
apartment (Sauer, 2015). Unruh was a 28-year-old World War II veteran who
sometimes served as a tank gunner in the German theater. During combat, he would
keep thorough journal notes on the Germans he killed, describing each dead body in
gruesome detail. After the murders in Camden, Unruh’s brother said that he was never
the same when he came back from World War II; however, there was no record of
Unruh having a mental illness (Sauer, 2015). He kept a makeshift shooting range in the
basement of his apartment, where he practiced with a German Luger he brought home

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from World War II. He also kept notes on neighbors and local merchants he felt had
slighted him, several of whom he killed during his rampage (Zimmer, 2019).
The night before the shooting, Unruh, who was gay, planned on meeting a man
at a local gay theater, but heavy traffic caused him to miss the meeting. He waited
seven hours at the theater and then went home, where he found a damaged rear gate
he had installed for his mother to access the apartment building. According to a
psychologist who interviewed Unruh after the attack, the broken gate triggered him to
carry out the shooting rampage (Gambardello, 2017). The following day, Unruh ate the
breakfast his mother cooked him, collected his Luger pistol and ammunition, went
outside near his apartment, and shot at and missed a bread truck delivery driver. He
then walked to a cobbler’s store, where he shot and killed the cordwainer. Next, Unruh
walked to the next-door barbershop, where he shot and killed a 6-year-old boy and the
barber.
Unruh went back outside and shot at a boy, missing him, then reloaded his Luger
and went to a drugstore where two of the people he believed wronged him worked. As
he approached the drugstore, he shot a patron who was exiting. He then walked into
the drugstore and killed two of his listed targets. Unruh went back onto the main road
and killed four motorists who were in the area by chance. He then went into a tailor
shop and shot two more people, including a 2-year-old boy. He then shot three more
people before he ran out of ammunition and retreated to his apartment.
Police Response. While details of the police response to this ASI are scarce,
approximately 50 police officers responded and surrounded Unruh’s apartment. How
the police officers discovered Unruh’s location is unknown. The officers who

14
surrounded the apartment indiscriminately fired machine guns and shotguns at the
apartment despite individuals in their field of fire (Sauer, 2015). The incident ended
when two police officers, who ascended the roof, threw two tear gas canisters into
Unruh’s apartment, causing him to come out unarmed and surrender to police (Sauer,
2015).
Texas Tower Incident, Austin, Texas – August 1, 1966
Charles Whitman, who was born on June 24, 1941, was raised in an abusive
home where his father physically beat his mother, Charles, and his two brothers.
Whitman’s father taught him and his brothers how to use firearms, and his father
considered Whitman a marksman (Lavergne, 1997). After high school, Whitman
enlisted in the U.S. Marine Corps, earned a sharpshooter’s badge, and excelled at
shooting rapidly at long distances and at moving targets (Lavergne, 1997). Using a
military scholarship, Whitman enrolled at the University of Maryland and later
transferred to the University of Texas at Austin. Several years later, Whitman married,
had his scholarship canceled for poor grades, and was honorably discharged from the
Marine Corps (Lavergne, 1997).
In May of 1966, Whitman’s mother divorced her abusive husband and moved to
Austin, Texas, with Whitman’s help. Several months after the divorce, Whitman sought
the help of an Austin Texas University psychiatrist for violent thoughts he was having.
During his only session with the psychiatrist, he made an ominous statement about a
fantasy “about going up the tower with a deer rifle and shooting people” (Lavergne,
1997, p. 71). Whitman was also abusing illicit drugs to stay awake. The drugs, which
included the amphetamine Dexedrine, kept Whitman awake and caused him severe

15
headaches (Lavergne, 1997). At around 12:30 am on August 1, 1966, Whitman went to
his mother’s apartment, where he killed her by strangling and then stabbing her. At
around 3:00 a.m., he went to his own apartment and stabbed his sleeping wife to death.
Whitman left a note that said he loved his mother and wife and admitted his violent
tendencies that he admitted to the school psychologist at Austin University (Lavergne,
1997).
For the next 7 hours, Whitman thoroughly planned his attack. He loaded a
footlocker with supplies, including a transistor radio, water, sweet rolls, and firearms that
he owned. Part of his careful planning included calling his wife’s employer to let them
know she was sick and would not be in that day (Lavergne, 1997). Whitman then drove
west of downtown Austin, where he rented a dolly and then cashed two $125.00 checks
at Austin National Bank. Next, Whitman purchased additional firearms and ammunition
at a local gun shop, then went home to clean the firearms and modify one of the
shotguns he purchased (Lavergne, 1997). At approximately 11:00 am, Whitman
packed his vehicle with the footlocker, dolly, and firearms and drove to the University of
Texas at Austin.
At about 11:30 am, Whitman drove to the campus entry gate and asked for a
loading zone permit for a delivery at a science building. Whitman received the delivery
pass but bypassed the science building and drove to the main building, where he began
unloading his footlocker, firearms, and the dolly (Mijares & McCarthy, 2015). He then
proceeded to the University of Texas Tower elevators with the items he had unloaded
from his vehicle. He rode the elevator up to the 27th floor, which accessed the
observation deck (Lavergne, 1997).

16
Upon arrival at the 27th floor, Whitman carried the footlocker to the stairs leading
to the observation deck. He then retrieved a shotgun from his footlocker, beat the
observation deck receptionist to death with the butt of the firearm, and shot four visitors
who were walking to the observation deck (Mijares & McCarthy, 2015). After
barricading the stairway entrance, Whitman carried the footlocker up to the observation
deck and laid out his firearms around the deck to fire from one position and move to
another quickly (Mijares & McCarthy, 2015). At 11:50 am, Whitman began carrying out
his attack from the observation deck by shooting at unsuspecting students and others
below. One minute later, a campus history teacher placed the first call to the Austin
Police Department switchboard.
Police Response. All on-duty Austin police officers were sent to the scene with
orders to cordon off the area to pedestrians and vehicles. Additionally, help was
requested from surrounding police agencies, including the state police, and armored
cars volunteered to evacuate the wounded (Mijares & McCarthy, 2015). At about 1:00
p.m., officers were ordered to retrieve several of the wounded from the stairwell of the
tower’s 27th floor. The approach to the tower was in Whitman’s field of fire, which
forced the officers to utilize a tunnel to enter the tower. Once inside, they ascended to
the 27th floor, where they found a series of entrances that led them to the roof above
the observation deck. One of the officers shot and killed Whitman, ending the rampage
(Lavergne, 1997). Whitman ultimately killed 14 people and wounded 31 others. This
incident was one of the first to be televised live.
Austin Police Department officers had no prior training or planning for this type of
incident, and there is no after-action report to document the lessons learned from this

17
event (Mijares & McCarthy, 2015; Lavergne, 1997). In fact, Lavergne (1997) stated,
“The department was not prepared for this incident and no other city had ever been
faced with a crime such as the one Charles Whitman inflicted on Austin from his perch
at the University of Texas Tower” (p. 246). Despite being unprepared for this novel
event, there were leadership problems that plagued the response. Meeks (2016)
analyzed the police radio traffic of the shooting and found that the response was
chaotic. Specifically, there was no command post to organize the response,
communications were poor, there was little cooperation among LE agencies, and no
one was leading the incident, which caused officers to act independently (Meeks, 2016).
Mijares and McCarthy (2015) argued that this incident, and others like it,
emphasized the need for LE to have specialized officers trained to address unusual
events. However, during this time, LE did not yet train or plan for this type of event.
Consequently, this event caused the first major shift in police response protocols and is
recognized as the impetus for the creation of SWAT teams nationwide (Lavergne, 1997;
Wallenfeldt, 2024). The creation of SWAT teams also led to police training that police
officers must contain a situation and then wait for SWAT team members to arrive.
These SWAT officers had more training and experience dealing with high-risk incidents
than patrol officers. While this training was appropriate for certain situations, such as a
hostage situation, it proved disastrous in the Columbine incident (Martaindale & Blair,
2019).
Mcdonald’s Massacre, San Diego, California - July 18, 1984
James Huberty came from a strict Christian family, was a loner as a child, and
suffered from numerous childhood illnesses. Later in life, he was convinced the world

18
was ending, which caused him to collect weapons and supplies (Hickey, 2003).
Huberty, who had a wife and two daughters, had several jobs before he and his family
moved to Tijuana, Mexico, from Canton, Ohio, where he worked as a security guard
until he was fired in 1984. According to his wife, Huberty felt lonely and defeated and
resented Hispanics because he was unable to speak Spanish (Hickey, 2003). Later
that year, in July, the family moved to San Ysidro, California, where Huberty was a
security guard at an apartment complex. Huberty was subsequently fired from this job
in July 1984.
On July 18, 1984, after Huberty took his family to the San Diego Zoo, he
changed clothes, loaded ammunition into his car, and walked out armed with several
firearms. As he left, he told his wife he was going to hunt humans (Hickey, 2003). His
wife, Etna Huberty, dismissed the threat despite knowing his mental health issues and
suicide attempt in 1983. Hubert drove a short distance down the street and pulled into a
local McDonald’s parking lot. Just before 4 pm, Huberty walked into the crowded
restaurant carrying three firearms and began shooting innocent victims (Posner &
O’Hara, 1984). While inside, Huberty drank soft drinks, threw French fries at victims,
listened to music on a radio he brought, and shot at arriving police officers (Houseman,
1984). Over the next 77 minutes, Huberty shot and killed 21 people and wounded 19
others. During the carnage, he methodically walked through the restaurant, shooting
victims and passing vehicles and the restaurant’s doors and windows.
Police Response. The San Diego Police Department began receiving phone
calls of a man shooting people at the McDonald’s within minutes of the first shots being
fired. A sergeant and four officers were initially dispatched to the scene. Around 4:07

19
p.m., the first officer, a SWAT officer, arrived at an area of about 300 feet from the
McDonald’s. Huberty immediately fired at him, after which the officer took cover and
called for additional resources.
An arriving sergeant recognized what was occurring and requested a SWAT
response (Sanders, 1984). Additional patrol officers arrived and established a
perimeter and diverted traffic around the McDonald’s while a command post was
established down the street. Several officers at the front of the restaurant rescued a
small child but had to retreat from intense gunfire when they attempted to rescue two
other young boys who were adjacent to the building (Sanders, 1984). Huberty, who
was firing from every side of the interior of the McDonald’s, thwarted officers from
moving closer.
As SWAT officers arrived, uncertainty pervaded the situation. Police
commanders feared that Huberty was holding hostages, which caused them to give
commands that officers, including SWAT snipers, not fire their weapons (Posner &
O’Hara, 1984). Adding to the confusion and uncertainty was the belief that there were
multiple shooters inside the McDonald’s, and the bright sun and the restaurant’s
smoked windows made it difficult for the police to see inside (Kavanagh, 2009). The
SWAT commander, Lieutenant Jerry Sanders, who was stuck in traffic responding to
the incident, countermanded an order by another field lieutenant who had given snipers
permission to shoot unless Huberty left the building. Lieutenant Sanders later said he
countermanded the order because he believed there were hostages inside the
McDonald’s and the entire SWAT team had not yet arrived (Posner & O’Hara, 1984).

20
At about 4:16 pm, two victims escaped the back door of the McDonald’s and
were debriefed at the command post. From the debrief of the two escapees, the field
lieutenant confirmed there was only one suspect. About 30 minutes later, after the
entire SWAT team deployed, SWAT Commander Sanders authorized the snipers to
shoot Huberty if they saw him (Sanders, 1984). Several minutes later, Huberty
appeared at the east doors of the McDonald’s, which did not have glass due to gunfire,
where a SWAT sniper shot and killed him (Posner & O’Hara, 1984). Seventy-three
minutes had elapsed from the first calls about the shooting to the SWAT sniper shooting
and killing Huberty.
Changes in the Police Response System. After the incident, patrol officers
were criticized for acting too slowly and not immediately intervening by entering the
building to confront Huberty. Some of this criticism came from survivors, several of
whom were wounded during the incident. Sanders (1984) said that had officers gone
inside, they would have likely been killed. Furthermore, Sanders said the suspect had a
clear view of police officers, whereas police had little to no view of the suspect. These
statements were echoed by then-San Diego Police Chief Kolender, who said that a
police investigation revealed that the decision not to intervene quickly was sound and
would have resulted in police officers being killed (Houseman, 1984).
In 1984, San Diego Police SWAT team members were patrol officers with
additional training beyond regular patrol officers. After the McDonald’s massacre, San
Diego Police created a full-time SWAT team that could respond to such incidents with
increased training, better equipment, and special weapons (Kavanagh, 2009). Police
nationwide also adopted this full-time SWAT team model to address similar incidents.

21
However, it was not until the Columbine tragedy in 1999 that there was a significant shift
in police tactics.
Columbine High School Active Shooter, Colorado – April 20, 1999
On April 20, 1999, Dylan Klebold and Eric Harris attacked Columbine High
School, where they planned on killing teachers and students with propane bombs
planted in the school cafeteria and then shooting fleeing survivors. Klebold and Harris
met in middle school in 1993 and were arrested in 1998 for illegally breaking into a van,
after which they were sentenced to participate in a juvenile diversion program. Several
months after the sentencing, they began planning the attack at Columbine High School.
Klebold and Harris had been planning the attack for about a year and mapped such
things as hallway lighting and the best places to hide during the shooting. They used
directions from the Internet to build the explosive devices they used and studied
students’ traffic patterns at the school to maximize the effects of their attack.
Documents examined post-incident by police detail a journal by Klebold that planned
out the attack to the minute and to-do lists the killers had in the months leading up to the
attack.
On April 20, 1999, at about 11:10 am, Klebold and Harris arrived at Columbine
High School in separate cars, which they parked in the student parking lot. They carried
the two propane bombs in duffel bags into the cafeteria. The bombs were outfitted with
detonators set to go off at 11:17 am. After placing the bags and not arousing suspicion
among the 500 students in the cafeteria, Klebold and Harris returned to their vehicles to
wait for the explosion. However, the explosives failed to detonate, but two other
explosives that had been placed in a field as a diversion did detonate. Realizing that

22
the propane bombs had malfunctioned, Klebold and Harris entered the school armed
with a variety of firearms, including a handgun, shotgun, and a carbine-long rifle. They
also carried additional explosive devices much smaller than the propane bombs.
As they walked into the school, they killed one student and wounded another as
they ate their lunches. For almost 47 minutes, the two walked through the school,
randomly shooting students, school staff, and teachers. When the pair entered the
cafeteria, they found it almost empty due to the evacuation efforts of teacher William
Sanders and two custodians who realized what was occurring. When Klebold and
Harris found the cafeteria empty, they walked to the classroom and library area of the
school and continued shooting students. A police officer who had responded to a 911
call exchanged gunfire with the suspects from about 60 yards but missed. The two
gunmen shot Sanders, who had helped evacuate students from the cafeteria, as he was
running to the office area. A fellow teacher pulled him into a classroom, but he died
three hours later while waiting for medical attention (Erickson, 2001).
Klebold and Harris reached the library at about 11:30 am, killed two more
students, and wounded 12 more. They then went back to the cafeteria at 11:44 am,
where they attempted to detonate the unexploded propane bombs. They failed to
detonate them but did activate the fire alarm and sprinklers from a small fire they had
started. At around 12:00 p.m., the gunmen re-entered the library, where they fired at
responding police and paramedics who were attempting to rescue the wounded.
Sometime between 12:05 and 12:10 pm, Klebold and Harris shot and killed themselves.
Police Response. The first officer to respond to the shooting was a school
resource officer for Columbine High School who heard on his police radio that a female

23
was down. When he exited his patrol vehicle in the senior student parking lot, he heard
a call over his school radio that there was a shooting inside the school. Harris shot at
the school resource officer as he exited his patrol car. Harris’s rifle jammed, and the
officer fired several rounds at him, missing. The officer radioed for additional officers to
respond to the scene (Erickson, 2001).
As other officers responded, they began setting up a perimeter around the school
and rescuing students in the open. SWAT teams from surrounding agencies also
responded to enter the school. The first SWAT team entered the high school at
approximately 12:06 pm. Inside the school, there were many hidden students,
teachers, and staff, which caused the SWAT teams to move slowly (Erickson, 2001).
Further complicating the situation for SWAT teams’ lack of knowledge of the building
layout, a lack of interoperable radios, and the blaring fire alarm further complicate the
situation.
Active Shooter Literature
Existing active shooter research focuses on a variety of topics, including attempts
to create a standard profile for active shooters, healthcare and active shooters, media
coverage of ASIs (Bonanno & Levenson, 2014; Majeed et al., 2019; Schildkraut et al.,
2018; Schildkraut & Muschert, 2014; Wilder, 2023), business and educational settings
(Blair et al., 2013; Martaindale et al., 2017), the characteristics of shooters (Gibson et
al., 2020), how police officers see their roles in ASIs (Phillips, 2020), police ASI training,
and critical evaluations of the Run, Hide, Fight method for civilians (Briggs & Kennedy,
2019; Duque et al., 2019). Anisin (2016) argued that research has increasingly
centered on prevention, risk/threat assessment, and behavioral analysis. However,

24
there is limited research on the LE response phase and the challenges responders face.
The research that does exist describes the response phases (Blair et al., 2013;
Martinez, 2012), how police officers are shot during an ASI (Blair & Duron, 2023), and
the evolution of LE training protocols for ASIs (Martaindale & Blair, 2019; Blair et al.,
2013).
ASIs and Systems Theory
There appears to be only one qualitative empirical study that examines the
challenges that first responders face during ASI response efforts. Duron (2020) utilized
systems theory and qualitative thematic analysis to examine five after-action reviews
(AARs) from large-scale ASIs. Those AARs pertain to the response by both the
Orlando Police and the Orlando Fire Department to the Pulse Nightclub ASI, the FEMA
and LVMPD AARs from the Route 91 Harvest Festival ASI in Las Vegas, the Aurora
Century 16 Theater ASI in Aurora, CO, and the Virginia Tech ASI. Duron (2020)
pointed out that systems theory has been used in multiple academic disciplines to
explore numerous topics, including disaster management. In the context of the ASI first
responder response system,
“I view the combination of first responder organizations that respond to an active
shooter event as a complex and dynamic open system (the first responder
system). The first responder system is open in that it interacts with its
environment and other systems (e.g., the school system). The first responder
system is dynamic in that it is composed of subsystems (e.g., LE agencies, EMS,
and fire departments) that all work together to maintain the system’s
effectiveness, which can be considered saving lives.” (Duron, 2020, p. 3).

25
Duron (2020) further suggests that when an ASI occurs, it influences the first responder
system and its subsystems, and the overall system function depends on the “efficiency
and collaboration of the subsystems.” Duron (2020) identified three primary themes and
four subthemes in analyzing systems in the selected AARs:
1. “Advanced Planning for an ASI
a. Interagency Collaboration
b. Equipment for Vehicles for First Responders
2. Training for First Responders
a. Understanding and Improvements in Command Structure
b. Improved Communications
3. Prehospital Care”
Duron’s (2020) assessment highlights the general dimensions of the first
responder system but fails to account for one crucial matter. During an ASI, police
officers will be the first to arrive at an active shooter as part of the first responder
system. As such, they are the pivot point for whether the response is successful and
whether interagency collaboration (with either or both police and fire) occurs. While
Duron’s research focused on the response of fire, EMS, and police, this dissertation
focuses on the police response during the initial stages of an ASI.

26
Figure 2
System Theory Applied to First Responders During an ASI
Note. Adapted From “’Shots Fired! We Have Many People Down!’: Common
Recommendations for Managing High-Casualty Active Shooter Events in the USA” by
A. Duron, 2020, International Journal of Disaster Risk Reduction, 65, Article
102548.2020 (https://doi.org/10.1016/j.ijdrr.2021.102548). Copyright 2021 by Elsevier.
Complex Systems Theory
Building on Duron’s (2020) system theory application to first responders, complex
systems theory (CST) provides further insight into the police response system. Dekker
(2011) stated that a system’s complexity increases when there is “professional
specialization, policies, procedures, protocols and structures” (Duron, 2020, p. 127).

27
The author also summarized several characteristics of complex systems theory,
including that complex systems are open systems, meaning they are “open to
influences from the environment in which they operate and influencing that environment
in return” (Duron, 2020, p. 138). Complex systems also contain feedback loops due to
small events producing significant results, known as the butterfly effect (Dekker, 2011).
Applying CST to an ASI, the police response system comprises specializations
(involvement of special teams, such as tactical or explosive ordnance disposal officers),
policies, procedures, protocols, and structures (e.g., the ICS). The police response
system is also open to outside influences such as other responders, victims,
bystanders, and the suspect shooter’s actions at the crisis site. Feedback loops in the
system include indiscriminate parking, as noted in numerous AARs (Broward County
Aviation Department, 2017; Connecticut State Police, 2018; Lindsey, 2014; Project
Management Team, 2014; Straub et al., 2016; TriData Division, 2009, 2014).
Indiscriminate parking of police vehicles causes major results centered on the inability
of ambulances and tactical assets, such as armored vehicles, to reach the crisis site.
Initial Police Response Phase Challenges
While Duron (2020) examined first responders’ ASE response, a seminal paper
by Renaud (2012) pointed out that LE leaders have difficulty deciphering chaos during
the initial response to large-scale critical incidents1. Renaud (2012) recommended
expanding National Incident Management System (NIMS) training to include
sensemaking during the initial response. Renaud (2012) posited that sensemaking and
1 An abrupt, powerful event involving potential injury and a law enforcement response. Usually, multijurisdictional.

28
asking a series of questions can assist the first arriving LE incident commander (IC)2
with understanding the problem. Furthermore, once the IC understands the threats,
they may begin to apply the NIMS’s tenets. Renaud (2012) suggested combining
classroom and scenario training to improve curricula and delivery. While not a novel
training concept, Renaud’s work was used to create an 80-hour California Peace
Officers Standards and Training and DHS certified curricula. The course is offered for
California LE supervisors once to twice annually, with about 20 students per class.
Renaud’s work addressed a gap in the chaos literature; it does not account for
ASIs involving uncertainty-related challenges. In the National Police Foundation’s AAR
on the Kalamazoo mobile active shooter in 2016, Straub et al. (2017) stated that LE
officers should be trained “to confront novelty and develop and implement a response
amidst chaos and uncertainty” (p. 20). Klein (2009) addressed the difference between
chaos and uncertainty by stating that each event requires a different approach. Chaotic
situations require more analysis, while uncertain and novel situations require more
information.
The Incident Command System (ICS)
According to Jensen and Waugh (2014), there is little empirical, peer-reviewed
research on ICS (Bigley & Roberts, 2001; Buck et al., 2006; Lutz & Lindell, 2008;
Moynihan, 2009; Jensen & Yoon, 2011) as well as professional magazine articles
(Bennett, 2001; Cardwell & Cooney, 2000; Dekker, 2011; Dudfield, 2008) and Naval
Postgraduate School (NPS) theses (Favero, 1999; Templeton, 2005). Narrowing the
2 The individual responsible for on-scene activities, including developing incident objectives and ordering
and releasing resources. The IC has overall authority and responsibility for conducting incident
operations (NIMS, 2017).

29
lens to LE use of ICS, the peer-reviewed literature is even more paltry. The literature
only briefly mentions the use of ICS by police officers (Buck et al., 2006; Waugh, 2009).
While there is no peer-reviewed research on the subject, several NPS theses explore
LE challenges when using the ICS (Moody, 2010; Renaud, 2012; Teeter, 2013). The
lack of published research combined with the debates about the efficacy of ICS makes it
challenging to analyze its use or effectiveness for LE in the initial response phase of an
active shooter. However, analyzing AARs and responder interviews provides insight
into police officers’ use of ICS during their response to ASIs.
ICS History
Historically, the roots of the ICS can be traced to the Military Reorganization Act
of 1920 as an organization for managing military efforts (California Governor’s Office of
Emergency Services, 2019). In 1970, Southern California endured a disastrous fire
season, which caused a significant loss of lives and property. In the aftermath, the U.S.
Forest Service initiated a project to help firefighting agencies improve coordination and
effectiveness during multi-jurisdictional fires (California Office of Emergency Services,
2019). The five-year project was titled Firefighting Resources of California Organized
for Potential Emergencies. The outcome of the group’s work was the Wildfire ICS,
which became popular with California wildland firefighters. The ICS also played a
critical role in developing the current NIMS after 9/11 and is mandated per Homeland
Security Presidential Directive 5 for use by every LE agency in the nation. However,
this directive has yet to be enforced. According to FEMA (2017), ICS provides an
approach to manage any type or size of incident by dividing the problem into a
hierarchical command and control structure. The ICS includes five major components:

30
command, operations, planning/intelligence, logistics, and finance/administration.
However, AAR data reveal that LE practitioners’ application of ICS was challenging
during the initial ASI response phase.
ICS Efficacy
While fire agencies nationwide use incident command structures in daily
operations, LE officers have less use for ICS in their day-to-day operations. Buck et al.
(2006) stated that ICS works for fire agencies because they combat fire, which is a
known threat, and therefore entails less uncertainty. Klein (1998) made similar
observations during his work on recognition primed decision making with experienced
fireground commanders who were making crisis decisions during fires. The author
concluded that firefighters were “fighting an adversary that does not change tactics or
add new weapons, so the experience gained one year applies to the next” (Klein, 1999,
p. 237). However, police leaders who respond to these events do not have the
advantage of confronting an adversary who does not change tactics. Furthermore, ASIs
are high-risk, low-frequency events, which means gaining multiple ASI response
experiences for police leaders is nearly impossible. Therefore, most LE leaders who
respond to ASIs will essentially be novices.
Police officers who first respond to a scene can usually resolve an incident
without using the ICS. Their use of the ICS in limited circumstances suggests that LE
officers only use ICS at large-scale events, such as an active shooter, and do so
infrequently, causing friction in the response. Buck et al. (2006) confirmed that the
primary use of ICS by police officers is at large-scale events, stating, “When the time
comes to participate in a complex disaster involving multiple agencies where ICS could

31
be helpful, LE personnel are not familiar with it to implement it successfully” because
they handle most incidents upon arrival without using ICS (p. 5).
While the federal government touts ICS as a one-size-fits-all solution, there has
been debate about its effectiveness in all situations among practitioners and academic
scholars (Jensen & Waugh, 2014). Further, practitioners, policymakers, and
researchers admit that ICS use by LE and other non-fire organizations has not been as
effective as fire (Buck et al., 2006). Police officers receive federally mandated ICS
training through classroom presentations or virtually, which does not train them in the
initial response phase, where many of the response challenges manifest. Despite the
mandate, some police responders believe that ICS does not assist them during their
response to large-scale incidents. As an example, police responders to the Pulse
Nightclub ASI in 2016 stated, “First responders from both OPD and Orange County
Sheriff’s Office (OCSO) reported that paying attention during ICS training is difficult as it
does not connect the structure to ‘real’ incidents” (Straub et al., 2017, p. 59). Straub et
al. (2017) further suggested that police leaders should “endeavor to re-examine ICS and
build a model that will be accepted and implemented in response to critical incidents” (p.
59). While ICS may be effective to address small and large incidents, it may not be as
effective for novel and uncertain incidents.
Renaud (2012) stated that ICS is unable to address the initial stages of an
incident, which the author called the “edge of chaos.” Renaud argued that this period
resists the structure of ICS and that improvisation and creativity are the best tools for
responders during that period. As previously stated, Renaud’s research was used to
create a training course for first-responding ICs that is held annually for a few students.

32
Despite the efforts, challenges continue to plague the police response to ASIs, and new
solutions and mitigation efforts must be developed. Further, a new model of ICS
focused on the centralized network aspects of the system will be explored and
developed in Chapter 5.
Chaos Theory
Chaos theory, a branch of mathematics and physics, explores the behavior of
complex and nonlinear systems susceptible to initial conditions (Lorenz, 1993). Edward
Lorenz introduced this model/theory in the 1960s while studying weather patterns.
Lorenz, a meteorologist, developed a mathematical approach/process to model how air
moves in the atmosphere. The broader area of chaos theory challenges the view that
complex systems are inherently unpredictable and nonlinear. The foundation of chaos
theory is that dynamic systems may appear unpredictable and random but still
demonstrate elements that reflect fundamental structure and order.
Lorenz (1993) stated that the atmosphere is a chaotic system, meaning small
changes in initial conditions can lead to drastically different weather outcomes. Longterm weather predictions are challenging; however, chaos theory has improved shortterm forecasting. Scientists use advanced models that consider the chaotic nature of
the atmosphere to make more accurate predictions. Chaos theory attempts to
comprehend system behavior that does not happen in a linearly predictable way
(Murphy, 1996). According to Stewart (1989), the basis for activities and behaviors of a
highly complex system is the initial conditions that are the stimulus for its functions. In
other words, nonlinear systems are sensitive to initial conditions and circumstances
(Stewart, 1989). Further concepts of chaos theory include bifurcation, cosmology, self-

33
organization, butterfly effect, and strange attractors that help explain how nonlinear
systems act at higher levels (Sellnow et al., 2002).
Bifurcation
Inside a system, changes in response to chaos are called bifurcations. These
represent points along a continuum where a system’s structure or direction is disturbed.
Bifurcations describe the breakdown of a formal system with sudden changes (Mathews
et al., 1999). Williams (1997) stated that crisis events and behaviors can be classified
as bifurcation points because they represent events that can drastically change a
system subtly or cataclysmically (Williams, 1997).
Two conditions that are associated with bifurcation include cosmology episodes
and self-organization. Cosmology episodes occur when a crisis event creates an
overwhelming sensation in those involved. Chaos theory posits that these episodes
result from consistent misinterpretation of feedback over time, disrupting the system’s
equilibrium. Weick (1993) described this as the collapse of sensemaking, suggesting
that organizations attempt to make sense of a crisis by comparing it to prior incidents.
However, many crises are novel and surprising, and organizations utilize and justify
standard procedures despite the novel nature of the crisis (Sellnow et al., 2002).
Cosmology episodes
Weick (1993) stated, “A cosmology episode occurs when people suddenly and
sincerely feel that the universe is no longer a rational, orderly system. What makes
such an incident so shattering is that the sense of what is occurring means rebuilding
that sense of collapse together” (p. 634). Weick studied the Mann Gulch fire on August

34
5, 1949, in the Helena Forest of Montana, which resulted in the loss of 13 lives and
revolutionized the way firefighters approach wildfires.
Weick (1993) described the case in the following way. The Mann Gulch fire
began as a small blaze in the Helena National Forest. The small size of the fire
prompted the dispatch of 15 smokejumper firefighters trained to parachute into remote
areas to fight wildfires. Among them was Wagner Dodge, the foreman in charge of the
crew. These men had not worked together before; no one knew Wagner or his
leadership ability and experience. As the smokejumpers descended into Mann Gulch,
they encountered challenging terrain and unfavorable weather conditions. Strong winds
pushed the fire in unexpected directions, rapidly altering the landscape. Dodge led the
men in a safe route toward the Mann Gulch fire, but things changed when they reached
a river as the 30-foot-high flames had crossed the gulch and were moving straight at the
team at 610 feet per minute.
Wagner did something uncommon and yelled at the crew to drop their tools and
equipment, after which he lit a fire in front of them and ordered them to lie down in the
area it had burned. The crew did not listen to Wagner and ran for a nearby ridge. Two
firefighters made it through a crevice in the ridge and were not injured. One crew
member made it over the ridge but was seriously burned and died the next day. Dodge
survived by lying down in the ashes of his backfire. After the fire passed over him,
Dodge and two survivors hiked out to find help. The eventual 4,500-acre fire took five
days and 450 firefighters to control. A U.S. Forest Service board of inquiry said crew
members would have been saved had they listened to Dodge.

35
Weick (1993) called this event a cosmology episode where there was a collapse
of sensemaking. Specifically, the firefighters found it more challenging to understand
what was occurring as the day went on until they could not perceive that the escape
Dodge ordered would save their lives. Furthermore, the crews did not listen to Dodge
because it was the opposite of what they had trained to do, and the event was novel
and the collapse of sensemaking. Weick (1993) posited that an individual’s reaction to
a cosmology event manifests in such statements as “I’ve never been here before, I have
no idea where I am, and I have no idea who can help me” (pp. 634–635).
Self-organization
Self-organization is another condition associated with bifurcation and is
described as a process where order reappears out of chaos and randomness (Stewart,
1989). The new order is generally created from inner guidelines rather than outside
influences (Seeger et al., 2001). During the flooding in New Orleans due to Hurricane
Katrina in 2005, the New Orleans Police Department faced several novel challenges.
One of them was the destruction of its communications infrastructure caused by the
hurricane’s intensity and levee breaches. In addition, its standard infrastructure, such
as police stations and organizational functions, was also ravaged (Adams & Stewart,
2015). The inoperative communications system made it difficult for police managers to
pass important information and messages down the chain of command.
Police command staff created a temporary and antiquated communications
system whereby runners transferred messages between top management and deployed
patrol officers (Adams & Stewart, 2015). This communication method affected the
NOPD command structure, which caused middle managers to use available information

36
to conduct LE and rescues throughout the city (Adams & Stewart, 2015). Dependence
on this ad-hoc command structure was a unique self-organizing situation because LE
agencies are paramilitary and operate in a hierarchical command structure (Adams &
Stewart, 2015).
Butterfly effect
Sensitive dependence on initial conditions is often called the butterfly effect
(Stewart, 1989). Stewart suggests that the flapping of butterfly wings produces small
changes in the atmosphere. Over time, what the atmosphere does deviates from what
it would usually have done based on model projections (Stewart, 1989, p. 141). Stewart
(1989) also described the openness and sensitivity of complex systems as unable to be
understood using standard methods. In this example, the flapping of the butterfly’s
wings signifies a slight change in the system, which causes a nonlinear chain of events
(Dekker, 2011). As an example, Kiel (1994) described the role communication played in
the Challenger Shuttle disaster as an example of the butterfly effect; “The butterfly in
this case was an error in communication, generating amplifying effects that had
unexpected outcomes posing a new set of problems for the space agency that still
linger today” (Kiel, 1994, p. 7).
The Cuban Missile Crisis in October 1962 was one of the most significant events
of the Cold War era. The U.S. and the Soviet Union engaged in a high-stakes standoff
that brought the superpowers to the brink of nuclear war. The crisis began when U.S.
U-2 spy planes detected the construction of Russian missile sites in Cuba. This
construction of missile sites led President John F. Kennedy to address the nation about
the existence of the missiles and demand their removal. During the 13-day standoff,

37
President Kennedy ordered a naval blockade to prevent further missiles from reaching
Cuba. The U.S. also announced that it would not permit Russia to deliver any more
missiles to Cuba and demanded the removal of weaponry that was already there. After
tense negotiations with the Soviet Union, they agreed to remove the missiles in
exchange for the U.S. publicly declaring they would not invade Cuba again, as they had
in the failed Bay of Pigs invasion (Allison & Zelikow, 1999).
In diplomacy, small actions and decisions can have far-reaching consequences.
During the crisis, President Kennedy and Premier Nikita Khrushchev made a series of
choices that had substantial ramifications. Amid the first days of discussion with his
staff and military leaders, President Kennedy was close to deciding on an air strike of
the Soviet missiles in Cuba. He ultimately decided against the air strike, believing that it
would cause the same difficulties the Japanese had during their attack on Pearl Harbor
and ultimately lead to another invasion of Cuba (Allison & Zelikow, 1999). President
Kennedy instead decided on a naval blockade to stop further shipments of Russian
missiles and weapons. Premier Khrushchev then decided to remove the missiles from
Cuba in exchange for a secret agreement that the U.S. would remove missiles from
Turkey (Allison & Zelikow, 1999). These decisions by President Kennedy and Premier
Khrushchev had significant consequences and prevented a nuclear war, demonstrating
the butterfly effect in international diplomacy.
Strange attractors
Another important aspect of chaos theory is the concept of strange attractors.
Strange attractors are organizing features inherent in the area where a phenomenon will
grow regardless of randomness (Murphy, 1996). Gleick (1987) stated that these

38
attractors can stabilize a situation and provide some measure of order during a crisis.
Furthermore, the attractors are considered strange due to their uncharacteristic nature,
and they subsist outside of the crisis. The Red River Valley Floods occurred in March
1997 near the border of North Dakota and Minnesota. Snowmelt, which ran through
many channels that fed the Red River, caused several major metropolitan areas to
flood, displacing thousands of people (Sellnow et al., 2002). During the crisis, the
National Guard “provided a means of communication and coordination that instilled a
form of confidence and order” (Sellnow et al., 2002, p. 285). Several of the Fargo,
North Dakota, city leaders initially expressed concern that the National Guard would
increase fear among the population and believed the city had lost control. However,
that was not the case, and the National Guard provided a sense of calm and helped
provide a sense of normality (Sellnow et al., 2002). Their presence was a strange
attractor that was a type of order in the chaos of the North River Flood.
Chaos theory has been broadly applied to political science, biology, physics,
medicine, urban development, organizational studies, disaster response, social
sciences, and crisis communication (Gleick, 1987). Ultimately, chaos theory focuses on
the disorder and unpredictability associated with chaos and the patterns and reorganization resulting from the chaos (Sellnow et al., 2002). Murphy (1996) also stated
that chaos theory is a good model for crisis events. Therefore, chaos theory is a useful
model for examining the challenges responding LE officers face during ASIs.
Furthermore, chaos theory aids in studying organizational crises due to its focus on the
disordered nature of systems and on comprehending complex systems (Seeger et al.,
1998).

39
Uncertainty and Novelty
The actions taken by the first arriving police officers or LEs “greatly impact the
outcome of the incident” (Straub et al., 2017, p. 83). Frigotto (2018) stated that there is
no opportunity to attempt trial-and-error adaptive decision-making due to short response
times for novel or uncertain events. Uncertainty and understanding of a novel event
mean that no plan or routine will provide the necessary countermeasures, and the
existing routine could be counterproductive (Leonard & Howitt, 2007). Public safety
responders are trained to respond to and observe common aspects of the event rather
than the uncommon during emergencies.
In the context of disasters and emergencies, uncertainty, and novelty result when
LEs experience events that they have never seen before or those that are not new but
pose a combination of unusual challenges (Howitt & Leonard, 2006). For example,
Leonard and Howitt (2007) discussed the New York Fire Department’s response to the
World Trade Center attack on September 11, 2001. The firefighters had never
experienced extensive structural damage and massive fires so high up in a building. As
a result, they did not anticipate the first tower’s collapse, let alone the second. Focused
on the rescue mission, firefighters failed to recognize the novelty of the incident, explore
alternative responses, or recognize the extreme peril they and the occupants of the
buildings were in. However, structural engineers who watched the incident on television
rapidly identified what was occurring. As Straub et al. (2017) noted, first-responding
police officers and command staff must train to recognize and respond to novel events.
Another form of uncertainty is a social theory named the bystander effect.
Specifically, it is a phenomenon where people in a group are less likely to help others in

40
an emergency than if they were alone (Darley & Latane, 1968). Latane and Darley
(1969) first identified this phenomenon when 38 witnesses observed but did not
intervene while a woman was stabbed to death in New York City. While Manning et al.
(2007) questioned the actual number of bystanders and some of the report’s details,
many subsequent studies have confirmed this phenomenon (reviewed in Fischer et al.,
2011; Latane & Nida, 1981).
Darley and Latane (1968) recommended a five-step model that posited that, for
intervention to occur, the bystander needs to notice a critical incident is taking place,
believe the situation is an emergency, develop a feeling of personal responsibility,
believe they have the skills to help, and then make a concerted decision to help. Latane
and Darley also identified three different psychological processes that could interfere
with completing the five-step process. The first process is a diffusion of responsibility,
which is the tendency to refrain from assisting when other people are present due to a
reduced feeling of responsibility. The second process is pluralistic ignorance, which
relies on other people’s reactions to recognize the need for help in an uncertain
situation. Finally, the evaluation apprehension process is the fear of being negatively
judged for misinterpreting the event, and there is no need for help.
Several studies revealed a reduced bystander effect in dangerous emergencies
(Clark & Word, 1974; Fischer et al., 2006; Harari et al., 1985; Schwartz & Gottliev,
1976). One reason for a reduced effect is that dangerous emergencies are recognized
quickly and less ambiguous, which increases the danger of not assisting (Fischer et al.,
2006).

41
Normal Accident Theory
Perrow’s (1984) formative work on normal accident theory (NAT) sought to
understand how accidents happened in high-technology systems. The theory states
that accidents will occur when high-tech systems are highly complex and tightly
coupled. Essentially, as a system becomes increasingly complex and has more
interacting components, there is the possibility that something will go wrong with the
system. Coupling explains how tightly connected and dependent the parts of the
system are on each other. Much like an assembly line, if a problem in one part of the
system occurs, it will pass into other parts of the system and can ultimately create a
system-wide failure.
Klinger (2005, 2020) applied the NAT framework to police use of force, where he
theorized that police shootings are normal accidents with a high level of complexity and
involve the tightly coupled interaction of police officers and citizens. Klinger suggested
that officer-involved shootings could be reduced by utilizing tactics that reduced
complexity and coupling.
Blair and Duron (2023) applied the NAT framework to the police ASI response in
the context of how often officers are shot during ASIs. They proposed that the current
ASI response puts officers in a complex situation and tightly couples the officers with
the adversary to stop the adversary from injuring or killing victims. Using the NAT
model, they predicted that officers would be frequently shot during ASIs.
During an ASI, the police response converges on the location of the shooting to
stop the adversary from killing and injuring victims. As more officers respond, the parts

42
of the system that begin to interact increase exponentially, thus increasing complexity.
Perrow (1984) stated,
“As systems grow in size and in the number of diverse functions they serve and
are built to function in ever more hostile environments, increasing their ties to
other systems they experience more and more incomprehensible or unexpected
interactions. They become more vulnerable to unavoidable system accidents” (p.
72).
The police response system, where officers work together to stop the suspect from
killing or injuring victims, is tightly coupled.
Purpose of the Study and Applications for Advancement
The purpose of this study was to collect and analyze data that could be used to
reduce uncertainty and chaos for LE responders in future ASIs and help inform active
shooter policy and legislative measures. Specifically, this study used qualitative
analysis of archival AARs and interview data to identify challenges that influence LE
response and then provide recommendations for addressing them.
Audience of the Study
This study has value for multiple stakeholder groups. This dissertation’s findings
pertain to numerous previously unexamined response factors that can help these
stakeholders formulate best practices and inform policy and legislation. This study
considered four target groups: policy and lawmakers, Law enforcement responders,
fire/EMS responders, and academic and think tank researchers.

43
Chapter 3: Research Methods
The purpose of this chapter is to describe the research methods used in data
collection and analysis. Included in this chapter are the approach, researcher
worldview, research design, participant descriptions, procedure, and data analysis.
Research Questions
The research questions and associated hypotheses proposed for this study are
as follows:
1. What are the known and unrevealed primary challenges for LE supervisors
that contribute to chaos and uncertainty during ASIs?
a. Hypothesis for RQ1. There are unrevealed LE response challenges
that have not been disclosed in AARs, which are contributing to
uncertainty and chaos at these events.
2. How does chaos differ from uncertainty when responding to an ASI? How do
response challenges due to uncertainty or chaos affect the police response to
ASIs?
a. Hypothesis for RQ2. Leadership decisions (due to chaos) and
inactions (due to uncertainty) are the primary causes of the response
challenges to ASIs.
3. What changes can be made to the LE response system to improve ASI future
response efforts and reduce uncertainty and chaos?
a. Hypothesis for RQ3. There is a lack of training and education for
supervisors responding to ASIs, which is contributing to uncertainty
and chaos at these events.

44
The research questions were limited to the response challenges LE officers faced when
responding to ASIs and similar events. The following section describes the primary
data analyzed to address these research questions and assess the validity of the
hypotheses. The primary data sources were AARs and interviews of LE who have
responded to ASIs.
Approach
This research study is a qualitative analysis of existing literature, ASI AARs, and
interviews of police responders to ASIs. While there is an increase in the literature on
ASIs, it does not focus on the LE response challenges or seek unrevealed problems
responders face. To discover these challenges, a qualitative design was most
appropriate for research on this topic. The qualitative approach involved a review of
AARs and interviews with police responders to ASIs.
Worldview
The researcher used a constructivist worldview approach to understand the
challenges police responders face during ASIs. The constructivist approach relies
heavily on the interviewees’ perspective of the research topic (Creswell & Creswell,
2018). The researcher conducted qualitative interviews to identify and better
understand the unrecognized LE response factors that contribute to chaos and
uncertainty. As a LE practitioner, the researcher sought to understand these unseen or
less visible factors and their impact on the LE response to ASIs to develop mitigation
measures to improve future response efforts. Further, the constructivist approach
allowed the researcher to explore the subjective meanings of the interviewees’
experiences (Creswell & Creswell, 2018).

45
Research Methodology: Archival Analysis and Qualitative Coding of ASI AfterAction Reviews
Every ASI should yield lessons learned that LE agencies could use to better
respond to future events. Capturing the lessons learned in ASIs entails a process that
relies on AARs, which are completed after critical incidents and focus on explaining
what happened, why the incident occurred, and how to prepare for future incidents
(National Police Foundation, 2020). AARs usually include subject matter experts who
identify areas for improvement. The review can take several months to complete.
AARs commonly have an agenda and schedule and are narrowly focused on scope
(Heal, 2009). LE officers from the OPD who responded to the Pulse Nightclub ASI, for
example, told AAR investigators that their training, which was derived from AAR
scenarios since Columbine in 1999, assisted them in their response efforts (Straub et
al., 2017).
Three criteria guided the selection of AARs for analysis:
1. The AAR involves an incident involving one or more adversaries.
2. The AAR is not a critique of the response to a natural or mechanical crisis.
3. The AAR is for an incident that occurred in the last 15 years.
Table 1 lists the AARs analyzed. They represent a variety of location types
(educational institutions such as K–12 schools and universities, commercial business
locations such as movie theaters and nightclubs, open or public space areas such as
parks and streets, and government facilities such as airports). The AARs describe
locations across the United States, including California, Colorado, Connecticut, Florida,
Massachusetts, Nevada, Texas, Virginia, and Washington, DC (Table 1). The reports

46
for these AARs were stored in a USC password-protected and encrypted cloud storage
folder.
Table 1
AARs to Be Analyzed (in Order of Date of Incident)
Incident Name Location Date Source Location
Type
Virginia Tech Blacksburg,
VA
April 16,
2007
TriData Division:
System Planning
Corporation (2009).
Mass shootings at
Virginia Tech:
Addendum to the
report of the review
panel.
Education
Century 16 Movie
Theater
Aurora, CO July 20,
2012
TriData Division
(2014).Aurora
Century 16 Theater
Shooting: After action
report for the city of
Aurora.
Commerce
Sandy Hook Newton, CT December
14, 2012
Connecticut State
Police (2018).
Connecticut State
Police after action
report: Newtown
shooting incident
December 12, 2012.
Education
Dorner Manhunt San
Bernardino,
CA
February
12, 2013
Police Foundation,
(2015). Southern
California law
enforcement
response to the
attacks by
Christopher Dorner
Open Space
Boston Bombing Watertown,
MA
April 19,
2013
Project Management
Team (2014). After
Open Space

47
Incident Name Location Date Source Location
Type
action report for the
response to the 2013
Boston Marathon
bombing.
Washington DC
Navy Shipyard
Washington
DC
September
16, 2013
Washington DC.
Metropolitan Police
Department (2014).
After action report
Washington Navy
Yard, September 16,
2013: Internal review
of the Metropolitan
Police Department
Washington DC.
Commerce
LAX Los
Angeles,
CA
November
1, 2013
Lindsey, G. (2014).
Active shooter
incident and resulting
airport disruption: A
review of response
operations.
Government
Wal-Mart LV Las Vegas,
NV
June 8,
2014
Thorkildsen, Z.,
Shultz, A.,
Woodmansee, T., &
Tracy, D. (2016). Las
Vegas after-action
assessment: Lessons
learned from the Las
Vegas Metropolitan
Police Department’s
ambush incident.
Commerce
Mobile ASI Stockton,
CA
July 16,
2014
Braziel, R , Devon
Bell, D & Watson. G.
(2015). A heist gone
bad, a Police
Foundation critical
incident review of the
Stockton Police
response to the Bank
of the West robbery
and hostage-taking.
Open Space

48
Incident Name Location Date Source Location
Type
Inland Regional
Center ASI
San
Bernardino,
CA
December
2, 2015
Braziel, R., Straub, F.,
Watson, G., & Hoops,
R. (2016). Bringing
calm to chaos
Government
Mobile ASI Kalamazoo,
MI
February
20, 2016
Straub, F., Cowell, B.,
Zeunik, J., & Gorban,
B. (2017). Managing
the response to a
mobile mass
shooting: A critical
incident review of the
Kalamazoo, Michigan
public safety
response to the
February 20, 2016,
mass shooting
incident.
Open Space
Pulse Nightclub Orlando, FL June 12,
2016
Straub, F., Cambria,
J., Castor, J., Gorban,
B., Meade, B.,
Waltemeyer, D., &
Zeunik, J. (2017).
Rescue, response,
and resilience: A
critical incident review
of the Orlando public
safety response to the
attack on the Pulse
Nightclub.
Commerce
Ft. Lauderdale
International
Airport
Ft.
Lauderdale,
FL
January 6,
2017
Broward County,
Florida (2017). Fort
LauderdaleHollywood
International Airport
active shooter
incident and postevent response.
Government
Route 91 Harvest
Festival
Las Vegas,
NV
October 1,
2017
FEMA. (2018). 1
October after-action
report.
Open Space

49
Incident Name Location Date Source Location
Type
Parkland Parkland,
FL
February
14, 2018
Marjory Stoneman
Douglas High School
Public Safety
Commission (2019).
Initial report submitted
to the Governor and
House of
Representatives and
Senate President.
Education
Borderline Bar Thousand
Oaks, CA
November
7, 2018
Ventura County
Sheriff’s Office
(2021). 2018
Borderline Bar and
Grill mass shooting
public safety
response after action
review.
Commerce
Virginia Beach, VA. Virginia
Beach, VA
May 31,
2019
Hillard Heintze
(2019). An
independent review of
the tragic events on
May 31, 2019.
Government
Uvalde Uvalde, TX May 24,
2022
Advanced Law
Enforcement Rapid
Response Training
(2022). Robb
Elementary School
attack response
assessment and
recommendations.
Education
Qualitative coding was used to analyze the AAR reports, as it provides a means
for systematic analysis using deductive (drawn from the literature) and inductive (drawn
from the data) coding. The coding process consisted of reading each of the AAR
reports three times. Each reading included a review of the entire document. For the
first reading, deductive analysis used codes developed using the literature review (see

50
below). The coded text was analyzed for commonalities and differences across the
reports, particularly with respect to chaos and uncertainty.
The hypothesis for RQ1 is that AARs have not revealed LE response challenges
that contribute to uncertainty and chaos at these events. The hypothesis for RQ2 is that
leadership decisions due to chaos and inaction due to uncertainty are the primary
causes of ASI response challenges. The hypothesis for RQ3 is that there is a lack of
training and education for supervisors responding to ASIs, which contributes to
uncertainty and chaos at these events. The following are the deductive codes drawn
from the literature review:
• Chaotic circumstances
• Indiscriminate parking, which is defined as officers parking vehicles at
critical incidents in a manner that blocks other public safety vehicles
from reaching the crisis site to assist. This addresses the hypothesis
for RQ 1.
• Inappropriate self-deployment, which is one or more individuals’
independent action without the ability to immediately intervene in an
ongoing situation or without a request from the jurisdiction in
command. This addresses the hypothesis for RQ2.
• Communication challenges, which are defined as responders referring
to incidents and tactics using different acronyms, lack of access to
communications devices such as radios, and unnecessary radio
communications. This addresses the hypothesis for RQ3.
• Uncertain circumstances

51
• Uncertainty about who is incident command (defined as not having a
formal IC, usually because the events are unfolding very rapidly). This
addresses the hypothesis for RQ2.
• Uncertainty about the lead agency (defined as not having one agency
managing incoming personnel or tactics). This addresses the
hypothesis for RQ2.
• Other themes
• Leadership problems centered on incident command (defined as
the failure to establish IC and lead the response). This addresses
the hypothesis for RQ3.
The AAR reports were reviewed for a second reading to identify emergent codes,
which are prominent themes and concepts not included in the list of deductive codes.
Emergent codes gleaned after the deductive coding process included novel incidents
during ASIs, training challenges, and refusal to obey instructions from other
jurisdictions. The emergent codes were defined as new inductive codes and themes.
During the third reading, the AARs were coded using these emergent or inductive
codes.
In-Depth Semi-Structured Interviews With ASI Responders and Qualitative Coding
of Interviews
Interviews with LE officers and supervisors who were directly involved in ASIs
addressed Research Question 1. The interviews provided important and previously
unavailable information, as some of the interviewees have not spoken with researchers
or policymakers about their experiences.

52
Interviewee Recruitment
Purposive sampling was used to identify interviewees. The population of LE
supervisors who have responded to ASIs was the target group for interviews but is a
population that does not typically discuss their experiences. Recruitment began by
formulating a list of potential interviewees from the researcher’s contacts and Dr. Frank
Straub’s National Policing Institute contacts. The researcher leads a team for the
California Association of Tactical Officers (CATO) that responds to ASIs to glean
lessons learned and disseminate lessons to members. The list included contacts the
researcher made through CATO. Dr. Straub has conducted in-depth AARs throughout
the country for the NPI and connected the researcher with leaders who have responded
to ASIs. The list also included individuals Dr. Straub recommended. Snowball
recruitment (asking interviewees to identify others who should be interviewed) helped to
identify other individuals.
The total number of interviewees for the study was 25 individuals. The sampling
was not random and not large enough to allow for statistical inferences. Despite this,
the information gleaned from the interviews addressed the research questions. The
total number of completed interviews depended on the saturation of themes generated
through the interviews. There was thematic saturation at 25 interviews, so recruitment
was ended.
Once potential interviewees were identified, they were contacted for a potential
interview. A standard consent procedure was used to describe the study, measures to
maintain interviewee confidentiality through the data collection and anonymity through
the data analysis, and possible risks and benefits to study participation. Confidentiality

53
and anonymity were important for this data collection process as interviewees might
reveal information about their actions during their responses that may be personally or
professionally embarrassing or hurt their professional careers.
During the recruitment procedure, the participants received an information form
and a copy of the interview questions. Sharing the questions helped build trust.
Building trust was extremely important to help encourage honest responses during the
interviews.
Interview Questions
Interview questions were formulated using results from the analysis of the AAR
reports. Questions from the National Police Foundation’s (2020) report on how to
Conduct an After-Action Review report was also used. This report lists best practices
for asking open-ended questions during AAR interviews. The researcher has worked as
a sworn LE officer, sergeant, and lieutenant for over 25 years. A master’s degree in
emergency services administration with previous thesis research exploring ASIs
provided the academic background, training, and experience to conduct these
interviews. Additionally, the researcher has interviewed over 30 LE responders to ASIs
during his work with the CATO AAR Team. This knowledge and experience prepared
the researcher for conducting the interviews with empathy.
Participants were scheduled for a 60-to-90-minute interview via the video
conference platform Zoom. After participants agreed to be interviewed, they received a
calendar invitation containing the Zoom video conference link. After the interviewees
provided their permission, the interviews were recorded in the cloud on Zoom, which
generated automatic transcriptions.

54
The researcher understood that, during the interviews, he would need to be
sensitive to the trauma these responders experienced. Recounting and providing
details about the participants’ involvement can be burdensome (NPF, 2020). The
researcher ensured that participants understood that responses to all questions were
voluntary, that they could skip questions, and that they could end the interview at any
time.
The researcher completed field notes after each interview to record perceptions
about how the interview went and whether any emergent themes needed more
clarification, as well as to conduct a self-assessment about improvement for future
interviews. These field notes were also coded as part of the qualitative analysis.
Anonymity and Interview Thematic Coding
After checking the automatically generated transcriptions for accuracy and that
all identifiers (names, locations, dates) were removed, the researcher deleted the Zoom
video recordings and used the transcriptions for the qualitative coding analysis. The
researcher created a code sheet to assign a random code to each transcription and
indicate the ASI aligned with the interview. The code sheet will be destroyed two years
after the dissertation research is complete to support manuscript writing after the
completion of the dissertation.
Interview Thematic Coding
The resulting text from the Zoom transcription were saved in Word and then
uploaded into NVivo 20 software. NVivo is a qualitative software platform that provides
the opportunity to code and conduct analysis across textual, audio, and archive
material. NVivo 20 is available for USC students, and this version was used for the

55
qualitative coding of the interview transcripts and the researcher's field notes. The
interview transcripts and field notes were coded three times: (a) deductive analysis, (b)
identification of emergent codes or themes, and (c) inductive analysis.
For the first reading, deductive analysis involved codes developed using the
literature review and were the same codes used in the coding of the AAR reports (see
below). The coded text was analyzed for commonalities and differences across ASIs,
particularly with respect to chaos and uncertainty.
The hypothesis for RQ1 is that AARs have not disclosed LE response challenges
that contribute to uncertainty and chaos at ASI events. The hypothesis for RQ2 is that
leadership decisions due to chaos and inactions due to uncertainty are the primary
causes of ASI response challenges. The hypothesis for RQ3 is that there is a lack of
training and education for supervisors responding to ASIs, which contributes to
uncertainty and chaos at these events. The following are the deductive codes drawn
from the literature review:
• Chaotic circumstances
• Indiscriminate parking, which is defined as officers parking vehicles at
critical incidents in a manner that blocks other public safety vehicles
from reaching the crisis site to assist. This addresses the hypothesis
for RQ 1.
• Inappropriate self-deployment, which is one or more individuals’
independent action without the ability to immediately intervene in an
ongoing situation or without a request from the jurisdiction in
command. This addresses the hypothesis for RQ2.

56
• Communication challenges, which are defined as responders referring
to incidents and tactics using different acronyms, lack of access to
communications devices such as radios, and unnecessary radio
communications. This addresses the hypothesis for RQ3.
• Uncertain circumstances
• Uncertainty about who is IC (defined as not having a formal IC, usually
because the events are unfolding very rapidly). This addresses the
hypothesis for RQ2.
• Uncertainty about the lead agency (defined as not having one agency
managing incoming personnel or tactics). This addresses the
hypothesis for RQ2.
• Other themes
• Leadership problems centered on incident command (defined as
the failure to establish incident command and lead the response).
This addresses the hypothesis for RQ3.
The transcripts and researcher field notes were reviewed for a second reading to
identify emergent codes. The emergent codes were defined as new codes and themes,
which are prominent themes and concepts in the interview transcripts not included in
the list of deductive codes. During the third reading, the transcripts and field notes were
coded using these emergent codes.

57
Chapter 4: Data Reporting and Analysis
This chapter presents the findings from a qualitative analysis of 16 ASI AARs and
25 semi-structured interviews of sworn LE members who responded to ASIs. These
findings address the research questions raised in Chapter 3:
1. What are the known and unrevealed primary challenges for LE supervisors
that contribute to chaos and uncertainty during ASIs?
a. Hypothesis for RQ1. There are unrevealed LE response challenges
that have not been disclosed in AARs, which are contributing to
uncertainty and chaos at these events.
2. How does chaos differ from uncertainty when responding to an ASI? How do
response challenges due to uncertainty or chaos affect the police response to
ASIs?
a. Hypothesis for RQ2. Leadership decisions (due to chaos) and
inactions (due to uncertainty) are the primary causes of the response
challenges to ASIs.
3. What changes can be made to the LE response system to improve ASI future
response efforts and reduce uncertainty and chaos?
a. Hypothesis for RQ3. There is a lack of training and education for
supervisors responding to ASIs, which is contributing to uncertainty
and chaos at these events.

58
After-Action Review (AAR) Reports3
AARs are “a team-based process following a particular training exercise or an
event that affords all participants the opportunity to reflex, provide their perceptions and
observations, and identify promising practices and lessons learned that can be applied
to enhance future responses to similar scenarios” (Zeunik et al., 2020, p. 1). AARs are
beneficial for training scenarios and tabletop exercises because they utilize real case
studies that simulate real-life field conditions (Zeunik et al., 2020). According to Zeunik
et al. (2020), LE agencies have used AARs to create learning organizations and
improve future response operations. One of the first LE ASI AARs that identified
numerous recommendations and lessons learned was the Columbine ASI AAR
(Erickson, 2001). This AAR contributed to major changes in LE ASI training and
response, and recent ASI AARs contain many of those lessons learned. These
recommendation topics included communication with other agencies, incident
command, planning and relationship building with other agencies, and critical incident
media relations. Since Columbine, numerous AARs have provided similar and different
lessons learned. The AAR data for this dissertation revealed several primary themes
and sub-themes about the primary response challenges faced by LE during ASIs.
These primary and sub-challenges from the dissertation qualitative analysis were
● incident command challenges
○ staging area difficulties
● unified Command challenges
● communication
3 Throughout this dissertation, “After Action Report” (AAR) is used to encompass similar phrases
including after action review, critical incident review, and incident response analysis.

59
○ inadequate communication with responders
○ interoperability
○ superfluous radio communication
● inappropriate self-deployment
● indiscriminate parking
● lack of or poor planning
The AAR data also revealed several unexpected and emergent findings. These themes
were
● novel elements during ASIs
● training challenges
● refusal to obey instructions from other jurisdictions.
The fact that AARs continue to list the same challenges is a serious concern for
public safety first responders. However, this phenomenon is not centric to ASIs. A
study by Donahue and Tuohy (2006) revealed leadership challenges in disparate types
of crises, including the Space Shuttle Columbia recovery, the Oklahoma City bombing,
Hurricane Katrina, and the anthrax attacks in 2001. One possible explanation for the
same issues is that ASIs, much like natural disasters, rarely occur, which makes it
difficult for responders to test and improve their strategies and tactics (Donahue &
Tuohy, 2006). Another possible explanation is that as time and distance from the
tragedy increases, other issues take priority in an organization. In the Columbine ASI, a
seminal event, there was an 18-month rapid transition in police tactics based on the
lessons learned. According to Donahue and Tuohy (2006), this rapid transition was due
to public scrutiny, the Columbine Police admitting they mishandled the ASI, and the

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rapid, nationwide dissemination of new police response tactics for ASIs. Columbine
was an outlier event, and no ASI since has had such a significant impact on the police
response system. A similar recent incident is the Robb Elementary ASI in Uvalde,
Texas. The botched police response to the Robb Elementary ASI resulted in
legislatively mandated ASI training for all LE officers per Texas Senate Bill 1852.
Further complicating the ability to improve the police response system is the lack
of candor from AAR interviewees due to fear of punishment or embarrassment. The
lack of candor means information that makes the lesson learned “meaningful and
actionable is lost” (Donahue & Tuohy, 2006, p. 12). The lack of candor is why this
research includes anonymous interviews with police responders. Further, there is a
lack of candor in the AAR process that centers on the fear of discipline from the police
organization, ostracism, and criminal and civil litigation.
Uncertainty and the Incident Command System (ICS)
ICS difficulties were coded under uncertainty due to the lack of an identifiable IC
in eight out of the 16 AARs. Additionally, the misapplication of ICS caused challenges
with situational awareness, interoperable communications, information flow within the
ICS structure, and difficulty in establishing a unified command. Fifteen AARs listed
incident command challenges.
Thematic Analysis Summary
1. Fifteen (93%) of the AARs exhibited incident command (IC) challenges.
2. Eight (50%) of the AARs indicated the lack of an identifiable IC:
1. Wal-Mart Active Shooter - Las Vegas, NV.
2. Boston bombing - Watertown, Mass.

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3. Century 16 Theater Active Shooter - Aurora, CO.
4. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL.
5. Pulse Nightclub Active Shooter - Orlando, FL.
6. Kalamazoo Mobile Active Shooter - Kalamazoo, MI.
7. Borderline Bar & Grill Active Shooter - Thousand Oaks, CA.
8. Robb Elementary School Active Shooter - Uvalde, TX.
3. The absence of a command structure led to problems with situational
awareness, communication interoperability, establishing unified command,
and management of the response. This finding reveals that when there is no
command structure, other response matters transpire.
4. In two incidents, ranking officers elected to take perimeter positions instead of
taking command:
1. Wal-Mart Active Shooter - Las Vegas, NV.
2. Borderline Bar & Grill Active Shooter - Thousand Oaks, CA.
Response Difficulties Caused by IC Challenges
1. The lack of an identifiable IC caused Unified Command problems in 3 of 15 ASIs.
1. Wal-Mart ASI - Las Vegas, NV.
2. Century 16 Theater ASI - Aurora, CO.
3. Kalamazoo mobile ASI - Kalamazoo, MI.

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Specific Incident Command Challenges from AARs
1. Virginia Polytechnic University Active Shooter - Blacksburg, VA. - April 16,
2007
“A formal incident commander and emergency operations center was not set up
until after the shooting was over mainly because events unfolded very rapidly. A more
formal process was used for the follow-up investigation” (TriData Division, 2009, p. 95).
2. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012
“Police and fire officials did not establish a unified (joint) command nor a single
overall commander until late in the first hour of the incident. Having a unified command
might have resolved police-fire communications issues regarding getting ambulances in
closer to victims and clarifying the level of risk to fire/EMS personnel” (TriData Division,
2014, p. 18).
“Better use of ICS, even just a few key parts, would have led to better incident
management. Some events unrelated to direct incident management delayed ICS
implementation” (TriData Division, 2014, p. 110).
3. Sandy Hook Elementary Active Shooter - Sandy Hook, CT. - December 14,
2012
“It reportedly took time at the outset to determine which agency was going to
assume overall command and control of the incident. Although the investigative
responsibility was established early through communication between the State’s
Attorney and Western District Major Crime, Connecticut State Police Senior Executive
level command staff was initially unsure of the agency role” (Connecticut State Police,
2018, p. 19).

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4. Washington Navy Yard Active Shooter - Washington DC. - September 16, 2013
“During the initial response, while the crisis was evolving and the gunman was
still clearly active, full Incident Command was not clearly established; however, the vital
ICS objectives were in place and Unified Command was soon formed” (Washington DC
Metropolitan Police Department, 2014, p. 38).
The Washington Navy Yard AAR stated that full Incident command was not
clearly established during the initial response. This lack of a “full Incident Command’’
supports the argument from Renaud (2012) that ICS is not valuable during the initial
response phase. The Washington Navy Yard AAR that “a large-scale response during
an ongoing and rapidly evolving event will often result in some confusion during the
initial establishment of Incident Command” (p. 38). This also provides further evidence
that the use of ICS during the initial response phase is difficult.
5. Wal-Mart Active Shooter - Las Vegas, NV. - June 8, 2014
“LVMPD policy indicates that the lieutenant serving as watch commander in this
situation would establish himself or herself as incident commander (IC), with another
lieutenant taking on IC duties if the watch commander is unavailable. However, the
lieutenant assigned as watch commander assessed the situation and elected to insert
himself into the perimeter team” (Thorkildsen et al., 2016. p. 21).
“The lack of a clearly identified, single IC both contributed to and was
compounded by the lack of an established staging area for arriving personnel”
(Thorkildsen et al., 2016. p. 21).

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6. Boston Bombing - Watertown Suspect Apprehension - Watertown, MA. - April
19, 2013
“There was confusion about who had overall authority in the field as ongoing law
enforcement activities were conducted. This issue became heightened as hundreds
and then thousands of out-of-town police officers responded to Watertown. Because no
Logistics Chief was assigned to coordinate incoming personnel, incoming personnel
were not briefed, incorporated into ICS, or—with the exception of the tactical teams—
organized into deployable teams or units. Instead, agency commanders and
supervisors focused primarily on commanding their own personnel. In addition, many
personnel did not recognize command authority from anyone outside their own agency”
(Project Management Team, 2014, p. 113).
“Establish a Statewide Policy Regarding on Scene Command During Complex
Critical Incidents. Law enforcement officials representing law enforcement agencies
from across the Commonwealth should create plans and policies that can be
implemented to maintain on scene command at complex incidents” (Project
Management Team, 2014, p. 113).
7. LAX Active Shooter - Los Angeles, CA. - November 1, 2013
“The application of incident command on November 1 indicated the need for
improvements in: situational awareness; alert and notification; interoperable
communications; the build-out of ICS structure; role definition between incident
command facilities; information flow within the ICS structure; and resource
management. Enhancements in these areas will strengthen the general preparedness

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of LAWA (Los Angeles World Airports) and its regional public safety partners” (Liindsey,
2014, p. 22).
8. Inland Regional Center (IRC) Active Shooter - San Bernardino, CA. - December
2, 2015
“While an initial command structure was established within eight minutes, not
until the arrival of other public safety leaders with enhanced experience in incident
command did the formalized unified incident command leadership structure emerge”
(Straub, et al., 2016, p. 60).
9. Kalamazoo Mobile Active Shooter - Kalamazoo, MI. - February 16, 2016
“While it is important to note that the suspect was apprehended within hours of
the third shooting, clear direction and assignments may have been made if unified
incident command had been established earlier in the evening. It is important to
establish unified incident command and identify a single incident commander (IC) as
soon as possible and practical to facilitate communication, situational awareness,
operational coordination, allocation of resources, and delivery of services. Protocols
that define incident command policies and procedures, how changes in command will
be addressed as an event evolves, and the roles and duties of the IC should be
established and agreed to among all regional partners” (Straub et al., 2017, p. 16).
10. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016
“During the initial response to the shots fired call, an OPD SWAT commander,
who was also the on-duty watch commander, established incident command when he
began providing tactical instructions over the radio. As soon as he arrived on scene, he
immediately formed a contact team with the other officers who had responded and

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entered the club. He remained the forward tactical lead inside the club and during the
final assault. While the SWAT commander led the response inside the club, during the
first hour of the incident there was no one who assumed command outside the club to
manage the overall operation as well as the staging and deployment of personnel and
resources as they arrived on the scene” (Straub et al., 2017, p. 47).
11. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6, 2017
“None of the people interviewed, including personnel in the BSO ICP, had a clear
understanding of who the Incident Commander was throughout the event which
hindered communications, situational awareness, and management of response
operations” (Broward County Aviation Department [BCAD], 2017, p. 12).
12. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017
“As the incident grew and more personnel reported to the scene, Incident
Commanders were required to split divisions, branches, and groups to keep the span of
control manageable. LVMPD should incorporate a command and control system
conforming to ICS which is specific to the needs of law enforcement. Just as ICS
developed from wildland firefighting and applied to structure firefighting, ICS command
and control needs to incorporate and meet the needs of specific law enforcement
situations” (FEMA, 2018, p. 33).
“An LVMPD lieutenant was assigned as the event IC during the three-day
festival. As is typical for a pre-planned event, incident commanders walk the venue
checking the welfare of those in attendance and of the officers working. Before shots
were fired, the lieutenant IC assigned to the festival was inside with other officers who
were working the music festival. Not in compliance with ICS, the lieutenant IC did not

67
transfer command before he exited the on-site CP to check on officers throughout the
venue. While walking back to the interior CP, he heard what sounded like fireworks.
Knowing fireworks were not occurring until the end of the show, he scanned the venue
as gunfire from an elevated position began raining down on the crowd” (LVMPD, 2019,
p. 33).
13. Borderline Bar Active Shooter - Thousand Oaks, CA. - November 7, 2018
“In the minutes after Sergeant Helus’ entry, command and control were not
established and little beyond containment was provided. By remaining on the perimeter
in a position of containment, the second supervisor had a limited view of the incident
and therefore a reduced level of situational awareness. Establishing a preliminary
command post as soon as possible and taking stock of the resources available at the
time would have given greater clarity and coordination of incoming resources” (Ventura
County Sheriff’s Office, 2021, p. 54).
“By failing to establish a command post and take control, the leadership on scene
was unable to absorb and evaluate all of the information in a comprehensive way
(Ventura County Sheriff’s Office, 2021, p. 55).
14. Virginia Beach Municipal Center Active Shooter - Virginia Beach, VA. - May
31, 2019
“While the VBPD’s response to the active shooter was appropriate and timely,
the ICS practices were not as strong. ICS roles and functions are important to provide
overall visibility on resources and emerging issues and to help drive response” (Hillard
Heintze, 2019, p. 94).

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15. Robb Elementary Active Shooter - Uvalde, TX. - May 24, 2022
“In the initial response to the incident, Chief Arredondo was actively engaged in
the effort to “stop the killing” up to the point when the attacker was located in Rooms
111 and 112, and the attacker fired on responding officers. iii. By this time, there were
dozens of officers on the scene, but Chief Arredondo did not assume his preassigned
responsibility of incident command, which would have entailed informing other officers
that he Robb Cmte Rpt was in command and leaving the building to exercise command,
beginning with establishing an incident command post. iv. Instead, he remained in the
hallway where he lacked reliable communication with other elements of law
enforcement, and he was unable to effectively implement staging or command and
control of the situation. Over the course of the next hour, hundreds of law enforcement
officers arrived at the scene. The scene was chaotic, without any person obviously in
charge or directing the law enforcement response” (Texas House of Representatives,
2022, pp. 74-75).
“The general consensus of witnesses interviewed by the Committee was that
officers on the scene either assumed that Chief Arredondo was in charge, or that they
could not tell that anybody was in charge of a scene described by several witnesses as
“chaos” or a “cluster”” (Texas House of Representatives, 2022, p. 62).
“A major error in the law enforcement response at Robb Elementary School was
the failure of any officers to assume and exercise effective incident command” (Texas
House of Representatives, 2022, p. 63).

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Interviews of Law Enforcement Involved in ASI
Interviews of LE 25 personnel involved in ASIs were completed. Anonymity was
afforded to each interviewee to encourage them to speak about the challenges they
faced without concern for negative repercussions. As previously stated, all interviewees
were involved in an ASI in the last 20 years. This section will present the interview data
for these interviews relative to ICS.
Thematic Analysis Summary
The interviews supported the AAR analysis findings that there are ICS
challenges in the LE response to ASIs. Twenty-two interviewees stated that the ASI
they were involved in had ICS and leadership challenges. While the AARs described
ICS challenges in a broad sense, the interviewees divulged more specific information
based on their individual experiences. Four interviewees shared their frustration with
command-level officers arriving and not taking charge. Interviewee 11 described this
issue, stating, “Lieutenant … was on scene but never on the radio. He did not take
charge!” Another interviewee said, “The assistant sheriff and other command staff were
on scene but did not take command or say they were on scene over the radio.”
It is not protocol for a higher-ranking officer to arrive at a critical incident and take
command. In fact, the higher-ranking officer can leave the IC already on scene in
charge or take command if there is an absence of leadership. However, in this incident,
both leadership and command structure were absent. The appropriate course of action
for the higher-ranking command staff would have been to take command.
One IC, who arrived to take command 20 minutes after the ASI began, spoke
about the lack of an IC and situational awareness of what had occurred up to that point.

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He had “never been to a critical incident where no one was in charge and there was no
structure.” The lack of an IC and command structure caused the interviewee to spend
critical time attempting to gain situational awareness before deciding on a proper course
of action. Elaborating on a lesson learned, another interviewee said other responders
did not know there was an IC because he did not announce it over the radio. After
attending a debrief where officers voiced their frustration about not knowing if there was
an IC, the interviewee said he should have broadcast that he was the IC. While this
occurrence was not enumerated as an ASI with no IC, it is important to mention that
announcing the IC via radio is crucial. One interviewee noted that no IC was
announced over the radio for over 20 minutes, which delayed the beginning of unified
command with fire and EMS. In total, nine participants mentioned the lack of an
identifiable IC during the initial response phase.
Two interviewees recalled how the IC actively participated in tasks that should
have been delegated to subordinate officers. In one ASI,
“The IC got personally involved in the evacuation [of injured shooting victims] and
did not set his own objectives to guide what officers were supposed to do from
my agency and from others. As a result, officers from other agencies selfdeployed without an assignment.”
An explanation for this might be that some agencies believe in leading from the
front, where supervisors are personally involved in non-supervisory tasks during critical
incidents. Elaborating on that sentiment, one IC said, “There are agencies that pride
themselves that leadership is on the frontline, and, man, I get it, but the worst thing you
can be doing is sitting on that X. It just gives you a narrow picture of everything.”

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An IC becoming involved in actions that are the responsibility of line-level officers
suggests a cultural phenomenon that distracts them and stifles their ability to observe
the response system from a strategic standpoint. It also hampers their ability to set
objectives, recognize patterns, and exploit opportunities. Heifetz and Linsky (2017)
stated that leaders need to “get off the dance floor and onto the balcony” to better
understand and observe a leadership situation comprehensively (p. 51).
Another IC challenge raised was the inexperience of responding supervisors
whose job was to take the IC role. One interviewee described this challenge during an
exchange at the ASI:
“The brand new lieutenant did not have a lot of experience with ICS when I asked
him to take command so I could run tactical command. He had a blank look on
his face and said, “OK, I will try and figure it out.””
The interview findings are similar to those of the AAR analysis, which indicates
this is a significant issue in the response phase, suggesting that IC training is lacking.
This question was asked to several participants after the identification of this emerging
trend. Interviewee 4 said, “Our officers and sergeants did great. Our failures were with
command staff.” A discussion referencing IC training will be in the emerging trends
section.
Staging Area Difficulties
A staging area is the location where resources can be placed while awaiting an
operational assignment (NIMS, 2017). Staging areas help mitigate inappropriate selfdeployment due to the large influx of police officers from nearby jurisdictions who
inevitably respond (Mueck, 2017). Staging area difficulties were an emergent code and

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coded under bifurcations. This is because breakdowns of the response system can
occur at an ASI when there are staging area challenges or the lack of a staging area.
Thematic Analysis Summary
Staging area difficulties were noted in seven (43%) AARs. The absence of a
staging area contributed to inappropriate self-deployment during the Sandy Hook
Elementary ASI and traffic congestion and inconsistencies in assignments during the Ft.
Lauderdale Airport ASI. This finding asserts that there are repercussions for not
establishing a staging area. During the search for suspects in Watertown, MA, after the
Boston bombing, officers self-deployed from staging areas due to the “absence of
information.” This demonstrates that ICs or their designees should provide information
to officers who are staged when feasible.
Specific Staging Area Challenges
1. Sandy Hook Elementary Active Shooter - Sandy Hook, CT. - December
14, 2012. “There was a delay in establishing a staging area for responding personnel
and failure of responding personnel to remain in the area of the CP to receive
assignments as the needs arose. Once the active shooting ceased, resources arriving
on the scene were not immediately directed to a staging location to wait, which resulted
in some personnel improperly self-directing their activities” (Connecticut State Police,
2018, p. 42).
2. Wal-Mart Active Shooter - Las Vegas, NV. - June 8, 2014. “However, radio
communication procedures were not followed, and a staging area was not established,
which hindered the coordination of the response at the incident site” (Thorkildsen et al.,
2016. p. 21).

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3. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“Lieutenant X also had responsibility to organize the mutual aid forces who were
responding in large numbers from other jurisdictions. Since no staging area or reporting
areas for mutual aid police had been established, most outside agency officers drove
directly to the theater parking lots and were assigned from there. The mutual aid police
vehicles contributed to the congestion in the parking lots” (TriData Division, 2014, p.
20).
4. Boston Bombing - Watertown Suspect Apprehension - Arsenal Mall
Staging Area - Watertown, MA. - April 19, 2013. “The UC did not designate a
Logistics Section Chief or Staging Area Manager to manage, coordinate and deploy
personnel staged at the Arsenal Mall. Because no command or management structure
was formally assigned to manage incoming mutual aid personnel, officers were not
assigned roles within the operation or provided briefings on the command structure,
status of the search, operational missions or priorities. It was not clear to in-coming law
enforcement personnel who had overall authority in the field as ongoing law
enforcement activities were conducted. As time went on, and in the absence of
information, officers began to self-deploy into the field. Some officers listened to radio
transmissions or heard media reports and took it upon themselves to deploy into the
field rather than being assigned by the UC or Tactical Operations Command (TOC)”
(Project Management Team, 2014, p. 117).
As a note, the Arsenal Mall served as the official staging area for the suspect
search in Watertown, MA. Further, there were over 2,500 officers from 116 federal,

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state, and local agencies who arrived at the staging area (Project Management Team,
2014).
5. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016. “OPD
personnel did not establish a secure staging area during the Pulse response, nor did
they initially consider the safety of the location of the command post” (Straub et al.,
2017, p. 60).
6. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6,
2017. “Staging areas for response resources and instructions for responding agencies
were not established” (BCAD, 2017, p. 22).
“Lack of adequate and proper staging contributed to traffic congestion and
inconsistencies in mission assignments for mutual aid responders” (BCAD, 2017, p. 26)
7. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “It became
challenging for the staging manager to manage resources from varying law enforcement
agencies. Not all strike teams deployed from staging were LVMPD personnel; they
included NHP, HPD, and NLVPD. These resources from other jurisdictions had the
training necessary to perform their function; however, communication became a
problem. There were more than 50 strike teams and numerous RTFs deployed from
the staging area. Not all had the necessary equipment, specifically radios to
communicate with one another. Communication improved when the staging manager
requested a member of each of the partnering agencies stay in the staging area with a
radio to communicate with his or her respective agency” (LVMPD, 2018, p. 39).

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Interview Analysis: Staging Area Challenges
Fourteen interviewees stated there were staging challenges. These were mostly
focused on three themes: the staging area was too small and quickly overwhelmed,
there was no staging area, and some officers completely bypassed the staging area and
inappropriately self-deployed to the scene. For example, one participant said,
“The [IC] assured me that the staging area [manager] had accounted for the
many officers that were on scene. Well, that wasn’t necessarily true. The reality
is they never went to staging. They all arrived, grabbed their guns, and selfdeployed.”
Communication Challenges
Communication is “any method of conveying information from one person or
place to another to improve understanding” (Heal, 2016, p. 59). In a tactical operation,
sound communications reduce friction between the many parts of the response
organization. According to Heal (2016), there are four fundamental and interrelated
requirements for effective communications: reliability, security, flexibility, and speed.
Out of these four, reliability is most significant in emergency situations because
responders who cannot rely upon the communication system will lose congruity (Heal,
2016). However, even a reliable communications system is subject to challenges
during a rapidly unfolding incident. Several of these challenges were exposed in the
AAR analysis and include inadequate communication between responders, radio
interoperability, and superfluous radio transmissions.
Communication challenges were coded under the butterfly effect or sensitive
dependence to initial conditions because they caused unexpected outcomes. For

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example, in the Borderline ASI, a Ventura County Sheriff’s deputy broadcast that a
sergeant had been shot. No one on scene acknowledged the transmission, indicating it
was not heard. This caused the unexpected outcome of no one knowing that the
sergeant had been shot and needed help.
Thematic Analysis Summary
Inadequate communication between responders causes confusion, and when a
receiving officer does not hear radio traffic, critical information can be missed. Six
(37%) AARs listed inadequate communication. The next communication theme was
officers’ excessive and unnecessary radio transmissions. This communication
challenge can inhibit pertinent information and intelligence from being relayed by ICs
and other law enforcement officers. Seven (43%) AARs listed superfluous radio traffic
as an issue. The third communication challenge was the lack of Interoperability
between responders. Four (25%) AARs identified this challenge.
Specific Communication Challenges
Inadequate Communications Between Responders
1. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“In part due to the volume of radio traffic and dispatcher workload on police and fire
frequencies some critical messages were either not successfully relayed to recipients,
or not understood between police and fire incident commanders. Police and fire must
train with public safety communications systems in mass casualty exercises to ensure
that all know how to communicate with each other in a large incident. It is part
knowledge of communication systems and part human communication that needs to
improve” (TriData Division, 2014, p. XIII).

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2. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016. “The lack
of a common radio channel and a tactical dispatcher became problematic when the
OCSO HDT announced the impending detonation of the explosive device they had
placed to breach the west wall, and several officers and deputies were unaware that the
breach was about to occur” (Straub et al., 2017, p. 64).
3. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6,
2017. “Communication with and instructions to responding law enforcement resources
responding after the second event were inadequate” (BCAD, 2017, p. 12).
4. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “It became
challenging for the staging manager to manage resources from varying law enforcement
agencies. Not all strike teams deployed from staging were LVMPD personnel; they
included NHP, HPD, and NLVPD. These resources from other jurisdictions had the
training necessary to perform their function; however, communication became a
problem. There were more than 50 strike teams and numerous RTFs deployed from
the staging area. Not all had the necessary equipment, specifically radios to
communicate with one another. Communication improved when the staging manager
requested a member of each of the partnering agencies stay in the staging area with a
radio to communicate with his or her respective agency” (LVMPD, 2018, p. 39).
5. Borderline Bar Active Shooter - Thousand Oaks, CA. - November 7, 2018.
“Approximately two minutes later, another deputy broadcast, “We have a Sam
(sergeant) Unit down.” Neither the dispatcher, nor any patrol deputies on scene
acknowledged or repeated this radio transmission. The watch commander also did not
hear the broadcast. The transmission is clear and there does not appear to be any

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other radio traffic that would have covered it” (Ventura County Sheriff’s Office, 2021, p.
49).
6. Robb Elementary Active Shooter - Uvalde, TX. - May 24, 2022. “And
although it should not have proved necessary had responders remained focused on
“stopping the killing” as soon as possible, as the incident dragged on, nobody tasked
any law enforcement responder to establish reliable communications between the south
and north sides of the building and with resources outside the building. Radio
communication was ineffective, so something else was needed for decisionmakers to
receive critical information, such as the fact that victims had called from inside the
rooms with the attacker. To the extent there was confusion among officers about
whether the scenario was an active shooter or barricaded subject, information that there
were wounded victims in the rooms would have clarified the existence of an active
shooter scenario” (Texas House of Representatives, 2022, p. 64).
Superfluous Radio Transmissions
1. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“Because unified command or a single overall incident commander had not been
established, individual police officers radioed for medical assistance without
coordinating with an incident commander. This resulted in duplicate requests,
unnecessary radio traffic, and an inability to control and prioritize use if EMS resources
(TriData Division, 2014, pp. 17-18).
2. Boston Bombing - Watertown Suspect Apprehension - Watertown, MA. -
April 19, 2013. “In addition, during the early part of the incident, it was difficult at times
to transmit or receive critical information by radio. Many of the first responders

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displayed poor radio discipline and several police departments reporting hearing
unnecessary chatter” (Project Management Team, 2014, p. 119).
3. Washington Navy Yard Active Shooter - Washington DC. - September 16,
2013. “At the height of the police response that day, over 1,000 radios were tuned to
the channel used by responding officers. We realize that a large number of those
individuals were merely listening to the transmissions; however, continual radio
transmissions by personnel stationed outside of the building created substantial
congestion. On several occasions, personnel who had entered the building and the
forward commander coordinating the contact teams were unable to transmit vital
information to one another due to the heavy radio traffic” (Washington DC Metropolitan
Police Department, 2014, p. 52).
4. Wal-Mart Active Shooter - Las Vegas, NV. - June 8, 2014. “The LVMPD
communications center (which includes dispatch and the 911 call center) was burdened
with repeated requests for updated information about the incident from LVMPD
personnel” (Thorkildsen et al., 2016. p. 20).
5. IRC Active Shooter - San Bernardino, CA. - December 2, 2015. “Police
radio traffic became overwhelmed, and officers in most need of a clear channel were
not able to obtain it because the response was so large” (Straub et al., 2016, p. 81).
6. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “Early in the
incident, radio traffic was congested with numerous reports of casualties, medical
transports, and active shooters in alternate locations. One officer using binoculars saw
the shooting platform on Mandalay Bay but was unable to relay this information
because of radio congestion. An officer also got on the radio and directed fellow

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officers to stop congesting radio traffic with casualty information. Fire department
personnel addressed these challenges by expanding their communications plan to
multiple radio TAC channels, limiting radio congestion, and supporting ICS framework
expansion” (FEMA, 2018, p. 45).
7. Virginia Beach Municipal Center Active Shooter - Virginia Beach, VA. -
May 31, 2019. “Communications with and between Building 2 were challenging, given
the extensive radio traffic between personnel coordinating activities outside of Building
2. As a result, officers actively engaging the shooter inside Building 2 had difficulties
communicating directly with each other - which at times place them in harm’s way due
to concerns regarding crossfire - and did not allow for effective coordination of
resources” (Hillard Heintze, 2019, p. 74).
Interoperability of Radio Systems
1. Kalamazoo Mobile Active Shooter - Kalamazoo, MI. - February 16, 2016.
“To the south of Kalamazoo City, but within Kalamazoo County, is the city of Portage.
Portage operates its own emergency communications for fire and police services, and
the radio system used by Portage is incompatible with the 800 MHz system used by
Kalamazoo City, Kalamazoo County, and Kalamazoo Township. While some KDPS
supervisors do carry an additional radio that can scan Portage’s radio traffic, officers
and deputies on patrol in Kalamazoo City and Kalamazoo County do not. This was an
area of concern during the response to the February 20 mass shooting” (Straub et al.,
2017, p. 24).
2. LAX Active Shooter - Los Angeles, CA. - November 1, 2013. “Aside from
the expected initial confusion that typifies such events, the establishment of Unified

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Command and build-out of ICP was delayed, non-interoperable radio systems caused
gaps in cross-agency coordination, and mutual-aid response, though substantial,
needed better resource management” (Liindsey, 2014, p. 14).
3. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “Additionally,
there was no interoperability of radio communications among agencies at the tactical
level” (FEMA, 2018, p. 28).
4. Borderline Bar Active Shooter - Thousand Oaks, CA. - November 7, 2018.
“At the time of the incident, no “ring-down line” between the CHP and sheriff’s office
existed. A review of historical information indicates that no “ring-down line” has ever
existed between the CHP and the sheriff’s office. A “ring-down line” allows dispatchers
to identify incoming telephone calls from other dispatch centers on a computer screen
so that the calls can be given priority over other incoming calls during an incident. This
did not appear to be a factor during the shooting, as none of the CHP dispatchers
shared having difficulty reaching the sheriff’s dispatch during post-incident interviews.
Nonetheless, the sheriff’s office is currently exploring the addition of the CHP call center
to the list of current ring-down lines that exist with other agencies” (Ventura County
Sheriff’s Office, 2021, p. 49).
“Recommendation #8: When a multi-agency team is deployed in critical
incidents, provide for radio interoperability or sufficient team members who can
communicate directly with the agency having primary jurisdiction for the incident. In the
absence of this, multi-agency participants must ensure communications about critical
information is pushed to all involved agencies quickly and concisely” (Ventura County
Sheriff’s Office, 2021, p. 53).

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Interview Thematic Analysis - Communication Challenges
The communication challenges stemming from the interviews were similar to the
AAR analysis. Eighteen out of 25 interviewees said they had communications
challenges, and 14 of those were frustrated with superfulous radio transmissions from
other police responders. However, one interviewee stated, “It became our culture
because if you are going to go on scene, don’t say it over the radio. Hit a button on
your computer so those who have command and control have the air.” It can be
concluded that a police agency that has a culture of proper radio transmissions during a
critical incident can help mitigate this challenge.
Inappropriate Self-Deployment
Inappropriate self-deployment was coded under cosmology because it causes
serious response issues that can create overwhelming sensations for those involved.
These severe issues include command and control challenges, officer safety,
accountability, and duplication of efforts. Inappropriate self-deployment can also lead to
misinterpretation of feedback over time, disrupting system equilibrium. When selfdeployment happens at an ASI, it can initially be appropriate. However, as more
responders converge on the incident, self-deployment can become inappropriate,
disrupting the response system’s equilibrium.
AARs often cite inappropriate self-deployment by police officers as a response
challenge in AARs; however, defining what constitutes inappropriate self-deployment is
difficult (Brookes, 2017). Currently, only AARs contain a definition, and existent
academic literature needs to provide a comprehensive definition. In the Christopher
Dorner manhunt AAR, the National Police Foundation identified numerous instances of

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inappropriate self-deployment. The AAR defines self-deployment as “the independent
action of an individual or individuals to an incident without the ability to intervene in an
ongoing situation or without a request from the jurisdiction in command” (National Police
Foundation, 2014, p. 54). Brookes (2017) expanded on this definition of selfdeployment by calling attention to the term’s individual or independent agency and
unrequested by stating they are common terms in AARs when referring to selfdeployment. Further, these terms suggest that officers who self-deploy are doing so on
their own accord without a mutual aid request from the host agency (Leonard et al.,
2014). This inappropriate self-deployment causes numerous response issues listed in
the AARs, including traffic control, personnel accountability, duplication of efforts,
command and control, and officer safety.
Contrarily, police self-deployment has been considered appropriate (Brookes,
2017). As an example, during the Aurora Century 16 ASI, police officers transported 27
victims to hospitals in their police vehicles without waiting for ICS approval. Hospital
staff stated that victims would have likely died without this transport method (TriData
Division, 2014). Appropriate and inappropriate self-deployment of officers creates
obscurity when defining and formulating solutions to self-deployment because even
when officers take lifesaving measures, they still create friction in the response
(Brookes, 2017).
While self-deployment can create friction, leadership and supervision also play a
role. According to Leonard et al. (2014), macro-level leadership in critical incidents,
such as unified command, tends to be cooperative. However, in tactical situations, an
authoritative command is essential. In these tactical situations, self-deployment can be

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controlled through immediate supervisory direction. Contrarily, Brookes (2017) posited
that adversarial events require a “fluid response that is neither strictly authoritative nor
collaborative” (p. 18). Despite this argument, someone must be in charge of the
response, or the incident will run on its inertia, proliferating multiple response difficulties.
Rational Choice Theory and Self-Deployment
One possible explanation for the conduct of officers who self-deploy
inappropriately is from the rational choice theory (RCT) perspective. Social scientists
use RCT to understand human behavior and state that humans behave rationally and
that their actions are for their objectives (Scott, 2000). RCT has been used in numerous
fields, including economics, philosophy, and psychology, to describe the criminal justice
system in the U.S. From this point of view, crime exists because individuals decide to
commit a crime despite knowing it is against the law, and they will be punished if caught
and prosecuted for the crime (Felson & Clarke, 1998; Piquero & Tibbetts, 2012; Scott,
2000). RCT also applies to an officer’s decision to self-deploy without invitation or
direction during an ASI, presuming that the officer’s self-interest objective is to respond
and assist in stopping the suspect and helping victims. However, this rational choice
may not be appropriate, and the officer could unwittingly contribute to the difficulties that
inappropriate self-deployment causes.
AAR Thematic Analysis Summary
Thirteen of the 16 (81%) AARs listed self-deployment challenges. Three of these
13 listed accountability and tracking of officers as an issue: Virginia Polytechnic
University active shooter, LAX active shooter, and Route 91 Harvest Festival. The San
Bernardino and Pulse Nightclub AARs state that during the initial response, the number

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of officers who self-deployed was appropriate; however, at a certain point, their number
became excessive and created self-induced friction (Braziel et al., 2016; Straub et al.,
2017). This implies that identification of when the self-deployment is becoming
excessive by the IC or their designee is critical.
Remedies to inappropriate self-deployment remain elusive. Brookes (2017)
recommended that police agencies accept inappropriate self-deployment as a wicked
problem,
4 which allows police leaders to encourage favorable behavior and mitigate
negative aspects. Police leaders must also understand that inappropriate selfdeployment can staunch a response, and their responsibility is to prevent it.
Specific Inappropriate Self-Deployment Challenges
1. Virginia Polytechnic University Active Shooter - Blacksburg, VA. - April
16, 2007. “Self-deployment of personnel presented a significant challenge. Numerous
LE officers from various federal, state, and local agencies converged on SHES and the
immediate area to provide assistance. The magnitude of response became problematic
for accountability purposes and created further problems accessing the school as all
roads became congested” (TriData Division, 2009, p. 95).
“Recommendation: Commanders must anticipate a large number of responses
of LE officers and other first responders converging on the scene at a mass casualty
event. It is critical to include staging as part of long-term planning for disaster response
at high profile locations, including primary and secondary parking plans with personnel
and equipment (such as cones, barriers, and signage) dedicated to the task as early as
possible” (TriData Division, 2009, p. 95).
4 A problem that is difficult or impossible to solve due to its complex and interconnected nature.

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2. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“The initial response lacked a coordinated, formalized mutual aid staging area or
staging officer, resulting in uncoordinated efforts and confusion. Officers from other
jurisdictions, at times self-assigned, duplicated efforts or engaged in activity not aligned
with current needs” (McGhee, 2016 p. 24).
“At least 27 victims were transported to hospitals in police cars, with at least one
officer making multiple round trips. If police officers had not decided to transport victims
without waiting for ICS approval, which was outside of existing protocols at the time, a
few more victims likely would have died, according to the hospitals” (TriData Division,
2014, p. 18).
3. Sandy Hook Elementary Active Shooter - Sandy Hook, CT. - December
14, 2012. “It reportedly took time at the outset to determine which agency was going to
assume overall command and control of the incident. Although the investigative
responsibility was established early through communication between the State’s
Attorney and Western District Major Crime, Connecticut State Police Senior Executive
level command staff was initially unsure of the agency role” (Connecticut State Police,
2018, p. 19).
4. Washington Navy Yard Active Shooter - Washington DC. - September 16,
2013. “Officers who self-dispatch to a scene, especially a large, rapidly evolving
incident, create concerns of officer safety, cause additional congestion in and around
the scene, and may neglect the need to maintain critical citywide operation and weaken
the department’s ability to respond to a potential secondary or additional incident.

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There were hundreds of officers who arrived on scene with a desire to enter the
building and assist with tactical operations. Fortunately, the Forward Commander on
the inner perimeter was able to coordinate the formation of the contact teams entering
the building. This coordination mitigated the officer safety issues raised by selfdispatching officers involved in the inner, tactical response; however, self-dispatching
still caused issues of congestion around the outer perimeter and near the command and
staging areas.
MPD has clear policies directing members to not self-dispatch to the scene. The
issue on the day of the Navy Yard shooting was that senior managers and command
officials did not take the initiative to enforce the policy and send self-dispatching officers
back to their regular assignments (when it was clear there was more than sufficient
personnel already on scene). This is a challenging issue that is rarely, if ever, trained or
exercised, but should certainly be included.
If not already in existence, agencies should establish clear policies regarding
self-dispatching. MPD has reiterated its policy regarding members not self-dispatching.
Officers should instead follow established protocols (Example: report to the appropriate
patrol district or nearest police facility) and if required to report to the scene of the
incident, do so at a designated location or staging area. Training should test the
officers’ understanding of self-dispatching policies” (Washington DC Metropolitan Police
Department, 2014, p. 43).
5. Wal-Mart Active Shooter - Las Vegas, NV. - June 8, 2014. “Quicker MultiAssault, Counter Terrorism Action Capabilities (MACTAC) might have prevented over
convergence of officers who self reported to the scene” (Thorkildsen et al., 2016, p. 19).

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6. Boston Bombing - Watertown Suspect Apprehension - Watertown, MA. -
April 19, 2013. “Police vehicles hindered access to and egress from the area. Unlike
the day of the bombings in Boston, there was no radio traffic reminding responding
personnel to maintain open roadways as they approached the scene. In an effort to
respond quickly to the ongoing incident, police officers stopped their vehicles at the
closest point of access to the ongoing scene and abandoned them” (Project
Management Team, 2014, p. 115).
“As time went on, and in the absence of information, officers began to self-deploy
into the field. Some officers listened to radio transmissions or heard media reports and
took it upon themselves to deploy into the field rather than being assigned by the
Unified Command or Tactical Operations Center. Others gained access into areas in
the field through professional relationships they had with colleagues already in the field.
Some officers did inquire about the need for assistance, but in some cases, were given
a request to deploy by an unauthorized individual. In some cases, because the
command structure was not evident, officers only responding to orders received by their
respective chain of command. When information about the potential location of the
suspect was transmitted over radios, many officers self-deployed to the residential
neighborhood where the boat was located. Each of those self-deployments created
significant in-field command and control and officer safety issues” (Project Management
Team, 2014, p. 117).
7. LAX Active Shooter - Los Angeles, CA. - November 1, 2013. “It was
difficult for responding agencies to maintain accountability during the initial response, as
mutual aid resources did not participate in a unified check-in process on arrival at the

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scene, some resources had self-deployed, and the lack of interoperable
communications between some agencies contributed to confusion and duplication of
resource requests” (Liindsey, 2014, p. 49).
8. IRC Active Shooter - San Bernardino, CA. - December 2, 2015. “The initial
response to the IRC involved many law enforcement officers from several different
agencies. While the number of law enforcement personnel was overwhelming, it was
justified at the time given the scope of the incident, the limited information about the
suspects and their location, the numbers of wounded victims, and the size of the IRC
complex. While most of the officers on scene were not formally dispatched, their
response was not considered self-deployment. For example, officers who were not
SBPD members were driving through the city and responded when they noticed the
unusual flight behavior of a San Bernardino County Sheriff’s Department (SBCSD)
helicopter. These officers were part of the second team to enter the building when they
were able to determine that the helicopter was over the IRC and the SBPD was
responding to an active shooter.
While the number of officers who initially responded to the IRC was necessary,
the manner in which they responded lacked coordination, adding to an already chaotic
scene. Many officers were not in uniform, and many were driving unmarked vehicles.
In addition, there was limited appreciation of the consequences of unattended police
vehicles blocking access routes to critical responding personnel such as tactical units,
fire, and emergency medical services (EMS). The duties of monitoring traffic and
keeping lanes of traffic open fell to a few officers who took command of the parking

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situation. In many cases, the routes were blocked with no way to quickly locate the
driver. This led to delays in response of critical tactical assets.
As information developed regarding the identities of the possible suspects, the
urgency to capture the suspects and the resulting shootout contributed to more
individuals self-deploying. Numerous officers took independent actions in an attempt to
locate the suspects. Some officers left preassigned positions at or near the IRC without
notifying incident command and responded without adequate situational awareness.
The uncontrolled numbers of officers responding and lack of parking discipline again
caused roads to be blocked and resulted in a delay of critical tactical assets being
available during the officer- involved shooting. In addition, many of the responding
officers arrived at the shooting scene after the shooting had stopped” (Straub et al.,
2016, p. 61).
9. Kalamazoo Mobile Active Shooter - Kalamazoo, MI. - February 16, 2016.
“Officers, including senior personnel, self-deployed to reported sightings of the suspect
by members of the community and/or reported gunshots, which proved to be false”
(Straub et al., 2017, p. 20).
10. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016. “The
number of law enforcement personnel who responded to the Pulse nightclub was
appropriate given the urgency and gravity of the radio broadcasts, conflicting
information about the number of suspects, the number of victims, and the number of
injured persons and the severity of their injuries. Although the majority of the first
responders were not formally dispatched to the scene, their response was consistent
with OPD and regional mutual aid policies, procedures, and protocols. Their immediate

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response, the formation of contact teams, and those teams’ entry into the club saved
innocent lives by stopping the killing and containing the suspect. In addition, many
officers who responded in the second wave - again, many of whom were not formally
dispatched - played an integral role in triaging injured persons and rescuing them from
the club. During the initial response, other officers took it upon themselves to ensure
that South Orange Avenue remained open to ambulances and other emergency
vehicles. However, as the number of officers on scene grew, self-deployment
negatively impacted an already chaotic situation. Within the first three hours,
approximately 300 local law enforcement officers were on scene. Instead of responding
to the UCC or other staging areas to check in and receive assignments, many officers
armed with patrol rifles self-deployed into the club or took positions along the perimeter.
Others stood by and waited for direction. According to OPD officers and Orange
County Sheriff’s Office (OCSO) deputies inside the club and on the inner perimeter,
they had never seen so many guns pointed at them and they questioned the necessity
of having so many heavily armed officers in unnecessary positions when they could
have been performing other critical functions” (Straub et al., 2017, p. 50).
“Uncontrolled self-deployment depletes resources that may be necessary to
respond to ongoing calls for service unrelated to the event. For example, two OPD
dispatchers remarked that at one point during the Pulse response, there were no
available units to respond to calls in the city or county” (Straub et al., 2017, p. 51).
11. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6,
2017. “Communication with and instructions to responding law enforcement resources
responding after the second event were inadequate. Estimates of up to 2600 law

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enforcement officers from the region responded to FLL with no designated staging area
to support deployment and assignment of duties. As a result, self-deployed law
enforcement resources having no knowledge of the airport hindered the response and
prevented employees with valid security badges from getting to their workplace to
support legitimate response operations” (BCAD, 2017, p. 12).
12. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “Selfdeployment of public safety personnel is a common issue at all levels during the
response to critical incidents, mass causality incidents, and other major disasters. In
the initial stages of this incident, personnel converged on the scene and assumed
response roles without first reporting to the staging area. This self-dispatching created
a staffing challenge for the next operational shift, as the intention was for some of these
personnel to relieve others the following morning. In total, several hundred off-duty
police officers self-dispatched to the scene. One in-service Las Vegas Fire Rescue unit
also self-dispatched to the scene. Overall, the self-dispatching made it difficult for
dispatchers and commanders on scene to maintain personnel accountability” (FEMA,
2018, p. 17).
“Many strike teams heard requests for resources over an LVMPD radio and selfdeployed to those requests, leaving the staging manager unaware and duplicating
efforts because resources had already been sent. Every resource that responded to
staging was needed and utilized. However, in hindsight, self-dispatching made it
extremely difficult for LVMPD to account for its personnel. At the time of the mass
shooting, 132 patrol officers, 23 sergeants, and 64 detectives were logged on as
working the valley. To date, LVMPD does not have an accurate account of the number

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of officers and support personnel who responded to 1 October. The best estimate
provided by the investigation indicates more than 1,500 responded. It is unknown how
many of those officers self-dispatched. A more controlled response of resources would
have been ideal” (LVMPD, 2018, p. 39).
“Recommendation #14: Create and strengthen policy to control and manage the
inevitable self-deployment of off-duty first responders during these types of incidents”
(LVMPD, 2018, p. 39).
13. Virginia Beach Municipal Center Active Shooter - Virginia Beach, VA. -
May 31, 2019. “In fact, on May 31, 2019, many key personnel “self-deployed,” in effect,
responding without command direction and knowledge of their assignment and the
location to which they should respond” (Hillard Heintze, 2019, p. 70).
“Surrounding law enforcement jurisdictions began to deploy to the scene. The
Virginia Beach Sheriff’s Office (VBSO), the Chesapeake Police Department (CPD) and
the Virginia State Police (VSP) offered support for the VBPD. However, VBPD was not
at the EOC or integrated at the ICP to help task and direct the additional personnel.
Initially, while some were directed by VBPD to report to the ICP, others responded to
the scene and self-deployed in an attempt to help the victims evacuating from Building
2” (Hillard Heintze, 2019, p. 95).
Interview Thematic Analysis - Inappropriate Self-Deployment
Eighteen of the 25 interviewees indicated there was inappropriate selfdeployment of officers during the ASI. Three participants said the staging area was too
small and quickly overrun, which caused officers to bypass the staging area and selfdeploy without an assignment. Two interviewees said officers did not report to the

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staging areas and instead inappropriately self-deployed without an assignment.
Describing this problem, an interviewee stated,
“The [IC] assured me that the Staging Area [manager] had accounted for the
many officers that were on scene. Well, that wasn’t necessarily true. The reality
is they never went to staging. They all arrived, grabbed their guns, and selfdeployed.”
One possible explanation for these officers not going to the staging area could be
the need for a supervisor to be with the officers. Describing how this issue is a friction
point, one interviewee said,
“When you have multiple people showing up without supervision it becomes hard
to manage. You don’t know them, you don’t know their policies and it creates
unnecessary confusion on the part of the IC and takes away valuable time to try
to figure out what to do with them because you have no authority over them.”
Another interviewee relayed a contentious exchange between himself and a
tactical team that was self-deploying to the scene without checking in with the IC:
“X called and said they were taking over the scene because they owned X.
When their tactical team arrived, they self-deployed, and I had to call them back.
We got into a verbal argument when they walked past me, and I asked them
where they were going.”
Many interviewees expressed frustration with inappropriate self-deployment and
how it slowed their ability to manage the scene. Several also expressed their irritation
with self-deploying officers from other agencies that would not adhere to their
instructions. For example, an IC from agency A would not have authority over an officer

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arriving from agency B. This situation is challenging for ICs. One interviewee said it
takes a strong personality to overcome. In his incident, a SWAT officer inappropriately
self-deployed into the crisis site and began telling officers, who were already on scene
and executing a planned suspect search, that they needed to “push really hard and fast”
to find the suspect. Several SWAT officers from the host agency with “strong
personalities” told the SWAT officer who self-deployed that they would not speed up the
search. The self-deploying SWAT officer yielded to the host agency SWAT officers.
Three of the seven interviewees who did not experience self-deployment
challenges said that terrain played a significant factor in stopping self-deployment.
According to one interviewee,
“There was one way in and out of the huge facility controlled by a gate, and that
made our lives so much easier. We would have lost control real fast had that not
been the case, so we were very fortunate in that respect.”
Another interviewee stated that the only road leading into the staging area where
the ASI occurred was the sole reason they could control officers coming into the crisis
site.
Indiscriminate Parking Challenges
During an ASI, officers who park their police vehicles indiscriminately cause
traffic congestion and block access routes for ambulances and armored rescue vehicles
trying to get to the scene. One example occurred during the Ft. Lauderdale Airport ASI
when officers parked their police vehicles on the roadway and left them running. Those
vehicles ran out of fuel, and the refueling caused further traffic congestion. The parking

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challenges were coded under cosmology because indiscriminate parking of police
vehicles disrupts the response system’s equilibrium.
Thematic Analysis Summary
Six of AARs (37%) listed Indiscriminate parking as a challenge.
1. Sandy Hook Elementary Active Shooter - Sandy Hook, CT. - December
14, 2012. “The narrow entry road to the school became a log jam of vehicles and made
ingress and egress up to the school for later-responding personnel difficult or
impossible. Even after the active shooting had ceased, responding officers parked their
vehicles in an obstructive fashion. Many of these first responders were CSP personnel,
and many of the cruisers were locked, some with the engines running. The agency
currently has a policy dictating that unattended department vehicles should be locked
and the vehicle keys removed, and some newer vehicles have the capability of disabling
the vehicle while it is still running” (Connecticut State Police, 2018, p. 14).
2. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“The traffic in the parking lot and parked police vehicles blocking roads made it difficult
to get fire apparatus and ambulances through the “maze” of vehicles and curbs to get
close to the theater and the wounded. Police incident command knew that access for
fire and EMS vehicles was clear on the south side of the theater (from East Exposition
Avenue), but it required driving over a low median strip. As best we can tell from
interviews with many police and fire first responders, the police did not provide access
directions or instructions for fire/EMS, assuming they could navigate their own way
through the parked cars as had police vehicles” (TriData Division, 2014, p. 18).

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3. Boston Bombing - Watertown Suspect Apprehension - Watertown, MA. -
April 19, 2013. “Police vehicles hindered access to and egress from the area unlike the
day of the bombings in Boston, there was no radio traffic reminding responding
personnel to maintain open roadways as they approached the scene. In an effort to
respond quickly to the ongoing incident, arriving police officers stopped their vehicles at
the closest point of access to the ongoing scene and abandoned them, often with
emergency lights on and doors left open. This bottleneck of vehicles hindered access
to the area by senior police officials, as well as egress from the area. This also was an
issue for the ambulance transporting a critically wounded officer and for police vehicles
that may have otherwise been able to pursue the fleeing suspect” (Project Management
Team, 2014, p. 115).
4. LAX Active Shooter - Los Angeles, CA. - November 1, 2013. “Another
challenge for Unified Command was the large numbers of vehicles parked on both
upper and lower CTA roadways. Without a pre-designated staging area, resources
reported directly to the scene and were quickly assigned responsibilities within terminals
and parking structures. Unified Command attempted to get responders to relocate their
vehicles to other locations, but in many cases it was unable to determine who the
vehicles belonged to, or the location of the operators. As these vehicles were delaying
the reopening of the CTA, Unified Command eventually had to resort to towing
responders’ vehicles out of roadways” (Liindsey, 2014, p. 49).
5. IRC Active Shooter - San Bernardino, CA. - December 2, 2015. “In addition,
there was limited appreciation of the consequences of unattended police vehicles
blocking access routes to critical responding personnel such as tactical units, fire, and

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emergency medical services (EMS). The duties of monitoring traffic and keeping lanes
of traffic open fell to a few officers who took command of the parking situation. In many
cases, the routes were blocked with no way to quickly locate the driver. This led to
delays in response of critical tactical assets” (Straub, et al., 2016, p. 61).
6. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6,
2017. “Law enforcement cars were parked on the roadway and left running which
caused congestion’ subsequently, those cars ran out of fuel and had to be refueled
which caused more congestion” (BCAD, 2017, p. 22).
7. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “The ease of
ingress and egress was not managed during the initial response to the incident, and
parked vehicles hampered easy entry and exit from the ICP and staging locations. An
overwhelming number of officers and leadership filled the staging area and occupied
Las Vegas Boulevard, not knowing the magnitude of the incident” (LVMPD, 2019, p.
38).
Interview Thematic Analysis
Fourteen out of 25 interviewees (56%) mentioned indiscriminate parking of police
vehicles as a challenge. Three interviewees who experienced indiscriminate parking
said that narrow roads contributed to the parking challenges. According to one
interviewee,
“The roads were tight, so we were having the same problem everyone does,
which is people parking their patrol cars in the middle of the road, getting out of
their cars, and running to the scene.”

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One interviewee expressed vexation with command staff after elected and VIPs
arrived. Specifically, he said,
“In the initial 30 minutes, I moved three cars personally. Then, I assigned a
sergeant to parking. That worked until the electeds and VIPs started showing.
My sergeant got outranked. A captain or the sheriff or undersheriff showed up
and told him to let the elected and VIPs park where they want, which caused us
problems.”
One interviewee commented, “There was 100% road blockage. We couldn’t even
get our Bearcat to the scene because there was 30 [police] cruisers completely blocking
the road.” The interviewee further said it took them precious time trying to get the police
vehicles moved so they could get to the crisis site with armored vehicle resources.
Despite the frustration of some interviewees, those who did not experience
parking challenges said they either had an informal or formal policy that stopped or
mitigated haphazard parking of police vehicles. In one incident where an ASI occurred
at a pre-planned event, parking plans were built into the incident action plan (IAP). The
interviewee said this helped them mitigate careless parking of police vehicles when the
ASI occurred.
Only one interviewee mentioned that the parking of fire and EMS vehicles
caused difficulty in reaching the crisis site. This incident occurred when he exited the
freeway, and fire and EMS vehicles were highly crowded. While he was able to
navigate around the emergency vehicles slowly, his response slowed.
Unified Command Challenges
The California Office of Emergency Services (2019) defines unified command as

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“a procedure that allows all agencies with significant geographical, legal or
functional responsibility over an incident to avoid operational conflicts, economize
resources by collocating at a single Incident Command Post and communicate
their operational goals and strategies to each other during structured planning
meetings” (p. 25).
FEMA (2017), in the NIMS guidance document, defines unified command as
“When more than one agency has incident jurisdiction, or when incidents cross
political jurisdictions, the use of Unified Command enables multiple organizations
to perform the functions of Incident Command jointly. Each participating partner
maintains authority, responsibility, and accountability for its personnel and other
resources while jointly managing and directing incident activities by establishing
a common set of incident objectives, strategies, and a single Incident Action
Plan” (IAP) (pp. 4–5).
Although Cal OES and FEMA define unified command, they do not discuss joint
command and its importance in the initial response phase (Table 2). Heal (2020)
discussed joint command versus unified command and the importance of potential ICs
in understanding the benefits and constraints of the two command architectures. Joint
command is the default mode when an agency needs urgent help from a nearby
jurisdiction. In this command relationship5, the senior commander from the supporting
units is subordinate to the primary IC (Heal, 2020). The host IC gives objectives and
orders to the senior commander of the supporting units. Supporting units are usually
deployed upon arrival, with only a briefing and general direction. The difficulty occurs in
5 How a response organization affixes responsibility, resolves conflicts, distributes resources and focuses
efforts (Heal, 2011).

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joint command when the supporting units from other agencies have vital skills (such as
fire or EMS) or are more significant than the supported agency (Heal, 2020). When
these situations occur, a unified command architecture is appropriate. Heal posits that
insistence on a unified command too early while managing a dynamic event, like an
ASI, will stall the response.
While the joint command is used throughout the initial police response, during the
Stop the Dying Phase, it is vitally important that the police IC integrates with fire and
EMS to establish unified command, thereby improving the response and helping to save
lives (Martaindale & Blair, 2019). Jacobs (2014) pointed out that delays in getting the
injured to a higher level of care could cost the lives of victims. He further explained that
the response delay is hampered by the lack of a unified command structure between
police and fire/EMS. Police ICs should understand the difference between unified and
joint command when they are intended for use and that establishing unified command
with fire/EMS as quickly as possible during an ASI is extremely important to save
victims’ lives. Unified command was coded under “chaos” because the lack of unified
command caused a lack of coordination among law enforcement and fire/EMS
responders.

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Table 2
Joint Command vs. Unified Command (Heal, 2020)
Joint Command Unified Command
Beneficial for Circumstances when
urgency of action is more
important than precision.
This is the “default mode”
for law enforcement
agencies.
For incidents that are multijurisdictional or
multidisciplinary in nature,
or when reinforcements
have critical knowledge or
experience.
Decisions made by Single commander from an
agency with primary
jurisdiction consensus of
supporting commanders.
Collaboration of multiple
senior commanders who
provide a “common voice.”
Responding commanders
are
Deployed with their units. Collocated at the command
post.
Priorities are set by Single commander from
agency with primary
jurisdiction with tacit
approval of supporting
commanders.
Collaborative effort by all.
Thematic Analysis Summary
Unified command challenges were found in 12 AARs (75% of all interviews). As
a note, unified command was not mentioned in the Borderline and Robb Elementary
School AARs; however, both incidents lacked a clearly identified IC during the initial
response phase. This would indicate that there were unified command difficulties. No
major themes concerning unified command were identified in the AARs. Some of the
reports did not divulge useful information that made clear unified command difficulties.
However, insightful points were indicated in several reports.
In the LAX ASI, the LAFD did not want to integrate with the police IC due to
security concerns about the command post being too close to the crisis site. The lack of

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unified command and an IC at the Aurora Century 16 ASI caused police officers to radio
for medical assistance without coordinating with an IC. At the Ft. Lauderdale Airport
ASI, the absence of unified command resulted in no common operating picture, which in
turn caused a lack of information regarding resources needed and challenges with the
development of objectives. During the Route 91 Harvest Festival ASI, there was no fire
presence at the pre-planned event, which caused command and control to be
disjointed. FEMA recommended that a unified command post should be established for
special events.
Specific Unified Command Challenges from AARs
1. Virginia Polytechnic University Active Shooter - Blacksburg, VA. - April
16, 2007. “There is little evidence that there was a unified command structure at the
Virginia Tech incident. Command posts were established for EMS and law enforcement
at the Norse Hall scene for law enforcement at another location” (TriData Division,
2009, p. 119-120).
“At Norse Hall, a unified command structure could have led to less confusion,
better use of resources, better direction of personnel, and a safer working environment”
(TriData Division, 2009, p. 20).
2. Aurora Century 16 Theater Active Shooter - Aurora, CO. - July 20, 2012.
“Because unified command or a single overall incident commander had not been
established, individual police officers radioed for medical assistance without
coordinating with an incident commander” (TriData Division, 2014, p. 17).
“Police and fire commanders did not establish a unified command during the first
hour and did not communicate effectively using available radio systems in the initial,

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critical minutes of response, triage and transport. No procedures were in place to
ensure face-to-face contact or direct communications between police and fire incident
commanders” (TriData Division, 2014, p. XIII).
3. Sandy Hook Elementary Active Shooter - Sandy Hook, CT. - December
14, 2012. “It reportedly took time at the outset to determine which agency was going to
assume overall command and control of the incident. Although the investigative
responsibility was established early through communication between the State’s
Attorney and Western District Major Crime, Connecticut State Police Senior Executive
level command staff was initially unsure of the agency role” (Connecticut State Police,
2018, p. 19).
4. Washington Navy Yard Active Shooter - Washington DC. - September 16,
2013. “During the initial response, while the crisis was evolving and the gunman was
still clearly active, full Incident Command was not clearly established; however, the vital
ICS objectives were in place and Unified Command was soon formed” (Washington DC
Metropolitan Police Department, 2014, p. 38).
5. Wal-Mart Active Shooter - Las Vegas, NV. - June 8, 2014. “In addition,
because of his rank, the watch commander continued to receive inquiries and requests
for direction from other officers and teams on the scene, making it unclear which officer
was nominally IC and which was actually directing the scene. This caused difficulty
when integrating unified command with the fire department and resulted in
miscommunication to the SWAT team leader, who received a briefing on the status
inside Walmart from the watch commander instead of from the established IC”
(Thorkildsen et al., 2016, p. 21).

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6. LAX Active Shooter - Los Angeles, CA. - November 1, 2013. “The
establishment of unified command the incident command post was delayed” (Liindsey,
2014, p. 14).
“LAFD did not initially integrate into unified command because of security
concerts of the location of the command post” (Liindsey, 2014, pp. 19-20).
7. IRC Active Shooter - San Bernardino, CA. - December 2, 2015. “While an
initial command structure was established within eight minutes, not until the arrival of
other public safety leaders with enhanced experience in incident command did the
formalized unified incident command leadership structure emerge” (Straub et al., 2016,
p. 60).
8. Kalamazoo Mobile Active Shooter - Kalamazoo, MI. - February 16, 2016.
“While it is important to note that the suspect was apprehended within hours of the third
shooting, clear direction and assignments may have been made if unified incident
command had been established earlier in the evening. It is important to establish
unified incident command and identify a single incident commander (IC) as soon as
possible and practical to facilitate communication, situational awareness, operational
coordination, allocation of resources, and delivery of services. Protocols that define
incident command policies and procedures, how changes in command will be
addressed as an event evolves, and the roles and duties of the IC should be
established and agreed to among all regional partners” (Straub et al., 2017, p. 16).
9. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016. “Unified
law enforcement command was established at the Pulse attack scene within the first
hour. However, Orlando Fire Department and emergency medical services (EMS)

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officials were not included in the unified command center and were unaware of the
discussions occurring and the decisions being made as a result.” (Straub et al., 2017,
p. 59).
10. Ft. Lauderdale Airport Active Shooter - Ft. Lauderdale, FL. - January 6,
2017. “Due to the lack of Unified Command, a common operating picture was not
developed resulting in a lack of information regarding resource needs and disjointed,
misinformed, and conflicting mission development” (BCAD, 2017, p. 24).
“With respect to Incident Command, it is understood that the actual shooting
event, suspect apprehension, and crime scene investigation are strictly law enforcement
operations. However, the subsequent notifications of shots fired and the resulting selfevacuation yielded response needs that fall under the jurisdiction of multiple agencies
including BCAD, the EMD, and ESFs #1, #6, and #8 and require use of Unified
Command. The failure to institute Unified Command directly contributed to inaccurate
and inadequate mission identification, development, and resourcing” (BCAD, 2017, p.
24).
11. Route 91 Harvest Festival - Las Vegas, NV. - October 1, 2017. “Without
fire presence at the event, command and control were fractured, independent, and only
involved LVMPD and Community Ambulance. For a special event of this scale, a
unified special events command post should be established among all agencies with
one IAP and a clear plan for emergency operations” (FEMA, 2018, p. 11).
12. Virginia Beach Municipal Center Active Shooter - Virginia Beach, VA. -
May 31, 2019. “The VBPD did not engage in the efforts to establish unified command.
VBPD command did not use the ECCS to assist in directing resources and were not

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focused on coordinated resourcing with other responders. Although VBPD operations
were in close proximity to the other operating command posts, they did not share an
operating environment that drove resourcing decisions.” (Hillard Heintze, 2019, p. 94).
Interviewee Thematic Analysis
Twenty interviewees discussed unified command challenges with fire and EMS.
Of all the response challenges, unified command weighed most heavily on the minds of
interviewees who understood that these challenges slowed their ability to assist the
injured. According to seven interviewees, training with fire and EMS was lacking for
several reasons. Several lamented that fire and EMS would not come into the warm
zone to rescue the injured. One interviewee said he would have done more integration
training with fire: “That’s where ours kind of fell apart was the link between law
enforcement and fire and then getting fire and medical comfortable going into the warm
zones.” Three interviewees said their relationship with fire and EMS waned after
training was complete, and it was almost forgotten.
The most frequently mentioned friction point with unified command was getting
fire to respond into the warm zone to rescue and treat victims. An interviewee said one
possible cause of this is the way fire departments characterize cold, warm, and hot
zones. In his ASI at a pre-planned outdoor event, “They [fire] determine hot versus
warm differently, and if they think there’s an active shooter that we haven’t located,
even though there’s not active shooting occurring, they interpret that as a hot zone and
will not respond.” He continued by saying that fire left the police “with victims laying on
the ground” because they determined the area to be a hot zone and would not respond.

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Still another interviewee stated that the problem lay with fire supervisors. After
establishing a warm zone safety corridor for paramedics to extract injured victims, they
were not allowed to come in. Specifically, the interviewee remarked, “We could not get
paramedics or fire to go inside. We explained that it was a warm zone, but it wasn’t the
individual troops. They were raring to go. It was their supervisors and commanders
who told them no.” While bringing in other first responders to the warm zone was a
significant challenge, another interviewee cited the difficulty as the location of the fire
agency’s command post. Specifically, they were not co-located with the police agency.
In one occurrence, “fire set up their own command post on the opposite side of the
building. They had to fix that, and eventually they linked up with police command. That
took about a half hour to fix.” Another interviewee noted the belief by fire that the police
CP was too close to the crisis site. This is the same finding that occurred in the LAX
ASI in 2013 due to security concerns.
When unified command worked properly, interviewees said that prior
relationships were the primary reason for their success. One interviewee relayed,
“We had been doing regular meetings with the battalion chiefs. We bring them
into the sergeant’s meetings, and we do scenario training, mainly for fires,
because once the fire kicks up, we attach our sergeant to the hip of the battalion
chief. So, yes, it was because of relationships, and we had done a lot of
tabletops prior to that point.”
Despite these challenges, several of the interviewees who did not experience this
issue said they had no problem getting fire and EMS into the warm zone to rescue
victims. Further, they did not experience any challenges because of their long-

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established relationship with fire and EMS. Indeed, one interviewee remarked that it
was not the actual training that mattered. The fact that they knew one another reduced
friction between police and fire/EMS.
One interviewee, whose ASI occurred inside of a large business, said it would
have been helpful for a representative of the affected business to have been involved in
unified command. He stated that one business representative in unified command
would have mitigated the confusion of getting multiple stories from different people while
trying to account for everyone.
Novelty
An ASI that is novel to some responders may not be unusual to other
responders. Using an example from the 9/11 terrorist attack, terrorists using planes to
destroy buildings was not a novel concept to aviation security experts. However, the
public, policymakers, and journalists had not considered this possibility before (Birkland,
2006). In the context of an ASI, some police responders may not have received training
or have ever considered a terrorist active shooter who takes hostages or what to do
when arriving at an ASI where there is no active gunfire, and the scene is quiet. This
unfamiliarity with these ASI types can lead to indecision and delayed actions.
Novel events were an emergent code revealed during the analysis of AARs. A
novel incident occurs when responders face a situation they have never seen before,
and their crisis decision-making is challenged (Straub et al., 2017). Novel incidents are
complicated for an IC and responders to manage because ASI training does not usually
prepare them to identify novelty and to make course corrections that are appropriate to
respond to new information and circumstances. Novel ASIs can cause inaction or

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hesitation in responders’ decision-making. Novel events were coded under cosmology
because inaction or hesitation in decision-making can create an overwhelming
sensation for those involved.
Thematic Analysis Summary
Novelty was discovered in three (18%) AARs.
1. Pulse Nightclub Active Shooter - Orlando, FL. - June 12, 2016. “In focus
groups with the assessment team, numerous officers said they could see neither down
the long narrow hallway leading to the two dressing rooms and the emergency exit at
the far end of the room nor down the hallway leading to the restroom where the suspect
was contained with hostages. Without clear visuals and with incomplete information
regarding the exact location of the suspect and hostages, SWAT officers determined it
was too risky to conduct a direct assault and maintained their positions behind and
around the bar, approximately 15 feet away from the entrance to the restroom where
the suspect was contained. In addition, the lack of gunfire led officers to determine that
the situation had transitioned from an active shooter to an armed barricaded suspect
with hostages. While the suspect was contained, officers searched and secured the
remainder of the Adonis Room, leading several patrons to safety” (Straub et al., 2017,
p. 54).
“While terrorists may be willing to die for their cause, and their “calling card is to
start killing people straight away,” there is ample evidence to suggest that they are just
as ready to embrace a resolution that provides them with some sense of
accomplishment or victory. Negotiations can create meaningful dialogue, exchange of
information, and opportunities to resolve the event without risking further injury to

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hostages, law enforcement personnel, or the suspect. In addition to buying time and
gaining important intelligence, the negotiation process provides much-needed time to
assemble tactical teams and prepare them for an assault if it does not succeed in
securing a peaceful surrender.174 In several instances, suspects have given up
voluntarily to police responding to acts of mass public violence or terrorist incident”
(Straub et al., 2017, p. 54).
2. Borderline Bar Active Shooter - Thousand Oaks, CA. - November 7, 2018.
“One of the most thought-provoking issues surrounding the incident was when to
attempt a second entry. All who reviewed the incident agreed that a second entry
needed to be made after the shootout between the suspect and Sergeant Helus and the
CHP officer. The questions to be debated centered on when the entry should have
taken place, where the entry would be made, and who would make the entry” (Ventura
County Sheriff’s Office, 2021, p. 56).
“In the moments after the exchange of gunfire between the suspect and law
enforcement, the SWAT team was requested. While a request for the SWAT team was
appropriate, the question of a second entry by patrol, prior to SWAT’s arrival, remains.
Factors which would contribute to a more rapid entry include: • Knowledge that there
were victims down inside, their condition was unknown at the time, and some may have
been in need of immediate medical care Note: Although unknown to personnel at the
time, it was later learned that all of the injured victims inside the building had suffered
mortal injuries and could not have been saved. • Knowledge that there were patrons
inside hiding • Outstanding suspect with a proven desire to kill Factors potentially
contributing to the delayed entry include: • Previous attempt to enter resulted in a

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shooting that left Sergeant Helus down • The gunfire stopped after the initial entry by
Sergeant Helus’ team • Experience level of the supervisor on scene • Experience level
and tactical knowledge of patrol resources on scene • SWAT training and experience in
tactical entries generally exceeds that of patrol” (Ventura County Sheriff’s Office, 2021,
p. 57).
“The SWAT captain has overall control and responsibility for the team and
provided much needed leadership in the moment to coordinate an entry team consisting
of personnel from multiple agencies. By becoming a member of the entry team, he
limited his ability to establish a tactical command position from which he could direct
incoming SWAT resources and develop a comprehensive tactical plan.
RECOMMENDATION #16 As with any management position, when resources allow,
leaders should resist the desire to become a part of the response itself. Managers are
charged with ensuring high level command and control of an incident and should focus
their efforts on broader incident command” (Ventura County Sheriff’s Office, 2021, p.
60).
3. Robb Elementary Active Shooter - Uvalde, TX. - May 24, 2022. “Although
the encounter had begun as an “active shooter” scenario, Chief Arredondo testified that
he immediately began to think of the attacker as being “cornered” and the situation as
being one of a “barricaded subject” where his priority was to protect people in the other
classrooms from being victimized by the attacker” (Texas House of Representatives,
2022, p. 52).
“Chief Arredondo and other officers contended they were justified in treating the
attacker as a “barricaded subject” rather than an “active shooter” because of lack of

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visual confirmation of injuries or other information. Chief Arredondo explained his
reasoning for not continuing an active shooter-style response, telling the Committee:
[W]hen there’s a threat … you have to visibly be able to see the threat. You have to
have a target before you engage your firearm. That was just something that’s gone
through my head a million times. … [G]getting fired at through the wall … coming from a
blind wall, I had no idea what was on the other side of that wall. But … you eliminate
the threat when you could see it. … I never saw a threat. I never got to … physically
see the threat or the shooter” (Texas House of Representatives, 2022, p. 53).
“It actually was an “active shooter” scenario because the attacker was preventing
critically injured victims from getting medical attention. i. An active shooter scenario
differs from a barricaded-subject scenario in that law enforcement officers responding to
an active shooter are trained to prioritize the safety of innocent victims over the safety of
law enforcement responders. ii. At first, the first responders did not have “reliable
evidence” about whether there were injured victims inside Rooms 111 and 112,
although circumstantial evidence strongly suggested that possibility, including the fact
that the attacker had fired many rounds inside classrooms at a time when students were
in attendance” (Texas House of Representatives, 2022, p. 74)
Analysis
U.S. police agencies use a standard response model for ASIs that includes Stop
the Killing and Stop the Dying strategies (Martaindale & Blair, 2019). However, when
novel incident variations occur, such as in Uvalde or Borderline, leadership and crisis
decision-making breakdowns are acute. One possible explanation for these acute
difficulties is that two conditions hamper novel emergency incident recognition (Frigotto,

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2018). The first is when an incident appears to responders as a recognized emergency,
but clues that novelty is present are neglected. Second, responders fail to identify
something unusual until it causes apparent harm (Frigotto, 2018).
Research shows that high reliability organizations (HROs)
6 use improvisation and
adaptation to confront novel events (Weick & Sutcliffe, 20015). In the Mann Gulch
tragedy, Weick (1993) contended that the firefighter survivors recombined their
comprehension of what was occurring to escape the fire. For example, while escaping
the fire behind him, the fire supervisor lit a fire in front of him and jumped through the
fire. In doing so, there was no combustible material for the fire to burn when it reached
him, thereby saving his life. Weick (1993) indicated that the previous experience of the
firefighters in the Mann Gulch incident played an essential role in effective improvisation
when confronting novelty.
In the law enforcement domain, ranking law enforcement officials who will be ICs
in large-scale critical incidents are regarded as poor at making quick decisions. The
cause of poor decision-making is that they are used to careful and thoughtful decisions
in their day-to-day duties, which do not translate into decision-making during rapidly
unfolding incidents, such as an ASI (Renaud, 2012). Renaud (2012) and Weick (1993)
state that checklists do not work in chaotic or novel circumstances. However,
improvisation and creativity are the answers when an IC confronts a new situation.
While it is unclear if improvisation by ICs would have proven helpful in Pulse,
Borderline, or Uvalde, several conclusions can be drawn when analyzing each event’s
novel nature.
6 HROs are organizations that achieve safety, quality, and efficiency goals by employing several
principles (Weick & Sutcliffe, 2015).

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These three events challenged the decisions of those in charge based on the lack of
visual confirmation of the suspect’s location, the absence of “active” gunfire, and the
presence of injured victims who required medical attention. The Pulse AAR states that
officers had “incomplete information regarding the exact location of the suspect and
hostages” (Straub et al., 2017, p. 54). In Pulse and Uvalde, the situation involved
hostages, which added further complexity to the response. From the information in the
AARs, it can be inferred that when there is no “active shooter” or stimulus to drive the
responding officer’s actions, decision-making regarding subsequent response actions
suffers. It is unclear if the officers and supervisors involved in these situations were
trained to manage and make crisis decisions during similar situations.
Interview Data Reference Novelty
Two interviewees said that they faced a hostage situation during an ASI. In one
incident, the tactical commander took several hours to attempt a hostage rescue. When
asked what he would have done differently, the interviewee said,
“Aggressive, more aggressive. Take the opportunities, the operational
opportunities, that we can. We could have probably got intelligence from an
adjacent room with technology. We know that certain things are going to give us
a leg up if we didn’t use them. We sat and waited, thinking there was a
possibility that he was just holding them [hostages] quiet in there. But we
absolutely could have done something more to get into that room earlier.”
In the other ASI turned hostage situation, the interviewee said they were unable
to rescue the hostages without officers being killed due to the suspect’s position of

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extreme advantage inside the crisis site. Further, they did not know the suspect’s exact
location, complicating the circumstances.
Two interviewees pointed out the novelty of encountering an active shooter
where the targets turned from innocent victims to arriving police officers:
“Once that person starts engaging the police, sure it’s still an active shooting, but
our tactics need to change because were no longer going in to save the victims.
We are the victims. So, we have to fight through that problem before we can
worry about the other people [victims]. So, in our shooting, we had the initial
arriving officers that were shot. We had a wave of officers that went up and were
shot, and then, at some point, it sinks in. We are not going to be able to keep
pushing bodies because now we are the ones who are taking fire.”
Undoubtedly, this case challenges conventional ASI police response models. It
is not simply stop the killing and stop the dying when the IC must consider the lives of
officers who are repeatedly being shot upon arrival.
In another ASI, an officer had been killed, and the crisis site still had injured
victims inside. The interviewee “was maxed out with what I was trying to do and was
struggling to deal with what was going on.” He was also worried about the officers
accidentally shooting one other and the officer’s death, which “had a tremendous
amount of weight on trying to do what was right.”
A similar type of incident where an officer had been shot and there were injured
and dying at the crisis site caused significant challenges for the first arriving supervisor.
The interviewee relayed that she knew from prior active shooter training almost 20

117
years prior that she remembered hearing that they needed to confront the suspect to
stop the killing. But with an officer down, the interviewee stated that she:
“believed that was what I was supposed to do or have my people do. I was not
willing to make that decision because it seemed like a suicide mission, so I
basically kept the perimeter and berated myself for not going in for [the downed
officer] and killing the suspect. I was unable to get past that limitation in my
mind, which prevented further instruction from me [to other officers].”
Emerging Themes from Interviews
Command Level Training. One emerging theme from the interviews that the
AARs did not mention is command-level training challenges. Twenty-one interviewees
said police leaders who take command at an ASI are sorely lacking in training.
Specifically, one interviewee pointed to this issue, saying,
“I think we do a great job training our line level. But as soon as the supervisors
get there or the lieutenant, we start to have serious issues setting up command
and control and filtering through the chaos. Instead, we create fog and friction
that doesn't need to be there.”
Several of the interviewees said they need more decision making training and
when they promote, their ability to make decisions quickly slows. To this point, one
interviewee remarked, “Decision making is a perishable skill, like shooting. When I
promoted to lieutenant, my decision making became sluggish.” This statement supports
Renaud’s (2012) assertion that when a LE officer holds rank, they become managers
and leaders, and their duties teach them to make decisions slowly and carefully.
However, that type of slow decision making is ineffective during a rapidly unfolding

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crisis. There also appears to be a cultural challenge when command-level members
participate in active shooter training. One interviewee’s statement rather poignantly
describes this problem:
“You know, our culture is they [command-level police officers] say, “I can’t make
it” or “I will be an observer.” They sit back because they don’t want to be
embarrassed because it is going to reveal some of their deficiencies relative to
critical decision making. We need to do a better job of requiring their
participation but also creating a training environment that allows them to fail
without embarrassment, so when in an actual situation, they can make good
decisions.”
Speaking to specific challenges with training, one interviewee said,
“There’s always such a focus on the tactics and those are perishable unless you
are training on it all the time. In my opinion, active shooter training should be
decision-making-focused. If you look at past active shooter incidents in our
country, it’s not that the three-person formation was wrong. It was the decision
making.”
Unquestionably, the lack of training for officers of rank is one of the primary
contributing factors to the incident command challenges that occur at ASIs. There was
no clear answer from the interviewees as to why the training for command leadership
was lacking. A further contributing factor to the ICS challenges is the cultural challenge
where command leadership shies away from training to avoid embarrassment. These
are two significant friction points that police executives face.

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Executive Command Leadership Presence. Twelve participants reported that
the presence of executive police command staff at an ASI contributed to substantial
friction points (Figure 3). Notably, this challenge caused the command structure to be
“ineffective.” One interviewee was particularly frustrated when “the rest of our chain of
command showed up and did not adhere to ICS. We had several captains, one brand
new, and two others who pretty much got in the way. The ICS became ineffective at
that point.” In another ASI, the interviewee lamented,
“Command staff were on scene asking for portapotties and food. It just wasn’t
the time for that. We weren’t there yet, and there was a lot of work to be done,
especially securing that property. I remember thinking they are trying to do
something they just don’t know what to do, so they went into logistics mode.”
One of the harshest criticisms came from an interviewee who said commandlevel officers arrived and began giving orders but not taking command: “Basically, they
were the peanut gallery without wanting to take responsibility.”

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Figure 3
Command Staff Interference With the Incident Commander
Two interviewees expressed their frustration that command-level officers arrived
but did not broadcast on the radio that they were on the scene, nor did they take
command. One interviewee arrived at an ASI scene with no command structure despite
a sergeant, the assistant sheriff, and another command staff member being on the
scene. In another ASI where an officer had been shot during the initial response, an
interviewee said:
“A lot of people showed up. Other sergeants, captains, even the sheriff, but no
one took control of the scene. Individuals were doing their own thing with their
own people. There was no command post established until the building was
cleared, people were taken to the hospital, and the investigation had begun.”
One interviewee pointed out,

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“When you are in command and just show up, it confuses people. You have
people who are in charge. The chief of police or the sheriff does not need to be
showing up and taking command of anything unless there is a complete absence
of leadership. It confuses people on scene, from officers up through the ranks.
You have a role to play, and it is not that role.”
While the intent of command staff leaders at an ASI is unknown, their presence
evidently causes response challenges for those already on scene.

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Chapter 5: Discussion
Chapter 5 incorporates the data analysis results with a broader discussion of the
implications for improving future police response efforts. This chapter answers the
research questions presented in Chapter 3. This chapter includes a response model
that more closely resembles the actual response than the hierarchical model of ICS, a
discussion of policy implications and suggested policies for police response at the state
level, and policy implications and suggested principles for inappropriate selfdeployment. The chapter concludes by discussing possible future research and the
implications for police practices during ASIs.
Research Question #1: What Are the Known and Unrevealed Primary Challenges
for LE Supervisors That Contribute to Chaos and Uncertainty During ASIs?
Hypothesis for RQ1: There are unrevealed LE response challenges that have not
been disclosed in AARs, which are contributing to uncertainty and chaos at these
events.
This research question (RQ1) addresses the abundance of AARs that assert
numerous police response challenges. To date, empirical research interviews have yet
to be conducted anonymously to support the AARs’ conclusions and determine what
information was not collected from interviewees. The analysis in this dissertation
supports the conclusion that there are known and unrevealed challenges for LE
supervisors that contribute to chaos and uncertainty during ASIs. The data from 16
AARs presented several primary themes and sub-themes about the primary response
challenges:
● Incident command challenges - 93%

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○ Absence of an IC - 53%
● Staging area difficulties - 43%
● Unified command challenges - 75%
● Communication
○ Inadequate communication with responders - 37%
○ Interoperability - 25%
○ Superfluous radio communication - 43%
● Inappropriate self-deployment - 81%
● Indiscriminate parking - 37%
The AAR data also revealed novelty training as emergent findings.
● Novel incidents during ASIs - 18%
The interview data specific to the above response challenges were not included
in this section as some interviewees were involved in an ASI from the AARs. However,
the interviews uncovered three response challenges that contribute to chaos and
uncertainty:
● Command level training - 80%
● Command staff presence - 48%
● Hostage situations - 8%
● Novelty specific to targets turning from innocent victims to police officers - 8%
The analysis in Chapter 4 supports the hypothesis for RQ1 that there are
response challenges that have not been revealed or addressed in AARs and that
contribute to uncertainty and chaos at these incidents.

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Research Question 2: How does Chaos Differ from Uncertainty When Responding
to an ASI? How Do Response Challenges Due to Uncertainty or Chaos Affect the
Police Response to ASIs?
Hypothesis for RQ2: Leadership decisions (due to chaos) and inactions (due to
uncertainty) are the primary causes of the response challenges to ASIs.
The AARs and interviews support the hypothesis that leadership decisions and
inaction cause response challenges. As previously mentioned, IC challenges were
present in 93% of ASI AARs. These include the lack of an IC, the inability to establish
unified command due to no police IC, situational awareness challenges, and overall
response management.
Research Question 3: What Changes Can Be Made to the LE Response System to
Improve ASI Future Response Efforts and Reduce Uncertainty and Chaos?
Hypotheses for RQ3: There is a lack of training and education for supervisors
responding to ASIs, which is contributing to uncertainty and chaos at these
events.
The interviews support the hypothesis that there is a lack of training for
supervisors responding to ASIs, contributing to uncertainty and chaos. The
recommendations section will cover improvements to future ASI response efforts.
Recommendations for Practice
Command Level Training
Martaindale and Blair (2019) discussed the evolution of active shooter training
after the Columbine ASI on April 20, 1999. As previously discussed, that incident
caused a significant shift in police response. Police no longer waited for a SWAT team

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to engage the shooter. Instead, their primary focus is to engage the shooter as quickly
as possible to stop the killing. Although the initial tactics focused on a team response,
they morphed into a solo officer response (Martaindale & Blair, 2019). Despite the
evolution in response tactics, the one area of training that has not advanced is
command-level training. When ASI AARs mention command-level response
challenges, the recommendations primarily focus on more ICS training (U.S. DOJ,
2023). Although ICS training is essential for command-level personnel, ICS does not
answer any questions or assist an IC with crisis decision-making. As one interviewee
stated, “The ICS that fire teaches is not the same as being under stress and having a
million life-changing critical things thrown at you.”
Despite several AARs mentioning additional ICS training to alleviate command
issues, the Borderline AAR does highlight the need for command response training.
Specifically, it states that agencies should
“refocus active shooter training to include a supervisory component and
command and control, leadership, and the importance of establishing a rally point
for command. Training should also include instruction to all personnel of the
need to assume a leadership role in the absence of a field supervisor” (Ventura
County Sheriff’s Office, 2021, p. 54)
An emerging theme from the interviews was command-level training challenges.
Twenty-one interviewees said police leaders who take command at an ASI need more
training before an incident. Renaud (2012) found that slow, deliberate decision-making
is ineffective in a rapidly unfolding incident, yet several interviewees stated that their
crisis decision-making skills diminished when they received promotions. The next

126
evolution of ASI training needs to include command-level training. The current
command-level training gap is causing significant challenges. To that end, a
recommendation is for agencies to develop an active shooter leadership course heavily
based on crisis decision-making and managing the chaos of an ASI. Further curriculum
recommendations are topics on how commanders should confront novelty and manage
the inherent chaos in these incidents.
Crew Resource Management
United Airlines created Crew Resource Management (CRM) in 1981 to train
airline crews to reduce pilot air using better human resources on a flight deck
(Helmreich et al., 1999). After a crash in 1978, the NTSB singled out the captain for not
listening to input from subordinate crew members (Helmreich et al., 1999). Early CRM
programs focused on changing behavior characteristics such as assertiveness by
subordinate flight crew members and autocratic behavior from the flight captain
(Helmreich et al., 1999). The overarching purpose of CRM in the airline industry is to
“optimize a crew’s interactions in times of high stress and little information when the
lives of many people are at stake” (Lubnau & Okray, 2001, p. 99). CRM has been
applied in other professions. In healthcare, it has helped to improve patient safety and
communication. In firefighting, it aided in improving human factors that contribute to
accidents and near misses.
Firefighters use several CRM factors, including improving communication,
making decisions focused on recognition-primed decision-making, maintaining
situational awareness, and teamwork to ensure critical information is shared (Lubnau &
Okray, 2001). One of the tenets of CRM in the firefighting context of teamwork is that

127
everyone is a safety officer. All look out for the team’s safety, and if they believe their
safety is jeopardized or disagree with an order, they engage in respectful conversation
with the commander. However, this does not mean they disregard the chain of
command or ignore the order (Lubnau & Okray, 2001).
Like airline cockpit crews, firefighters, and healthcare professionals, police
officers make crisis decisions in high-risk situations. Adapted to LE, CRM can help
police officers avoid undesired outcomes discovered in this research, such as
inappropriate self-deployment, indiscriminate parking, leadership challenges, and
communication. The tenets of CRM can transfer over to an ASI response, potentially
mitigating the loss of life and improving the response system. One possible challenge
for implementing CRM in active shooter response is that it may bypass the chain of
command. However, this is different from the purpose of CRM. It simply encourages
input when a subordinate sees something unsafe while keeping the authority of the IC
intact. CRM use in the police response system to an ASI is ripe for future research
efforts.
New Model for the Incident Command System
Contrary to NAT, which hypothesizes that complex and tightly coupled systems
are prone to failure even when safeguards and warning systems are added (Perrow,
1984), high reliability organizational theory says those systems can be accident-free
operations (Roberts & Rousseau, 1989). Roberts and Rousseau (1989) researched
organizations that operated in hazardous environments, where errors could be
catastrophic, and had no accidents. Examples included the U.S. air traffic control

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system, aircraft carriers, submarines, and international banking. Weick and Sutcliffe
(2015) offered five principles of Highly Reliable Organizations (HROs):
1. HRO Principle 1: Preoccupation with Failure. HROs invite error reporting and
near-miss experiences because they provide data that can be used to improve
response.
2. HRO Principle 2: Reluctance to Simplify. HROs take purposeful steps to “create
more complete and nuanced pictures of what they face and who they are as they
face it” (Weick & Sutcliffe, 2015 p. 8).
3. HRO Principle 3: Sensitivity to Operations. This sensitivity focuses on paying
attention to the front-line level where the work of an organization is being
implemented.
4. HRO Principle 4: Commitment to Resilience. HROs develop the ability to control
and recover from unavoidable errors that occur in an organization.
5. HRO Principle 5: Deference to Expertise. Weick and Sutcliffe (2015) stated,
“Rigid hierarchies have their own special vulnerability to error. Errors at higher
levels tend to pick up and combine with errors at lower levels thereby making the
resulting problem bigger, harder to comprehend, and more prone to escalation”
(p. 14). To avoid these errors, HROs give decision-making authority to those
who have situational awareness of the problem with the most expertise,
regardless of their rank.
Weick and Sutcliffe (2015) pointed out the rigidity of hierarchies and their
susceptibility to errors in HRO Principle 5. The hierarchical nature of ICS is also prone
to errors when used by LE officers, as evidenced in the AAR analysis and academic

129
literature (Straub et al., 2017; Waugh, 2009). The FEMA AAR for the Las Vegas Route
91 ASI suggests that “LVMPD should incorporate a command and control system
conforming to ICS, which is specific to the needs of law enforcement. Just as ICS
developed from wildland firefighting to structure firefighting, ICS command and control
needs to incorporate and meet the needs of specific law enforcement situations” (p. 33).
The Orlando Pulse Nightclub AAR also suggested that “law enforcement leaders and
researchers should endeavor to re-examine ICS and build a model that will be accepted
and implemented in response to critical incidents” (Straub et al., 2017). Moreover, one
interviewee stated, “The ICS that fire teaches is not the same as being under stress and
having a million life-changing critical things thrown at you.” Finally, Moynihan (2009)
stated, “National crisis policy now effectively mandates the ICS, assuming that it is
generally applicable to all forms of crises. In truth, there is little empirical evidence as to
whether this assumption is accurate” (p. 911). Based on the ICS findings of the AAR
analysis, Renaud’s (2012) research, and the statements above, a new centralized
network ICS model is recommended for the initial police response to an ASI.
The hierarchical nature of ICS does not account for how “network factors shape
its operations” (Moynihan, 2009, p. 88). Based on its failure to account for the network
properties of ICS, the recommended initial response model is a centralized network that
more closely resembles the initial response. At the inception of an ASI, the response
resembles a network of responders with a police leader in the middle of the network.
The police leader is centralized in the network as a group of officers respond to the
scene to stop the suspect from killing innocent victims. The police leader can also

130
direct the establishment of a staging area to mitigate inappropriate self-deployment and
indiscriminate parking. When feasible, the police leader will establish unified command
with Fire/EMS to begin the Stop the Dying Phase.
Figure 4
Initial Police Response Network Model
As the incident begins to stabilize, it will morph into the ICS hierarchy. While
there is no algorithm for the decision to transition to ICS, the tempo of the incident can
help drive a police leader’s decision-making regarding the implementation of the
traditional ICS model. Nonetheless, there will still be elements of ICS that collaborate
across the silos of the ICS. This collaborative system resembles a hierarchical network

131
hybrid. Special operations forces used this type of hybrid system during the Iraq War
when battling terrorist networks (Fussell & Goodyear, 2017).
Figure 5
ICS Hierarchical Network Hybrid Model
Note. Officers are free to collaborate across ICS silos to fulfill IC objectives.
Commanders who consider and visualize these recommended models during a
response can help with a more integrated response network while still adhering to the
overall purpose of ICS. Furthermore, they understand there will be a transition period
from an initial response centralized network to the hybrid ICS model.

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Policy Recommendations
After the 9/11 terror attacks, national legislators shaped policy without using
AARs to help inform policy. Rather, policy went forward without any references to
studies, and there was no attempt to systematically learn how to address the terrorist
threat from an evidence-based standpoint (Birkland, 2006). One of the goals of this
research study was to provide evidence of ASI police response challenges to help
inform policy for legislators and police agencies. This study provides evidence that can
aid in developing policy.
As of this writing, California Assembly Bill (AB) 2710 (Police Active Shooter
Response Legislation) passed the California State Assembly Public Safety Committee
but did not progress through the Committee on Appropriations in the California State
Assembly. The bill was presented and drafted by the author, utilizing data from this
study and is authored by Tom Lackey (AD-34). This legislation is presented as
recommended language for policymakers interested in police active shooter response
legislation. CA AB 2710 reads as follows (See Appendix B for AB 2710 fact sheet):
SECTION 1. The Legislature finds and declares both of the following:
(a) The Robb Elementary School active shooter incident in Uvalde, Texas, had
numerous police response challenges. These challenges included the lack of an
identifiable incident commander, the indiscriminate parking of police vehicles,
radio communication problems, and inappropriate self-deployment of police
officers. These challenges are also present in many other active shooter
incidents.

133
(b) It has become evident that fixing these police response challenges can
ultimately save the lives of innocent victims. Protocols and guidance must be
established to stop an Uvalde-type response from reoccurring.
SEC. 2. Section 13508.1 is added to the Penal Code, to read:
13508.1. (a) The commission shall develop guidelines for law enforcement
agencies to prevent unnecessary radio transmissions and inappropriate selfdeployment of law enforcement officers during an active shooter incident. (b) For
purposes of this section, “law enforcement agency” means any agency or
department of the state, or a political subdivision thereof, that employs any peace
officer as described in Chapter 4.5 (commencing with Section 830) of Title 3 of
Part 2.
SEC. 3. Section 13653 is added to the Penal Code, to read:
13653. (a) Each law enforcement agency shall do each of the following at an
active shooter incident:(1) Identify the incident commander. (2) Prohibit the
indiscriminate parking of police vehicles. (b) As used in this section, the following
terms have the following meanings: (1) “Incident commander” means the
individual responsible for on-scene activities, including developing incident
objectives and ordering and releasing resources. The incident commander has
overall authority and responsibility for conducting incident operations. (2)
“Indiscriminate parking of police vehicles” means parking a police vehicle in a
manner that blocks a roadway and prevents ambulances and other emergency
vehicles from accessing the crisis site. (3) “Law enforcement agency” means any
agency or department of the state, or a political subdivision thereof, that employs

134
any peace officer as described in Chapter 4.5 (commencing with Section 830) of
Title 3 of Part 2.
SEC. 4. If the Commission on State Mandates determines that this act contains
costs mandated by the state, reimbursement to local agencies and school
districts for those costs shall be made pursuant to Part 7 (commencing with
Section 17500) of Division 4 of Title 2 of the Government Code.
While the importance of legislative policy relative to improving the police
response to ASIs is critical, some police agencies lack an ASI response policy or have
policies that need improvement. These agencies can benefit from using this research
study to inform active shooter response policy. Seven AARs mention police agency
policies specific to ASIs. These policy mentions focused on one agency’s current ASI
policy relative to ICS and the remaining recommended policies for inappropriate selfdeployment, radio discipline, and indiscriminate parking. The U.S. DOJ Uvalde AAR
noted that police agencies that responded to Robb Elementary “lacked adequate related
policies and, in most cases, any policy on responding to active attackers” (U.S. DOJ,
2023, p. 402). Further, the U.S. DOJ report recommends every policy agency “must
have a clear and concise policy on responding to active attacker situations” (U.S. DOJ,
2023, p. 402). To that point, active shooter response policies are recommended for the
following:
1. An IC is clearly identified over the radio.
2. Unified Command with other public agencies is established.
3. A policy that prohibits superfluous radio transmissions by responding officers.
4. A policy that prohibits indiscriminate parking.

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2. A policy that prohibits inappropriate self-deployment.
3. A policy that command level police officers at the rank of sergeant or above
be required to take annual training specific to their role in an ASI.
While policies to mitigate challenges and improve the police response system are
not a panacea, they can potentially have a positive effect on the response and mitigate
self-induced friction.
Stakeholder or Target Group Analysis
Stakeholder analysis is an established tool used to identify and describe agents,
their interests, intentions, and interactions and how they influence the decision making
process (Brugha & Varvasovsky, 2000). Often target groups (policy developers, policy
enforcers, and those impacted by policy change) may not behave as expected when
policy changes are designed. Therefore, it is essential to understand motivations and
drivers and contemplate how target groups are likely to react to change (Sanddfort &
Moulton, 2015). This information can be used to develop strategies for managing the
stakeholders or target groups, comprehend the policy context, and measure the viability
of future policies (Brugha & Varvasovszky, 2000).
In the law enforcement policy domain, it is important to consider the stakeholders
involved in state legislative measures focused on policy mandates and the development
of active shooter response guidelines. This analysis was used in the development of
California Assembly Bill 2710. Table 3 summarizes the primary stakeholder groups,
their involvement in law enforcement active shooter response policy development, and
their interest in the matter. This framework is adapted from Varvasovszky and Brugha
(2000).

136
Table 3
Stakeholder Characteristics Around the Development of Active Shooter Response
Legislation
Stakeholders
Characteristics
Involvement in
the issue
Interest
in the
issue
Influence/power Position Impact of
issue on
actor
State
legislators
Create and pass
legislative
measures
High High Supportive High
Special interest
groups
Police
representative
groups who
support or
oppose
legislation
High High Opposed High
Police
command staff
Has an interest in
policies that are
mandated by
legislation and
could affect the
agency
High Medium-high Opposed Medium
Police training
staff
Responsible for
policy
implementation
Medium Medium Supportive Low
Police officers
and
supervisors
Responsible for
following policies
Medium Low-medium Supportive Low
Logic Model
A logic model is a tool that graphically organizes information and displays
thinking. It describes a planned action and its expected results and provides a snapshot
of an individual’s or group’s thinking about how their idea or program will work
(Knowlton & Phillips, 2013). They are also helpful in documenting a program’s
outcomes and anticipated outputs. In the context of this research project, Figure 6
displays a logic model that incorporates research recommendations as inputs and

137
aligns them with activities, outputs, and possible outcomes that will lead to a preferred
result. The inputs focus on who is required to implement the recommendations, while
the activities center on the actual research recommendations. The outputs and impacts
are the direct results of implementing the recommendations. Recommendation
implementation outcomes are the desired result of implementation, which is the overall
improvement in the ASI police response system. Finally, external factors could impact
the implementation.
Figure 6
Logic Model for Creating Active Shooter Incident Response Recommendations
Inputs Activities Outputs Outcomes Impacts
Resources
required to
implement the
research
recommendations.
• Police
Executives
• Police Trainers
• State
Legislators
• Interest Groups
• State Law
Enforcement
Bodies (e.g.,
CA POST)
Actions needed to
implement
research
recommendations.
• Command level
training
• ASI Response
Policies
• Understanding of
the network
properties of ICS
• Crew Resource
Management
principles
• Law
Enforcement
Safety Reporting
System
Direct result of research
recommendations.
• Improved crisis
decision making by
commanders.
• Mitigation of
inappropriate selfdeployment and
indiscriminate
parking.
• Enhanced
communication
• Incident commander
identified.
• Ability to address
novel incidents.
• Reduced time
establishing Unified
Command.
Changes that result
from the
implementation of
recommendations
• Improvement of
ASI police
response system
• Implementation
policies that are
supported by
training and
education.
• Reduction of loss
of life
• Quicker
treatment of
victims
• Lessons learned
are implemented
into police
training and
education
programs.
Long term
changes in the
social context
Increased
police
legitimacy and
trust with the
communities
they serve due
to improved
response
system.
External Factors
What factors could affect expected activities, outputs, and
outcomes?
• ASI occurrences where significant response challenges
are comparable with the response to Robb Elementary,
Uvalde, which could lead to weak governance by
legislators during a policy window.
• Police interest groups resistant to any ASI legislative
mandates or guidelines.

138
Law Enforcement Safety Reporting System
The aviation industry utilizes the Aviation Safety Reporting System (ASRS),
which gives pilots, controllers, flight attendants, maintenance personnel, and
dispatchers a platform to report to the National Aeronautics and Space Administration
(NASA) “actual or potential discrepancies and deficiencies in aviation safety” (NASA,
n.d., para. 1). According to Stanford and Homan (1999), in the early 1970s, there was
no incentive to report near misses, and “many of the most informative and trend-setting
incidents were not passed on to the aviation industry” (p. 39). Further, aviation experts
have noted that for every aviation accident, there are most likely 500 near misses for
every mid-air collision (Stanford & Homan, 1999). The ASRS was formed to report
safety events and to promote and increase aviation safety. There is also limited legal
immunity from prosecution for reporting per Title 14 of the Code of Federal Regulations
(Gao et al., 2021). The purpose of providing immunity from legal prosecution is to
encourage safety reporting. NASA is an independent third party for reporting, and the
reports are anonymized before being passed on to the FAA (Stanford & Horman, 1999).
Pilots have ten days to report an issue through the NASA online portal;
otherwise, they lose legal immunity. Once a report is received, it is passed on to an
analyst for initial screening. If the report is criminal or an accident, there is no immunity,
and the report is passed on to the FAA. If there is an urgent safety concern, the details
are quickly given to the FAA, and an alert bulletin is sent out (Stanford & Homan, 1999).
In LE, there is no mechanism for officers and commanders to self-report errors
that occur during large-scale critical incidents, such as an ASI. While some ASIs
produce an AAR, many do not, indicating that many lessons learned are being lost,

139
much like the pre-ASRS era in the airline industry. There is one current system,
however, managed by the NPI, which is termed the Law Enforcement Officer Near Miss
Reporting System. Furthermore, this system is not specific to collecting anonymous
data from officers and commanders involved in ASIs. To collect this insight and
information, the U.S. DOJ or other government entities should create an anonymized
reporting system for police officers and commanders involved in ASIs to report near
misses, mistakes, and other friction points that can inform future response efforts.
Further, much like the ASRS, reports should be anonymized and collected by a third
party, and reporters should have some legal immunity. Legislation can help accomplish
these goals.
One crucial stumbling block to creating a reporting system is the liability of
reporting lessons learned. There must be strong protections for police reporters
because of the litigious nature of LE operations; therefore, restricting the use of reports
in lawsuits is vital. One suggestion from Donahue and Tuohy (2006) is to incentivize
reporting by making federal and state funding contingent on an agency reporting
lessons learned after an event. Taking this recommendation one step further, state and
local funding can be an incentive for an agency that reports to build on the lessons
learned through training and education programs. These reports would be used to
create lessons learned information that would be analyzed, synthesized, and sent to
police agencies nationwide.
The Swiss Cheese Model and Active Shooter Response Challenges
The above recommendations aim to improve future police response efforts to
ASIs. Jim Reason’s Swiss cheese model encapsulates these recommendations and

140
the possible repercussions of not following them (Figure 7). Reason, who proposed this
theory of failures, said accidents within some complex systems could be caused by a
breakdown or absence of safety barriers across four levels within a system (Wiegmann
et al., 2022). Reason’s theory is commonly called the Swiss cheese model because it
explains the “failure of numerous systems barriers or safeguards to block errors, each
represented by a slice of cheese (Stein & Heiss, 2015, p. 278). The Swiss cheese
model is designed to help safety specialists discern holes at the system level that can
lead to an adverse event. Recognizing the holes in the system creates opportunities to
mitigate a future unfavorable event (Wiegmann et al., 2022).
Employing the Swiss Cheese Model to the police response system to an ASI and
integrating each recommendation as a slice of cheese, this research posits that ignoring
the recommendations can lead to one of the primary response challenges, including
leadership challenges, indiscriminate parking, inappropriate self-deployment, and
communication issues.

141
Figure 7
Swiss Cheese Model of Active Shooter Response Challenges
Recommendations for Future Research
This dissertation is the first academic study to interview police responders to an
ASI, most in an IC role. Additional interview research is needed to glean additional
unrevealed response challenges. Further research endeavors should also focus on
how to implement the tenets of CRM into the initial response phase and how the U.S.
DOJ can implement a LE reporting system specific to ASIs. Future police active shooter
training curriculum should include how to recognize and confront novelty and working in
novel environments.
Further research should examine the reasons for the lack of unified command at
ASIs. In particular, there is a need for a root cause analysis of selected ASIs that
exhibited unified command issues. This research should entail interviews with both fire

142
and police personnel. This research should be a priority as the lack of unified command
at an ASI can delay the treatment of wounded victims. Finally, while communications
challenges in this research study were focused internally, future research should be
done to study external communication challenges.
Conclusion
The study aimed to examine AARs and interview police responders to discover
the primary response challenges. This research has effectuated those primary
response challenges and discovered several unreported ones, including command-level
training, novelty, executive command staff challenges, novelty during an ASI, and
confronting a suspect who is targeting police after killing innocent victims.
The AAR and interview analyses addressed three research questions and
hypotheses. The primary and emerging response challenges were then used to
establish recommendations to improve future police response efforts and ultimately
save the lives of innocent victims.

143
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Appendix A: Interview Script
1. Introduction – My name is Travis Norton, and I am conducting interviews with law
enforcement who have experienced active shooter incidents.
2. Do I have your permission to record this interview?
1. [Make sure Zoom meeting has automatic setting to “cloud recording”; if
yes, then turn on recording]
2. [After recording turned on, say on recording: “Thank you for allowing me to
record the interview.”]
3. As a reminder, I am conducting this study to study the initial response to active
shooter incidents. I will ask you questions about your decisions and actions
during the active shooter incident you were involved in.
4. You can choose to not answer any question that I ask.
5. You can stop or end the interview at any time.
6. Are we okay with moving forward with the interview?
1. [If yes, then continue to the interview questions]
2. [If no, then thank the person and end meeting]
7. Let’s start with some information about you. Please tell me a little about yourself
and your law enforcement career.
1. [Probe: How long have you worked in law enforcement?]
2. [Probe: How did you get started in law enforcement?]
3. [Probe: Have you always worked in the unit you work in now?]
8. Let me move to your training. Please tell me about the active shooter training you
have received.

156
1. If you are a supervisor, when was the last time you received training
specific to supervisors and critical incident response?
i. [Probe: Were there any decision-making exercises in this
training?]
ii. [Probe: Was there any training related to unified command?]
iii. [Probe: Who provided the training?]
9. In your opinion, what worked well in that active shooter training?
10.What would you change about active shooter training?
11.Let me turn now to the active shooter incident. Are you okay talking about this?
12.Let’s talk about the day that the event occurred.
13.Where were you when you got the call, and what was the first thing you did?
14.Can you share with me what you were thinking at the time?
15.Please walk me through your drive to the scene.
16.What was going on with radio communications?
1. [Probe: What, if anything, did you say on the radio?]
17.So, you arrive at the scene. What did you do when you arrived and parked your
car?
18.What happened after you parked your car?
19.What was happening at the scene?
20.Who was in charge at the scene? Please tell me how you knew who was in
charge.
1. [Probe: If no one was in charge, how much time passed before the
incident commander was identified? How was this done?]

157
2. [Probe: Was there an incident commander?]
i. Tell me how the ICs actions and decisions affected the incident.
ii. Was the IC clearly identified?
iii. Was there uncertainty about who the incident commander was?
1. If so, describe what happened
3. [Probe: If you were the incident commander, walk me through your actions
and decisions]
i. Would you have done anything different at the IC?
ii. Did any training on ICS help prepare you for your response?
21.What was the most difficult decision you had to make? Was there a command
post established?
1. Where was it located?
2. Who established the command post?
3. Did you ever report to the command post?
i. If so, tell me what happened.
22.How did you know what to do?
1. [Probe: Did you have information about what was happening? How did
you get this information?]
2. [Probe: Did others know their roles and responsibilities? How did they
know?]
23.Please tell me what was happening with communications at the scene.
1. [Probe: Were there communication issues focusing on unnecessary radio
traffic? Explain what happened.]

158
24.Please tell me what was going on with parking at the scene.
1. [Probe: Was there indiscriminate parking of police vehicles that interfered
with incoming public safety resources? Explain what happened.]
25.Please talk to me about what law enforcement, emergency services, and any
other first responders were doing at the scene.
1. [Probe: Were officers inappropriately self-deploying to the scene? Explain
what happened.]
2. [Probe: Were there any arguments among responders? What were those
arguments?]
3. [Probe: Was unified command with fire/EMS established?
i. Tell me about how this happened.
ii. Were there any problems with establishing unified command?
iii. If there were problems, what were they, and how were they
solved?
26.Tell me what happened with the suspect.
1. [Probe: Did the suspect ever take hostages? If so, tell me what
happened.]
2. [Probe: Tell me about the “stop the dying” phase.]
27.Was there anything about your active shooter incident that you had not seen or
heard about before?
28.Thank you for sharing your experience about this incident. I appreciate your
honesty. Is there anything else you would like to share with me about the
incident, your training, or the aftermath?

159
29.That is the end of my questions. Thank you again for talking with me today. I
appreciate your help with my research project.
1. [End meeting]

160
Appendix B: AB 2710 Fact Sheet
Several AARs did not fit the inclusion criteria. However, they have many of the same
challenges as the 16 AARs reviewed.
Assemblyman Tom Lackey 34th District

AB 2710: Peace Officers: Incident Commanders
Background
Research reveals that over half of active shooter
incidents do not have an identifiable incident
commander. The absence of an identifiable incident
commander leads to problems with situational
awareness, confusion among responders,
communication interoperability, and establishing a
unified command with fire/EMS and other police
agencies and management of the response. Most
imperative is that the lack of an incident
commander causes the response to run on its own
inertia, which in turn leads to critical delays in
treating injured and dying victims. This makes
identifying an incident commander during an active
shooter incident essential to save lives and create a
sense of leadership in a moment of chaos.
This research also reveals that indiscriminate
parking is present in 70% of active shooter events.
Indiscriminate parking is a serious issue in these
incidents because police vehicles parked
haphazardly near the crisis site can cause
congestion issues that interfere with the ability of
ambulances and armored rescue vehicles to access
the crisis site.
The problem of indiscriminate parking can
potentially jeopardize lives if these life-saving
assets cannot access victims or contain the threat.
For example, during the Inland Regional Center
terrorist attack in San Bernardino, the parking of
police vehicles caused a "delay of critical tactical
assets during the officer-involved shooting."
In addition to the parking, excessive radio traffic is
understandable during these events. However, this
problem can exacerbate the situation, create
confusion among responders, and hinder the ability
of officers to broadcast important information and
intelligence. Our emergency personnel are critical
to saving lives. Therefore, they must have the
resources to complete the mission effectively and
efficiently.
The Problem
Existing law requires law enforcement agencies to
maintain collaborative protocols and relationships
with local and state first response entities, including
law enforcement agencies, fire departments, and
emergency medical services providers and agencies,
so that those entities shall act effectively and in
concert to address active shooter incidents across
California. It further addresses protocols for the
incident command system; however, it does not
require the identification of an incident commander
in an active shooter situation. Therefore, there is no
point of contact between agencies to help
coordinate and create a safer environment for all
parties.
Solution
To improve the safety of those involved in an
incident, for both victims and emergency personnel,
an incident commander should be appointed to
manage the situation and create seamless
coordination between on-scene agencies, reserve
parking closest to the crisis for armored vehicles
and ambulances, and reduce radio usage to prevent
radio traffic from hindering the communication of
important crisis information.
What This Bill Will Do
AB 2710 would require each law enforcement
agency at an active shooter incident to identify the
incident commander, as defined, and prohibit the
indiscriminate parking of police vehicles.
This bill would require the commission to develop
guidelines for law enforcement agencies to prevent
unnecessary radio transmissions and inappropriate
self-deployment of law enforcement officers during
an active shooter incident.
Staff Contact
Izzy Swindler
(916) 319-2034
Izzy.Swindler@asm.ca.gov

161
- Dorner AAR
- White paper on the attacks in France
- Mobile attacks from Stockton
- Oakland incident

Abstract (if available)

Abstract The Columbine active shooter tragedy on April 20, 1999, fundamentally changed the police response system. Despite these changes, law enforcement (LE) response challenges are a serious concern and can put lives at risk. These response challenges include incident command, indiscriminate parking, inappropriate self-deployment, communications, and unified command. These difficulties contribute to uncertainty and chaos during the response. Researchers have yet to investigate the active shooter police response system and the complications that arise during the response. To address this research gap, this study examined the quality of the initial LE response, which is the crucial decision-making point in determining the number of lives lost and saved. The study examines qualitative interview data and archival after-action review data to (a) identify essential factors leading to ASI injury and death, conceptualized as uncertainty and chaos, and (b) develop recommendations to help inform policy and ASI training. Qualitative interview data revealed response complications not listed in the archival after-action reviews. This qualitative interview data includes the lack of command decision-making training, incident commanders facing life and death decisions, difficulties helping innocent victims when the adversary targeted police, and friction when executive command staff were present. The study concludes with numerous recommendations to address response challenges and inform future response efforts.

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Asset Metadata

Creator Norton, Travis (author)

Core Title An examination of the law enforcement response to active shooter incidents in U.S. cities: findings and implications for improving future response efforts

School School of Policy, Planning and Development

Degree Doctor of Policy, Planning & Development

Degree Program Planning and Development,Policy

Degree Conferral Date 2024-08

Publication Date 06/20/2024

Defense Date 06/07/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag active shooter incidents,active shooter response,OAI-PMH Harvest,police active shooter response

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Takahashi, Lois (committee chair), Southers, Erroll (committee member), Straub, Frank (committee member)

Creator Email opdswat@ymail.com,travisno@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113996WTL

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