Lessons on Interoperability: The Shootings at Columbine

National Capital Special Operations Symposium

Ottawa, Ontario

November 14-15, 2012

Presentation Outline

Case Study: Columbine

Lessons, Problems, and Barriers

Improving Interoperability and Response Outcomes

Columbine High School

Approximately 2,000 students 120 Teachers 20 Staff Personnel 75 Classrooms 25 Exterior Doors Gymnasium, Cafeteria, Library

and Auditorium 250,000 square feet

Explosives

“Walk in, set bombs at 11:09

for 11:17. Leave….” 

Small Arms and Knives

Improvised Explosive Devices

46 EXPLODED DEVICES Outside 2 Library 26 Class/Hall 14 Cafeteria 4

30 UNEXPLODED DEVICES Outside 13 Library 5 Class/Halls 6 Cafeteria 6

Initial Operations: Fire/EMS

Triage/Transport

Transported 26

Triaged over 160

Staging Resources

Fire Strike Team

Command and Control

Communications

Fire/EMS Organization

P IO L IA S O N

S A F E TY

A ID E

S E C O N D A R Y E M S

S TA G IN GE M S

C O M M U N IC A TIO N S

TR IA G E

TR A N S P O R TA TIO N

M E D IC A L

TR IA G E

TR E A TM E N T

Y U K O N /C A L E YD IV IS IO N

TR IA G E

TR E A TM E N T

E A S TD IV IS IO N

TR IA G E

TR E A TM E N T

W E S TD IV IS IO N

S TA G IN GF IR E

TA S K F O R C EF IR E

O P E R A TIO N S L O G IS TIC S

F IR E /E M SC O M M A N D

Initial Operations: Law Enforcement SWAT

Find shooters

Protect students

Transport wounded

Secure perimeter

Check evacuees for weapons

Reunite parents and students

Law Enforcement Organization

In it ia l S W A TTeam s 1 -4

S econ d ary S W A TTeam s 5 -9

S W A T S tag in g

Tac tica l S n ip ers

Tac tica l O p era tion s

C H S C on tro l

In te rview in g

P aren t C on tro l

Tran sp ort

E vacu ation

In n er P erim eter

O u ter P erim eter

S tag in g A reas

P aren t C on tro lV ic tim A ss is tan ce

S cen e C on tro l

C rim e S cen e

C oron er

S earch

In te llig en ce

P aren t C on tro lV ic tim A ss is tan ce

In ves tig a tion s

L A W E N F O R C E M E N T

Jefferson County Schools

Help get students out of building

Account for students

Move students to another location

Reunite students & parents

Mental health service

Victim advocates

Brief families and media

Communications Problems

Controlling ground-space

Incompatible communications

Channel congestion

System overload

Command and Control Problems Weak coordination

Low situational awareness Paramedics under fire

Impact

Slows down the response

Creates inefficient use of resources

Reduces operational effectiveness

Endangers first responders

Unified Command: Strategic Objectives

Secure perimeter

Locate/eliminate shooters

Reach/move wounded

Triage, treatment, transport

Joint Operations: Total Response

FIRE6 Departments

166 Personnel

EMS7 Agencies

80 Personnel

LAW ENFORCEMENT28 Agencies

Over 900 Personnel

Incident Dynamics

Improvised Explosive Devices

Small Arms Fire

Multiple Casualties

First Responders Taking Fire

Structure Fire

Crime Scene

Incident Details

188 Shots Fired by Harris and Klebold

141 Shots Fired by Law Enforcement

89 Improvised Explosive Devices

15 Killed

160+ Triaged

24 Transported

Lessons Learned

Information Situational Awareness

Communications Redundancy Multi-channel/system operations

Command and Control Resource Management

Joint Operations Multiple jurisdictions and disciplines

Common Problems Planning

Independent Planning Jurisdictional/Organizational Boundaries

Organizing Not Coordinated or Integrated Separate Structure/Process

Communications Incompatible Systems Congestion/Overload Loss of Infrastructure

Operational Outcome Factors

Inter-Organizational Planning

Response Structure

Decision Making Process

Communications Systems

Planning Options

No Planning Not important, not enough

time

Position Based Planning This person, in this position,

does this function

Threat Based Planning If/Then

Jurisdiction Based Planning Separate Structure/Process

Capabilities Based Planning Objectives/Priorities/Resources

Joint Regional Planning Integrated and Coordinated

Structure/Process

Response Planning

C3 Requirements

Operations Simple/Complex

ImpactDamage

ThreatScenario

Organizational Structure

Separate

Coordinated

Integrated

Separate Structure

O LP

IC

O LP

IC O LP

IC

O LP

IC

O LP

IC

A B

C

D E

Coordinated Structure

O LP

IC

O LP

IC

O LP

IC

Integrated Structure

Unified/Joint Command

Operations Planning Logistics Fin/Admin

Operational Decision Making Cycle

Sense Making

DecisionMaking

Execution

Assessment Planning

Action

Social Context of Decision Making

Local view of operations

Local actions effect others

Available time effects success of operations

Common intent to achieve coordinated action

Develop common ground before incident

Consistent exchange and interaction builds social

relations

Results of Improved Social Relations

Improves acquisition and interpretation of information

Reduces decision time and improves quality of decisions

Reduces uncertainty regarding roles, responsibilities and abilities

Reduces goal conflict Improves coordination Improves ability to adapt

Communications Systems Effective coordination depends on efficient

communication Development of systems based on typical

incidents High frequency events Simple Low information demands

System not capable of dealing with catastrophic incidents Low frequency events Complex High information demands

Frequency and Complexity

ComplexSimple

Frequency

Low

High

Complexity

Single: Jurisdiction Discipline Level of Government

Multiple: Jurisdictions Disciplines Levels of Government

Information Exchange Amount and Rate

Barriers to Integrated Operations Denial/Avoidance

Financial Limited Resources Competing Priorities

Technical Obsolete Equipment Incompatible Systems

Cultural Competition Territorialism Self-Sufficiency

Operational Effect

Separate Structure Separate Process Separate Systems

Delayed information Inaccurate information Incomplete information Different levels of

awareness Unclear reporting

relationship Conflicting decision

strategies Inefficient resource use Increased risk to personnel

Improving Response Effectiveness

Technology

People

Inter-Organizational Approach

Technological Independent organizations that need to talk to

each other Communications systems are the primary

concern Operational practices do not need to change

Operational Inter-dependant organizations that need to work

together Operational systems are the primary concern Operational practices must change

Definition of Interoperability

Technical Interoperability: the condition achieved among communications systems when information can be exchanged directly and satisfactorily between users

Operational Interoperability: ability of agencies to accept services from other agencies and to use those services so exchanged to enable them to operate effectively together

Common Sense Definition

The degree to which organizations or individuals are able to operate together to achieve common goals.

Developing Technological Solutions

Focus Communications systems, equipment

Purpose Establish a link – voice/data

Problems Ignores importance of operational practices Does not recognize complexity of large scale

incidents Impact

High dollar cost, low impact on effectiveness

Developing Operational Solutions

Focus Regionalized Operational Networks

Purpose Integration, Collaboration, Coordination

Problems Difficult to change organizational culture Denial, competition, territorialism, self-

sufficiency Impact

Low dollar cost, high impact on effectiveness

Separate vs. Integrated Operations

Unity of Effect

MaximumNegativeImpact

MaximumPositiveImpact

ConflictedEffects Cancel Out

Positive SynergyPositive Effects Build on

One Another

Negative SynergyNegative Effects Build on

One Another

0

A New Framework

Old Framework Interpretation: Interoperability is a technical problem Approach: More money, better technology

New Framework Interpretation: Interoperability is a people problem Approach: Change the way we work together, use

technologies to support operational networks

Operational Networks

Relationships formed in order to work together to pursue shared goals, address common concerns, and attain mutually beneficial ends.

Organizations exchange information and undertake joint activities but retain their individual autonomy

Organizations rely on trust and embedded social relationships to provide effective services and reduce costs

Problems are typically resolved through discussion, and rules and norms of reciprocity ensure cooperation

Initiating Operational Networks

Small groups of leaders

Accept interdependence

Acknowledge shared latent risk

Motivated to improve capacity and performance

Approach: change working relationships

Goal: small wins, build network gradually

Developing Operational Networks

Determine which organizations should be included in the Ops Net

Understand the nature of current relationships

Relationships

Number of links

Type of interactions

Level of interactions

Strength of relationships

Willingness to commit to collective action

Power and decision making

Accountability

Interactions

Breadth Depth Frequency Level Strength/Trust Content/Issues

Operations

Incident Structure ICS/NIMS Integrated

Decision Process Assessment Planning Action

Operational Performance

Organizational Integration Decision Coordination Quality of Information Shared Awareness and Understanding Resource Coordination

Outcomes

Lives Lost/Saved Property Damage Social, Political, Economic Impact Time to Recovery

Evaluating OP NET Interactions

Breadth Depth Frequency Level Strength/Trust Content/Issues

Fire B Law EMS

Fire A X X X

Fire B X X

Law X

Evaluating OP NET Operations

Incident Structure ICS/NIMS Integrated

Decision Process Assessment Planning Action

Fire B Law EMS

Fire A X X X

Fire B X X

Law X

Evaluating OP NET Performance

Organizational Integration

Decision Coordination Quality of Information Shared Awareness

and Understanding Resource

Coordination

Fire B Law EMS

Fire A X X X

Fire B X X

Law X

Evaluating OP NET Outcomes

Lives Lost/Saved Property Damage Social, Political,

Economic Impact Time to Recovery

Incident A Incident B Incident C

Preventing C3 Breakdown

Operational Break down cultural barriers Develop a joint operations mentality Establish regional C3 practices Integrated structure and process Regional planning and leadership

Preventing C3 Breakdown Technical

Multiple channel/system operations Regional communications Leverage existing equipment,

infrastructure Back-up communications systems Offload logistical communications to

secondary channels or systems Use currently available, affordable

solutions

Improving Response Outcomes Bring your operational network together Map out how the Ops Net functions

Who included How work together – Structure/Process How exchange information – Communications

Evaluate current performance against criteria Develop goals for future performance Plan changes operational and technical

approach to achieve goals

Improving Operational Performance

DecisionProcess

Organizational Structure

CommunicationsTechnology

Performance

People

“Even if you are on the right track, you will get run over if you just sit there.”

Will Rogers

William L. Pessemier, PhD

Firefighter Safety Research Institute

wlpessem@mho.net

303-419-0599