According to the interim report on the elementary school shooting in Uvalde, there were 376(!) law enforcement officers that responded. How do we make sense of the fact it took such a long to neutralize the shooter? One way is to see the problem as what the researchers Klein, Feltovich, and Woods refer to as a fundamental common ground breakdown.
The term “common ground” refers to a kind of shared understanding between people who are coordinating in some way, so that the participants can predict each other’s future actions. To take a simple example, if you and I are playing a board game, “whose turn is next” would be part of the common ground.
For a group of people to coordinate, they need to maintain common ground, shared understanding of the situation and what actions they expect others to take.
Because incidents are dynamic and the respondents have access to different information, a common risk during incidents is the erosion of common ground. One particular risk is what Klein et al refer to as confusion over who knows what.
During the shooting at Uvalde, many of the officers believed that Chief Arrodondo was the incident commander:
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.”Interim report, p62
But Arredondo saw himself in the role of a responder trying to resolve the situation directly, not as an incident commander working on coordination.
[W]hile you’re in there, you don’t title yourself … .I know our policy states you’re the incident commander. My approach and thought was responding as a police officer. And so I didn’t title myself. But once I got in there and we took that fire, back then, I realized, we need some things. We’ve got to get in that door. We need an extraction tool. We need those keys. As far as … I’m talking about the command part … the people that went in, there was a big group of them outside that door. I have no idea who they were and how they walked in or anything. I kind of – I wasn’t given that direction.Interim report, p63
you can always hope and pray that there’s an incident command post outside. I just didn’t have access to that. I didn’t know anything about that.
Here’s another example of how common ground got eroded: different understandings of the situation based on whether you were inside or outside.
Also, the misinformation reported to officers on the outside likely prevented some of them from taking a more assertive role. For example, many officers were told to stay out of the building because Chief Arredondo was inside a room with the attacker actively negotiating.Interim report, p63
Another challenge that Klein et al discuss is communication problems, which we also see in Uvalde. In a previous post, I wrote about how Chief Arredondo believed that the shooter was barricaded alone in the room. There was evidence to the contrary, but that information didn’t reach him during the incident.
There was a series of phone calls with a student inside Room 112, initiated by the student calling 911 at 12:03 p.m. Radio traffic communicated to those officers who could hear it the fact that a student had called from within the classroom. Several witnesses indicated that they were aware of this, but not Chief Arredondo.Interim report, p62
In particular, the police radios didn’t work properly inside of the school, a fact that is mentioned multiple times in the report (emphasis mine)
An effective incident commander located away from the drama unfolding inside the building would have realized that radios were mostly ineffective, and that responders needed other lines of communication to communicate important information like the victims’ phone calls from inside the classrooms.Interim report, p8
Uvalde CISD police officers commonly carried two radios: one for the school district, and another “police radio” which transmitted communications from various local law enforcement agencies. While the school district radios tended to work reliably, the police radios worked more intermittently depending on where they were used.Interim report, p14
Upon entering the building, the officers tried but were unable to communicate on their radios.Interim report, p51
As mentioned in the narratives above, there were important events happening outside the north and south ends of the west building. In part due to the difficulty of maintaining radio communications within the building, not everybody inside the building received all of this information.Interim report, p62
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.Interim report, p64
Fundamental common ground breakdown is an ever-present danger whenever we coordinate, and it’s especially dangerous during incidents. The shooting in Uvalde is a painful reminder of this failure mode.