There is no way to list or train for the innumerable mass casualty scenarios that a responder could face on any day, at any time, in any place. This means that no emergency response can be perfect and no plan flawless. However, rather than focusing on the “what ifs” after an incident, responders need to decide on the “what nows.” The military and civilian responders to the 16 September 2013 Washington Navy Yard shooting have done that. Not only have the involved agencies created their own lessons learned, they have also coordinated with each other to bridge the response gaps that were exposed. Key takeaways from the shooting as well as actions that have been taken since the incident were shared on 17 September 2019, when public safety agencies throughout the National Capital Region convened to reinforce communications efforts and address any remaining interoperability concerns.

On 16 September 2013, building 197 at the Washington Navy Yard became the site of 60+ minutes of violence that continues to inspire policy change among the Capital Region agencies that responded that day as well as other public safety agencies that have read and heeded their lessons learned in after-action reports. The District of Columbia’s Homeland Security and Emergency Management Agency (DC HSEMA), Office of the Statewide Interoperability Coordinator in conjunction with the U.S. Department of Homeland Security, Cybersecurity and Infrastructure Security Agency, DHS Emergency Communications Division has been conducting an analysis of after-action reports from that active shooter incident.

The September 2019 DC HSEMA Interoperability Summit on “The Navy Yard Shooting Review: 6 Years Later” addressed the chain of events that occurred before, during, and after the shooting, and showcased the efforts that have been made to address after-action report recommendations related to communications and interoperability gaps that affected the incident response. Three key takeaways from the summit involved: communication; practices, procedures, and policies; and experience and training.

Communication

Communication in extreme circumstances saves lives, but after-action reports following the Navy Yard shooting exposed communication gaps. Based on lessons learned, Charles Guddemi, statewide interoperability coordinator for DC HSEMA, emphasized the need to create a healthy ecosystem in interoperability communications. In fact, common communication procedures for emergency scenarios – for example, activating the fire alarm – can hinder the ability of responders to communicate effectively. Something as simple as having an earpiece and moving people who are not part of the incident to another radio channel can bridge this communication gap.

U.S. Park Police pilot, Ken Burchell, discovered another communication gap as he provided aviation support on the day of the shooting. Despite having a sophisticated $14 million helicopter with multiple communication channels, he was unable to communicate with the Metropolitan Police Department (MPD) officers on the ground. To resolve that problem, he promptly landed at Anacostia Park and recruited an MPD K9 unit with a handheld radio and personal radio earpiece to serve as a radio liaison between the air and ground responders.

Another emergency response task that can hinder communication involves call-taking, where procedures and policies of call-taking agencies vary. When there is more than one call center, information can be disconnected or missed altogether. However, during an ongoing active response effort, normal call-center operations must be able to integrate innovative approaches that gather all pertinent information in a timely manner (e.g., “tactical dispatching,” “text to 911”).

Even when all policies and procedures are effectively executed, technological communication may hinder response efforts. For example, maps and the addresses in computer automated dispatch (CAD) technology must be regularly reviewed and updated to ensure that all street names and locations are identifiable by call-takers and can be conveyed in real-time to the boots on the ground. Not having exact building locations during the Navy Yard shooting slowed response from non-military law enforcement agencies.

Karima Holmes, who is the director of the Office of Unified Communications (OUC), described some of the changes that OUC has undergone as a result of the gaps exposed during the 2013 incident. CAD is now more complex and missing addresses and locations for both the Navy Yard and District universities have been added. OUC also now has direct connect capability with surrounding regions and is able to rapidly transfer to other call centers. By using “plain-talk,” interagency communication is clearly understood by all involved.

When technology fails, back-up plans and procedures should be in place. To overcome communication challenges, lessons learned from the Navy Yard shooting provided some possible solutions. David Mulholland, administrator of the Arlington County Emergency Communication (911) Center, suggested stripping away capabilities throughout trainings and exercises to build contingency thinking. Often, trainings and exercises are predictable for participants. This tactic introduces uncertainties that can be introduced or altered in real-time based on the participants and their responses. When exercises are predictable, it is difficult to build a preparedness culture that expects the unexpected. Mulholland warned that, even with multiple redundancies in place, responders should not be lulled into a false sense of security.

Practices, Procedures & Policies

In addition to communication, the practices, procedures, and policies of the Navy and civilian law enforcement responders created response delays. For example, standard lockdown procedures at the Navy Yard hindered entrance and movement of outside law enforcement responders. In fact, the various security measures that were designed to prohibit intruders had the same effect on those attempting to neutralize the threat.

Throughout any response scenario, needs change as the incident progresses. Therefore, responders need to be able to adapt their knowledge, skills, and training to fit the current scenario. What works for one incident may not be effective for another. Valerie Parlave, who served as the assistant director in charge of the Washington Field Office of the Federal Bureau of Investigation (FBI) during the incident, noted that special events planning provides many coordination and collaboration opportunities to explore various scenarios and build local-federal relationships.

Following the Navy Yard shooting, Rear Admiral Carl Lahti, Naval District of Washington, acknowledged that the Navy’s security force needed to be augmented. That event showed that the internal resources of the Navy are not as robust for active shooter events as they are for defending assets overseas. Traditionally, the Department of Defense (DOD) has worked in silos, but events like the Navy Yard shooting highlight the need for the DOD to learn how to work between forces – both military and civilian.

Scott Boggs, managing director of homeland security and public safety for the Metropolitan Washington Council of Governments (MWCOG), reminded participants that “interoperability is not just about technology, it’s about relationships.” COGs are a valuable resource for building relationships, identifying resources, and overcoming interoperability barriers.

Such relationships can help fill various resource gaps. For budget-restricted agencies, it may not be possible to purchase equipment for low-frequency events. However, as Guddemi pointed out, “You don’t always need to buy, sometimes you just need to borrow.” Having relationships and interagency procedures in place would facilitate this possibility.

In addition to having critical resources, they also must be strategically positioned in order to help rather than hinder responses. For example, parking without designated staging areas can prevent resources from accessing the scene or delay resources from leaving the scene. This occurred during the Navy Yard shooting. Cathy Lanier, who is now chief of security for the National Football League, recommended having “go kits” at the entrances to facilities to provide access and navigational tools for complex responses.

“Collaboration is no longer an option. In today’s interconnected society, agencies and organizations must communicate with each other, coordinate resources, and align priorities.” –Charles Guddemi (Protecting Life and Civil Liberties: Masters of Collaboration, 2013)

Experience & Training:

As Chief Peter Newsham of the Metropolitan Police Department (MPD) said, the likelihood of responding to a mass casualty with people who have actually experienced such events is unlikely. This makes responding to a complex incident like active shooters even more difficult.

Prevention and deterrence through regular background checks to help detect potential insider threats is critical, but not fail-proof. An active shooter response will be needed again, at some unpredictable time in some undisclosed location, so responders need to be vigilant and prepared. Interagency training exercises provide opportunities for response teams to work together and familiarize agencies with each other, their tactics, their plans, and their capabilities.

Pre-incident familiarization of large-scale venues would help responders pinpoint specific locations and maneuver through complex facilities. Although this was not done before the Navy Yard shooting, efforts have been made to bridge this familiarization gap between military and civilian agencies. In fact, Lahti announced that the Navy Yard would like to host an active shooter training with summit participants to be able to exercise as a team and close some of the existing response gaps.

A discrepancy in command structures was another lesson learned from the Navy Yard shooting. Keil Green, who is the chief executive officer of Lafayette Group, described emergency and interoperability challenges that occurred at the Navy Yard and similarly at the Fort Hood shootings in 2014. As a result of after-action reports, it was recommended that base personnel have dispatch in speed dial rather than calling 911 to avoid response delays. However, unified command with interoperable communications between military bases and civilian agencies is the ultimate goal. During a large-scale, ongoing incident, unified command provides a common operating picture, but it has to contain the right people. During the Navy Yard shooting, two incident command centers were working separately to achieve the same goal, but without either having a comprehensive operating picture. As such, some efforts were unnecessarily duplicated, and others were hindered.

Mass casualty incidents draw many responders with good intentions. However, Lanier pointed out that officers’ instincts to respond made it challenging to control who was entering the building, so a staging area should have been set up earlier. In addition, during such incidents, some officers are still needed at their daily posts and should not abandon their current responsibilities. Others who should respond should not take on inappropriate or less effective roles – for example, an incident commander entering the building in tactical formation rather than leading from the command center. Such position-specific roles and responsibilities should be designated in advance to provide the most robust coordinated effort.

Throughout responders’ careers, they must learn to embrace critical thinking techniques. Whether a mass shooting or another mass casualty situation, responders must be empowered to act rapidly within their abilities and scope of practice without having to delay response. They need to be able to instinctively engage even when direct orders from leadership cannot be immediately obtained. This type of thinking can be leveraged during planned events to prepare for unplanned, no-notice incidents.

What Now?

The Navy as well as law enforcement agencies in and around D.C. continue to make changes to address recommendations made in the Navy Yard shooting after-action reports. Rob Shaffer is the director of operations for Naval District Washington and discussed how lessons from the Navy Yard incident as well as other significant shaping events have helped to guide and improve response efforts, which include: improved interoperability, overarching policy changes, Incident Command System compliance, and new training initiatives. However, there will always be more relationship building and joint training opportunities to leverage.

The agencies who responded to the Navy Yard shooting in 2013 included some responders who had past experience with mass casualty incidents and many more who experienced their first active shooter event on that day six years ago. Although examining lessons learned and implementing after-action recommendations will not change the past and will not address all possible gaps that could be encountered in the future, these critical post-incident actions will enhance future responses and better prepare all public safety agencies for the next unexpected incident.

It is important to note that, although the odds of any particular responder being involved in a mass casualty incident like the Navy Yard shooting – let alone two or more – is not high, it is still imperative for all agencies to absorb the lessons learned and recommendations from those who have. By building relationships, changing policies and procedures, and learning from those who have been there, public safety agencies will be better positioned to respond no matter who is scheduled to work on the day the next mass casualty incident occurs.

Special thanks to Charles Guddemi for inviting DomPrep to this important event and for always being open to share valuable lessons learned and recommendations that benefit public safety agencies across the country. Thanks also to all the summit participants who not only played key roles in neutralizing the Navy Yard threat in 2013, but continue to serve and protect the public within their capacities every day.

Additional Resources

DC HSEMA, Government of the District of Columbia, and U.S. Department of Homeland Security, “The District of Columbia Communications Interoperability Summit: A 6 Year Review of the Washington Navy Yard Shooting

Department of the Navy, “Report of the Investigation Into the Fatal Shooting Incident at the Washington Navy Yard on September 16, 2013; And Associated Security, Personnel, and Contracting Policies and Practices

Metropolitan Police Department, “After Action Report Washington Navy Yard September 16, 2013; Internal Review of the Metropolitan Police Department Washington, D.C.

 

Catherine L. Feinman

Catherine L. Feinman, M.A., joined Domestic Preparedness in January 2010. She has more than 35 years of publishing experience and currently serves as editor of the Domestic Preparedness Journal, DomesticPreparedness.com, and The Weekly Brief. She works with writers and other contributors to build and create new content that is relevant to the emergency preparedness, response, and recovery communities. She received a bachelor’s degree in International Business from the University of Maryland, College Park, and a master’s degree in Emergency and Disaster Management from American Military University.

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