Communications breakdown led to chaotic response

On 20 July 2012, a lone gunman dressed in tactical clothing and armed with tear gas grenades and multiple guns killed 12 people and injured 70 others in a shooting spree inside a movie theatre in Aurora, Colorado.

In the chaos that followed, a number of things went wrong, including police and fire officers having difficulty communicating and coordinating with each other - for instance, 28 minutes elapsed before contact was made between the fire battalion chief who was in charge of the emergency medical response and the police lieutenant in charge of law enforcement.

According to the official report into the incident - just released - “The glaring omissions of a lack of communication between police and fire commanders, and the lack of a victim transportation coordinator, could have jeopardized having as favorable an outcome as was obtained,” referring to the nonetheless successful transport and treatment of the injured.

To illustrate the disconnect between the operational picture obtained by fire and police, at one point a fire battalion chief remarked to a colleague, “So far, it’s running pretty smooth.” But in reality at that exact moment “police were facing a chaotic situation and ambulances were not getting through to many of the wounded”, according to the report.

The report came up with 80 recommendations for improvement, many of which have already been implemented - such as keeping master lists of police and fire mobile phone numbers, replacement of the computer-aided dispatch system and a new radio system (due for installation over the next 18 months).

Areas highlighted for improvement include (quoting directly from the report):

Unified or Single Overall Command - 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. This is not to imply that response actions in the first minutes should have been held up until a joint command was established; any such delay could have negatively affected the outcome.

Fire-Police Communications - 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 personnel and 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 communications that need to improve.

Notifications in Communications Centre - Messages to the public safety communications senior managers did not result in getting senior communications managers back to duty soon enough. This contributed to a lack of adequate arrangements to bring in relief telecommunicators and to brief the next shift on incident status.

Emergency Operations Centre - Some of the resource coordination and logistics that could have been facilitated through an activated emergency operations centre did not occur. Aurora’s Emergency Operations Centre (EOC) is a limited operation that needs improvement and greater visibility within the city’s structure.

The full report can be read here (PDF).