POV: ‘It is time to demand adherence to NIMS/ICS and accountability for failure to implement’

By Joe Dixon

To better protect and serve our communities, all first responders must be prepared to establish and execute a plan at a moment’s notice, particularly when faced with a major incident. Carrying out such plans often requires resources that extend beyond a single agency, underscoring the importance of coordination, before, during and after incidents.

No matter the scale of such plans or the depth of resources, failures can occur. In small incidents, shortcomings often go unnoticed (Faith et al., 2011). But when the incident complexity leads to casualties or major property loss, investigations and reports are certain to follow.

In the aftermath of September 11, 2001, the lack of coordination and communication was identified as a critical problem in after-action reviews (9/11 Report, p. 397). The failures were extensive and costly.

To address these failures and other shortcomings, President George W. Bush directed the establishment of a common approach for managing all types of incidents. The resulting National Response Plan (NRP) provided guidance for governmental and non-governmental resources. Most assuredly, the establishment of the NRP and NIMS/ICS would ensure that fire and law enforcement – the two groups often first on the scene of incidents – would operate from the same playbook. If you know better, you should do better, right?

Instead, what we have seen is continued failures of command and coordination at major incidents. Let’s consider how such failures have been identified in other major incident investigations and reports.

Post-incident findings

The following major incidents received extraordinary attention and scrutiny, highlighting common themes in response failures – incident command and communications.

Columbine shooting: April 20, 1999; 15 killed, 24 injured (Columbine Review Commission, 2000)

• Law enforcement commanders should be trained to take command and communicate incident objectives (p. 79).
• Law enforcement agencies should facilitate communication plans with agencies with whom they might reasonably be expected to interface with (p. 84).

Virginia Tech shooting: April 16, 2007; 32 killed, 17 wounded (TriData Division, 2009)

• Failure to open an EOC immediately led to communications and coordination issues during the incident (p. 122).
• There was little evidence of a unified command structure (p. 119-120).

Aurora theater shooting: July 20, 2012; 12 killed, 70 shot (TriData Division, 2014)

• Better use of ICS would have led to better incident management (p. 110).
• LE was unable to communicate with fire despite interoperability (p. 23).
• There was no unified command (p. 24).

Sandy Hook shooting: Dec. 14, 2012; 26 killed, 28 shot (Connecticut State Police, 2018)

• Multiple Command Posts and EOCs were activated (p. 43).
• There was insufficient communication (p. 41).

Boston Marathon bombing: April 15, 2013; 3 killed, 264 injured (Project Management Team, 2014)

• No command and accountability for incoming resources (p. 113).
• Report of superfluous radio traffic and unwanted chatter (p. 119).

Orlando, Florida, Pulse nightclub shooting: June 12, 2016; 49 killed, 53 injured (Straub et al, 2017)

• No established staging with self-deployment of approximately 300 area LEA personnel (p. 59)
• Orlando Fire was not included in the UCP (p. 59)
• OFD paging system failed (p. 65)

It is clear that 9/11 was not the first or last major incident wherein communication contributed to loss of life. Columbine occurred two years prior, with the report published in 2000.

More recently, the management of the scene at the Uvalde School District shooting has come under scrutiny. The Texas House of Representatives Interim Report describes the scene as chaotic and uncoordinated. It further suggests that the personnel on scene were devoid of leadership skills and basic communications.

A call to action

Why is it that more than two decades after 9/11, some agencies continue to resist implementation of NIMS/ICS? Homeland Security Presidential Directive -5 (HSPD-5), the National Response Plan (NRP), and NIMS/ICS plotted a path to improved preparation, planning, response, mitigation and recovery to/from major disasters and event/incidents of all sizes. Why is it acceptable to read report after report identifying the same mistakes? Is it not the definition of insanity to do the same thing over and over and expect a different result? Why aren’t we doing better?

If we don’t owe it to the many lost souls on 9/11, what about subsequent losses that may have been prevented with improved incident management? Are local, state, tribal and territorial jurisdictions required to adopt NIMS to receive federal preparedness grants? The NIMS Implementation Objectives for Local, State, Tribal, and Territorial Jurisdictions provide clarity for NIMS implementation requirements. As recipients and subrecipients of federal preparedness (non-disaster) grant awards, jurisdictions and organizations must achieve, or be actively working to achieve, all of the NIMS Implementation Objectives. It seems adoption (on paper) has not translated to implementation and practice.

It is time to demand both adherence to NIMS/ICS and accountability for failure(s) to implement. But where do we begin? As is so often the case, the first step is acknowledging that there is a problem.

Law enforcement in focus

Some law enforcement agencies tasked with scene management at many of our nation’s deadliest active shooter/mass casualty events have come under scrutiny for poor coordination.

In a 2019 Police1 article marking 20 years since the Columbine shooting, Lt. Col. (ret.), Mike Wood shared his insight on this topic:

We need to do a better job of integrating fire, EMS and police resources, particularly at the senior leadership levels, to ensure a coordinated response to mass violence. Comprehensive deployment doctrine must be drafted, agreed to and trained. Senior leaders need better training to fulfill their roles as on-scene commanders. Responders from all public safety disciplines need more opportunities to train together and develop an appreciation for how they fit into a collaborative response.

I could not agree more and hope we are not talking about how the first responder community could be communicating better in another 20 years. We know better and therefore should do better.

Learning from crises

Capturing lessons learned from crises is a widespread practice that allows first responders to share both what went right and what went wrong from past experiences in order to improve future responses. The strategies/tactics, procedures, guidelines, etc., that are developed are often shared at conferences and in professional forums. Theoretically, this system of sharing should increase the level of preparedness amongst responders, so why aren’t we doing better?

What hasn’t happened is not as important as what must happen – NOW – and we all have an impact:

Civilians: Civilians have been conditioned and educated on the importance of saying something whenever something seems out of place, and they have demonstrated the ability to incorporate run, hide and fight when needed. Once they activate the emergency response system, they expect a coordinated effort to save lives and property.

Fire service: The fire service has embraced the value of lessons learned and mutual aid. We openly share our close calls, near misses, and after-action reviews to alert our colleagues to potential threats. We seek meaningful training with other agencies. When a NIOSH report is released, it becomes training material for departments across the industry.

Law enforcement: I am a fire chief and have served as an executive-level chief in three fire departments. The struggle to coordinate is real. If I have heard “OPS PLAN” once, I have heard it a thousand times. Whereas an Incident Action Plan (IAP) would be appropriate for coordinating resources ahead of a large event, law enforcement prefers to use OPS PLANS. An OPS PLAN serves a similar purpose to an IAP but is based off independently developed LE plans and orders. The key for law enforcement: NIMS/ICS calls for practitioners to use common terminology and forms. This is critical to ensuring efficient and clear communication.

On the positive side, there is a Law Enforcement Officer (LEO) Near Miss website. While access to most of the information is deemed both restricted and sensitive in nature, I am glad to see the concept adopted.

A path forward

The focus of the 9/11 Report was to generate both common protocols and language for multi-discipline/agency crisis responses. In late 2020, the All Hazards Incident Management Teams Association (AHIMTA) and the International Association of Chiefs of Police (IACP) collaborated in an attempt to better understand the failure of Law Enforcement Agencies (LEAs) to fully embrace ICS. The areas identified included:

• Development of a cadre of law enforcement practitioner as instructors to deliver NIMS/ICS training;
• Executive support;
• Acceptance/implementation of Incident Action Plans versus operational and event plans;
• ICS mentorship and development; and
• Increased partnerships with emergency management.

The topic areas identified in the report provide a path forward while allowing LEAs to maintain jurisdictional priorities and policies. However, the message is clear: For the LEAs still using the term Ops Plans as an institutionalized local approach should adopt IAP terminology to avoid confusion going forward.

Further, C3 Pathways has developed an Active Shooter Incident Management Checklist that is being used by hundreds of law enforcement, fire and EMS agencies across the country. The document has been validated for design, content, format and usability, and it is subjected to ongoing testing and improvement. C3 Pathways grants free copyright usage permission to first responders.

The Active Shooter Incident Management Checklist does the following:

• Sequences key items to save time;
• Identifies key communication paths;
• Clearly distinguishes tasks and roles;
• Pinpoints needed delegated decision-making; and
• Integrates the response across disciplines.

Like any other tool you use, the checklist is enhanced with training and familiarity.

Final thoughts

Those we serve across this great nation expect trained first responders working together to mitigate hazards. The stakes are too high to continuously show up at critical scenes and miss the mark because of poor communication and coordination among our teams. We need to employ the appropriate levels of coordination and communication to combat negative outcomes. In other words, teams should play from the same playbook using common language to achieve maximum impact. We can do better and must do better…or be prepared to talk about how common failures associated with incident command and communications shortcomings continue to plague us decades from now.

About the author

Joe Dixon is the fire chief in Gainesville, Florida, after having served as chief in Goldsboro, N.C., and assistant chief in Howard County, Maryland. He holds a bachelor’s degree in fire science from the University of Maryland University College and a master’s degree in organizational leadership from Waldorf College. His advanced professional certifications include Certified Emergency Manager, Fire Investigator, Fire Officer IV, Hazardous Materials Technician, Fire Instructor III, FEMA L449 TTT (Advanced ICS Instructor), CFO and EFO. He currently serves the industry as chair of the Black Chief Officers Committee and as a member of the NFPA 1710 committee.

References

1. AHIMTA (2020). Law Enforcement Implementation of ICS
2. C3 Pathways (2022). Active shooter incident management checklist.
3. Columbine Review Commission (2001). The Report of Governor Bill Owens’ Columbine Review Commission.
4. Connecticut State Police (2018). After-Action Report: Newtown Shooting Incident.
5. Faith, K., Jackson, B., & Willis, H. (2011). Text analysis of after-action reports to support improved emergency response planning. Journal of Homeland Security and Emergency Management, 8(1), 1-16.
6. FEMA (2003). Presidential Policy Directive/PPD-5: Management of Domestic Incidents.
7. National Commission on Terrorist Attacks upon the United States (2004). The 9/11 Commission Report: Final report of the National Commission on Terrorist Attacks upon the United States. Authorized ed., 1st ed. New York, Norton.
8. Project Management Team (2014). After action report for the response to the 2013 Boston Marathon bombing.
9. Police1.com (2019). Roundtable: 20 years after columbine, are all schools safer?
10. Straub, Frank, Jack Cambria, Jane Castor, Ben Gorban, Brett Meade, David Waltemeyer, and Jennifer Zeunik (2017). Rescue, Response, and Resilience: A Critical Incident Review of the Orlando Public Safety Response to the Attack on the Pulse Nightclub. Critical Response Initiative. Washington, DC: Office of Community Oriented Policing Services.
11. TriData Division: System Planning Corporation (2009). Mass shootings at Virginia Tech: Addendum to the report of the review panel.
12. TriData Division: System Planning Corporation (2014). Aurora Century 16 Theatre shooting: After action report for the City of Aurora.