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Report on Active-Shooter Exercise at FPC Points to Serious Flaws in Command, Communications and Cooperation

| August 11, 2015

fpc active shooter exercise

The exercise at FPC featured dozens of students playing the part of injured victims, above. The exercise took place on June 11. (© Jon Hardison for FlaglerLive)

There was much back-patting between police, fire and government officials after a June 11 mass-shooting exercise at Flagler Palm Coast High School, where a suspect “killed” several people and injured 39 before he was “eliminated.” The exercise was to test the county’s emergency infrastructure, from police to rescuers to the hospital’s ability to handle a local catastrophe.

The county may have passed the test at its basic levels, but with no flying colors in sight.

At the time, the various players in the exercise knew little of how well—or how poorly—they’d done in the eyes of objective evaluators, none of whom were from Flagler County. They’d find out in the after-action report and improvement plan. That report paints an alternately commending and unflattering, at times troubling, picture of an emergency response system that can work well in its individual parts, but poorly as a coordinated, cooperative and unified response. (FlaglerLive obtained a nearly final draft copy of the report.)

In brief: there was no unified command and no proper incident command structure as prescribed by protocols developed for just such incidents. There was dangerously poor communications from within the walls of FPC to the outside world, because the school, like many large buildings and schools around town, hampers radio signals, and poor communication between fire rescue in the field and the hospital. There was little cooperation between the Flagler County Sheriff’s commander and Flagler County Fire Rescue’s commander. Participants mixed their roles, rescuers lacked key equipment to move patients, participants would tell evaluators that in a real-life emergency, they’d do things differently, defeating the purpose of the exercise, and it took the Palm Coast Fire Department 74 minutes to make contact with 54 staffers from the time the incident began. (“It didn’t go as well as we’d hoped so we’re working on repairing that,” Palm Coast Fire Chief Mike Beadle said.)

Evaluators are recommending more rigorous training and workshops between law enforcement agencies and rescue agencies.

“We understand that sometimes they tell you things that you don’t want to hear but that’s what training is all about and doing the right thing,” Beadle said Monday. He compared the experience to Palm Coast’s recent upgrade to a 2 in the 5-scale fire protection rating also known as the Insurance Services Office rating, or ISO, where the lower the number, the better the rating. “So we got our ISO up to down to the two points. We heard the criticism from the ISO and followed their recommendations, which is similar to an after-action report. You follow those recommendations and you make the system better. I hope we never have to test that out in Flagler County, but God forbid if we ever did, at least we have an understanding of what each side does, and the law enforcement.”

What Needs Work

Kevin Guthrie, Flagler County’s emergency services director and the principal organizer of the exercise, said it boiled down to three categories, each of which needs work: training, policy and equipment.

A response that worked well in its component parts but poorly as a unified response.

Fire departments need to do more joint training with law enforcement, schools and the hospital. “Policies need to be updated and tweaked to include things on a scene that need to happen,” Guthrie said. For example, policy, rather than accepted practice or assumptions, needs to state who will be in charge of treatment, transport and triage at a scene, which agencies will take control of specific matters, how fire rescue and law enforcement integrate together, how and when resuers enter an area that’s not entirely secure. “Right now, there’s no specific policy that all agencies have agreed to on how or when fire rescue goes in to start treating people,” Guthrie said.

Then there’s equipment. “We have a lot of great tools,” Guthrie said, “we have a lot of great equipment but is there equipment we’d like to purchase that would enhance our response capabilities, and that’s where I have to leave that.”

The after-action report’s rundown of the exercise illustrates specifically what worked and what didn’t along the way.

“The basic fundamentals of Incident Command were not engaged,” evaluators concluded. “When asked why elements of the National Incident Management System/Incident Command System were not implemented, the overwhelming response was, ‘we would have done it if it were a real world event.’ Exercise participants were advised at the beginning of this exercise to respond to all challenges as if it were a real world incident.”

Click on the image for larger view. (© Jon Hardison for  FlaglerLive)

Click on the image for larger view. (© Jon Hardison for FlaglerLive)

But there were problems in the choreography of the exercise. For example, when the exercise began, the command post of the sheriff’s office was already at the scene. That would obviously not be the case in an actual incident, when that post would have to be set up–or, in the case of the sheriff’s mobile command unit, driven in.

Flagler County Fire Chief Don Petito said he’d only cursorily reviewed the report, noting that it was still in draft form. But from what he’d read, he said the conflict between commanders was necessarily a setback. “It’s like a chaotic scene. Initially we have certain things the cops do, and certain things the firemen do. Once we figure out what it is we get together and say, this is what we’re doing,” Petito said.

There were serious flaws in the rescue operation, too: “The ranking officer on scene continued to be part of the search/rescue team instead of establishing command and managing the incident, once the shooter was eliminated,” evaluators found. “Witnesses and victims with minor injuries were moved deeper into the school instead of sheltering in place until they could be evacuated from the school.” There was also “poor situational awareness,” from what rooms and areas had and had not been searched to the number of cops at the scene or the number of severely injured victims, and there was poor coordination or police escorts for fire rescue personnel in the school.

One reason for that was the limited number of sheriff’s deputies at the scene: Just 14 were directly involved at the school, though flaws became apparent beyond mere numbers of personnel used.

Casualties Twice Over

Specifically, two people in critical condition and five others in one room were overlooked for more than five minutes before rescuers doubled back and started getting them out. When two cops entered the building with a triage and litter team, the litter team was left behind the cops, leaving them exposed. Deputies supposed to operate as a search team started operating as a rescue team as well. One cop picked up the rifle the suspect had used and carried it around with him to the room where contact was eventually made with the suspect: that’s considered moving evidence.

casualties FPC exercise

A casualty. Click on the image for larger view. (© Jon Hardison for FlaglerLive)

The triage of casualties was flawed, too, once victims were taken outside. Patient information cards that designate injury levels were filled out poorly. The color-coded tarps used to separate victims by injury levels were positioned in such a way as to make treatment difficult—a problem Petito said was easily remedied—while patients were left unattended for long periods. The absence of a designated Medical Branch Director created communication havoc. (The exercise evaluators focused more heavily on rescuers rather than on law enforcement because, other than for command and communications issues, the sheriff’s office asked not to be evaluated, several officials familiar with the exercise said, for fear of retaliation.)

The errors started with the designation of the mass-casualty incident: authorities declared it as a Level 2 incident, when it should have been declared a Level 3 incident—the difference being that a type 3 incident, lower on the scale of gravity, centers on a state or urban level incident, as opposed to a type 2, which implicates state or national-level incident management. The evaluation report does not specify who was responsible for the error. Face-to-face communication at the scene was judged “poor.” Communications from the field to the hospital was inadequate.

Incident Command Breakdown

Evaluators severely criticized the incident command structure, or lack of it, as “several key components” of the command structure “were not achieved,” in large part because the sheriff’s office and fire rescue did not cooperate well: “Law enforcement did not coordinate entry at the front of the school nor establish a person ‘in charge’ (operations) at this location,” the report concludes. “Law enforcement set up Incident Command for themselves in the command post while fire set up in the rear of their truck—this is not unified command.” For lack of such a unified command, considered critical during a mass-casualty event, operations section chief and subordinate divisions and teams were never set up, while the sheriff’s office’s commander, Steve Brandt, “was making all tactical decisions from the command level.” Fire rescue’s commander was Capt. Richard Bennet.

One glaring absence from the command structure: any school or school district representation.

Flagler County Fire Flight hovered. Click on the image for larger view. (© FlaglerLive)

Flagler County Fire Flight hovered. Click on the image for larger view. (© FlaglerLive)

Brandt and Bennett eventually did work together, but at the prompting of an exercise controller, the report notes. Among the report’s recommendations: “All Flagler County and municipality public safety agencies should complete a basic [Incident Command System] refresher course.” In May, Flagler County Emergency Services Director Kevin Guthrie held just one such course, and berated various agencies for not showing up.

“It was mentioned that had this been a real world incident,” report recommendations note, “the Palm Coast fire chief or deputy chief would have assumed command.” Recommendations further state that Flagler County Fire Rescue’s commander at the scene should have been the branch director of all EMS operations.

Petito said it would not necessarily be the case that in a real-world incident the Palm Coast Chief would automatically assume command in a Palm Coast-based incident. “It depends on where it is. If it was at FPC, probably not because we would have been already entrenched form across the street,” Petito said, referring to the Flagler County Fire Rescue station at the county airport, within sight of the school campus. “It depends on who gets there and who’s running it.”

Booting Out Public Information

The public information system did not work as planned. The public information officer designated to be at the command post, the county’s Julie Murphy, was actually ordered out of the sheriff’s command post, even though Murphy’s role would have been to closely monitor developments in the command post so as to relay close-to-real time, accurate information to media and others. “The PIO should work from the Command Post area and an assistant PIO established in order to run the operation of the JIC,” the evaluators concluded, referring to the Joint Information Center. There is conflicting information about whether a Joint Information Center, considered a key part of the response to a mass-casualty event, was actually established.

Several public information officers were involved in the exercise—from the county, Palm Coast, the sheriff’s office—but evaluators noted that they did not see them “collaborating or sharing information,” though in part that was because they were not provided timely information to start with.

The Dispatch Center and the Hospital

At the 911 dispatch center, observers were unable to evaluate whether the shift supervisor assigned the right communication channels, whether a proper, common channel for use by all field responders was assigned, and whether additional manpower was called in when necessary. The dispatchers did not know—or were not told– who the incident commander was. There was no knowledge of a unified command structure at the 911 center.

A 911 center in full control of nerves and emotions.

“This caused a great deal of confusion, leaving dispatchers unable to direct questions from the field units,” the report states, though it is just as possible, the report notes, that some “significant” transmissions were missed by the dispatchers. One reason for the confusion: the computer-assisted dispatching system, designed to make responders and dispatchers’ job easier, “did not prove to be ‘user-friendly’” as it became overloaded with notes, then froze for several minutes in the middle of the emergency. Despite those setbacks, the 911 staff “performed very well together as a team,” handling emotions and floods of information professionally and with steady hands.

At Florida Hospital Flagler, the hospital was able to prepare for the influx of patients when, monitoring a dispatch channel, it heard the first call about the shooting at 9:38 a.m., and set up a hotline for worried parents quickly enough (along with a request for additional security in anticipation of overly anxious parents). A hospital command structure was established and a briefing conducted. Observers noted that while the incident command post was too crowded and a hospital safety officer recommended a hospital lockdown, which would have prevented people from coming to the hospital to look for family or friends, hospital staff was clear about individual roles, “resulting in clear operational awareness for all staff members.” But the hospital staff had trouble getting through to 911, and the hospital had recurring problems maintaining communications with Flagler County Fire Rescue. There was also an exercise-technique lapse: patients kept arriving without the tags that identified the nature of their injuries, thus making triage more difficult.


Petito had this explanation for the communications lapses with the hospital: “One word: inundation: there’s only one frequency to talk to them on,” he said, so if all the rescue units are trying to talk to the Emergency Department at the same time as they’re bringing patients, “communications could easily get screwed up.” But there are efforts afoot to remedy the logjam, Petito said. “It would be a collaboration between the hospital and us.” And, he said, it is only in the rarest times that such a situation would occur—if, in fact, there were to be a mass-casualty event.

“The chance of us having that event are very low compared to a single person having a heart attack, so that’s where we need to keep concentrating our training on, is a low frequency event,”  Petito said.

The emergency department staff “appeared ready for the [mass-casualty incident] and comfortable with their roles,” the report states. Hospital staff also “did an excellent job of calming parents and attempting to meet all of their needs.” But after staff ushered parents to a secluded area, two school psychologists stood by without interacting with parents, as their role requested, and had to be asked by an evaluator who they were. Only then did the evaluator realize they were psychologists. “They informed the evaluator they didn’t know what their roles were and were there simply to observe the process,” the report states. They left without any contact with parents.

Petito said that since Guthrie assumed the county’s responsibilities as emergency services director, “he’s provided more training and stabilization in the incident command realm than in the entire history of Flagler County. I want to see that continue.”

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15 Responses for “Report on Active-Shooter Exercise at FPC Points to Serious Flaws in Command, Communications and Cooperation”

  1. EJ says:

    In the fire service, command can be passed (and usually is) to the most highest ranking fire official that is at the scene. So to say that the station at the airport would have command throughout the ENTIRE event because it’s the closest, is not really accurate.

  2. PeachesMcGee says:

    The lack of communication is not surprising.

    If something like this would happen, we’re going to need body bags not stretchers.

  3. Sonny Boy says:

    Guthrie please!

  4. John F. Pollinger says:

    As a former Incident Command Instructor, I can say it is paramount for every member of each agency to attend a training class for Incident Command as outlined in the National Incident Management System (NIMS). The premise of the training is predicated on using Incident Command even at the basic level of an emergency. As an example, a deputy first arriving at the scene of a motor vehicle crash is the Incident Commander until such time as the event broadens and escalates after initial assessments determine the need for more traffic control, EMS, etc. thereby requiring broader levels of responsibility and assignment of authority. Even the COPS volunteers need training as they can be used for perimeter traffic control, freeing sworn officers to other tasks. Egos have to be set aside and duties have to become second nature to all. It can only be accomplished if Incident Command training is afforded to all and each participant “buys in” to the concept. Otherwise, failures outlined in this report are doomed to repeat themselves at the expense of the public they serve.

    • brnwtrs7 says:

      Unless those individuals who are thwarting this command structure are no longer allowed to serve the public.

      It’s time for those authorities who we have hired to take care of the public welfare to get rid of those who think that their job is bigger than the welfare of all.

  5. Enlightened says:

    This is what happens when the Sheriff gets rid of all his deputies with experience. Chaos!

  6. Footballen says:

    Unified Command is what was supposed to happen but getting one hot head to work with another during a very stressful time in next to impossible unless they have trained to do so. NIMS and ICS were made a very integral part of the S.O. five or six years ago but I see that has fallen to the wayside or all the skilled people were fired.

  7. Just a thought says:

    The problems are,and always will be, Petito and Beadle despise each other and Petito’s comment about closest station is evidence of his total lack of leadership skills and understanding of the command structure. As long as each of them posture about who has command there will never be any improvement.

  8. Ron says:

    Get a hold of retired Capt. Michael Stein FDNY. After the WTC attacks he develop a command post radio to be used in all hi rise buildings in NYC and subways. This equipment is a must and a life saver. Just call the Uniform Fire Officers Association they will put you in the right direction. They also have a template for inter agency command that you may want to look at. There are plenty of agencies that have had the training and are experts. Use these resources and your training.

  9. Heading North says:

    Well spoken John Pollinger!
    It is obvious your expertise and experience speaks for itself!
    Flagler County lost its chance for a real Police Officer to be their Sheriff when you got beaten!
    Good luck John!!

  10. Matt says:

    Or just do nothing save all of the money being spent and stop the worst first thinking that our country has become accustomed to.

  11. David S says:

    Mr John you are 100% correct with your comments without proper communications and training you are asking for complete failure I have delt with this many times on the fireground.

  12. wishful thinking says:

    Another example of why it is about time for Flagler County voters to insist we change the charter to eliminate a ‘constitutional officer elected Sheriff and force staff and the commission to be responsible to HIRE a qualified chief of police who knows what they are doing !
    I still can’t figure out the difference between a ‘democratic’ and ‘republican Sheriff’… Can any of you?

  13. Jack D. Howell says:

    I am a current instructor in the State of Florida for NIMS. I also taught NIMS at the Jacksonville Sheriff’s Academy, along side Kevin, and throughout the state. Further, I also incorporate NIMS into all the Graduate and Undergraduate college courses I teach in the area of terrorism/Bio-Terrorism. The creation of NIMS was a result of the 9/11 after action reports and to fix problems in command and control. As a Colonel of US Marines, I know a thing or two in command and control especially when engaged in combat!

    What I am shocked by is that our county and city agencies still have major intra-agency communication problems. This should have been fixed several years ago when Federal funding was available to fix such issues. No excuse for this.

    I’ m also surprised that an exercise of this magnitude did not get the attention from the big wigs who really needed to get in to the roles they would be filing if this was for real. Nobody should have been exempted or you end up with the piss-poor results as the after action report stated. We must also remember that this is about command and control and not about egos!

    Kevin Guthrie has his act together….learn from him; listen to him!

  14. YankeeExPat says:

    So where are the tinfoil hat club folks, warning us that this is the implementation of “Jade Helm?”

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