Aurora Colorado Theater Shooting After Action Report

The Aurora theater shooting incident is the largest shooting incident in the history of the U.S. in terms of the number of casualties. Perpetrated by one James Eagan Holmes, the 20th July 2017 incident left 12 people dead and 58 people critically injured. Overall, response to the incident was commendable, with the police and fire personnel arriving within five minutes after the shooting. The Aurora Police Department, the Aurora Fire Department, hospital-based emergency departments, and Emergency Management Services (EMS) worked together to manage the crisis. The agencies collaborated in evacuating victims, apprehending the suspect, searching the theater building, providing emergency medical care, transporting victims to hospitals, and assisting families of victims. Nonetheless, similar to other previous incidents, inter-agency coordination and communication difficulties were experienced. These difficulties provide crucial lessons for leadership within the field of emergency management.

The 20th of July 2017 was a sad day for the American nation. A few minutes past midnight, a gunman interrupted what was to be an enjoyable debut of the movie The Dark Knight at Century 16 Movie Theater in Aurora, Colorado. Tactically dressed, the gunman threw teargas and opened fire on the audience, killing 12 and injuring 58 people (TriData Division, 2014). Until June 2016, when the Orlando nightclub shooting occurred, the Aurora incident was the second largest mass shooting incident in the history of the U.S. in terms of number of casualties. Identified as James Eagan Holmes, a postgraduate medical student at the University of Colorado, at the time of the shooting, the perpetrator of the Aurora shooting incident was arrested by the police behind the movie theater a few minutes after the shooting. Upon arrest, Holmes made the police aware that he had installed homemade explosive devices in his Paris Street apartment, located approximately five miles from the movie theater (Garrett, 2012). The police responded immediately, evacuating about five buildings surrounding the suspect's apartment. In August 2015, the court sentenced Holmes to life imprisonment without parole.

While the Aurora shooting incident reignited the historically contentions gun control debate in the U.S., it provided crucial lessons for emergency response. The next sections focus on how the incident was handled, especially in terms of initial public safety response, establishment of incident command, scene stabilization, incident mitigation, multi-agency coordination, and challenges. Finally, lessons from the incident are provided.

Local law enforcement agencies, in conjunction with the Fire Department and emergency services, are usually the first responders to major incidents such as shooting incidents (TriData Division, 2014). In the event of such incidents, quick and well-coordinated response is crucial for saving victims, arresting the perpetrator, as well as effective management of the crisis (Bjelopera et al., 2013). For first responders, however, responding to emergencies is often a challenging undertaking, in large part, due to the lack of complete information about the incident.

Broadly speaking, response to the Aurora shooting incident was swift and effective. In less than two minutes following the shooting, the Aurora police had already arrived at the scene (Garrett, 2012). When the police get to the scene, their primary responsibility is to secure the victims. Several reports have praised the Aurora police for their effective response to the incident (TriData Division, 2014; Osher, Illescas & Brown, 2014). The police did not wait for ambulances. Instead, they used police vehicles to rush victims to local hospitals. Also, in about ten minutes upon arrival at the scene, the police had already arrested the suspect. The suspect notified the police of explosives he had booby-trapped in his apartment before heading to the theater, causing the police to swing into action immediately in an attempt to evacuate five buildings surrounding the suspect's residence.

The police's commendable response was further observed in the establishment of the Aurora Police Victim Services Unit as well as a Family Reunification Center to assist the families of victims (TriData Division, 2014). When such an incident occurs, it is common for such a facility to be established. With the support of trained volunteers from nearby jurisdictions, the facility recorded the names of victims and offered a variety of services to their families, including travel support as well as emergency medical attention. On the whole, the Aurora police did a commendable job in terms of evacuating victims, transporting casualties to hospital, apprehending the suspect, and collecting evidence.

The response of the Aurora Fire Department (AFD), local hospitals, and the Public Safety Communications Department was also laudable (TriData Division, 2014). The AFD arrived to the scene within less than six minutes after the shooting. AFD's personnel immediately embarked on providing medical care at the theater. On their part, local hospitals -- especially the University of Colorado Hospital, Swedish Medical Center, Denver Health Medical Center, and Children's Hospital -- and provided praiseworthy emergency medical care without prior notification of victim influx. In fact, not even a single patient was redirected to another hospital.

In the wake of the shooting, the Public Safety Communications Department responded to approximately 6,000 calls, four times more than its daily average. Throughout the incident, the communications department answered calls within the recommended call-answering parameters. The communications department not only responded to calls, but also contacted nearby jurisdictions to request for mutual assistance. With cooperation between the police, the Fire Department, local hospitals, and the Public Safety Communications Department, all casualties had been transported to hospital within an hour after the shooting.

In the event of an emergency situation, the incident commander is responsible for managing personnel and resources at the scene with the aim of ensuring seamless response to the incident (Bjelopera et al., 2013). Ordinarily, Aurora has three district police commanders on duty: one duty lieutenant and two duty captains (TriData Division, 2014). The duty lieutenant is responsible for responding to any emergency situations within the city. Duty captains are always on call, but at the time of the shooting, the duty captain was off-duty, consequently responding to the incident from home.

While the Aurora Police Department (APD) claims to employ National Incident Management System (NIMS) guidelines in responding to critical incidents, the department does not use the Incident Command System (ICS) (TriData Division, 2014). For the APD, the duty lieutenant or any other high ranking officer is assumed to be the incident commander in the event of a major incident. Accordingly, the lieutenant on duty at the time of the Aurora shooting was the initial commander, with the incident command post being established at the lieutenant's location. However, a formal incident command post was established later on. On the whole, though NIMS guidelines were not employed, the initial establishment of incident command during the Aurora shooting was fairly commendable.

Scene stabilization can often be a daunting challenge for first emergency responders in the wake of a mass shooting and other emergency situations. The difficulty often stems from the complexity of controlling the crowd (Bjelopera et al., 2013). Without effective scene stabilization, emergency response could be a disaster. Following the Aurora shooting incident, the police first established a perimeter around the scene to prevent members of the public from entering the scene. Next, the police prevented movie patrons from leaving the scene so as to interrogate them as eyewitnesses. Though some patrons had left, the police managed to detain a substantial number. Several patrons volunteered to respond to questions from the police (TriData Division, 2014).

At the same time, the police checked for more casualties amongst the crowd and looked for potential suspects and/or accomplices. The police also searched the interior of the theater in an attempt to apprehend the suspect and searched the exterior (especially in parking lots) for potential booby-trapped explosives. The police further stabilized the scene by transporting the patrons to the nearby Gateway High School (TriData Division, 2014). Scene stabilization also involves handling the media. In the event of an emergency situation such as a mass shooting, journalists camp at the scene in an effort to cover and gather information about the incident. The police dealt with the media at the parking lots. On the whole, stabilizing the scene was not as complex as one would expect. This could be due to the fact that the incident occurred at midnight, a time when there is little traffic and movement of people.

Incident mitigation essentially involves damage control or minimizing the impact of an incident (Bjelopera et al., 2013). During the first few minutes of an active shooting incident, first responders must do whatever it takes to prevent the loss of life. Following the Aurora shooting, the police undertook a number of measures to mitigate the incident. First, the interior and exterior of the theater was extensively searched in an effort to find the suspect as well as possible explosive devices. The attacker was apprehended just a few minutes following the arrival of the police. This was crucial in impeding the shooter's progress. Under police custody, the shooter could not cause more loss of life or destruction of property. After the search, the police confirmed that there were no secondary shooters or explosives. This was also crucial for mitigating the loss of life. Further mitigation was done by evacuating buildings surrounding suspect's apartment, transporting patrons to a safe location, and transporting victims to hospitals. On the whole, the police and other first responders at the scene did a fairly excellent job in mitigating the incident.

Generally, no single agency has sufficient resources on its own to respond to an active shooter incident or other major incidents. As such, multi-agency collaboration is vital (Bjelopera et al., 2013). Local agencies (e.g. the police, the Fire Department, Emergency Management Services and hospitals) and even federal agencies must work together to ensure the incident is addressed as swiftly and effectively as possible.

A number of agencies were involved in responding to the Aurora shooting incident: APD, AFD, hospital-based emergency departments, and Emergency Management Services (EMS). These agencies worked together to evacuate victims, apprehend the suspect, search the theater building, provide emergency medical care, transport victims to hospitals, assist families of victims, and communicate with the media. Though there were challenges of communication and coordination, collaboration between the agencies was quite creditable.

More effective inter-agency coordination was seen at the suspect's residence, where even the Federal Bureau of Investigations (FBI) was called upon to assist (TriData Division, 2014). Generally, the FBI is not involved in mass shooting incidents as they fall within the jurisdiction of local agencies. Nonetheless, the FBI is often quick to assist if requested by local agencies to do so. The FBI may support local agencies in processes such as investigations, security clearance, and disaster response. In this case, the FBI was specifically involved in detonating the explosives planted in the suspect's apartment and collecting forensic evidence from the apartment. Indeed, the evidence collected by the FBI would later become valuable for trial and prosecution.

Evacuation and denotation procedures at the suspect's apartment mainly involved the APD, AFD, FBI, and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) (TriData Division, 2014). The APD was involved in evacuating the suspect's and neighboring buildings. The AFD was on standby to put out any fire resulting from an explosion and to take care of any wounded personnel. The FBI and the ATF were involved in analyzing and denoting the explosives.

Reports have termed inter-agency coordination at the suspect's residence as exemplary (TriData Division, 2014; Osher, Illescas & Brown, 2014). Indeed, inter-agency coordination was more effective at the suspect's apartment than at the theater. This was particularly embodied by the establishment of a unified command structure. Throughout the entire two days of evacuation and denotation, the APD, AFD, FBI, and ATF collaborated effectively, constantly exchanging ideas on how to go about every step. This led to a successful evacuation and denotation procedure.

Public safety organizations face an uphill task in the event of a major incident such as a mass shooting incident. When such an incident occurs, the aim of responders is to handle it in the most effective and efficient way possible, keen on minimizing the impact of the incident and apprehending the suspect(s) before leaving the scene (Bjelopera et al., 2013). Achieving these outcomes is often not a straightforward undertaking.

In spite of commendable response to the Aurora shooting incident, a number of challenges were experienced. One of the major challenges experienced was slow response on the part of the AFD and EMS. According to reports, emergency medical personnel arrived at the scene more than fifteen minutes after the reporting of the incident (Kinsey, 2012; TriData Division, 2014). This was quite slow given that emergency medical personnel are among the first responders to a major incident. Worse still, the head of the local EMS arrived over sixty minutes after the occurrence of the shooting.

Reports have attributed the rather slow response of the AFD and emergency personnel to poor communication between the APD and the AFD (Osher, Illescas & Brown, 2014; TriData Division, 2014). More specifically, the police have been blamed for failure to relay information directly to fire personnel and failure to create a joint command immediately upon arrival at the scene. The communication breakdown led to delays in personnel dispatches, poor assessment of risk, delays in conveying information to paramedics, congestion at the scene (which created difficulties in accessing seriously injured victims), and the use of police cars to transport victims to hospitals. Communication breakdown between agencies at the scene of an incident is a common problem (Kinsey, 2012). Previous incidents such as Connecticut's Sandy Hook School shooting have also experienced the same challenge. With a unified command established immediately on arrival at the scene, there would have been better communication between the police and fire officials, possibly leading to a more effective response.

Given the problem of interagency coordination during emergency response, the U.S. Department of Homeland Security (DHS) established the NIMS, a standardized, nationally applicable approach for responding to emergencies. NIMS provides valuable guidelines for ensuring effective and fruitful collaboration between all emergency responders, including local, state, and federal agencies as well as private and non-governmental organizations (TriData Division, 2014). An important element of NIMS is the ICS, which stipulates procedures for establishing accountability, command and control, communication, and order during emergency response.

As mentioned earlier, there were deficiencies in the employment of ICS at the theater. First, a unified command (between APD and AFD) was not established until one hour after the shooting occurred. There were also delays in establishing the incident command post. However, the use of ICS at the suspect's residence was outstanding. While failures in employing ICS guidelines have been associated with communication breakdown between the police and fire personnel, it is believed that the outcomes are unlikely to have been different if ICS had been employed immediately upon arrival at the scene (TriData Division, 2014). Even in the absence of a unified command, most incident command functions were carried out by police and fire command. In other words, commanders and first responders made quite effective decisions in spite of not having a formal command system. All the same, the possibility that more effective deployment of ICS would have led to better outcomes cannot be ignored.