Making Sense Out of Justice Tragedies

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Emma Gonzalez

Emma Gonzales, a survivor of the 2018 Parkland Fl. school shooting, has become an anti-gun-violence activist. Portrait by Jon Lion. Photo by Vince Reinhard via Flickr.

After the Parkland, Fl., school shooting last Feb. 14, the nation’s anger focused for a while on then-school resource officer Scot Peterson, who appeared to freeze outside the school while the gunman was firing.

“It’s easy…for people to go, ‘Oh, he should have known that that person was up there,’” Peterson, who was suspended and later resigned, said in a TV interview six months later.

Peterson explained that he stationed himself outside the building because that was where he believed the threat was located when he heard shooting.

Could we learn from asking different questions, designed to understand why it made sense for Scot to do what he did? Did our questions and conclusions lead us to deeper understanding and prevention, or did we add Scot to the list of those damaged by the Parkland shooter?

For a moment, let’s put away our natural bias to find people at fault. Let’s accept Scot Peterson’s account as accurate.

When we engage in a response to an adverse outcome event, we naturally create assumptions about the situation and, more to the point, people’s reaction to the situation. Pause for a moment and think about all the things that were not known by Scot. He did not know if there was a shooter – his first reaction was the thought that someone was lighting firecrackers.

He only heard a few shots. Were they the first shots or the last? He did not know where the shots were coming from; some reports suggested the football field.

Radio communications were not supporting the information-gathering and sense-making that Scot was attempting to conduct.

The later video showed four-plus minutes of nothing happening. If there was a school shooter, shouldn’t there be more activity? Just in case, Scot clears the area and begins shutting down the school. His dispatch does not have any information because incoming 911 calls are being routed elsewhere.

There is nothing to confirm an active shooter.

Five-six minutes. This can seem like a long time to someone watching the video. There seems like so much time to react, to do something. But emergent situations are not like a video. Your mind races as you try to make sense of a flood of often-conflicting information.

When I flew aircraft, I was often accused of calm multi-tasking. From my experience five minutes can seem like an eternity, or it can go by in what seems like seconds. Granted, some people are better at this than others . But we should ask, “How much of success and failure can be attributed to luck?”

Philip Zimbardo, a world-renowned psychologist, who is best known for the Stanford Prison Experiment, has studied heroism and action in the face of adversity. He has asked what makes a villain and what makes a hero.

Zimbardo said in his 2011 TED Talk:

“Some people argue humans are born good or born bad; I think that’s nonsense. We are all born with this tremendous capacity to be anything, and we get shaped by our circumstances—by the family or the culture or the time period in which we happen to grow up, which are accidents of birth; whether we grow up in a war zone versus peace; if we grow up in poverty rather than prosperity.” (Zimbardo 2011, TED, Ideas Worth Spreading)

It is doubtful that Scot was born bad. His history suggests otherwise. The circumstances definitely influenced Scot’s actions and decisions.

Through research and experience as an accident investigator, I developed a process designed to look for and assess the myriad of things that influence decisions and actions. The process is called the Learning Review.

The Learning Review replaced Serious Accident investigation in the U.S. Forest Service in 2013, and has been used on all fatal accidents since then.

Through this process the organizational response to incidents shifted from finding simple cause and blame to understanding the network of influences that shape decisions and actions, which led to the a sincere focus on learning from the event.

It’s important to raise this history in The Crime Report now, because criminal justice professionals and the journalists who cover them have begun to wrestle seriously with the opportunity to learn in the aftermath of unexpected outcomes.

The National Institute of Justice and the Bureau of Justice Assistance are in the process of launching a dozen demonstration sites where all-stakeholders teams will explore the process of how to conduct “sentinel event reviews.” These are seen as comprehensive, forward-looking event reviews that aim for prevention. They are not disciplinary performance reviews of individuals.

Supported by technical assistance from the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania, the local teams will explore the sources of mistaken releases, wrongful convictions, “near misses,” avoidable shootings—all the events that can jeopardize public safety at many levels.

This federal effort amounts to a bet on the commitment and ingenuity of frontline state and local actors. It provides room to experiment with lessons derived from precursors such as the Milwaukee Homicide Review Commission, Elder Death Review panels, and opioid death review efforts, and from its namesake “sentinel event reviews” that the Joint Commission requires for hospital accreditation.

Ivan Pupulidy

Ivan Pupulidy, PhD. Photo courtesy Ivan Pupulidy.

The Learning Review can supply a core process template that criminal justice review teams can adopt, evaluate and modify.

Editors Note: See also Ivan Pupulidy’s TED talk on Learning Reviews.

 Ivan Pupulidy, Ph.D., first developed and implemented the Learning Review as a U.S. Forest Service Director. His career has integrated academic research with real world applications, based on his experiences as a mine geologist, exploration geophysicist and a U.S. Coast Guard pilot for rescue and law enforcement missions. He welcomes comments from readers.

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