Like a fatal airliner crash, a mass shooting of schoolchildren is an event that no one—no one—wants.
When a plane crashes, the National Transportation Safety Board conducts a full investigation. Every time.
When pilots or passengers witness a “near miss” event they can report it anonymously through a channel administered by NASA. A detailed analysis is triggered.
These reviews aim for learning and prevention. Their success in promoting aviation safety has been startling.
But when schoolchildren are murdered, nothing comparable follows.
Instead, information (and misinformation) dribbles out to the media. Reciprocal finger-pointing and agenda-mongering saturate the coverage.
Blaming—or escaping blame—becomes the whole point. Anyone—and particularly any lawyer within range—shuts down the flow of information. Opportunities for learning are forfeited; public confidence is gutted.
We need the capacity for routine mandatory, federal, all-stakeholders reviews after every completed episode of fatal school violence and after every narrowly averted one.
Our shared revulsion should be used to mobilize safety-oriented collaborations, not to motivate a hunt for scapegoats.
Beyond the “Good Guy,” “The Bad Guy,” and Their Guns
The primal horror we feel after every school shooting eclipses the fact these are not simple events. Every fatal school shooting, like every plane crash, is a system failure.
The system protecting school kids is not a stark good guys versus bad guys arrangement. It is not even a “complicated” mechanical system, like a jetliner at rest.
Like a jetliner in operation, a school safety system is complex. When this system fails, it is not because some faulty “eureka part” in a linear sequence of causes and effects has malfunctioned and can be replaced.
No single component ever explains the event independently.
Individual mistakes and omissions combine with each other and with underlying system weaknesses and then—but only then—the tragedy explodes.
We might argue in the abstract that a gun is “the” root cause of the tragedy, but with an estimated 380 million guns already in circulation that won’t get us very far. We could claim that prevalent rates of mental illness are the problem, but countries with similar mental health profiles suffer nothing like our child gun death toll.
Arguments over a single “fix” and over ranking potential “fixes” waste crucial time. To this point, they’ve prevented all progress in any direction. We need lots of repairs, in many areas, not one magical cure.
Our impressive advances in aviation safety have been built on the recognition that we don’t live in a world of switches and gears that mechanically “cause” tragedies; we confront a socio-technical environment of conditions and influences that don’t dictate outcomes, but that do bend the probabilities.
Even the fragmentary accounts of the Uvalde nightmare show that the massacre was made possible by the interactions of myriad factors. Mental health care and monitoring; gun availability; police hiring, training, tactics, equipment, dispatch; local coordination and peer culture all played a role.
Even if the Uvalde police should have intervened immediately instead of waiting—zigged when they chose to zag—that leaves questions. Why did they make that choice? Why did that “make sense” to them? Why did they have to confront that choice in the first place? Were they the last line of defense, or the only one?
Learning From Tragedy
What we need are not one-off “performance reviews” of individual cops, or teachers, or departments; we need full-scope “event reviews” that illuminate their influences on each other and the impacts on all of them of system pressures.
A crucial aspect of the system-based etiology (manner of causation) of these disasters—both the fatal ones and the narrowly averted ones—is that it can illuminate deep system weaknesses. Since these are never “single cause” tragedies we can generate a wealth of targets for study and improvement by examining any one event.
We have promising proof of this concept in the school shooting context.
During a general exploration of “sentinel event” and other learning-oriented reviews of adverse outcomes such as wrongful convictions, officer-involved fatalities, and opioid overdose deaths, the Department of Justice supported the National Policing Institute in a program examining completed and averted school shootings and compiling a data-base of events and lessons learned.
That effort provided insights for (and about) students, staff, parents, and police. It offers recommendations for preparations, relationships, culture, and facilities. It blazed a trail forward.
Instead of being paralyzed by complexity we need to exploit its key lesson. Safety—and its opposite—aren’t found within individual components of the system; both danger and resiliency emerge from the components’ interactions or failures to interact.
Things “fall between the cracks,” or are prevented by a “good catch” because of conditions and influences that no one-off scrutiny of a lone department (as in Uvalde) can capture. A practice of learning from events can help us identify individual contributions to be made to a safe collective future for our schoolchildren.
These major reviews will require extensive subject matter expertise that is beyond the capacity of jurisdictions like Uvalde. And the review products can benefit from a standard format and a central utility for collecting and disseminating their data.
The process will have to clear away the barriers that we currently see operating in Uvalde—the obstacles to the free flow of information that lawyers for cities, police departments, and other implicated actors feel it is “prudent” to pile up.
The fact is, the financial liabilities involved are ultimately covered with public money, either directly from public funds or from risk pools and indemnification schemes funded by tax revenues, and not from the pockets (or budgets) of the people and departments who are running for cover.
In this context, the lawyers’ traditional advice—”Don’t say a damned word!”—is perverse. No public actor should have that option.
The public wants this public money spent to compensate victims and survivors, not hoarded. The public certainly does not want the hoarding of those funds to starve learning efforts that can prevent a repetition. What taxpayer wouldn’t pay to save the next schoolchild’s life?
This kind of safety-oriented capacity is well within the reach of the federal government, which has the resources to staff it, and, through its educational and other municipal funding programs, the incentives—both the carrots and the sticks—to induce participation.
Just as airlines and airplane manufacturers are compelled to participate in aviation safety processes by the cumulative power of licensing and other requirements, state and local governments and their agencies could be compelled to cooperate in school safety reviews.
Doing this would simply recognize the proper role of public leaders after one of these tragedies. It’s a role that Dr. Ivan Pupilidy identified during his work with the U.S. Forest Service.
The leaders’ role is not to scramble to avoid a reckoning, but to hold themselves “accountable for learning” why the tragedy happened.
Building a platform for learning from school shootings is better than sending “thoughts and prayers.”
It can bolster the safety of our children. It can provide a model for fine-grained local “culture of safety” continuous improvement.
One reason plane crashes are rare, and have become rarer, is that we learn from them.
There is nothing we can do to rewind the clock after a Newtown or Parkland or Uvalde event. In our political climate it can seem as if there is nothing else we can do either. A sense of helplessness sets in.
But we can show that we—all of us—are desperate to learn why the catastrophe happened, and to see that it doesn’t happen again.
James M. Doyle is a Boston defense lawyer and author, and a regular columnist for The Crime Report. He welcomes comments from readers.