Sandy Hook Shooting Final Report (PDF)

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The official report of the State of Connecticut on the Sandy Hook shootings was released today: "Report of the State’s Attorney for the Judicial District of Danbury on the Shootings at Sandy Hook Elementary School and 36 Yogananda Street, Newtown, Connecticut on December 14, 2012" in a 44-page PDF. Unfortunately, the investigation did not reveal why the shooter chose the school as his target.


The obvious question that remains is: “Why did the shooter murder twenty-seven people, including twenty children?” Unfortunately, that question may never be answered conclusively, despite the collection of extensive background information on the shooter through a multitude of interviews and other sources. The evidence clearly shows that the shooter planned his actions, including the taking of his own life, but there is no clear indication why he did so, or why he targeted Sandy Hook Elementary School.  (Page 3)

It is important to note that it is unknown, what contribution, if any, the shooter’s mental health issues made to his attack on SHES [Sandy Hook Elementary School]. Those mental health professionals who saw him did not see anything that would have predicted his future behavior. (page 35)

Having made my first pass through the report, there is a lot to digest and a lot to be disturbed by. Several specific things disturb me, however, centered on the above quotes, from the point of view of threat analysis. Given the understanding that this kind of threat is still very rare, planning for rare catastrophic events is precisely what emergency management does, and within that context, this report should send cold shivers down your spine. I have said in several other forums in the past 11 months that some things seriously bothered me about Sandy Hook and the initial reports but that I was going to withhold judgement until the final reports were made and then, the release of the bulk of the evidence and early detailed scholarly commentary on that evidence. That process can sometimes take years (5-15 years). This report published today did not get us there, but it got us quite a bit further and, in some ways further than I had hoped because several potenial sources for answers seem to have terminated in dead ends. In particular, it seem that his writings and journals simply won't tell use what I had hoped to get from them.
Both 'sides' are wrong:
Because of the type of approach Lanza took and because of his background, most of the approaches to protecting students people throw around immediately are almost entirely useless. Because of the level of planning/intelligence demonstrated in the forensic analysis and the fact that exactly none of that planning was ever exposed to an outsider, even under the twin, polar-opposite responses of 'take away all firearms from everyone everywhere', and 'arm all teachers to levels of training equivalent to that of US Secret Service/Protective Services', the threat would still have happened roughly the way it did. The latter quite well confirmed by an instructor in a class last year who had been Protective Services  in three Administrations: he does not believe it is normally possible to "stop" an attack before it is initiated by the shooter except by complete accident or error on the part of the shooter.
Firearms were irrelevant because even if we could ban certain classes of weapons and make them magically disappear worldwide, it would not have stopped the plans being made. Lanza could easily have switched to a run of the mill pump shotgun or even a double barrel shotgun and done the same damage even with a complete ban on "assault weapons" (and I object to the very category definition) or by using a baseball bat, the contents of a kitchen cabinet/garage/ workshop, a motor vehicle, or say... a pressure cooker and fireworks and some ball bearings. None of those changes would have made the defender's job easier and none of them would have resulted in less carnage. Remember that Columbine was not a successful school shooting, it was a failed bombing. If the bombs in the Columbine lunchroom had detonated, hundreds of students would have been killed and the shooting deaths would have been a mere footnote which bored the shooters enough that they shot themselves early just to break the monotony of having had full control of the school. Eliminating weapons would have caused him to plan for new ones which might actually become highly effective as a consequence.
Armed teachers everywhere won't stop the initial violence (the trigger event) because before that moment, there is nothing to stop. Armed teachers might prevent the spread of an incident or force it in a different direction, but no more and best in conjunction with well-planned lockdown and internal response. An armed teacher is largely a potential help when the shooting has already started and is moving toward the room or body of students which has an armed protector: by shooting at the shooter (who violated or attempts to violate the lockdown), you may stop them, but you will more likely just drive them to go to somewhere else. By acting primarily in that circumstance, armed teachers also reduce their chance of being caught up in "friendly fire".
Threat identification is worthless in this case because there was no threat to identify. Adam Lanza was not connected to the stool (in years) and had no contact. The school had no reasons, rational or otherwise, to consider Lanza a threat. Even when he had been in that school, he was non-violent, even when bullied he did not fight back, was not apparently bullied to any extraordinary extent, anyway. The one piece of work he had done in the fifth grade: a story about strolling with grandma while gunning down kids, was never turned in and therefore never seen by the teachers. There was no discernible rational or irrational reason for this man to have targeted this school and those two classrooms. He had not been committed (voluntarily nor involuntarily), had committed no crimes, no history of domestic violence, or from what we can tell, violence against animals, no drugs, alcohol, etc., so he would not have been considered a threat outside of the school either. He appeared to be as sane as many people who run for public office--- STRANGE with neon lights and a pink feather boa--- but not really "nuts" in the mass-murder sense.
Even when we as a society do have more to work with, our threat identification still normally... well... sucks. We commonly persecute students in school who are not threats and give the dangerous ones a pass. Health professionals did not believe Lanza was violent. Eric Herris was in juvenile process (with Dylan Kleibold) for breaking into and stealing from a parked car and having been caught with bomb-making materials (plus a history of having set some off in the neighborhood and threats against a specific family) plus alcohol abuse. While plotting and planning the Columbine murders, he had his case worker and mental health professionals eating out of his hands and would have left that program with high recommendations. VA Tech, the Giffords shooting, Simon's Rock are all failures to identify threats in educational contexts, but we cannot necessarily count on it getting much better. Zero-tolerance usually put in place after shootings generally makes it much worse: we persecute even more innocent people and don't catch any real threats at all.
Guns, neither taking them away nor adding more solve the primary problems:
So, in a basic sense, if either main "side" in these dramas gets their way: comprehensive gun control or arming of substantial numbers of teachers, adult students, and SROs, it simply WON'T MATTER. They are not inherently preventable incidents. Gun control might stop a lesser crime here or there and maybe save a few lives. Arming trained defenders in the school might likewise get lucky and get a win, such as an armed/trained teacher in a Sparks-like situation who might have a backup to failed negotiation. But overall, neither solution, even discounting substantial implementation problems, can work. Some elements of one or other might reasonably find their way into a larger strategy of mitigation, but not prevention itself.
Mitigation Is Possible But Not As 'Glitzy':
Luckily, there are substantial ways to mitigate such disasters. Law Enforcement response times have been shrinking markedly since the three hours of Simon's Rock and equally dismal Columbine. The first officer arrived within four minutes at Sandy Hook, and was moving in just a minute more. At Sparks, Nevada, the original response was three minutes. This is phenomenal! In both cases, the shooters were dead by the time the police arrived: police were still, in effect, second responders. I predict continued improvements shaving off seconds from that initial arrival and shaving off seconds from the formation and dynamic entry. But, there is little in the long run that this can accomplish by itself, either. The secondary effect of fast police response is that EMS can potentially go in close behind them, especially if force protection is available to watch them while they work.
But the biggest gains to be seen are in the way you build the school/classroom space and the way you train the students. My fellow presenter at the IAEM conference, the Emergency Manager from Southern Methodist University, demonstrated quite well the differences between layouts, between windows and doors which make a classroom a killing field versus someplace which would deny and frustrate an attacker, allow victims to coordinate and communicate, to potentially escape or counter-attack ("Hide", "Fight", or "Flight" as they call it, or ALICE as other programs approach the problem). The Emergency Coordinator of the University of California at Fullerton also described changes being done at her school to thwart attackers and how they weathered a surprise incident where a nearby shooting spree boiled onto their campus while the Emergency Coordinator, her most experienced deputy, and the police chief were all out of pocket and the metropolitan police who were chasing the suspects had no ability to communicate by radio with the campus police. The organization largely did what it was trained to do and had a successful outcome.
In Sandy Hook, two classrooms full of students right next to where the shooter was active escaped with no injuries because they quickly hid in the restroom and blocked the doors. A SHES staff-member realized early on what was occurring, herded staff and students into their rooms to orchestrate a lockdown, and communicated with 9-1-1 throughout the incident (page 15). These responses worked. At Sparks, Nevada, one teacher confronted the shooter while the majority of his students escaped. A quick and well-orchestrated lockdown prevented the shooter from entering any of the school buildings (from the playground where the shooting started) and may have resulted in his rapid suicide when he realized he had lost control of the situation.
No Feel-Good Political Change:
The campus changes and the training changes going on are not the kind of whiz-bang, feel-good, easy political changes which will make people feel good even about a bad solution. Doing it right takes time, money, political conviction, and a lot of buy-in, as well as, likely enough, trial and error. But it is the right thing to do and among the very few things even remotely possible. Some guns in the hands of trained people inside the school (as well as sensible use of, say, pepper spray or mace) might give the first reponders (the teachers and staff) some more options in what is usually a tactically lousy situation. There may even be sensible gun-control methods which might modify the parameters in an attack or two. Deeper work with the police on security/intelligence inside the school as well as community volunteer groups (CERT, Sheriff's Auxiliary) can provide more, sooner, and better options for response. But the real energy should go into the school/classroom layout and the training of students, staff, and teachers whether that follows the Run, Hide, Fight or ALICE methodology.
No Scapegoat, Just Hard Work:
The worst part about this report is that it does not identify any single scapegoat who made all of this possible. No one simply screwed the pooch and enabled the shooter's behavior. That means there are no easy or feel-good things we can go after to punish the wrong-doer and to feel good about ourselves and about our own kids' safety: we just have to slog through the hard stuff a little at a time. The dramatic changes in response to these horrors over the last twenty years, from Simon's Rock to Sparks, Nevada, however, makes me certain that we are actually going in the right direction and that progress is being made.



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