The roots of failure to act quickly enough at the Uvalde school shooting were systemic and cultural. Certainly, the incident commanders made poor decisions throughout. Others failed to step up and challenge those decisions. There was poor training, leadership, triaging, and communication. But the critical learning for you is to make sure your systems and culture don’t leave you vulnerable to something similar.

Let’s cross the Department of Justice report on the Uvalde school shooting with Amy Edmondson’s insights into complex failures, David Brooks’ perspective on the dangers of ever-increasing bureaucracy, and the basics of crisis management.

Department of Justice Report

Attorney General Merrick Garland’s headline on the report is that, “Had law enforcement agencies followed generally accepted practices in an active shooter situation and gone right after the shooter to stop him, lives would have been saved and people would have survived.” Instead, responders treated the situation as a “barricaded suspect” operation that did not need immediate action, even as more officers arrived and the signals of ongoing danger multiplied for more than an hour resulting in 21 students and teachers dead and 17 injured

There was a critical decision failure by school Police Chief, Pete Arredondo, coupled with neither the town’s police chief nor the county sheriff challenging the decision or assuming incident command. The report details the lack of active shooter training, failure to triage victims once the shooter was neutralized, and complete communication breakdown throughout.

Complex Failures

Amy Edmondson defines intelligent, basic and complex failures like the Uvalde incident which have not one, but multiple causes, and often include a pinch of bad luck in a variable situation. Potentially catastrophic. Often preceded by subtle warnings.

Further, Edmondson’s research shows that one of the prerequisites of intelligent failures is psychological safety, which is required for people to ask questions, admit their own weaknesses or mistakes, offer ideas, and challenge the status quo.

Ever-increasing bureaucracy

Yesterday, the New York Times’ David Brooks wrote about how the growing bureaucratization of American life is drowning out our ability to innovate and make good decisions. He described the growth of administrators and their focus on supervision, control, enforcing the rules, collecting data and issuing work surveys and reports. He cited Philip K. Howard who wrote that “Studies of cognitive overload suggest that the real problem is that people who are thinking about rules actually have diminished capacity to think about solving problems.”

The basics of crisis management

The critical difference between strategic, tactical and crisis leadership is that strategic leadership is about creating and allocating resources ahead of the action. Tactical leadership is about managing resources during the action. Crisis leadership requires both at the same time.

Crisis leaders need to be prepared in advance and then react to events and bridge the gaps between the current and desired states. They should inspire, enable and empower others to get things vaguely right quickly, and then adapt along the way – with clarity around direction, leadership and roles.

The priorities should be to deal with 1) physical threats, 2) reputational threats, and 3) financial threats – in that order.

And note the basics of triage, treating, in order:

  1. The injured who can be helped by immediate intervention
  2. The injured whose intervention can be delayed
  3. Those with minor injuries who need help less urgently.

And not treating 4. The “expectant” who are beyond help.

Implications for you

When you confront what Amy Edmondson calls either a basic or complex failure, it’s tempting to blame the people on the scene. Before you do that, take a step back and look at your systems and culture.

Understand the actual behaviors and decisions.

Evaluate relationships, paying particular attention to psychological safety.

Dig into the pervading attitude of your organization and whether it’s run by administrators focused on rules and compliance or leaders focused on inspiring, enabling and empowering others.

Look hard at your real values making sure integrity and respect are front and center, complemented by a third value of either innovation, accountability, collaboration or customer-centricity depending upon your core focus.

Be sure the environment and context support the other cultural components you want and that you’ve built a system of high-performing interdependent parts.