we explored Novelty, Cognitive Bias, and Situational Awareness and how each of these applies to Hospital Emergency Management. This case study focu

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1 October After-Action Report August 24, 2018

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This report was compiled by the Clark County Fire Department and the Las Vegas Metropolitan Police Department in collaboration with the Federal Emergency Management Agency National Exercise Division with the intent of distributing best practices and lessons learned for other communities around the country to better prepare for a mass casualty incident should one occur. Given the ongoing threat environment throughout the country, it was the intent of the agencies involved to provide this information as timely as possible.

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Table of Contents

Table of Contents ………………………………………………………………………………………………………………. ii

Executive Summary …………………………………………………………………………………………………………….1

Methodology …………………………………………………………………………………………………………………….2

Background and Timeline …………………………………………………………………………………………………….3

Assets and Capabilities ……………………………………………………………………………………………………………… 3

Preparedness Investments………………………………………………………………………………………………………… 4

Route 91 Harvest Festival …………………………………………………………………………………………………………. 7

The Shooter: Stephen Paddock ………………………………………………………………………………………………….. 8

Timeline………………………………………………………………………………………………………………………………….. 9

Overview of Response ……………………………………………………………………………………………………………. 10

Observations and Recommendations ………………………………………………………………………………….. 11

Pre-Incident Special Events Planning ………………………………………………………………………………………… 11

Emergency 9-1-1 Services and Notification ……………………………………………………………………………….. 13

Initial Response to the Scene …………………………………………………………………………………………………… 16

Fire Mutual Aid and Scene Management ………………………………………………………………………………….. 17

Tactical Operational Response ………………………………………………………………………………………………… 23

Operational Coordination ……………………………………………………………………………………………………….. 30

Public Information Notifications ………………………………………………………………………………………………. 34

Resource Management …………………………………………………………………………………………………………… 37

Operational Communications ………………………………………………………………………………………………….. 42

Family Assistance and Victim Services ………………………………………………………………………………………. 45

Responder Wellness……………………………………………………………………………………………………………….. 47

Tribute ………………………………………………………………………………………………………………………….. 49

Conclusion ……………………………………………………………………………………………………………………… 50

Appendix A: Abbreviations and Acronyms ………………………………………………………………………….. A-1

Appendix B: Timeline of Response …………………………………………………………………………………….. B-1

Appendix C: Core Capability Mapping ………………………………………………………………………………… C-1

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Executive Summary

On October 1, 2017, over 22,000 people attended the Route 91 Harvest Festival in Las Vegas, Nevada. On the third and final night of the festival, a lone gunman opened fire into the crowd from the 32nd floor of the Mandalay Bay Resort and Casino. The gunfire continued for over ten minutes, resulting in the deaths of 58 people and injuring more than 850, including first responders. Two local police officers responding to the incident were among those wounded by gunfire.

As the shooter engaged in this horrific act of mass violence, first responders made quick decisions, acting with bravery and professionalism to secure the scene and save lives. The cooperation between local fire departments, law enforcement agencies, and local private ambulance companies at the scene was exceptional. Off-duty public safety personnel also assisted in the response, providing valuable surge support for local responders. The Las Vegas community as a whole came together in response to this unprecedented situation to assist the survivors and responders of the shooting.

In the wake of this incident, it is important to evaluate the strengths and areas for improvement observed during the response—both to enhance the internal response capabilities of the Clark County Fire Department (CCFD) and the Las Vegas Metropolitan Police Department (LVMPD), as well as to share the knowledge gained from this incident with public safety agencies from across the country to assist in their preparedness efforts. Key conclusions from this report include:

 Strong cross-agency collaboration is critical for a quick and effective response.  Response training that is tailored to address an incident of mass violence is an especially valuable

preparedness investment.  Coordinated, cross-agency planning for an incident of mass violence is necessary for successful

outcomes. The response brought together 13 responding agencies and three private ambulance companies to address a highly chaotic scene, neutralize the threat, and tend to the hundreds of victims. The responding law enforcement and emergency service agencies coordinated efficiently to clear civilians from the area, establish an Incident Command structure, and organize an effective response. Across several elements of the response, strong collaboration among these organizations was critical to the speed and effectiveness of their efforts. Conversely, when responders encountered communication barriers, these barriers hindered some aspects of their response coordination.

Heavy local investment in Multi-Assault Counter-Terrorism Action Capabilities (MACTAC) and Hostile Mass Casualty Incident (MCI) training, as well as other formal training investments by CCFD, LVMPD, and surrounding jurisdictions, also proved especially valuable. Responders cited training and exercises as being responsible for their ability to mount an effective response. Responders also identified additional training, such as emergency medical care, that would be of value to local agencies. Training and mass casualty exercises played a vital role in response efforts, prompting agencies to consider how best to prepare their personnel for potential future incidents.

The importance of coordinated planning across agencies cannot be understated in terms of its impact on this response. When agencies followed pre-established plans and procedures, they improved communication and strengthened the response. Where plans were not integrated or not widely known and understood by responders across all responding agencies, difficulties arose. Strengthening plans, policies, and procedures across Southern Nevada public safety agencies will reinforce their capabilities, allowing them to respond as effectively as possible in future emergencies.

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Methodology

This report was developed through close collaboration between CCFD, LVMPD, and the Federal Emergency Management Agency (FEMA) National Preparedness Directorate. The FEMA After-Action Report (AAR) development team conducted extensive research to ensure that the assessment of the fire department and law enforcement response to the shooting at the 1 October 2017 Route 91 Harvest Festival was both comprehensive and accurate to the best degree possible. In the early morning of 2 October, CCFD and LVMPD created the Route 91 Task Force, which included four members from CCFD and three members from LVMPD. The task force gathered information by conducting hundreds of interviews, issuing surveys, and reviewing hours of dispatch tapes and hundreds of pages of dispatch notes. 24 departments and/or offices participated in interviews related to the 1 October response. The CCFD Route 91 After Action Administrator Report outlines responses of fire department personnel to interview questions regarding what went well and what could have gone better during the 1 October response. LVMPD also conducted a department-wide survey of personnel with an assignment on 1 October and received 672 responses. This information was provided to the FEMA AAR development team to support the After-Action analysis.

The FEMA AAR development team also reviewed a wealth of documents, reports, and plans to provide insight into Clark County’s existing preparedness efforts and the resources available to address mass violence of this scale and complexity. They incorporated background information provided by responding agencies by analyzing internal training records and standard operating procedures (SOPs). In addition, they reviewed AARs from similar incidents of mass violence to identify any recurring issues and challenges, as well as to understand how this incident’s response may have differed. Lastly, the team conducted open- source research on the response, including reviewing accounts of radio communications and 9-1-1 calls, to ensure consistency within reports.

From this information, the team synthesized observations and recommendations with an emphasis on identifying strengths and areas for improvement related to the response. The team organized these observations under 11 broad focus areas pertaining to the response, which were then mapped to FEMA’s core capabilities (See Appendix C). These observations were also mapped to the relevant discipline(s) or organization(s) and are denoted within the report as follows:

 Law Enforcement  Fire  Regional/Statewide Agencies

This report is intended to assist both Clark County public safety agencies, as well as jurisdictions across the country, to improve their preparedness for incidents of this type.

Much of what is included within this report is based on the feedback and materials provided by responding partners. The FEMA AAR development team carefully examined the materials provided by responding agencies. The following local agencies and organizations were involved in the response to 1 October: CCFD, LVMPD, the Henderson Police Department (HPD), the Henderson Fire Department (HFD), the North Las Vegas Police Department (NLVPD), the North Las Vegas Fire Department (NLVFD), Las Vegas Fire & Rescue (LVFR), the Clark County School District Police Department (CCSDPD), the University of Nevada Las Vegas Police Department (UNLVPD), the Boulder City Police Department (BCPD), Nevada Highway Patrol (NHP), the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF), the Federal Bureau of Investigation (FBI), Community Ambulance, American Medical Response (AMR), and MedicWest Ambulance.

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Background and Timeline

Assets and Capabilities

Clark County Fire Department

CCFD is the largest paid fire department in Nevada and is responsible for protecting the famed Las Vegas Strip, the largest part of the Las Vegas Valley spanning 293 square miles, and a county covering 7,790 square miles. The department is led by Fire Chief Greg Cassell, CCFD’s 10th chief. CCFD aims to respond with integrity, serve with compassion, and uphold their mission to provide for the safety and health of their Southern Nevada communities and visitors through professional emergency response, fire prevention, and public education.

The department has 30 full-time fire stations maintained by 705 personnel, including 638 suppression personnel and 67 authorized support staff positions. All CCFD rigs provide Advanced Life Support (ALS) services. CCFD also oversees the state’s largest volunteer force with 170 volunteers, who serve in the rural parts of the county at 13 volunteer stations. Additionally, CCFD sponsors Nevada Urban Search and Rescue (US&R) Task Force 1, one of only 28 US&R teams in the country. Nevada US&R Task Force 1 is capable of deploying 80 personnel and over 80,000 pounds of equipment in less than four hours by military airlift or by mobilizing 11 vehicles on the ground. This team brings an all-hazards capability to an incident commander and has done so on eight federal missions and one state mission to date.

CCFD responded to 132,938 calls in 2016 – 3,805 fires, 122,408 medical calls, and 6,725 other calls, including false alarms and mutual aid responses in other jurisdictions. In addition, the department provides fire and rescue services to the nation’s ninth-busiest airport.

Dispatching for CCFD is managed by the Fire Alarm Office (FAO). This dispatch center is a joint, auto-aid collaboration between CCFD, LVFR, and NLVFD. FAO is a secondary public safety answering point (PSAP). LVMPD is the primary PSAP. 9-1-1 calls for service go through LVMPD’s 9-1-1 Center initially and then are sent to the FAO based on the need for service.

CCFD Deputy Chief John Steinbeck serves as the Emergency Manager for Clark County and oversees the Office of Emergency Management (OEM). OEM provides a single point of coordination for Clark County public safety projects, including planning, training, exercises, and response and recovery efforts. In this capacity, OEM works closely with Clark County public safety organizations to facilitate a coordinated approach to multi-agency activities.

Las Vegas Metropolitan Police Department

LVMPD is an independent agency and joint city-county police force for the City of Las Vegas and Clark County, Nevada and is the largest law enforcement agency within the state. The department is led by Sheriff Joseph Lombardo, the 17th elected Sheriff for Clark County, and is responsible for an area of 7,560 square miles.

LVMPD’s vision is to be the safest community in America, and its mission is to serve people, strengthen relationships, and improve the quality of life. In 2016, the department answered 1,127,169 9-1-1 calls, participated in 468,543 dispatched events, performed 1,453 Homeland Security special investigations, and had an average response time to emergency calls of 6.4 minutes from the time the call was dispatched. LVMPD has nine area commands, one airbase, and three detention centers all maintained by 5,533 personnel that were employed the day of the event.

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LVMPD’s Homeland Security Division addresses terrorism and multi-hazard events at the local law enforcement level. The division is comprised of the Organized Crime Bureau, the Emergency Operations Bureau, the Southern Nevada Counter Terrorism Center (SNCTC), K9, Air Support, the Special Weapons and Tactics (SWAT) Bureau, and the LVMPD All-Hazard Regional Multi-agency Operations and Response (ARMOR) Section, which handles Chemical, Biological, Radiological, and Nuclear (CBRN) response. SNCTC’s Emergency Management Section provides preparedness planning and response actions, including operational support during incidents.

Housed at LVMPD’s headquarters, SNCTC is a 24/7 all-crimes and all-hazards fusion center that is comprised of staff from 27 different partner agencies. SNCTC’s Counter Terrorism Section (CTS) is responsible for mission areas that support the prevention of terrorism and mass casualty attacks.

Preparedness Investments

The MACTAC program is a prime example of the community’s commitment to integrated preparedness and training across jurisdictions and disciplines. Formed in 2009 in response to the attacks that occurred in Mumbai, India, the program was put in place to provide a regional, coordinated response to prevent over-convergence. The MACTAC regional concept allows a multi-discipline (e.g., police, fire, emergency medical services (EMS)) and a multi-agency (e.g., valley-wide first responders) coordinated response. The LVMPD MACTAC Section facilitates training to all Las Vegas Valley first responders, including critical infrastructure operators and community education personnel.

The LVMPD Emergency Management Section and the Clark County Office of Emergency Management strive to achieve and maintain community resilience through various activities, including ongoing training and exercises to prepare for, respond to, and mitigate possible critical incidents in the community. These training and exercises also encourage collaboration among community stakeholders. Annual seminar and tabletop exercises are conducted in conjunction with the LVMPD Events Planning Section for large-scale events in the Las Vegas Valley, including NASCAR, Electric Daisy Carnival, Life is Beautiful, Rock ‘n’ Roll Marathon, and New Year’s Eve. The LVMPD Emergency Management Section also conducts an annual functional communications exercise with community partners’ mobile command vehicles, dispatch centers, and emergency operations centers. This exercise ensures efficient use of interoperable radio channels and alternate communication methods on a day-to-day basis and during a critical incident. Additional exercises are conducted on an as-needed basis, which is determined by the current threat environment and requirements of the community.

A whole community approach has been taken to improve operational coordination across agencies. Enhancing this coordination is accomplished by bringing together public and private sector partners at federal, state, and local levels. These stakeholders include law enforcement, fire, the military, federal agencies, tribal entities, EMS providers, emergency management agencies, and private sector partners. Integrating these agencies during the preparedness phase allows for a unified approach to incident response.

To prepare their community for a complex coordinated attack (CCA), CCFD and LVMPD have made the preparedness investments included in Table 1.

Multi-Assault Counter-Terrorism Action Capabilities (MACTAC)

Developed in response to the 2009 coordinated attacks in Mumbai India, MACTAC is a counterterrorism response strategy that employs advanced tactics for first responders to respond to and mitigate a high-threat situation across multiple locations.

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Table 1: Clark County Preparedness Investments

Year Action 2005 LVMPD created the ARMOR Section, which is a collaborative effort integrating multiple law

enforcement agencies of Southern Nevada in the detection, response, mitigation, and investigation of CBRN incidents.

2006-Present LVMPD created SNCTC. This center has an all-crimes, all-hazards approach and is operational with a 24/7 watch station that implements the National Suspicious Activity Reporting Initiative.

2007-Present LVMPD established the Silver Shield program, which is a statewide critical infrastructure protection program for information.

2007-Present LVMPD conducts critical infrastructure drills on an as-needed basis to include critical infrastructure and key resources, hotels, utilities, schools, and other entities. The purpose of these drills is to gauge response times and reinforce training and trends.

2009-Present LVMPD has been conducting private sector training on active assailants, utilizing “Run, Hide, Fight” concepts from the U.S. Department of Homeland Security.

2009-Present LVMPD conducts no-notice drills with every patrol squad on an annual basis. The purpose of this test is to gauge response time and readiness to respond to a MACTAC-style incident.

2009-Present LVMPD established train the trainer MACTAC cadre training schools to create a pool of additional trainers that can instruct on active assailant response tactics. There are currently instructors in all local jurisdictions from first responding agencies.

2012 CCFD appointed a full-time captain to the SNCTC Fusion Center and MACTAC cadre.

2012 Clark County participated in the Joint Counterterrorism Awareness Workshop Series (JCTAWS) sponsored by the National Counterterrorism Center, the U.S. Department of Homeland Security, and the FBI. JCTAWS is a nationwide initiative designed to improve the ability of local jurisdictions to prepare for, protect against, and respond to complex terrorist attacks.

2013-Present Quick response teams, composed of police, fire, and EMS, worked New Year’s Eve events.

2013-2014 The Southern Nevada Fire Operations (SNFO) Hostile MCI working group was established in 2013. It consisted of 14 representatives from all Southern Nevada fire and law enforcement agencies. The working group met monthly to develop an integrated fire response policy and Incident Command System (ICS) training to augment law enforcement’s existing response policies addressing active shooter incidents (ASIs) and CCAs.

2014 All Southern Nevada fire departments adopted the Hostile MCI response policy, which outlines the integration of fire with law enforcement on incidents with a hostile element and potential for large loss of life. Nearly 5,000 Southern Nevada fire and law enforcement personnel will utilize this policy in the event of a large-scale hostile incident and/or CCA.

2014 All LVMPD lieutenants attended a mandatory LVMPD tabletop exercise (TTX) where players encountered an MCI or ASI.

2014-2016 CCFD developed the Street Level ICS for LVMPD, NLVPD, NHP, HPD, and Las Vegas Marshals. Street Level ICS is a simplified approach to ICS and advocates for CCFD personnel as a support mechanism in training and on incidents. By the end of 2016, approximately 200 law enforcement officers from various departments attended the training.

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2014-2016 CCFD and LVMPD jointly delivered emergency response training to Harrah’s Las Vegas Hotel, Palms Casino Resort, SLS Las Vegas Hotel & Casino, Rio All-Suite Las Vegas Hotel & Casino, and MGM Grand Las Vegas Hotel & Casino. This training was presented to approximately 300 hotel and casino staff in security, risk management, and supervisory roles. The presentation covered CCAs, fire and law enforcement response, and Southern Nevada resource capabilities.

2014-2016 Fire and law enforcement companies and squads conducted training on coordinated communication and movements within a Rescue Task Force configuration. Approximately 500 personnel from all Southern Nevada fire and law enforcement agencies participated.

2014 (August)

Fire and law enforcement participated in a collaborative incident critique of an ASI that resulted in the deaths of two LVMPD officers. 40 personnel attended the incident critique.

2015-2017 CCFD began working with private sector fire protection engineers to address sabotaged life safety systems in a CCA in which attackers use fire as a weapon.

2015-2017 CCFD presented Hostile MCI response policy to LVMPD MACTAC cadre members. Approximately 200 personnel attended this presentation.

2015-2016 Subject-matter experts from CCFD, LVMPD, and the LVFR Communications Division assisted in the development of a report by the InterAgency Board titled “Active Shooter/Hostile Event Guide Book for Fire, Law Enforcement and EMS.”

2016 (March-December)

CCFD assisted in conducting LVMPD’s reality-based training. Law enforcement officers were instructed by fire personnel, with CCFD embedded into LVMPD’s training division. 40 LVMPD lieutenants participated in the training.

2016 (March-December)

CCFD formed a cadre of 19 captains to assist in proctoring reality-based training scenarios as ICS subject-matter experts.

2016 (September)

CCFD conducted training on tactical elevator operations for LVMPD MACTAC training officers.

2016-2017 LVMPD MACTAC created specialized training for officers working in the Tourist Safety Division, to include active assailant response training for the tourism corridor.

2017 LVMPD MACTAC presented a class to CCFD on training, culture, and informational awareness related to emergency response for cross-training purposes.

2017 (January/February)

CCFD co-instructed training to LVMPD officers of all ranks on command and control.

2017 (March)

CCFD presented an informational class to the LVMPD Academy on CCFD’s emergency response models, training, culture, available resources, and mission in assisting law enforcement. Participants also discussed the future of fire and law enforcement’s working relationship. 55 academy recruits received this training, and the training is now part of the academy curriculum.

2017 (April)

CCFD ICS subject-matter experts assisted in proctoring LVMPD’s MACTAC scenario-based training. They developed scenarios to improve the working relationship between CCFD and LVMPD. Approximately 240 CCFD personnel and 60 LVMPD lieutenants attended the 2017 training.

2017 (June)

CCFD presented an informational class to the LVMPD Academy on CCFD’s emergency response models, training, culture, available resources, and mission in assisting law enforcement. Approximately 35 academy recruits received this training.

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Route 91 Harvest Festival

The Route 91 Harvest Festival is one of approximately 21,300 events and conventions that take place in Las Vegas per year. In 2017, 6,646,200 people attended conventions in Las Vegas.1 The Route 91 Harvest Festival is a country music festival organized annually since 2014 and staged at the Las Vegas Village concert venue in Las Vegas, Nevada. Route 91’s approximately 17.5- acre venue plot is assembled directly across from the Mandalay Bay and the Luxor Hotel & Casino and is one of two open-air venues on the Las Vegas Strip. The fourth annual Route 91 concert series was held between September 29, 2017 and October 1, 2017. The venue was accommodating over 22,000 attendees when Stephen Paddock opened fire on the crowd on the night of October 1, 2017.

1 http://www.lvcva.com/stats-and-facts/visitor-statistics/

Figure 2: Route 91 Harvest Festival Site Map

Figure 1: Mandalay Bay and Las Vegas Village

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The Shooter: Stephen Paddock

The perpetrator of the 1 October 2017 shooting, Stephen Paddock, was born in Clinton, Iowa in 1953. His father, Benjamin Hoskins Paddock, was a convicted bank robber who escaped prison and was considered one of the FBI’s most wanted in 1969. In 1977, Stephen Paddock received a degree in business administration from California State University, Northridge. He then worked as a government employee for the U.S. Postal Service and the Internal Revenue Service. Later, Paddock worked as an internal auditor for a company, which later became the defense contractor Lockheed Martin, and then in the real- estate business.

Paddock did not have any criminal record prior to the shooting, save receiving a minor traffic citation, and had no known military experience. In 2016, Paddock moved to Mesquite, Nevada located approximately 80 miles northeast of Las Vegas. Paddock lived in a home with his girlfriend for several years. Residents of the community claimed Paddock was a private individual who deliberately kept a low profile.

Paddock gambled regularly and frequented casinos in Las Vegas, including the Mandalay Bay, which he would visit as often as twice a month. Six days prior to the shooting, Paddock checked into the Mandalay Bay, staying in a room on the 32nd floor. Paddock, unbeknownst to his neighbors and family members, legally and discreetly amassed an arsenal of weaponry, 33 items of which he acquired in the year prior to the incident. Law enforcement would discover 23 firearms inside Paddock’s Mandalay Bay corner suite, which overlooked the Route 91 Harvest Festival.

Figure 3: View of the Las Vegas Village from room 32-135

Figure 4: Mandalay Bay 32nd Floor

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Timeline

The table below provides a timeline of key events leading up to the shooting and during the subsequent response effort. The timeline highlights events and actions that significantly impacted the response or that offer the context necessary for a high-level overview of the incident. See Appendix B for a comprehensive timeline.2

Table 2: Timeline of Key Events of Response

Time Event October 1, 2017 9:40 PM Jason Aldean begins his performance on the Main Stage at the Route 91 Harvest Festival.

10:05 PM Paddock fires his first shots into the Las Vegas Village area from his room on the 32nd floor of Mandalay Bay.

10:06 PM Dispatch receives the first radio traffic from an officer and phone call from a civilian referencing the incident.

10:11 PM LVMPD officers arrive on the 31st floor along with armed Mandalay Bay security officers. 10:13 PM CCFD Battalion 2 establishes Incident Command on Las Vegas Boulevard. 10:15 PM Paddock fires his last shots into the Las Vegas Village area. 10:16 PM Paddock self-terminates between 10:16 and 10:18 PM. 10:17 PM First responding officers arrive on the 32nd floor of Mandalay Bay. 10:18 PM Officers make contact with a wounded security guard and cover down on Paddock’s

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