ORLANDO, Fla. – An independent review of the Orlando Fire Department’s response to the 2016 Pulse shooting found that, overall, the response followed protocol, but communication failures hindered some decision-making as the department rendered aid during the tragedy.
The 43-page review, conducted by the National Police Foundation, was released this week more than 2 1/2 years after 49 people were killed at the downtown Orlando gay nightclub on June 12, 2016.
Fire Department Chief Roderick Williams requested the analysis of the department’s reaction to better prepare the department for future mass casualty events, according to a statement from the department.
More than 60 OFD command staff, firefighters, paramedics, dispatchers and call takers were interviewed as part of the process. Investigators also listened to 911 calls, read dispatch transcripts and social media posts and reviewed news coverage of the attack.
'Out-of-date' active shooter policies, new plan hadn't been implemented yet
The report found that the Orlando Fire Department’s response on June 12 was “reflective of existing department policies, as well as fire and emergency medical services generally accepted national practices.” In some cases, however, those policies had not been updated since 2001.
A recent ProPublica and WMFE investigation found that the Fire Department had been working since 2013 to update its active shooter protocol, but those efforts were not in place when the Pulse nightclub shooting happened on June 12, 2016.
According to John Miller, the New York City Police Department’s deputy commissioner of counterterrorism and intelligence, methods of terrorism are constantly evolving, which requires frequent updates to mass casualty response protocol.
"If you’re working on the techniques you developed two years ago, you’re way out-of-date,” Miller said.
Police on scene at Pulse had asked Fire Department staff to go into the nightclub to help get out trauma patients, but no policy was in place for that response and bulletproof vests purchased by the Fire Department were back at headquarters. About 20 vest were purchased for the department in 2015, according to the ProPublica report.
"We don't have the equipment or the training to stop bullets. Our firefighters aren't designed to take on bullets,” Williams told News 6 a month after the shooting. “They don't have guns. We don't carry guns. We don't carry protective gear like law enforcement, bulletproof vests."
Since the shooting, ballistic vests have been assigned to every seat on the department fleet and all commend vehicles carry extra vests and helmets.
The National Police Foundation review found that “public safety agencies more generally, must not only train, but also ensure that policies, procedures, and protocols and training are put into practice.” The review also noted that national-level standards, or a template, for this type of response were not created until after the Pulse attack.
After the shooting, Williams said the department reviews those "policies every year now (to) make sure they’re applicable to today’s society and what’s happening."
Lack of communication with police impaired transport of victims
The report found that some protocol in response to an act of terrorism, including setting up the Fire Department command at the same location as Orlando police, was not followed, which caused an underutilization of OFD transport vehicles for victims.
The Fire Department did not have a representative at the Unified Command Center, which “exacerbated communication challenges, reduced OFD’s situational awareness, and impaired coordination between OFD and OPD until after the Fire Chief and other OFD executives arrived on scene," according to the report.
The distance between the Fire Department and the command center continued to impair the department's response, the report states.
It's also why, when Orlando Police Department SWAT officers breached a wall on the outside of the club, the Fire Department Arson and Bomb Squad technicians were taken by surprise. They were unaware of the plan and initially thought an improvised explosive device had been detonated, the review found.
The lack of communication also temporarily stalled the Fire Department's rescue vehicles from transporting victims rescued from the club to the hospital.
"As a result, OPD underutilized the EMS transport units on scene and relied on officers to transport patients directly to the hospital," the report said.
Of the 55 people taken to area hospitals, only 16 were transported by OFD. Orlando police took 15 patients. The rest were taken by Orange County Fire Rescue and Rural/Metro Ambulance of Central Florida, which made keeping track of the victims difficult, according to the National Police Foundation review.
In the days after the shooting, the Fire Department received criticism of its response. An Orlando police officer wrote in an incident report that he had seen several wounded Pulse victims not being let into Fire Station 5, next to the nightclub on Orange Avenue. According to the review, the station was placed on lockdown for about 10 minutes after reporting gunfire.
"They opened the bay door and began triaging and treating patients," at 2:13 a.m., 11 minutes after the gunman opened fire inside the club, according to the report. Another Fire Department unit was already at the scene.
The department transported approximately 16 of the injured patients to hospitals and treated many others at the scene, according to the independent review.
"Treatment and services that were rendered was excellent," Williams said in an interview with News 6 Wednesday. "I think our crews did a good job. We did a good job with what was presented in front of us."
More than 50 people were injured in addition to the 49 who died during the shooting.
OFD leaders weren't notified of attack for 3 hours
The report was critical of internal communication with Fire Department leadership during the incident, which was delayed due to some not receiving the alert from the computer-aided dispatch, or CAD, system.
The Fire Department’s executive leadership was not aware of the attack until about three hours after it started,"due to a combination of failures in communication technology, deficient processes, the overwhelming nature of the event, and the demands placed on the communications center," according to the report.
Williams arrived at the scene at 6:22 a.m., after the lone gunman was dead.
Williams said he wishes he was there within 30 minutes of the shooting.
“The presence of senior-level leaders during the initial stages of, and throughout the event, would have facilitated OFD decision-making and operations, the establishment of unified command, and interagency collaboration, particularly with law enforcement,” according to the report.
After the attack, a new alert process was put in place, which requires communication staff to follow up within three minutes after a page is sent out if they have not heard back.
Recommendations and changes address mental health
Since the shooting, the Orlando Fire Department has implemented new polices, including training for treating trauma patients in mass casualty situations as well as deploying ballistic equipment and bulletproof vests to all field personnel.
Since June 2016, Fire Department employees have each completed a 16-hour tactical emergency care training course.
New changes also address the mental health effects of mass trauma events on first-responders.
According to the review, in the immediate aftermath of the shooting, "the level of trauma experienced by first responders on scene was not fully recognized."
One firefighters described feeling “very alone after the incident and had no one to talk to."
In the months following the attack, the director of the city of Orlando's Human Resources Division
provided information regarding post-incident stress and the services that were available.
Fire Department leadership and Orlando government officials attended a session at the University of Central Florida Restores clinic, which specializes in treating military members, first responders and veterans who have been affected by trauma. New training was provided for the Health and Safety Division to help those staff act as liaison between OFD staffers and mental health services personnel.
A peer support group also facilitated group debriefings and met with each shift to provide support. The group repeats this on various anniversaries of the attack. The National Police Foundation commended their work in the report.
The report also recommended the need for further research regarding how to assist first responders, victims and survivors of mass violence.
"For us to get better, this is a holistic view of what transpired that night so we can learn from it, get better and better serve our citizens," Williams said.