HARTFORD, Conn. (WTNH) — Connecticut State Police released a new report Friday on the agency’s response to the December 2012 shooting at Sandy Hook Elementary School that left 26 children and educators dead.

The report was released Friday afternoon on the State Police website. Troopers did not explain why it took five years since the shooting to complete the after-action report, in which agencies review officers’ actions in an emergency situation.Related Content: Read the new Connecticut State Police Sandy Hook shooting report

A 20-year-old gunman killed 20 first-grade children and six educators inside the school before killing himself. Officers from the Newtown Police Department were the first to respond to the scene. A prosecutor’s report in 2013 said that nearly six minutes passed between the arrival of the first Newtown police officer, and the time officers entered the school.Related Content: Judge to decide whether to toss Sandy Hook parents’ lawsuit

The report outlines ten recommendations for police to coordinate emergency response.(Source: Connecticut State Police)

  • Pre-Incident Planning

    Pre-incident planning is critical for active shooter or other mass casualty incidents. Police departments of all sizes must plan in advance for a large-scale critical incident response, including pre-planned mutual aid agreements and mutual assistance. Such planning should include identifying high risk target areas, building diagrams, appropriate staging areas and command post locations, establishing joint command with local police agencies, fire, and EMS, as well as compiling internal contact telephone numbers and testing communications procedures.
  • Command and Control

    Staging Area: It is important that the Incident Scene Commander establish a staging area for emergency personnel as soon as practically possible, and all responding units, including those that self-dispatch, should report to the Incident Command Staging area for appropriate task assignments. Failure to do so can limit management control, increase risk, and severely hinder accountability.

    Second Duty Commander: Designate an individual not involved in the incident to be responsible for the remainder of the troop patrol functions. Typically this function would fall back to the second in command (Troop Master Sergeant) when the senior commander is focused on a major incident. During this incident, the initial first responder team was comprised of the Commanding Officer and Executive Officer, as well as the duty supervisor. While Troop A was able to devote virtually all of its resources to this incident for the first several hours, this will not always be the case. It may be necessary in some instances to assign regular patrol operations to other troops within the district or adjoining districts.

    Mutual Aid: All responding personnel and mutual aid that are not immediately needed should be staged at a nearby location. This will ensure their rapid deployment when their services are necessary, without flooding the incident scene prematurely. In accordance with NIMS/ICS guideline, assign a staging officer from the primary jurisdiction who may direct assignments. It is preferably to reach agreement before an emergency incident regarding span of control and the authority of outside agency supervisors to direct officers from other agencies.

    Building Side Nomenclature: Standardize the designation of the front, rear, and sides of a building (e.g. “A” side, “B” side, etc.) and reinforce during training to ensure compliance and understanding among first responders. All involved agencies should operate under one system. Ensure all submitted reports reflect consistency in reporting.

  • Crime Scene Management

    Reducing Stressors: Reduce noise and light stressors at incident scenes as soon as possible. Attempt to identify non-combatants and distinguish between potential threats and civilians. Sound and low light conditions add to confusion and make it difficult to make timely and appropriate identifications. Additional stressors may hinder evacuations and search and rescue efforts.

    Scene Security: Access to and from the crime scene should be strictly controlled from clearly established entrance and egress points, and reserved only for authorized personnel that have a legitimate and clearly defined reason for being on scene. No personnel should be allowed within a crime scene unless there is a legitimate law enforcement purpose. Agencies should consider video streaming or other means for crime scene viewing to assist in minimizing

    unnecessary crime scene traffic. Clearly established crime scene zones should be created and closely monitored with established ingress and egress points. Current policy and protocols should be reviewed to ensure that clear roles, responsibilities, and scope of authority are established for crime scene management.

    Command Post (CP): CP operations were set up during the early stages of this incident at various locations, including a Crime Scene Processing CP at Sandy Hook Elementary School, a Criminal Investigation CP at the Emergency Operation Center, and an overall Incident CP at the Sandy Hook Fire House. As more emergency response personnel, family members, and media continued to converge on the scene, access to the Incident CP at the Fire House became difficult and it became apparent that it was an error to establish a CP at the school. At no time should any type of CP be set up inside an active crime scene, and commanders should be prepared to set up CP locations in a location that is outside of the crime scene and not widely accessible to the public.

  • Equipment

    Body Armor: The Department currently provides body armor for each trooper; however, personnel are not required to wear the armor at all times. The department, in consultation with relevant labor unions, should consider revisiting the policies on body armor. Additionally, the armor provided to all troopers would not have protected responding personnel from the type of ammunition used at this scene. The Department should consider providing additional ballistic

    protection beyond the standard issued body armor for an extra layer of protection, especially to those who may be called to respond to an active shooter situation.

    Medical Kits: Troopers assigned to patrol should have ready access to a medical kit. In the months following the Sandy Hook shooting incident, all CSP personnel were issued Individual First Aid Kits (IFAKs) and trained in their use. While the main purpose of the IFAK is to assist wounded officers, the skills and equipment can be used for civilian injuries as well.

    Decontamination and Hydration: Many active crime scenes require decontamination and hydration stations and in this instance, several officers did not have access to clean water for washing and drinking. Consider procurement of a suitable “cleanup/hydration” station for use at major emergencies if not readily available from local emergency services.

    Technology: Even with limited cell phone service, unit and district commanders should be able to communicate through the use of a smart phone or tablet. It should be noted that the agency has begun the process of updating phone technology and should consider issuing tablets with Wi-Fi hot spot capabilities. The Agency should also review the technology capabilities for detectives within the Major Crime Units and update equipment and software as needed.

    Major Crime: Each district Major Crime Unit should establish and maintain the equipment and resources necessary to respond to a mass casualty event within their respective geographic area of responsibility. Additionally, in accordance with available resources, the units should also have a secondary crime scene processing van and plan for its utilization.

    Mobile Command Vehicle: The CSP was fortunate to have the use of various locations to use as CP locations. However, the Agency does not currently have an adequate mobile command vehicle with multi-functionality designed to handle an incident of this magnitude. Consideration should be given to acquiring a mobile command vehicle.

  • Training

    Active Shooter: In response to the Hartford Distributor’s active shooter incident in Manchester, CT in 2010, the department implemented mandatory training specific to active shooter incidents for all personnel during in-service. Additionally, all CSP personnel are given active shooter training at the recruit level. Numerous CSP first responders to Newtown indicated that the previous training they received provided an increased level of confidence. Future training would be beneficial to personnel, and should encompass additional response dynamics to include evacuation protocols, treatment of the injured, establishing perimeter zones, incident command and scene management, and setting up initial scene security. Active shooter training should include incorporating “stressors” to inoculate troopers to sensory overload. Troopers should also be mindful of the potential for “blue on blue” encounters and ensure muzzle discipline at all times. All levels of command should participate in integrated training exercises in mass casualty events to include the effective management of personnel, resources, technology, and command post operations.

    Medical: The department has established a continuous EMS training schedule, and has also offered advanced training workshops in Tactical Combat Casualty Care (TCCC).

    Emergency Vehicle Operation: It is critical for responding personnel to arrive to any incident safely. Despite the large law enforcement response to Sandy Hook Elementary School, there were no department accidents. All police departments should ensure their personnel are trained in emergency vehicle operation at the recruit level and on a regular basis thereafter.

    Integrated Tactical Response: The FBI and the CSP responded in an integrated, tactical manner, which was influenced by prior training and pre-established professional working relationships. Local, state, and federal tactical teams should train together on joint problem solving scenarios to ensure success during future integrated operations.

    Incident Command System and Unified Command: The CSP established its command presence within minutes of the incident. Other supporting agencies, with few exceptions, operated seamlessly and collaboratively within the existing operational framework. Organizations and individuals unfamiliar with the ICS and Unified Command concepts should train accordingly.

  • Communications

    Radio Communications: Continuous radio updates were critical for personnel responding to Newtown. If an outside agency is provided a radio, ensure team leaders are advised accordingly. Use plain talk when communicating between agencies and attempt to increase effective communication between agencies. Clearly Defined Roles and Responsibilities: Clearly defined roles and responsibilities should be established to limit miscommunication and potential for future errors. Protocols should be put in place in order to voice concerns upward through the chain of command without fear of reprisal.

    Internal Agency Communication: The Agency kept the public informed through the Public Information Office and kept the families informed with informational meetings. The Agency should improve communications within the CSP, particularly with those who were involved directly as first responders.

  • Self-Dispatching

    Organizations, response units, and individuals proceeding on their own initiative directly to an incident site, without the knowledge and permission of the host jurisdiction and the Incident Commander complicate the exercise of command, increase the risks faced by responders, and challenge accountability. Mass casualty and active shooter response plans should include preselected and well-marked staging areas and a plan for handling self-dispatched personnel. Dispatch instructions should be clear. Law enforcement agencies should be familiar with deployment plans and quickly establish incident site access controls. When identified, selfdispatched resources should be immediately released from the scene, unless incorporated into the Incident Commander’s response plan.
  • Mental Health and Wellness

    Ensuring access to care: The magnitude of this incident, especially given the age and number of victims, certainly had an impact on all responding personnel. The agency must ensure that responding personnel are receiving proper mental health services prior to an event and long after. Employee Assistance Programs are a critical component to a long term mental wellness process. Additionally, the CSP currently has a confidential employee assistance and peer support (STOPS) program. They also have established policy and procedures outlined in the A&O Manual which addresses dealing with potentially distressed employees through the Personnel Early Awareness and Intervention System. Commanders should be prepared to deal with the short and long term effects on personnel who respond to mass casualty incidents. Investigators, responders, and the families of those who were involved in this investigation should be provided EAP and other resources in order to deal with any potential adverse effects.

    Limiting impact of trauma: Commanders should strive to minimize the potential adverse effects of crime scene exposure and all law enforcement personnel should be mindful to avoid unnecessary exposure to trauma. Crime scene access should be given only to individuals with a legitimate law enforcement need, regardless of rank.

    Long term care: Mental health experts maintain that effects of post-traumatic stress may not manifest until years after the event. CSP leaders should continuously support their personnel’s health and well-being in the short and long term.

  • Law Enforcement Collaboration

    Due to the magnitude of this incident, there was an overwhelming law enforcement response on the local, state, and federal level. All available resources were made available to investigative personnel. Commanders established effective communication between the States’s Attorney as well as other law enforcement partners. It is important to have effective working relationships and personal points of contact in place before the need for the contact arises. Establishing and maintaining law enforcement partnerships is critical to overall mission success.
  • Reporting

    The agency utilizes an in-house system to document investigations. There were some issues regarding late reports and the submission of reports that had errors despite having been approved by a supervisor. The agency should emphasize the importance of report writing competencies and strive to take immediate corrective steps to prevent inaccurate, untimely, and poorly written reports. The Agency currently has policies and procedures outlined in the A&O Manual that address reporting requirements and these policies and procedures should be followed and enforced. Additionally, at the time of the incident certain units did not fully utilize the electronic reporting system which made it difficult for the assigned investigators to access and review reports; however, since that time the system has been implemented in all units agency-wide and now all reports are completed through the same system.
  • Support Services

    Death Notifications: Accurate and timely death notification to victims’ families should be one of the highest priorities. Delays in notification were a great source of frustration for agency personnel at the firehouse CP location and added confusion, frustration, and stress for the family members. Policy and procedures should be clearly established and enforced to ensure accurate

    and timely death notifications are made to family members. If feasible, consider honoring family

    requests to view the victim.

    Family Liaison Program: The family liaison program was an important victim assistance program that provided support and communication to the victims’ families. The agency should continue to develop this program and include it in operational response protocols for mass casualty incidents, along with other victim services as deemed appropriate. Family and Individual Meetings: In addition to assigning liaison officers to each impacted family, CSP made every attempt to keep the families informed of the case investigation through individual and group meetings. The purpose of the meetings was to provide accurate and timely information and to dispel circulating rumors. The meetings were private and helped prepare the families for upcoming media releases. The practice of conducting individual and group family meetings should be sustained and included in operational protocols. Ensure that meeting guidelines are set and adhered to ahead of time. LE should be prepared to answer questions and provide assistance to individuals who are grieving. Victim assistance should be done in consultation with mental health and grief counseling experts.

    Scene Walk-Throughs: Family members were allowed to visit the school once the crime scene was cleared. In the future, this could include victim advocates, mental health professionals, and LE personnel to answer questions and assist as appropriate. .

  • Public Information

    PIO released accurate and timely information to the numerous media outlets. PIO was able to convey information without compromising the investigation, and at the same time honoring the privacy of the impacted families. PIO should further consider preparing operational plans for similar mass media events and anticipate the various equipment and personnel needs that may arise.

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The report concludes that the police response was handled “effectively”, and commended the actions of the teachers, school staff, and first responders that day.

… The response to the December 14, 2012 attack at Sandy Hook Elementary School was handled effectively. Had it not been for the heroic actions of the teachers, school staff and the response force, the number of victims could have been higher. Although the response to the attack at Sandy Hook Elementary School is commendable, this AAR conveys many recommendations and lessons learned for improving response and rescue capabilities to better meet the challenges of this type of emerging threat. This important information should be shared with other jurisdictions around the country so the nation benefits from Connecticut State Police’s experience, both in preparing for the police response to mass casualty events and the subsequent investigative and support service challenges they pose.”