Tuesday, March 28, 2017


The process of producing the report was flawed at every turn. TriData was apparently chosen because it had done a report for the Department of Homeland Security on Columbine. The problem is the Columbine report is something very different. The first two sentences on page one of TriData’s Columbine report make that clear. “This report is an analysis of the fire service and emergency medical services (EMS) operations and the overall response to the assault on Columbine High School at Littleton, Colorado, on April 20, 1999. Incident command, special operations, and mass casualty emergency medical services are featured.” Tridata’s work at Columbine was not an analysis of the crime itself.

The Virginia Tech report was never meant to be an analysis of the fire service and emergency medical services. The Virginia Tech report was intended to be a far broader document—an analysis of the worst campus shooting in this nation’s history. The following is a direct quote from the “The Addendum”—the name given the final version of the Governor’s Review Panel Report on Virginia Tech. The quote is taken from Governor Kaine’s executive order directing the panel to accomplish the following:

1.         “Conduct a review of how Seung Hui Cho committed these 32 murders and multiple additional woundings, including without limitation how he obtained his firearms and ammunition, and learn what can be learned about what caused him to commit these acts of violence.”

2.      “Conduct a review of Seung Hui Cho's psychological condition and behavioral issues prior to and at the time of the shootings, what behavioral aberrations or potential warning signs were observed by students, faculty and/or staff at Westfield High School and Virginia Tech. This inquiry should include the response taken by Virginia Tech and others to note psychological and behavioral issues, Seung Hui Cho's interaction with the mental health delivery system, including without limitation judicial intervention, access to services, and communication between the mental health services system and Virginia Tech. It should also include a review of educational, medical, and judicial records documenting his condition, the services rendered to him, and his commitment hearing.”

3.         “Conduct a review of the timeline of events from the time that Seung Hui Cho entered West Ambler Johnston Dormitory until his death in Norris Hall. Such review shall include an assessment of the response to the first murders and efforts to stop the Norris Hall murders once they began.

4.       “Conduct a review of the response of the Commonwealth, all of its agencies, and relevant local and private providers following the death of Seung Hui Cho for the purpose of providing recommendations for the improvement of the Commonwealth's response in similar emergency situations. Such review shall include an assessment of the emergency medical response provided for the injured and wounded, the conduct of post-mortem examinations and release of remains, on-campus actions following the tragedy, and the services and counseling offered to the victims, the victims' families, and those affected by the incident. In so doing, the Review Panel shall to the extent required by federal or state law: (i) protect the confidentiality of any individual's or family member's personal or health information; and (ii) make public or publish information and findings only in summary or aggregate form without identifying personal or health information related to any individual or family member unless authorization is obtained from an individual or family member that specifically permits the Review Panel to disclose that person's personal or health information.”

5.         “Conduct other inquiries as may be appropriate in the Review Panel's discretion other- wise consistent with its mission and authority as provided herein.”

6.         “Based on these inquiries, make recommendations on appropriate measures that can be taken to improve the laws, policies, procedures, systems and institutions of the Commonwealth and the operation of public safety agencies, medical facilities, local agencies, private providers, universities, and mental health services delivery system.”

In other words, the Review Panel was tasked to review the events, assess actions taken and not taken, identify lessons learned, and propose alternatives for the future. The panel was intended to review Cho’s history and interaction with the mental health and legal systems and of his gun purchases. “The Review Panel was also asked to review the emergency response by all parties (law enforcement officials, university officials, medical responders and hospital care providers, and the Medical Examiner). Finally, the Review Panel reviewed the aftermath—the university’s approach to helping families, survivors, students, and staff as they dealt with the mental trauma and the approach to helping the university heal itself and function again.”

But if you look at the credentials of the head of TriData, Philip Schaenman, you find a man whose background is limited and does not include much in terms of the requirements as laid out by Governor Kaine. If you google Schaenman, one of the entries is entitled: “Fireman, Philip Schaenman.” His background includes fire administration and he is “known to the fire community for leading studies and research on first responder issues,” according to the Web site for TriData, whose products include titles such as “Fire in the United States” and “International Concepts in Fire Protection.” The question is, do you send a fireman to analyze mass murder? You certainly don’t send a policeman to analyze or put out a fire.

Indeed, the Columbine report is a better report than TriData’s effort on Virginia Tech, probably because it deals with an area that TriData knows something about—emergency responses by fire and medical services. The Columbine report never analyzes the warning signs or the actions of people in positions of authority prior to April 20, 1999, which was one of the principal mandates at Virginia Tech.

That said, there are sections of the Columbine report that do pertain to the Virginia Tech tragedy. Inexplicably, though, these sections are not sufficiently developed in the Tech report. For example, the Columbine report repeatedly refers to the importance of the Incident Command System (ICS) in responding to a crisis. While the Columbine report refers to ICS with reference to fire service personnel managing major incidents and crises, a major flaw at Virginia Tech was the poor management at the ICS-equivalent level.  Given the emphasis on the role of the ICS in the Columbine report, it is puzzling why TriData did not put greater emphasis on that aspect of the Virginia Tech report. There was mismanagement and poor decision-making on the part of Tech’s command structure after the double homicide at West Ambler Johnston—of that there is no doubt. This mismanagement contributed to the murder of 30 more people at Norris Hall nearly two and one-half hours later.  TriData never addresses this critical point, but both the Department of Education and a jury in Montgomery County, Virginia found Virginia Tech to be negligent.

The problem with the Virginia Tech report may, in fact, not be so much TriData, but then-Governor Kaine and then-Attorney General McDonnell. They apparently did not fully check out options other than TriData. For example, a far better model for the state of Virginia to follow would have been the 174-page report produced at the behest of Colorado Governor Bill Owens. (To be continued) 

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