Organizational Failure: An Exploratory Study of the Public Safety Response to the Orlando Nightclub Shooting

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Organizational Failure:

An Exploratory Study of the Public Safety Response to the Orlando

Nightclub Shooting

By

DAVID PROOST

Student number: s1500546 Supervisor: Sanneke Kuipers Second reader: Gabriele Landucci

A Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of

Master of Science

in Crisis and Security Management at

University of Leiden June, 2018

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ACKNOWLEDGEMENTS

I owe a debt of gratitude to Dr. Sanneke Kuipers, who provided invaluable guidance and stimulating conversation in the preparation of this thesis. I want to take this opportunity to say thank you, Dr. Kuipers, for helping me navigate this process and supporting my interest in this subject. I also greatly appreciate the efforts of Aïcha Chaghouani in providing

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ABSTRACT

This study aims to explain how organizational failures lead to impediments in the emergency response to the 2016 Orlando nightclub shooting by public safety agencies in terms of normal accident theory and high reliability theory. The first goal of this study is to create tools for classifying and interpreting the organizational failures leading to impediments. The second goal is to identify what organizational failures explain the impediments that emerged during the emergency response in order for similar organizations to prepare themselves more adequately for potential future mass casualty shootings. This is of great importance because unresolved organizational failures make organizations prone to escalation of an incident. Previous research applied both theories in analysis of accidents and near-misses in

technological organizations. This study has reframed both theoretical approaches to assess the organizational origins of the impediments during the emergency response in a

non-technological context by carrying out a qualitative content analysis. The analysis shows that complexity and a lack of organizational learning are the most significant causes for the impediments that emerged during this emergency response.

Keywords: organizational failure, emergency response, normal accident theory, high

reliability theory, complexity, tight-coupling, organizational learning, prioritization of safety, organizational structure and communication.

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ABBREVIATIONS

EMS Emergency Medical Services

HDT Hazardous Device Team

HRT High Reliability Theory

NAT Normal Accident Theory

OFD Orlando Fire Department

OPD Orlando Police Department

OSCO Orange County Sheriff’s Office

PIO Public Information Office

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1. INTRODUCTION

This chapter begins by providing a background to the chosen case study, covered in this thesis. The description of the background will briefly introduce the challenges faced by public safety agencies during the emergency response to the 2016 Orlando nightclub shooting. Thereupon, the purpose of the research and the social and academic relevance of this study will be presented. Lastly, the research questions and the structure of this study will be outlined.

1.1. Background

Shortly after midnight on 12 June 2016, a lone gunman entered the Pulse nightclub in Orlando, Florida, and opened the fire on innocent visitors1_{. The horror of the Orlando} nightclub shooting ended as the deadliest terrorist attack in the United States since the September 11 attacks on the World Trade Center Complex in New York City. This massacre claimed the lives of 49 innocent individuals and injured 58 other people. According to the FBI, the Orlando nightclub shooting should be labelled as an act of terrorism (Straub et. al., 2017: xi). Unfortunately, the terror of this evening does not stand alone. Mass-casualty shootings pose an ever-present challenge to societies and public safety agencies (Bakker, 2014: 28-30; Blair & Scheweit, 2014: 1-3). In recent years, the number and severity of civilian public mass shootings and mass killings has showed an increase on American soil (Reed Smith et. al., 2018: 1). It is undeniable that communities from all across the (western) world will continue to be targets of these attacks (Blair & Schweit, 2014: 20; FBI, 2016: 1).

As demonstrated by other disastrous coordinated attacks – the 2013 Boston Marathon Bombings and the 2015 San Bernardino attacks at the Inland Regional Centre – individuals and groups driven by ideological, political, or individual motivations proceed to commit acts of mass public violence (Braziel et. al., 2016: xiii; Edward et. al., 2014: 1-3; Global Terrorism Databese; Ostaeyen, 2016: 1-4). The Boston Marathon Bombing and the San Bernardino attacks as well as the Orlando nightclub shooting confronted public safety units with responding to these horrific incidents in a rapid, efficient and coordinated manner. The responding public safety units had to operate under extremely difficult and rapidly changing circumstances. Some main challenges confronting these agencies during the response to the Orlando nightclub shooting were:

1_{An overview of the chronological course of events from the moment the shooting starts till the moment the area} surrounding the nightclub was officially identified as safe can be found in appendix A.

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- The transition of state in the operational and tactical approach from active mass shooter to barricaded suspect with terrorist motives taking people hostage;

- The difficulties in assessing the scene of the crime because of the complex layout of the nightclub and darkness during the night;

- The protection of the safety of attendees in the club, who later became the subject of the hostage, and public safety personnel responding to the incident;

- The persistent threat that secondary (fire)attacks could take place.

The responding public safety agencies collaborating to de-escalate the situation include: the Orlando Police Department (OPD), Orange County Sheriff’s Office Hazardous Device Team (OSCO HDT), OPD Special Weapons and Tactics (SWAT), Emergency Medical Services (EMS), Orlando Fire Department (OFD) and the Public Information Office (PIO).

Public safety agencies in Orlando have a long history of checklists, procedures, evaluations and trainings linked to the department’s response to disastrous events2_{. However,} as the horrific event unfolded the situation became more problematical and multifactorial. The joint operation was obstructed by a lack of coordination, a clear strategic outlook and unified command and control (Homeland Security Presidential Directive, 2008: 9; Straub, et. al., 2017: 47-48).

1.2. Problem outline

Thorough analysis of incidents can lead to important insights into an organization’s

performance and potential for improvement on how to respond om emergencies. However, progression can only be made when the investigating organization uses proper theory-based approaches to achieve the required level of analysis. Although the notion that organizational factors influence incident causation has been widely accepted (Leveson, 2009: 227;

Shrivastava et. al., 2009: 1380-1382 Vuuren, 1998: 5), theoretical approaches explaining organizational failures underlying impediments and accidents have not been formulated (Vuuren: 1998: 5-6). Proper insights into the organizational failures leading to incidents or

2_{This is illustrated by the fact that OPD officers are obliged to complete ‘’Federal Emergency Management}

Agency (FEMA) independent study (IS) training module IS-700 (National Incident Management System ‘NIMS’: An Introduction). Meanwhile, all OPD supervisors are required to attend IS-800 (National Response

Framework: An Introduction), IS-200 (Incident Command System ‘ICS’ for Single Resources and Initial Action Incidents), and IS-100 (Introduction to Incident Command System). 204 All OPD general and command staff (lieutenants, captains, deputy chiefs, and chief of police) received G-300 (Intermediate ICS for Expanding Incidents) and G-400 (Advanced ICS) training’’ (Straub et. al., 2017: 66).

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impediments are highly needed in order to prevent that recommendations for improvement will be largely based on ‘’wild guessing and good luck or focus on the wrong problem’’ (Vuuren, 1998: 16).

Incident investigations, such as the official ‘2017 Critical Incident Review of the Orlando Public Safety Response to the Attack on the Pulse Nightclub’, tend to focus on the identification of practical ‘learning points’ of the responding agencies while underestimating the organizational factors leading to emerging impediments and incidents (Vuuren, 1998: 16-17). By not identifying the organizational failures underlying these impediments,

investigations on incidents, as was the case in the aforementioned investigation, tend to be of a superficial level.

1.3. Purpose of the study

This research will analyze how organizational failures lead to impediments in the emergency response to the 2016 Orlando nightclub shooting by public safety agencies in terms of normal accident theory (NAT) and high reliability theory (HRT). Due to the limited knowledge into organizational failures causing impediments, the following two sub-goals have been

formulated:

- to create tools for description and classification of organizational failures leading to impediments during the emergency response to the 2016 Orlando shooting based on NAT and HRT.

- to identify what organizational failures explain the impediments that emerged during the emergency response to the 2016 Orlando shooting based on NAT and HRT. The ’’concept of organizational failure is still only partly understood by researchers and hardly acknowledged by organizations’’ (Vuuren, 1998: 11). By gaining more insights into the origins of disasters, similar organizational structures may prepare themselves more effectively to future public mass shootings. According to Shrivastava et. al., it is hardly possible to expand on the origins of accidents within organizations without referring to NAT and HRT (2009: 1357). Both theoretical views are dominant schools on the origins of

accidents. However, most research into the root causes of (escalation of) incidents using NAT and HRT has focused on failures and accidents in a technological organizational context (Vuuren, 1998: 138-139).NAT, on the one hand, argues that accidents are inevitable within complex and tightly coupled organizations, whereas HRT claims that organizations can invest

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in the prevention of accidents. Despite the influence of NAT and HRT, both theoretical views ‘’limit the progress that can be made toward achieving highly safe systems by too narrowly defining the problem and the potential solutions’’ (Leveson, 2009: 243)’’. Therefore, the characteristics of both theories will be reframed to explain how organizational failures could lead to impediments during this complex emergency response.

This approach is characterized by the belief that NAT and HRT have similar

implications for practice and that they both perceive the phenomena underlying incidents at different moments in time. The reframed characteristics presented in this research are a

starting point for future studies on interpreting the organizational root causes of impediments.

1.4. Social relevance

In recent years, high-level impact mass shootings increased in multiplicity and severity in the United States (Blair & Schweit, 2014: 20; FBI, 2016: 1). Therefore, it is very important to ensure that public safety agencies have access to information, tools and training needed to meet up to the responsibilities and challenges posed by these threats. This examination of the responding public safety units will be a valuable addition to the already existing - and

growing - body of knowledge that public safety units can use to prepare themselves for future emergency response to acts of mass public violence.

If governments can get a deeper understanding of the causal trajectories that lead to impediments, they can prepare themselves to manage them more efficiently. Effective and adequate emergency response can save lives, property, markets, infrastructure provision, public services, policy agendas and political careers (Boin, et. al., 2017, 9). This is of great relevancy during an era in which acts of mass public violence pose a seemingly bigger threat on many levels of society.

1.5. Academic relevance

Within the academic debate, both NAT and HRT are only applied to highly technological organizations, such as ‘’nuclear power plants and nuclear weapons, aircraft and air traffic control, genetically-modified organisms, new chemicals, and computer software underlying nearly everything’’(Leveson, 2009: 227; Perrow, 1994; Tamuz & Harrison, 2006: 1655-1657). Although both theoretical approaches have been popularized by applying them to accidents in technological contexts, this study aims to understand the organizational root

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causes of emerging disasters within the context of a non-technological organization operating under hazardous circumstances. This is highly needed due to the lack of theory based

approaches to explain the organizational failures leading to impediments in a socio-organizational context (Vuuren, 1998: 5-6).

By doing so, this study will go beyond the current state of debate and will present a view through which to understand what organizational failures were debit to the impediments that emerged. This is of great importance because ‘’organizational factors play a key role in almost all accidents and are a critical part of understanding and preventing’’ failures that are likely to escalate into disasters during an emergency response (Leveson, 2009: 227). Multiple scholars in the domain of organizational theory and sociotechnical disaster already noted the urgency to apply NAT and HRT as complementary views (Rosa, 2005: 229-232; Shrivastava et. al., 2009: 1357-1358). This study aims to fill this gap in the literature by looking at the organizational failures leading to the main obstacles that emerged confronting public safety agencies during their emergency response.

This research aims to function as a catalysts for consolidation and reinforcement of the policies, protocols, strategies and operations of public safety agencies. Identifying the

organizational limitations and shortcomings in the hours after the attack started can provide insights for strengthening of strategies and further academic research regarding this domain of interest. The outcomes of this study can weigh heavily in dilemmas and policy-questions of whether or not the organization of public safety agencies functions conform best practices during devastating crises.

1.6. Research questions

Based on the research aim, two research questions have been formulated.

Sub-question What are the main impediments faced by public safety agencies during the emergency response to the 2016 Orlando shooting?

Main question How did organizational failures lead to impediments in the emergency response to the 2016 Orlando shooting by public safety agencies in terms of normal accident theory and high reliability theory?

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1.7. Structure of the research

This is the end of the first introductory chapter. The second chapter will provide the literature review in which NAT and HRT will be explained. Underlying these theoretical approaches is the divergence between the levels of aggregation of NAT and HRT instead of a contradiction. The factors said to drive organizations into accidents (NAT) and the factors to prevent

accidents from taking place (HRT) will be used to assess the impediments that emerged during the emergency response. The third chapter provides the research methodology in which the methodological choices will be clarified. This chapter will include the process of data collection, data analysis, and the validity and reliability of the research. The fourth chapter will present an analysis of the collected data. The impediments that emerged will be identified and the organizational failures that lead to the emergence of the impediments during the response will be outlined. Thereupon, the main findings will be discussed and the results will be placed in a wider perspective, leading to the concluding answers to the research questions. The fifth chapter will provide the discussion reflecting on the results against the background of the applied theories. This chapter also includes the limitations of this study. The sixth chapter will provide some concluding remarks and recommendations for further research.

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2. LITERATURE REVIEW

The previous chapter outlined the scope of the research. This resulted in an overall purpose and research questions. This chapter will define the main concepts and review relevant theories to land in a conceptual framework that is going to be used throughout the research. It discusses the organizational causes for failures in terms of NAT and HRT. The causes of failures include complexity and tight-coupling (NAT), lacking prioritization of safety, insufficient organizational learning and a lack of organizational structure and

communication (HRT). This study argues that both theories look at the same phenomena at different moments in time. The structure of this chapter will now be outlined. First, the

preconditions of disasters within organizations from a socio-technological perspective will be briefly touched upon. Second, an explanation on why NAT and HRT are complementary instead of competitive will be presented. Third, the key characteristics of the origins of accidents according to NAT and HRT will be outlined. Lastly, the expectations of this study will be discussed.

2.1. Some concepts defined

In this study, the ‘problems’ or ‘obstacles’ that obstructed an adequate emergency response will be referred to as impediments. The emerging impediments were characterized by, for example, overlapping roles and responsibilities among different public safety agencies or failure to enable medical services to provide emergency medical care due to lacking instructions.

An effective emergency response signifies the multi-organizational reaction to urgent threats by neutralizing the dangers and risks as adequate as possible. In order to do so, a comprehensive and strategic picture of the dynamic situation is highly needed (Boin et. al., 2017: 16). However, organizations in an emergency response network could be under

command of different actors. Therefore, a multi-organizational emergency response according best practices has to be characterized by an optimal awareness and preparedness of each other’s expertise and missions. Responding public safety agencies aiming to minimize the number of victims requires horizontal and vertical coordination (Cher et. al., 2008: 68; Frierich et. al., 2000: 41). In order to coordinate responding personnel throughout the whole organization structure, the network of responding safety units must have a thorough

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communication mechanisms (Perry & Lindell, 2003: 343). This also will enhance the distribution of resources and the creation of an agreed-upon strategy.

The organizational failures causing impediments to emerge is defined as ‘’non-technical latent failures within the structure of the network, which after a considerable time may trigger one or multiple active failures by those at the sharp end of incident causation‘’ (Vuuren, 1998: 9). In this study, the organizational failures that lie at the heart of accidents will be based upon NAT and HRT. A thorough explanation and analysis of the characteristics of NAT and HRT will be presented in section 2.3. to 2.10.

2.2. Intelligence within organizations

Threat, urgency and uncertainty creates problems for a rapid emergency response (Boin et. al., 2017: 7). According to Turner, ‘’actors’ organizations resolve these ‘problems’ by following rules of thumb, using rituals, relying on habitual patterns, or, more self-consciously, by setting goals and making plans to reach them’’ (1976: 378). However, resolvent of threats for organizations is very difficult to realize due to the fact that they are open systems and

therefore can never be sure if their preparations will be sufficient for achieving their aims (Thompson, 1967: 10).

Turner examined the preconditions of large-scale disasters from a socio-technological perspective by including characteristics such as imperfect knowledge distribution,

centralization of decision-making, gaps in responsibility and failures of compatibility (Turner, 1978: 3-6, 23-24, 58, 66). Turner linked human control over organizations and processes to seemingly innocent errors and weaknesses that can evolve into multiple interacting causes that pose threats with disruptive potential. He introduced the concept of the ‘’incubation period’’ in which he described the accumulation of seemingly innocent organizational flaws and errors, eventually causing the potential for (escalation of) disasters to unfold (Turner, 1978: 3, 38, 121-124).

High-quality intelligence within organizations can prevent failures from escalating into disasters. In order for intelligence to prevent escalation of these errors ‘’it should be clear, timely, reliable, valid, adequate and wide-ranging so that it is understandable by the users, is available when needed, is perceived similarly by different users, captures reality, gives a full account of the context, and poses the major policy alternatives’’ (Turner, 1976: 379). Turner argues that if failure of intelligence occurs, organizations can no longer take precautions to prevent escalation from happening and can no longer adequately respond to

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de-escalate the consequences of accidents (Turner, 1976: 380). Thus, if organizations experience disruptions to its basic structure or fundamental values, an adequate response of actors can no longer be taken for granted (Pheng and Ann, 1997: 231-233).

Turner argues that in modern society, socio-technological organizations become more complex and interconnected to other (sub)organizations. This increases their vulnerability if an organization is confronted with disturbances. The large-scale disasters that pose a threat on society in this day and age are characterized by complex and interwoven socio-technological processes. This is due to the fact that ‘’when a threat does materialize (…), the consequences in modern, technology-dependent mass societies can be much bigger than they used to be (lower frequency but higher impact)’’ (Boin et. al., 2017: 10).

2.3. NAT and HRT in another context

The idea that (organizational) crises are an unwanted by-product of modern, technology-dependent society has been a primal notion in Perrow’s NAT. This theory argues that (organizational) crises are inevitable due to complexity and tight-coupling, no matter what organizations do to prevent them from happening, whereas HRT claims that organizations can contribute significantly to the prevention of failures by applying strategies investing in

organizational learning, prioritization of safety and structure and communication.

The debate between these seemingly competitive theoretical approaches ‘’developed into a contest of concepts and illustrative examples’’ and there seems to be no systematic analytical way to resolve the debate between these two dominant schools on the origins of accidents (Leveson, 2009: 227). It is believed that this theoretical deadlock is maintained due to the way both approaches are articulated (Leveson, 2009: 229).

However, HRT and NAT should not be seen as opposing views, and, instead, should be perceived as complementary perspectives (Shrivastava et. al., 2009; La Porte, 1994). Although the theories are seemingly conflicting approaches, they perceive the phenomena underlying the (organizational) crisis at different moments of time, and do not contradict each other (Shrivastava et al., 2009, 1368). Despite diverging motivations – NAT looks at

organizational processes causing impediments that are likely to escalate into disaster, and HRT focuses on organizational processes that conduce the level of reliability – both these theoretical approaches have similar implications for practice. According to NAT,

organizations can reduce the likelihood of organizational accidents by decreasing the level of complexity and loosening the coupling between various actors and subsystems. Initiatives

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proposed by HRT, such as organizational learning, prioritization of safety, and organizational structure and communication, can be interpreted as efforts to indirectly or directly align the impediments caused by complexity and tight coupling, which is the central notion within NAT (Shrivastava et al., 2009, 1366).

Therefore, both theories will be applied as complementary perspectives to assess the organizational failures underlying the impediments during the emergency response. Applying NAT and HRT simultaneously as two complementary theories to this case allows for a more in depth examination of the organizational failures that caused the impediments, since each theoretical approach supplements the weak point of the other. This supplementary usage is illustrated by the fact that NAT fails to adequately set forth factors to determine the influence of high-level pressure on risk levels for personnel within an organization, whereas HRT does set forth indicators that can be linked to this issue. Likewise, HRT falls short in aligning the potential of accidents due to rigid beliefs within the organization while NAT assigns factors that are related to this organizational factor.

In the next section, the characteristics for organizational failure and escalation

grounded in NAT and HRT will be assessed. By doing so, a theory-based view can be created through which to examine the organizational root causes of impediments that served to be an obstacle during the emergency situation.

2.4. Normal Accident Theory

The central thesis of Perrow’s (1994) NAT holds that disasters are unavoidable in complex, tightly-coupled organizations. These two factors lie at the heart of an organization’s potential to cause disasters (Perrow, 1999: 72-80). The more complex organizations become, the more difficult it is to comprehend the system as a whole. Tight-coupling within an organizations relates to rigid beliefs, little slack opportunities in personnel and equipment or sequences of processes that not vary due to existing protocols. This gives rise to the inability to improvise and change tactics. Disasters or failure to respond to disasters as adequate as possible are therefore caused by the juncture of complexity and tight-coupling. These failures are regarded as ‘’normal’’ or ‘’system’’ disasters since these attributes are deeply rooted in the system (Perrow, 1999: 5).

Perrow claims that complicated and hazardous organizations cause situations in which it becomes very difficult for anyone to understand the interplay between sub-units within the organization in its entirety. According to this view, this is the case in highly developed

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technological systems in which many safeguards are built in to reduce the chances of

escalation into disaster. Attempts to reduce this potential, such as redundancy to prevent local failures from snowballing into disasters, may increase the level of complexity and tight-coupling, and thus, undermines the main aim being sought (Perrow, 1999: 72-80). This study assumes that organizations can reduce their potential on which failures can escalate into disasters by reducing the level of complexity and tight-coupling.

2.5. Characteristics of complexity

According to NAT, it is inevitable that complex organizations yield unforeseen interaction among multiple actors. Accidents can emerge from seemingly innocent factors or localized failures that can damage the organization as a whole. Complex interaction refers to the interaction among actors characterized by unexpected and unplanned sequences under

unfamiliar circumstances. In more complex organizational structures, there is insufficient time and comprehension to monitor and control these interactions (Shrivastava, 2009: 1360). The key characteristics said to drive complexity in organizational processes will be briefly summarized.

1). Sub-organizations can have multiple responsibilities and functions. This means that these actors can fail in various directions at once because these actors have to

distribute their attention. The focus on one specific task can be at the expense of another responsibility this actor may have. If a failure appears within a (sub-) organization that conducts multiple tasks it is likely that this leads to negative

consequences on various aspects within the whole system (Perrow, 1999: 72-73). This ‘spillover’ of organizational flaws in one sub-system within the organization can lead to a dangerous situation for other parts of the organization. The complexity that is built in organizations will increase the likelihood of dysfunctional interaction. As the interactive complexity within an organization grows, organizational failures are more likely to escalate into disasters due to the multifactorial interactions between sub-systems (Leveson, et. al., 2009: 235).

2). Sub-organizations can have a lack of knowledge about the roles and

responsibilities of other specialized actors within the organization structure. When sub-organizations fail to have a thorough understanding about the roles and

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responsibilities of other sub-organizations within a multi-organizational structure, this will reduce the chance to control incidents and to de-escalate accidents. Efforts to avoid these obstacles and escalation of disasters can be achieved by building in redundancy to prevent these organizational errors leading to impediments. However, this will create increased complexity which can undermine the very goal being sought (Leveson et. al., 2009: 228). Low-level operations and strategic leaders can therefore not anticipate adequately to emerging danger because there is a lack of oversight and incomplete knowledge in regard to one another. This is necessary to predict the

implications of their activities due to incomplete knowledge about other units (Perrow, 1999, 81-82). A deficient understanding about the main tasks, roles and

responsibilities within the interplay of sub-units will increase the potential on which impediments can emerge during joint actions or operations.

2.6. Characteristics of tight-coupling

The second conception that Perrow recognizes as a contributor to ‘standard’ disasters is ‘tight coupling’ (Perrow, 1999: 89-93). In this study, tight-coupling will be defined as the ‘’degree and type of interdependence among system components, that is, whether and how the

behavior of one component can impact the behavior of other components. The amount and type of coupling (interdependencies among components) determines the component

interactions during system operation and hence the visibility and comprehensibility of the component interactions’’ (Leveson, 2009: 3). This concept is identified by the notion that organizations can leave little space for appliance of other tactics and improvisation. This is exampled by a rigid organizational belief on how certain actions should be carried out, the belief that certain activities can only be carried out in a particular order or in a situation in which substitution of personnel is not attainable (Shrivastava et. al., 2009: 1360; Perrow, 1999: 90-94). This understanding of tight coupling applies to highly regulated organizational structures. Consequently, these organizational systems are somewhat less prepared to handle and manage crises outside the standard operating context (Perrow, 1999: 92-95). In tightly-coupled organizations, interacting defects tend to snowball into inevitable disasters (Perrow, 1999: 25, 35). The factors said to drive tight-coupling in organizational processes are:

1). Protocols and rigid beliefs as to proper course of action can cause a situation in which organizations hold on to prescribed steps that inhibit efficient action-taking. In

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this way, organizations tend to depend only on one method to accomplish a goal, such as de-escalation of an incident. Substitution of equipment and personnel is not readily possible, and where possible, it can only happen in a prescribed way. If organizations hold on to pervasive and long-established thoughts and beliefs on how to operate under difficult and hazardous circumstances, these beliefs can influence the decision-making in a counter-effective manner. According to Turner, this poses a danger that affects ‘’decision-making procedures and mold organizational arrangements and provisions so that there is a possibility of a vicious, self-reinforcing circle growing up’’ (1976: 388). This is exampled by protocols that are being hold onto, although they are not in line with best practices given the specific circumstances of a situation (Perrow, 1999: 90-94). When an organization is tightly-coupled, the organization is more likely to face incidents.

2). An organizational structure characterized by conceptual slack creates the potential of a ‘divergence in analytical perspective among members of an organization over theories, models, or causal assumptions pertaining to its production or organizational processes’ while operating under unified command (Schulman, 1993: 364). This implies that diverging strategies among actors within the organization can be

maintained simultaneously and that units with other domains of expertise can also be integrated into strategic operations carried out by other units. However, a lack of ‘’slack’’ within an organization leaves little space for substitution or addition of materials or experts (Perrow, 1999: 93-94). Tightly-coupled systems that have a lack of ‘’slack’’ fail to absorb shocks and adapt their conventional approach to the

changing circumstances. When this is the case during a multi-organizational approach, impediments during the joint operation are likely to emerge.

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2.7. High Reliability Theory

HRT developed as a response to NAT as formulated by Perrow (Sagan, 1993: 14-16; Shrivastava et. al., 2009; 1358; La Porte & Consolini, 1991). HRT appertains studies on organizations managing high-risk processes that go through very little calamities (La Porte & Consolini, 1991; Roberts, 1990b). According to HRT, organizations that operate under hazardous circumstances can prevent failures from escalating into disasters due to ‘’effective management of innately risk technologies through organizational control of both hazards and probability’’ (Rochlin, 1993: 15). This suggests that human operators can recover from an undesired chain of events or prevent major accidents from unfolding.

To reduce the potential on which organizational failures can escalate into disasters, organizational structures have to incorporate the prioritization of safety, organizational

learning and a strong organizational structure and communication (La Porte, 1994; La Porte & Consolini, 1991; Sagan, 1993: 16-24; Roberts & Bea, 2001; Weick, 1987). HRT implies that organizations who fail to maintain error-free invest insufficiently in these three main catalysts of disasters. Therefore, this research assumes that if the prioritization of organizational

learning, prioritization of safety and organizational structure and communication leads to error-free organizations, this automatically means that neglection of these factors leads to failure within the organization. By now, the characteristics of these factors will be outlined to assess the organizational failures that lead to the impediments during the emergency response to the Orlando nightclub shooting.

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2.8. Characteristics of organizational learning

The multiorganizational interplay between the responding public safety agencies is an example of a high reliability organization. High reliability organizations are characterized by the fact they ‘’operate in an unforgiving social and political environment, an environment rich with the potential of error, where the scale of consequence precludes learning through experimentation, and where to avoid failures in the face of shifting sources of vulnerability’’ (Enya et. al., 2018: 10; Weick et. al., 2008). A great deal of the academic work on high

reliability organizations concentrates on the organizations competence to learn over periods of time and progressively adapt their processes on contextual developments in order to prevent failure from appearing (Roberts, 1990a, Roberts & Bea, 2001). Sagan puts forward trial and error functions as a chance for organizational learning to occur. High reliability organizations have to trust on preparative simulations and anticipation on potential defects in order to prevent incidents to impede a joint operation (Sagan, 1993: 25-26; Wildavsky, 1988: 17). The characteristics of organizational learning will be now be outlined.

1). Organizations can contribute to the prevention of accidents when they facilitate realistic simulations and learn from these exercises to cope with the circumstances of real-life hazardous incidents. When existing simulations of incidents fail to prepare staff members for deployment and reacting adequately on realistic coordinated assaults, they enlarge the potential in which interacting failures can escalate into disasters (Shrivastava et. al., 2009: 1363). By enabling staff members to prepare them adequately for real-life operations, the reliability of organizations to maintain and execute error-free activities can be magnified. Organizations can contribute

significantly to the prevention of disaster or escalation by learning from past defects or simulation of disasters (Shrivastava et al., 2009: 1362-1363). When an organization fails to provide effective tools to prepare staff members for realistic accidents, the potential on which failures can escalate into disasters will increase.

2). Simulations should not only prepare staff members to realistic incidents, but should also serve as a means for deepening interpersonal contact among various sub-units within the organizations. Training should be focused on the involvement of all sub-units within the organization in order to vindicate situational awareness across all levels of expertise (Shrivastava et. al., 2009: 1379-1380). In dynamic work situations, no single sub-system within an organization can acquire the rapidly expanding data needed for an adequate response. Therefore, these units have to collaborate to collect,

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synthesize and analyze the data needed to create and execute action-taking plans. A high level of ‘’interwoven situational awareness appears to facilitate response to dynamic, constraint-bound situations’’ (Sonnenwald, 1999: 462). Whenever organizations fail to facilitate this situational awareness throughout an organization structure, they are more likely to face difficulties when formulating of an agreed-upon operation structure.

3). Organizations can decrease the chance that organizational failures escalate out of control by analyzing past failures in similar organizations from various aspects. This could bring many lessons learned that will suggest that there are problems in the process of development at organizational aspects. Analyzing past failures reports can lead to preventing occurrence of similar kind of failures extracted from past bitter experience (Shrivastava et. al., 2009: 1362-1364). Learning from lessons gained through similar situations allows for significant knowledge to benefit current and future programs and trainings within organizations. By showing how failures in organizations under similar circumstances are caused, countermeasures to prevent them from emerging can be taken. Therefore, organizations should organize the analysis of cause of big failures, incidents and/or de-escalating responses to an incident, to set countermeasures, and deploy the result to all sub-units within the organizational structure. By assessing the cause of certain impediments or incidents in similar organizations, lessons learned can be deployed and integrated in existing policies, protocols and training tools. By failing to doing so, organizations are more likely to face unforeseen incidents or impediments during an emergency response to de-escalate the incident.

2.9. Characteristics of prioritization of safety

Various high reliability theorists argue that the prioritization of safety is a critical concern to prevent disasters from occurring (Roberts, 1990a; 18-22; Sagan, 1993: 17-19). Automatic safety systems and safety protocols are built-in means to prevent that personnel is exposed to threats and risks. If these measures fail to prevent a dangerous situation, it is up to the

experience and training of human operators to provide instructions to recuperate from this chain of events. Failure to provide these instructions will increase the chances of an undesired situation to escalate into a full-blown accident (Vuuren, 1998: 5-6). A decrease in the level of

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disasters within an organizational structure is only accomplishable when strategic managers acknowledge that the safety of the responding personnel has to be affirmed at all costs (La Porte & Consolini, 1991: 2-4). The characteristics of prioritization of safety will now be presented.

1). Organizations should create an environment in which possible dangers are detected before or during early stages of the incident. This prevents potential catastrophic implications for staff members. Organizations should cultivate

resilience by consistently maintaining the level of safety as the top priority to protect personnel over other operation pressures. Since the level of safety rapidly changes under hazardous circumstances, periodic evaluation about the safety of staff members is very important. When strategic leaders fail to prioritize safety concerns over

seemingly short term effectiveness, they increase the likelihood of escalation into accidents. So, if responsible strategic leaders cannot meet up to the safety standards for the personnel, the potential for escalation into disasters increases (Vuuren, 1998: 5-6).

2.10. Characteristics of organizational structure and communication

According to HRT, it is highly important to implement a proper organizational structure and communication. It permits decentralized action-taking, addressing and responding to threats, while upholding a central cohesive and coherent bundle of beliefs, assumptions and focus points of operating staff personnel (Roberts, 1990b; Roberts & Bea, 2001; Sagan, 1993: 21-25). Furthermore, this theoretical approach also considers inter-organizational communication to be an important factor for reducing the likelihood that a disaster unfolds or an incident escalates. Inter-organizational communication relates to the interaction and integration between officials and leaders of various units within the organization structure. The expertise and the skills of a variety of sub-units enhances the development process of strategy through suggestions from multiple backgrounds and perspectives (Roberts, 1990b; Sagan, 1993: 21-25). By now, the characteristics of organizational structure and communication will be outlined.

1). Organizations can reduce the likelihood of occurring accidents by assigning responsibility and accountability to low-level personnel. If such a culture is

implemented within the organizational structure, it will allow decentralization of the authority while maintaining a structured set of assumptions and primary aims among

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the various operating actors (Sagan, 1993: 21-25; Roberts & Bea, 2001). This

means that organizations should facilitate decentralized decision-making connected to the given contextual circumstances and centralized decision premises controlled by strategic leaders (Rijpma, 1997: 17). The decentralization of authority gives staff members the mandate to take decisions, but they under direct responsibility of

strategic leaders and are still controlled in terms of the assigned goals to fulfill. When an organizations fails to implement this level of centralization and decentralization, the lack of flexibility and autonomy of personnel to respond appropriately on specific circumstances can escalate into disasters.

2). Organizations can reduce the potential on which accidents occur by facilitating inter-organizational communication. Establishing effective ways to distribute the relevant information over all responsible actors will increase the understanding and trust among the various units within the organizational network. This will enhance efficiency during high-risk processes by avoiding overlap in data gathering. By sharing information in a centralized format, the decision-making process will be enhanced due to the fact that all relevant sub-organizations have access to thorough assessments of the situation. Grasping the complexity of emergency situation raises the need for open and direct information sharing in order understand the tasks and responsibilities of all sub-units (Jefferson, 1998). Information sharing will also prevent that actors do not get in each other’s way during operational activities. Creating

measures to get a deeper comprehension about the knowledge base and areas of expertise will reduce the likelihood that organizational failures lead to impediments. By facilitating a base to comprehend the incident and the actions that have to be taken across all levels of the organization, the coordination between the sub-units will be harmonized (Rietjens et. al., 2009: 414). A lack of inter-organizational communication can create big losses of material and human resources (Kaynak & Tuğer, 2014: 443). When an organization fails to facilitates inter-organizational communication obstacles are more likely to impede the joint decision- and action-taking.

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2.11. Expectations

This research assumes that if organizational learning, prioritization of safety and

organizational structure and communication leads to error-free organizations, this also implies that neglecting these factors lead to failure within organizations. Therefore, this study will use the identified factors, according to NAT (complexity and tight-coupling) and HRT (lacking organizational learning, failure to prioritize safety and a lack of organizational structure and communication), that are debit to failures within organizations as frames through which to assess the impediments that emerged during the emergency.

After discussing the characteristics of the origins of disaster, some expectations of this study will now be outlined. According to NAT, actors responsible for multiple tasks and functions in a context of rapidly changing circumstances have a high potential to fail in more directions at once. Actors are more likely to focus on one aspect of the operation instead and fail to anticipate and prepare themselves for further negative consequences. Furthermore, if units within the organization fail to have a thorough comprehension about the expertise and responsibilities of other units it is more likely that both actors do not work cooperatively under structured command. According to this theory, the level of complexity contributes to the emergence of obstacles during rapid action-taking aimed to prevent de-escalation. It is also expected that holding on to protocols/rigid beliefs and failure to provide slack

opportunities in strategies serves as an obstacle for improvisation and actions that fit the context of the situation, signifying tight-coupling. This increases the potential on which obstacles impede an operation according best practices.

According to HRT, organizations increase the potential on which obstacles can emerge if they fail to conduct joint exercises between various sub-units within the organization on a regular basis. Organizations that fail to train their staff members to make decisions under high capacity stress situation increase the chances of escalation of incidents. This indicates a lack of organizational learning. Furthermore, it is expected that failure to prioritize safety concerns of personnel over short term effectiveness will increase the likelihood of escalation. Failure to facilitate centralization and decentralization simultaneously and failure to facilitate inter-organizational communication among the various sub-units also increases the potential on which impediments will occur. This signifies a lack of organizational structure and

communication.

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3. METHODOLOGY

The previous chapter discussed the relevant theories and the conceptual framework. In this chapter, the methodological considerations will be justified. This chapter will include the research design, data collection method, analysis of data, validity and reliability, the operationalization of the concepts, and, lastly, the methodological limitations of this study.

3.1. Research design

Since this study examines a contemporary real-life phenomenon through contextual analysis a qualitative research will be carried out. A qualitative research design suits the goal this study aims to fulfill, because this study will shed a light on the emergence of impediments in a specific context (Strauss & Corbin, 1990: 17). A detailed qualitative case study will help explore the organizational failures underlying the impediments, but may also help to get a deeper understanding of organizational complexities under similar circumstances which potentially cannot be captured through quantitative research (Bryman & Bell, 2007: 64; Zainal, 2007: 6). This research method enables the researcher to interpret and to perceive a thorough understanding of the studied case. A quantitative research fails to do so due to the fact that an individual’s level of understanding of root causes of incident causation cannot be measured in numbers (Bryman & Bell, 2007: 112). In this study, the dependent variables are the impediments. The independent variables are the organizational failures causing them to emerge.

The primal nature of this qualitative case study is exploratory. Exploration is needed when a theory has not yet been applied to new contexts in order to find out which concepts of the phenomenon are useful for future studies. According to Kumar, exploratory research - or pilot studies – is a type of research which generally is used to explore a problem that has not been studied more on depth. Therefore, exploratory studies are conducted with the aim to clarify and define the origins of a given problem (Kumar, 1999: 11). This research fits this criterium because it aims to provide theory-based means to assess the organizational failures underlying impediments in a non-technological context in terms of NAT and HRT.

Exploratory studies are also characterized by using a relatively small sample size. The findings of this exploratory study will help develop operational definitions and establish empirical building blocks for future studies (Idowu, 2016: 2; Zainal, 2007: 3).

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3.2. Research strategy

A case study design is the most suitable research design for the purpose of this study. Carrying out a case study enables the researcher to gain in-depth knowledge about a phenomenon in a specific context, because of the focus on the individual instead of the general. This method enables the researcher to study the circumstances in which certain phenomenon could unfold in greater detail, in particular organizational processes (Babbie, 2010: 309; Easton, 2010: 119-120). The focus of a case study is limited to a ‘’particular instance of something’’ (Babbie, 2010: 309). This single instance is the emergency response of the public safety agencies to the 2016 Orlando nightclub shooting as the unit of analysis. Yin has put forward the following three criteria to determine whether a case study is an appropriate study design: “case studies are the preferred method when (a) "how" or "why" questions are being posed, (b) the investigator has little control over events, and (c) the focus is on a contemporary phenomenon within a real-life context” (2009: 2).

Conducting a single case study provides the opportunity to retain the holistic and crucial attributes of real-life circumstances in organizational processes. Due to the latent nature of organizational failure, in-depth data analysis about the impediments is necessary. To develop a deeper understanding of the organizational causes leading to impediments,

information about ‘how’ these impediments can be explained is required. Therefore, the following main research question in this study has been formulated: how did organizational failures lead to impediments in the emergency response to the 2016 Orlando shooting by public safety agencies in terms of normal accident theory and high reliability theory?. Consequently, the first criterium that Yin put forward is fulfilled. Second, this research is based on a post-hoc review of the incident which indicates that the researcher could not control or influence the behavioral events during the emergency response. The emergency response to the mass-casualty shooting already had taken place indicating that only the quality and the type of research could influence the results (Yin, 2003: 7). The third conditions that Yin put forward is also fulfilled, because this study focuses on a contemporary situation in real-life context as opposed to a historical phenomenon.

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3.3. Data collection

This qualitative study applied a purposive sampling method which means that the research was sampled a priori with a research goal in mind (Bryman, 2012: 418). Qualitative research is a very attractive research method, because of the potential richness of information and data collected. The downside of this rich source of data is that this may lead to difficulties when attempting to find the proper analytic paths (Bryman & Bell, 2007: 129). After deciding the direction of this study and the formulation of the research questions, it was decided to use the official evaluative inquiry ‘’A Critical Incident Review of The Orlando Public Safety

Response to the attacks on the Pulse nightclub’’ as the main source for analysis. The reason that this official inquiry has been selected as the main source for assessment and evaluation is based on the notion that this report is the most extensive and high-handed evaluative documentation on this emergency response. This report has also been chosen as the main source of analysis because this public inquiry follows a clear cause and event chain and provides detailed insights in the decision-making processes among the staff members of the various safety agencies. The report is well structured and chronologically sets forth the dilemmas and difficulties facing the public safety agencies whereas other

publications relating to this subject matter fail to provide this structured assembly of data and information that permits conclusion drawing. The document provides a summary of the findings of the assessment team of the Police Foundation staff. The inquiry draws from the findings of expert observations and provides a useful source of data to detect the

organizational failures that served as a cause for the impediments during the emergency response. No secondary referencing was used in this research in order to prevent

misinterpretations as much as possible. The risk of misinterpretations and false data increases when not basing the analysis on official and original sources of information (Thurén, 2005, p.53).

The first method of data collection is desk research. As argued by Merriam

‘’documents of all types can help the researcher uncover meaning, develop understanding, and discover insights relevant to the research problem’’ when conducting desk research (1988: 118). Desk research entails the assessment of existing studies, rather than physical investigations. This helps clarifying the context of primary data research (Bryman, 2012: 13). Desk research provides an initial understanding of the research phenomena and is an

appropriate research method for producing thorough descriptions for organizational phenomena through document analysis (Bowen, 2009: 29).

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sources, such as public records, were interpreted in the light of NAT and HRT to recognize patterns in the document’s data (Bryman, 2012: 13). Document analysis is an attractive method due to the availability of public official records. It also enables the inclusion of a detailed description of the studied process. Lastly, usage of documents as a source for analysis provides broad coverage of the context in which certain events took place. Therefore, one official ‘’document may be the only necessary data source for studies designed within interpretive paradigm’’ (Bowen, 2009: 31).

3.4. Analysis of data

A concern when carrying out a qualitative study is related to the absence of a commonly agreed-upon systematic approach to analyze data (Feagin et. al., 1991: 7; Yin, 2009: 14-15). This study attempts to analyze the findings as systematically as possible by using the three-step-model for qualitative data analysis as formulated by Miles and Huberman. This approach contains three basic steps to analyze data, namely data reduction, data display, and lastly, conclusion drawing/verification (1994).

Reducing data refers to decreasing the amount of raw data into more wieldable and organized information by categorizing, summarizing and coding data (Miles & Huberman, 1994: 55-56). The data was carefully studied to identify and collect all obstacles,

impediments, difficulties and lessons learned relating to the emergency response to the 2016 Orlando shooting. The characteristics of the organizational failures were also thoroughly outlined in the literature review. This provided a base for analysis to identify the

organizational failures underlying these impediments.

Thereafter, the impediments and obstacles were categorized and coded in order to link them with the organizational failures that serve as an explanation for these errors during the response. Coding can be defined as ‘’labelling assigning units of meaning to the descriptive or inferential information compiled during a study. Codes are usually attached to ‘chunks’ of varying size – words, phrases, sentences or whole paragraphs’’ (Miles & Huberman, 1994: 56). Emphasis was placed on the accurate reflection of the data and the inclusion of all relevant data into categories by thoroughly assessing to sources of analysis. This prevented important data from being excluded in the research findings.

Thereafter, the research findings were displayed in the form of a table. The cells in the table were used to organize and display the relevant results linked to the organizational

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failures (Miles & Huberman, 1994: 57-61). This process helped to formulate a clear overview of which organizational failures lead to certain impediments. The table showing the research findings in section 4.7 provides a summary of the main results of the analysis. It is important to note that this study did not assign a ranking through numbers when analyzing the

impediments due to the fact that ‘’rare experiences are no less meaningful, useful or important than common ones. In some cases, the rare experiences may be the most

enlightening one’’ (Krane et. al., 1997: 214). After the analysis of the relevant data and the process of coding and categorization, the researcher had a clear empirical foundation to develop the concluding remarks.

3.5. Validity and reliability

Yin (2009) discussed the four following criteria for testing the quality of empirical social studies: construct validity, internal validity, external validity and reliability. First, construct validity relates to ‘’identifying correct operational measures for the concepts being studied’’ (Yin, 2009: 40). In order to do so, it is important to specify the subject matter in terms of well-defined concepts and characteristics, and second, to determine operational measures that match these concepts (Yin, 2009: 42). This study has attempted to strengthen the construct validity by, on the one hand, clearly defining the theoretical approaches, and on the other hand, operationalizing the reframed characteristics accurately. This study aimed to be transparent in the formulation of these indicators in order for the reader to reconstruct how the study has been carried out from beginning till end (Gibbert et. al., 2008: 1470-1472). This is exampled by the operationalization table in section 3.6 in which each of the characteristics of the organizational failures has been outlined.

Second, internal validity refers to ‘’seeking to establish a causal relationship, whereby certain conditions are believed to lead to other conditions, as distinguished from spurious relationships’’ (Yin, 2009: 40). This explorative study attempts to establish a cause-and-effect relationship between the impediments and the organizational failure leading to these

obstacles. When explaining the organizational failures underlying impediments, individual considerations can play a role. Although this study looks at the empirical considerations by examining the literature and official inquiries, some causal structures cannot be directly observed. However, the validity of this research is guaranteed due to use of the most important investigative source on the 2016 emergency response to the Orlando nightclub shooting (Yin, 2009: 41).

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Third, external validity is about ‘’defining the domain to which a study’s findings can be generalized’’ (Yin, 2009: 40). This is oftentimes problematic in qualitative case studies due to the small amount of analyzed cases. Therefore, the external validity of this research is likely to be low (Yin, 2009: 40; Gibbert et. al., 2008). However, this study does not aim to generate conclusions that can be generalized. Instead, it aims to provide some generalizable insights into how certain theories can explain the impediments that occurred due

organizational failures during comparable situations. In order to present general results, and to increase the external validity, it is necessary to assess various multi-organizational structures responding to an urgent threat.

Fourth, reliability relates to ‘’demonstrating that the operations of a study – such as the data collection procedures – can be repeated, with the same results’’ (Yin, 2009: 40). The reliability of this study is increased by clearly defining the steps being made to fulfill the aim of this study. Furthermore, by using public documentation sources the potential of replication of this study has been advanced. This will help the reader to understand and reconstruct the results from this research (Yin, 2009: 41-42).

3.6. Table 1: Operationalization

This study looks into the organizational root causes of impediments during the emergency response and it aims to assess which organizational failures explain the obstacles during the response at the Orlando nightclub shooting. In order to do so, the main theoretical

characteristics on the origins of accidents according to NAT and HRT are outlined and summarized in table 1 presented at the next page. Various examples of main impediments to the emergency response identified in the official 2017 Critical Incident Review were also categorized. These were linked to the organizational factors (complexity, tight-coupling, a lack of organizational learning, a lack of prioritization of safety and a lack of organizational culture) underlying the impediments.

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Table 1 provides an overview of the characteristics of the organizational failures causing impediments to emerge. The characteristics of these organizational factors are also linked to an example as identified in the official 2017 critical incident review.

Theory Organizational factors Characteristics Example Normal Accident Theory (NAT)

Complexity - Sub-system within the organization has multiple responsibilities and fails in various directions at once by not distributing their focus evenly and/or by focusing too much on certain aspects of the operation.

- Limited awareness and knowledge about the

- The OPD was responsible for the establishment of an incident command, the formulation of a contact team with other officers, leading the response inside the club and the designation of safe staging areas. However, OPD waited too long before they gave clearance about the safety of various areas surrounding the scene or further instructions on how to operate. This hindered medical and fire services to respond adequately and fulfill their responsibilities. These public agencies were also not safe for potential secondary attacks or explosions. This led to a situation in which these services were impeded in their tasks to provide life-saving

emergency care and were also not safe while waiting for further instructions (Straub et. al., 2017: 60).

- Leaders within OPD relied on OSCO HDT to conduct the explosive breach during the assault(s), but a lack of

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expertise of specialized personnel in other sub-units within organization.

knowledge about one another’s expertise caused a situation in which both actors operated apart from each other without streamlined coordination during crucial moments causing a situation in which the wrong resources were sent to OSCO HDT and valuable time was lost (Straub et. al., 2017: 56).

Normal Accident

Theory (NAT)

Tight-coupling

- Protocols and rigid beliefs as to proper course of action are not in line with best practices.

- Organization fails to provide slack opportunities in tactics and strategy.

- This was signified during the use of existing protocols on how to react to a hostage. It quickly became clear that current hostage negotiation policies were not adjusted to the context of a terrorist attack. Still, the existing protocols were leading during the unfolding of the attack. The responsible actors chose not to change strategy in their negotiation techniques. The Orlando nightclub shooting functioned as a catalyst for the re-examination of the used negotiation protocols (Straub et. al., 2017: 58).

- Law enforcement personnel failed to integrate emergency medical responders into their rescue task during the active shooter. Despite this would ensure victim-extraction (Straub et. al., 2017: 71). This led to important time not being used optimally to safe victims in the nightclub and this posed a

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higher pressure on medical services surrounding the nightclub. High Reliability Theory (HRT) Lack of organizational learning

- Organization fails to conduct realistic simulation and training on a regular basis.

- Organization fails to facilitate training aimed to deepen interpersonal contact between sub-units.

- Organization fails to learn from lessons gained through past emergency responses to similar mass casualty shootings.

- OPD SWAT did not prepared themselves to an incident of this magnitude and were mentally ill-prepared to the sight of the high amount of victims inside the nightclub. This

disrupted and shocked them so severely that they lost their concentration during the neutralization-operation inside the club (Straub. et. al., 68).

- OPD and OSCO HDT both claimed that it took relatively long before an agreed-upon command structure was formulated due to the lack of training on a regular basis between the teams. This remained an obstacle during the whole joint operation (Straub et. al., 2017: 56).

- The OPD failed to implement lessons learned from a similar emergency response to the 2015 San Bernardino attack, although the knowledge gained through the incident review of this emergency response was known within the OPD (Straub et. al., 2017: 73).

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High Reliability Theory (HRT) Lack of prioritization of safety

- Organization fails to prioritize safety over short term effectiveness.

- Many of the first responders, especially law enforcement members, were not well equipped to safeguard and defend themselves from the dangers posed by the shooter (Straub et. al., 2017: 70). High Reliability Theory (HRT) Lack of organizational structure and communication

- Organization fails to facilitate centralization and decentralization simultaneously.

- Organization fails to facilitate inter-organizational communication.

- No supervisor was designated as scene safety officer to channel coordinated activities, and affirm that effective ingress and egress are maintained (Straub et. al., 2017: 59).

- OPD PIO, EMS and OFD did not get access to the unified command center. This led to a situation in which did not get the resources to keep the public and their units informed periodically (Straub et. al., 2017: 108).

Organizational Failure: An Exploratory Study of the Public Safety Response to the Orlando Nightclub Shooting