Recent U.S. headlines have been dominated by school shootings. The bulk of the stories have been about the assassination of Charlie Kirk on the campus of Utah Valley University and the corresponding political fallout. On the same day, there was also a shooting at Evergreen High School in Colorado, where a student shot and injured two of his peers. This post isn’t about those school shootings, but rather, one that happened three years ago. On May 24, 2022, at Robb Elementary School in Uvalde, Texas, 19 students and 2 teachers were killed by a shooter who managed to make his way onto the campus.

Law enforcement were excoriated for how they responded to the Uvalde shooting incident: several were fired, and two were indicted on charges of child endangerment. On January 18, 2024, the Department of Justice released the report on their investigation of the shooting:  Critical Incident Review: Active Shooter at Robb Elementary School. According to the report, there were multiple things that went wrong during the incident. Most significantly, the police originally believed that the shooter had barricaded himself in an empty classroom, where in fact shooter was in a classroom with students. There were also communication issues that resulted in a common ground breakdown during the response. But what I want to talk about in this post is the keys.

During the response to the Uvalde shooting, there was significant effort by the police on the scene to locate master keys to unlock rooms 111/112 (numbered p14, PDF p48, emphasis mine).

Phase III of the timeline begins at 12:22 p.m., immediately following four shots fired inside classrooms 111 and 112, and continues through the entry and ensuing gunfight at 12:49 p.m. During this time frame, officers on the north side of the hallway approach the classroom doors and stop short, presuming the doors are locked and that master keys are necessary.

The search for keys started before this, because room 109 was locked, and had children in it, and the police wanted to evacuate those children (numbered p 13, PDF p48):

By approximately 12:09 p.m., all classrooms in the hallways have been evacuated and/or cleared except rooms 111/112, where the subject is, and room 109. Room 109 is found to be locked and believed to have children inside.

If you look at the Minute-by-Minute timeline section of the report (numbered p17, PDF p50) you’ll see the text “Events: Search for Keys” appear starting at 12:12 PM, all of the way until 12:45 PM.

The irony here is that the door to room 111/112 may have never been locked to begin with, as suggested by the following quote (numbered p15, PDF p48), emphasis mine:

At around 12:48 p.m., the entry team enters the room. Though the entry team puts the key in the door, turns the key, and opens it, pulling the door toward them, the [Critical Incident Review] Team concludes that the door is likely already unlocked, as the shooter gained entry through the door and it is unlikely that he locked it thereafter.

Ultimately, the report explicitly calls out how the search for the keys led to delays in response (numbered p xxviii, PDF p30):

Law enforcement arriving on scene searched for keys to open interior doors for more than 40 minutes. This was partly the cause of the significant delay in entering to eliminate the threat and stop the killing and dying inside classrooms 111 and 112. (Observation 10)

In hindsight, we can see that the responders got something very important wrong in the moment: they were searching for keys for a door that probably wasn’t even locked. In this specific case, there appears to have been some communicated-related confusion about the status of the door, as shown by the following (numbered p53, PDF p86):

The BORTAC [U.S. Border Patrol Tactical Unit] commander is on the phone, while simultaneously asking officers in the hallway about the status of the door to classrooms 111/112. UPD Sgt. 2 responds that they do not know if the door is locked. The BORTAC commander seems to hear that the door is locked, as they say on the phone, “They’re saying the door is locked.” UPD Sgt. 2 repeats that they do not know the status of the door.

More generally, this sort of problem is always going to happen during incidents: we are forever going to come to conclusions during an incident about what’s happening that turn out to be wrong in hindsight. We simply can’t avoid that, no matter how hard we try.

The problem I want to focus on here is not the unavoidable getting it wrong in the moment, but the actually-preventable problem of fixation. We “fixate” when we focus solely on one specific aspect of the situation. The problem here is not searching for keys, but on searching for keys to the exclusion of other activities.

During complex incidents, the underlying problem is frequently not well understood, and so the success of a proposed mitigation strategy is almost never guaranteed. Maybe a rollback will fix things, but maybe it won’t! The way to overcome this problem is to pursue multiple strategies in parallel. One person or group focuses on rolling back a deployment that aligns in time, another looks for other types of changes that occurred around the same time, yet another investigates the logs, another looks into scaling up the amount of memory, someone else investigates traffic pattern changes, and so on. By pursuing multiple diagnostic and mitigation strategies in parallel, we reduce the risk of delaying the mitigation of the incident by blocking on the investigation of one avenue that may turn out to not be fruitful.

Doing this well requires diversity of perspectives and effective coordination. You’re more likely to come up with a broader set of options to pursue if your responders have a broader range of experiences. And the more avenues that you pursue, the more the coordination overhead increases, as you now need to keep the responders up to date about what’s going on in the different threads without overwhelming them with details.

Fixation is a pernicious risk because we’re more likely to fixate when we’re under stress. Since incidents are stressful by nature, they are effectively incubators of fixation. In the heat of the moment, it’s hard to take a breath, step back for a moment, understand what’s been tried already, and calmly ask about what the different possible options are. But the alternative is to tumble down the rabbit hole, searching for keys to a door that is already unlocked.