The "fog and friction" of an active-shooter drill, mixed with a mass casualty response exercise nearby at Wright-Patterson Air Force Base, Ohio, led a security forces airman to erroneously fire his M4 carbine through a locked hospital door last summer, according to an Air Force investigation.
There were communication lapses throughout both drills, especially when a real-world medical incident caused members involved in the casualty drill to report to the base hospital's emergency room, according to a command-directed investigation released Wednesday.
"There should have been a knowledge of the events that were taking place," said Col. Thomas P. Sherman, 88th Air Base Wing and base commander, in a follow-up phone call with reporters Wednesday.
The active shooter exercise was planned for noon Aug. 2 and executed by the 88th Air Base Wing Inspector General (88 ABW/IG), which also produced a master scenario events list, officials said. The drill was conducted at the base's Kittyhawk Chapel, located about a mile from the hospital, with role players simulating casualties.
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According to the report, the 88th IG was aware of the nearby mass casualty exercise, held by the 88th Medical Group (88 MDG) at the WPAFB Medical Center to test their mass casualty response procedures. But it was not incorporated into master scenario events list for the day.
As the exercises progressed, things began to go wrong when a jogger -- an 88th MDG employee -- called another 88th MDG member "who was screaming and crying due to an injury received while running" on base, the report said.
"This was the beginning of bleedover from exercise to real-world events," as the jogger was located and brought to the hospital's ER, the report said.
"Simulated casualties for the 88 MDG exercise were reporting at the same time as the real-world injured jogger and at the same time first responders were responding to the active shooter exercise at the chapel," officials said.
Those acting as patients of the mass casualty exercise -- wearing painted blood and other mock injuries -- converged with the screaming jogger in the emergency room, Sherman said.
It "was a convergence of multiple events that were taking place at the exact same time," he added during the phone call, calling the events "poorly planned."
"There became a belief, and a sincere belief, that this was an actual active-shooter event," Sherman said of the two simultaneous exercises, plus the injured jogger. "That began the cascading effect of 9-11 calls."
Because of the additional confusion and crossover of personnel, someone at the medical facility called in a real-world shooter incident. The hospital staff also issued a "code silver" over the intercom, a code informing hospital personnel that an active shooter situation is in progress and initiating a facility lockdown, investigators said.
"After hearing the 'code silver,' an 88 MDG employee in the hospital Red Clinic called 9-11 via cell phone, which sends the call off-base to the 9-11 Call Center," the report said. "This led to a 'code 99,' or officer in distress call, among civilian law enforcement agencies. The 'code 99' resulted in notification and activation of mutual aid responders from the Dayton area, the state of Ohio, and at the national level (FBI, ATF)."
Security forces on base also responded to the hospital where the real-world shooter incident was reported.
Members of the 88th Security Forces Squadron (88 SFS) came upon a locked door in the hospital center. An SFS airman fired "rounds from an M4 through the window of the door, causing additional 9-11 calls to be made from the hospital reporting a real-world active shooter," the report said.
"An M4 was used to breach a locked door that could not be opened with a key card," the investigation said.
In the follow-up interview with reporters, officials would not comment on whether anyone had been trying to barricade themselves behind the door the airman fired at. Sherman said that finding is part of a separate investigation headed by the Air Force Office of Special Investigations, and that those findings were referred to the member's commander to take appropriate action.
Sherman said five rounds were fired because five shell casings were found, disputing previous reports that three rounds had been fired. The airman successfully breached the door -- the entrance to the Red Clinic -- after firing his M4, Sherman confirmed.
"The hospital was in operation," he said, without confirming whether there were people directly behind the Red Clinic door.
The investigation also found lapses in communication protocols.
"Mutual aid responders had challenges communicating with the incident commander (IC)" heading the active-shooter drill, the investigation stated.
In addition to incompatible radio connections between the Air Force and local law enforcement systems, the IC "was not immediately and readily identifiable," the report said. "This added to the confusion for mutual aid responders who did try to check in" with officials when they arrived on base.
Once the airman fired his M4, the IC attempted to explain the situation and otherwise stop the security forces team. But because the IC wasn't properly identified, "approximately 50 area mutual responders bypassed the IC, breached the locked front door of the hospital and entered with weapons drawn," officials said.
The active-shooter drill occurring at the Kittyhawk Chapel was known base-wide, Sherman said. But the unit-level mass casualty drill at the hospital center was not.
Effective base-wide communication must happen before simultaneous events like this occur, especially an active-shooter drill, Sherman said, agreeing with the report's recommendations.
"While realism is important in training exercises, all personnel must always be fully aware of exercise vs. real-world situations," investigators said in their final recommendation. "Coordinating with all concerned organizations and then sticking with the agreed-upon plan is essential to keeping everyone fully aware."
That also goes for first responders working the scene, the report said.
"There needs to be a better process for security forces to identify themselves to personnel taking shelter," it said. "Air Force personnel are trained to 'Run, Hide, Fight' while in shelter. If personnel follow this training, it is imperative they know how to identify friendly forces and when the 'all clear' is given."