Learning From a False Alarm

The announcement came a bit after 9 a.m. at the New Hanover County Government Center in Wilmington, North Carolina.

“This is an exercise. This is an exercise. This is an exercise,” said the voice of County Manager Chris Coudriet, blaring from speakers throughout the building on August 1. “There is an active shooter in the building.”

Coudriet, hearing his own voice in his office, was confused. The recorded message had been used in October for a pre-planned active-shooter training for employees, but he wasn’t aware of any scheduled follow-up drills. It would be unusual, he thought, for the county’s risk management team to spring an unplanned exercise on the government complex by simply playing the message without first alerting administrators. But maybe they had.

“Because we do fire drills on a regular basis, we’ve all been conditioned. When we hear a message and it says, ‘This is an exercise,’ we move into the protocol we have in place,” Coudriet told Route Fifty. “So I, along with everyone in the suite I was in, started to exit the building.”

Outside, Coudriet encountered Jennifer Stancil, the county’s risk manager. The county did not have an active-shooter training planned, she told him. It was still unclear what was happening, but the decision, Coudriet said, was obvious: treat it like a real emergency until it’s proven not to be one.

“I would say within 90 seconds or less of hearing that message, it was confirmed by our risk manager, our emergency manager and others that, wait a minute, this was not an exercise,” he said. “So it was effectively never treated as such.”

New Hanover County, a southeastern coastal county with about 227,000 people, did not have an active-shooter protocol in place until 2016. The October 2017 drill was the lone large-scale test of the policy, which instructs employees, depending on their location and proximity to the shooter, to “run, hide or fight” during an active threat, Stancil said.

On Aug. 1, employees adhered to that training, either sheltering in place or evacuating the building as the emergency management director contacted 911. Dispatchers, located onsite at the government complex, alerted law enforcement but did not characterize the incident as a drill. First responders arrived and set up a command center in the parking lot, then did an initial sweep of the building to determine whether an active shooter was present on the property.

“Once that was done, they then had to do a much more detailed sweep of the building, checking every office, every closet and behind every door,” Coudriet said. “This is a large complex, so that took an extended period of time.”

During that process, Coudriet and other officials began piecing together what had happened. The active-shooter protocol allowed county employees working in the sprawling government complex to punch a code into their phones to trigger the alarm “in case it happens in one office, so it can go out throughout the government center,” Stancil said.

This was the likely explanation, administrators figured, despite the alert’s repeated insistence that ‘This is an exercise.’ That message, originally recorded for the drill in October, had never been updated to omit the disclaimer, Coudriet said—meaning it’s the only recording an employee could have disseminated to signal a threat.

“When that message was set off, it should not have said, ‘This is an exercise, this is an exercise.’ It should have simply communicated, ‘There’s an active shooter in the building,’” Coudriet said.

After law enforcement officials cleared the building, the county’s technology team and risk managers went inside to confirm that the alarm had been initiated from a handset inside the offices.

“That’s when we definitively said it was an inadvertent action,” Coudriet said. “I would say we felt we had a pretty good handle on it within 30 minutes of the message. But once that event started there was no way that law enforcement or anyone else was going to suggest that we not advance this through the entire effort.”

The employee in question wasn't aware of having triggered the incident, because the process for setting off the alarm was nearly identical to other routine tasks, Coudriet said.

“When the notification effort was established, we wanted to make it simple, and in making it simple we created a step that was too similar to using the phone for regular business,” he said. “That has since been changed.”

The employee was not disciplined. After the unplanned drill, Coudriet addressed employees and told them it could have happened to anyone.

“Anybody in that room could have done it,” he said. “Anybody in this building who uses our system could have set that off.”

In addition to modifying the alarm trigger, officials updated the alert recording to take out the "exercise" language and implemented all-clear messages to signal the end of an active threat. The incident wasn’t exactly a happy accident, but it did allow the county to assess in real time the efficiency of a relatively untested policy, Coudriet said.

“It pointed to existing deficiencies in our protocols, and there have been changes... but it also demonstrated that there were things that were obviously improved from the exercise in October,” he said. “There is a silver lining in every cloud. I wish we had not put our organization and law enforcement and the people in the building consuming public services at the time through this. We would not have planned it this way, but there are certain things that we have learned and are implementing and are continuing to implement.”

Other municipalities can learn from New Hanover County’s experience, Coudriet said. The incident demonstrated that it’s crucial to have specific plans for various threats and to train employees on those protocols.

“We’ve done that. We’ve made changes—there were things we learned in October that we probably didn’t advance enough. There’s been incremental progress,” he said. “When you have that exercise, learn from it. When there is a real event, learn from it. Make changes. It’s a continuous process.”

Municipalities should also recognize that responses will sometimes deviate from the plan based on the specific situation, Coudriet said.

“There’s going to be a plan in place that articulates the basic principles of what we need to do, but every exercise will be a little different and we need to learn from that,” he said. “It is a continuous planning effort that hopefully none of us ever have to deploy, but it’s important that there is a plan, and that you exercise it and learn from it.”