Rarely a month passes without U.S. cities erupting in protests and riots, after police officers shoot a citizen. Civic leaders confronting angry demonstrators sagely urge calm, patience and understanding, capped by passionate promises for police reform. Subsequent investigations produce reams of reports, followed by tweaking of policies, procedures and practices. Still, an average of three Americans are killed by officers every day of the year, and the rift between police officers and citizens steadily widens.
A sobering new factor has arisen recently: retribution. Attacks on police officers across the nation leave little doubt that the current “system” of law enforcement is seriously broken.
To stop the mindless killing on both sides of the “Thin Blue Line,” law enforcement might study three incidents:
In Beavercreek, Ohio, on Aug. 9, 2014, 22-year-old John Crawford walked toward a Wal-Mart’s checkout area, carrying a toy rifle and talking to his mother on a cell phone. Two concerned shoppers called 911 to report a man with a gun was in the store. Police officers arrived, confronted Crawford and shouted commands that made no sense to the startled young man. His ostensibly slow compliance prompted police officers to immediately fire, killing Crawford.
On Nov. 22, 1994, Ralph Peterson prepared to fly from Bridgeton, Missouri, to Iron Mountain, Michigan. The pilot acknowledged a controller’s instructions, but mistakenly taxied his twin-engine Cessna onto the wrong runway. A TWA commercial airliner, accelerating to takeoff speed on the same runway, struck the Cessna and sheared its top off, instantly killing Peterson and his passenger.
Both incidents involved systems dependent on human factors, and both ended tragically, thanks to poor communication. Both were thoroughly investigated, but the ultimate outcomes were quite different.
The police-involved fatality yielded no changes in procedures, perpetuating a system that virtually guaranteed the same type of tragedy would happen again. In contrast, the fatal taxiway incident led to positive changes in aviation.
Why such diametrically opposite outcomes? The answer lies in distinctly different "external learning systems." In aviation, an independent team of National Transportation Safety Board (NTSB) experts gathers evidence after an accident, analyzes data, and issues nonbinding recommendations designed to prevent similar incidents. The Missouri taxiway accident resulted in NTSB recommendations that improved pilot-controller communications and signage along taxi routes. Law enforcement has no analogous “external learning system” to prevent future deadly incidents.
Consequently, Americans are dying at an ever-increasing rate through encounters with police. In 2015, at least 1,209 people were killed by police officers. As of Dec. 27, 1,137 people had died this year (killedbypolice.net). According to PoliceOne.com, it is estimated that roughly 25 percent of officer-involved shootings concern mistake-of-fact scenarios like the Crawford shooting.
Indeed, the authors’ sons were killed by frightened, amped-up police officers who made deadly mistakes. Those senseless tragedies drove us to become vocal advocates for systemic improvements in how police-involved deaths are investigated.
As professional aviators with operational and flight testing experience, we know that aviation’s proven protocols could save countless lives, if adopted by police departments. Other high-hazard sectors — medicine, aerial firefighting, offshore drilling, and electrical utilities — have learned from accidents and developed protocols to determine the cause of fatal incidents. These yielded policies, processes and procedures designed to prevent fatalities, as opposed to only finding fault and affixing blame.
For example, the U.S. civil space program suffered a massive tragedy on Jan. 28, 1986. Space shuttle Challenger sat on a Florida launch pad that fateful morning, its external tank and solid rocket boosters sheathed in ice. Halfway across the country, a rocket engineer passionately pleaded with his bosses and NASA managers to not launch Challenger. He repeatedly warned that flexible O-rings between sections of the twin solid-fuel boosters could fail, because they were being exposed to unprecedented low temperatures.
The engineer was ignored, managers gave the “Go” order, main engines and boosters ignited, and, 73 seconds after liftoff, Space Shuttle Challenger exploded, killing seven astronauts.
Subsequently, the Rogers Commission issued a hard-hitting report citing NASA and contractor managers’ failure to heed experts’ warnings as key contributors to the disaster. Recommendations from this outside commission ultimately were adopted, significantly improving the shuttle program’s procedures — and greatly enhancing crew member safety.
Compare the Challenger tragedy’s investigation with those of officer-involved shootings. NASA and its contractors did not investigate themselves. They empaneled independent experts and gave them full latitude to scrutinize the space agency’s processes, procedures and practices. Hence, the Rogers Commission focused on finding causes for the Challenger accident, not assigning blame and punishing those responsible.
Such an independent, find-and-fix approach is rare in law enforcement. Not only do most police agencies investigate their own officer-involved incidents, they focus on whether officers complied with the law and departmental policies, as opposed to identifying correctable causes. Even agencies that generally do a good job of identifying why their officers used deadly force have no vehicle to share those findings. A centralized database to store lessons learned, backed by a robust dissemination system, simply do not exist.
Further, most police agencies that investigate themselves find their officers’ use of force to be justified — and nothing changes.
Albert Einstein described insanity as “doing the same thing over and over again, and expecting different results.” Until leaders examine other high-hazard sectors’ operations and centralized external learning systems, law enforcement will continue to lose trust and credibility. And Americans will continue to die during encounters with police officers.
The President’s Task Force on 21st Century Policing touched on the need for a centralized external learning system. Its final report recommends that “Congress should develop and enact peer review error-management legislation…similar to the Healthcare Quality Improvement Act of 1986 that would support the development of an effective peer review error-management system for law enforcement similar to what exists in medicine.”
Back to aviation: As this chart shows, deaths attributed to aircraft accidents have steadily decreased, even though the number of flights has increased to millions per year. Finding and fixing the cause of accidents, rather than finding fault, has made commercial air travel America’s safest mode of transportation.
Reducing aircraft accident rates is directly related to the NTSB’s independent investigations, which focus on what occurred. A final report and recommendations for preventing future accidents go to the Federal Aviation Administration, which can accept or reject them. Fault-finding is secondary to pinpointing the cause of a deadly accident and fixing whatever contributed to it. Investigation findings also are captured in a federal Aviation Safety Database, ensuring lessons learned are available to everybody in the aviation industry.
We believe aviation’s NTSB model can and should be applied to law enforcement. A new Federal Management System could fund and oversee statewide peer reviews to ensure independent investigations, while prosecutors review incidents in a criminal-law context. Mirroring NTSB processes, incident data and analyses would be tightly held during investigations, then released via public hearings.
Abandoning a myopic focus on fault-finding, and expanding investigations to identify causes that lead to prevention, are essential first steps to build trust and re-establish the legitimacy of today’s law enforcement community.
Michael M. Bell, Lt. Colonel, USAF retired, was a senior command pilot whose son, Michael, was killed by police on Nov. 9, 2004. William B. Scott is a former USAF flight test engineer and retired Aviation Week and Space Technology bureau chief. His son, Erik, was killed by police on July 10, 2010.
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