As I sit down to write, it has been just over 72 hours since 26 people stood dumbfounded on a North East Ohio range. What had taken place seemed nothing short of unbelievable. Regardless of how it seemed, it had happened. Our ears were ringing and the gun had fired…
72 hours seems like a long time. In fact it seems like an eternity. It’s taken 3 days to start actually assembling the situation into a shareable format for several reasons, but maybe the most important reason is that the lessons to be learned are so important that they need to be clear and well organized despite the fact that I don’t really want to write them…
My goal is simple with what I am going to share:
I want to help others to avoid the situation that the 26 of us faced. I want others to avoid the potential consequences that could result from the mistakes that we made on the range.
What I don’t want to do is place blame. Instead, I think it is most appropriate for me to simply accept responsibility for my own actions where appropriate. I will not avoid pointing out where I disagree with the assumptions, policies and actions of others. My intention is not to disparage or disrespect anyone. Instead, my goal is to provide appropriate lessons so that this type of situation can be avoided in the future.
You see, LUCK is the only thing that kept someone from death or serious injury. CHANCE is the only reason an amazing firearm training facility isn’t facing closure. A ROLL OF THE DICE and the kind nature of the range owner is the only reason I’m still allowed to conduct firearms training at the facility. I don’t want to rely on LUCK and as difficult as it may be to admit, we didn’t have to rely on luck. We could have taken steps that would have certainly prevented the situation.
We didn’t take those steps. Hell, we didn’t even recognize them at the time. Instead, lack of attention followed some small errors that followed simple oversights which resulted in a potential catastrophe. If you spend any time studying disasters, you quickly find out that rarely is a single decision or action the cause of the misfortune. Instead, errors stack and eventually reach a point where the situation is virtually irrecoverable. A perfect example of the compounding impact of stacked errors is the sinking of the container ship El Faro. It isn’t a gun story, but the conceptual transfer is there. I think it is worth a read especially if you find yourself in a position of leadership on the range.
Sometime between 1:00 and 1:30 PM on our fourth day of training, while standing on a “cold” range, in a group away from the firing line, Massad Ayoob drew a .38 double action revolver from a Massad Ayoob Group Instructor’s holster in order to demonstrate the proper trigger press of the DA revolver. Mas opened the cylinder of the gun to verify that it was unloaded, and then closed the cylinder as he raised the gun slightly above his head and directed the muzzle skyward. Massad spoke briefly about the trigger press, placed his finger on the trigger and pressed it smoothly to the rear. The wheel gun bucked and barked and a .38 caliber slug left the range.
As I mentioned above my primary goal is to analyze my actions (or lack of action) in this situation. No, I am not ultimately responsible for the situation. I had the opportunity to speak with Massad by phone briefly yesterday afternoon, (May 24, 2018,) and he made it clear that he accepted responsibility for the negligent discharge. We will take some time to examine what Mas (and others) could have done differently to prevent the situation, but neither you nor I will ever have the ability to control other people. What we do have the ability to control is our own behavior.
I could have taken action to prevent this incident and I did not. With the aid of hindsight it is easy to see the chain of decisions I made that allowed the situation to take place. Looking back it is easy for me to identify key moments where taking some uncomfortable but simple action would have changed the course of the day.
Many folks have communicated with me both publicly and privately encouraging me to stop kicking myself. The sentiment is appreciated, however, I don’t feel like I am beating myself up. Instead I am openly and honestly taking stock. Just because we got lucky this time doesn’t mean we will get lucky next time. Instead, as a professional defensive shooting instructor that hosts other instructors, I need to be ready to seize the opportunity and create a safer situation on the range for all involved when necessary.
A Cold Range Mentality
The range portion of the MAG-40 is run as a “cold” range. On a cold range, every time a shooter completes their turn on the firing line, their gun is inspected to ensure that it is unloaded. Cold ranges are typically run with the objective of increasing the level of safety for all involved. Theoretically, if a student makes an error with gun handling or gun safety, the consequences will be avoided because of course, the gun is unloaded.
I don’t run a cold range. Instead, for Safety Solutions Academy courses, I run a “hot range.” I expect students to assume the very serious responsibility for the loaded gun that they are carrying on the range and intend to carry in the real world.
In my experience, cold ranges, can foster a mentality that the unloaded gun can be handled with a different set of rules than the loaded gun. The problem is that because people make mistakes, eventually a gun that is assumed to be unloaded isn’t. I saw the cold range double standard developing with both students and instructors as the course progressed. The primary example that I should have been more aware of was how safety infractions were assessed. One student in particular had two relatively serious safety infractions. MAG instructors allowed the student to continue with the course after the safety violations. I actually don’t have an issue with the continuation. What I do take issue with is that it seems that the condition of the gun was a significant factor in why the student was allowed to continue. In the case of both situations the continuation was justified with a statement of something like, “and the gun was unloaded.”
My failure in this situation was the fact that I did not protest the justification for the continuation of the student. A simple protest of, “the condition of the gun is irrelevant to this situation” could have spurred a conversation to help and dispel the cold range mentality that had developed.
Cold ranges are a thing and cold ranges are utilized frequently. I doubt I am going to have a significant impact on the practice. What I do hope to do is impact YOUR mentality when on a cold range.
As I saw the issues developing I should have had the courage to speak up and make my observations clear to all involved.
The Bystander Effect
Speaking of having the courage to speak up, I feel fairly confident that I allowed the “Bystander Effect” to prevent me from intervening when I needed to stop our progression toward potential disaster. You can read a bit about the bystander effect here or here.
I feel like the primary aspect of the bystander effect that was at play was “Pluralistic Ignorance.” The gist is relatively simple, when in a group of people are faced with a situation that presents some kind of a gray area, people are less likely to intervene. It could be a fear of embarrassment if you find that you are wrong or overreacting, or even just a questioning of your desire to react when you see others not reacting. The larger the group the stronger the bystander effect seems to be.
Looking back, I can distinctly remember specific points in class where I was uncomfortable with actions that were being taken. Moments before the gun fired, when it was being drawn, I made eye contact with another instructor who was in attendance at the class as a student and he made eye contact with me. It’s as if we were both sizing up the situation and the other’s reaction to it to decide our course of action. Obviously, I know now that I should have acted. At the time, however, that was not the conclusion I came to. Instead I made the decision to ride it out.
I don’t need the approval of others in order to take action
The larger the group of people, the more committed I need to be to take action.
Speaking up in this MAG-40 wasn’t an easy task. After all, the group of people was 26 strong and included a significant number of firearms educators. Despite the fact that I was the host and my extensive experience teaching, it simply seemed that my interruption would likely be just that, an interruption. Let’s face it, no one wants to be THAT GUY!
The tone of the class had been set from day 1 at an intense rate. Mas rarely took the time to allow students to finish their questions before rolling into his answer. On the range, the pace was similar and with 26 people there was a push to keep things moving so that we could finish on time.
The size of the group and the pace shouldn’t have entered in to my willingness to interject with regards to safety, but that may have been a factor.
I Don’t Need Your Approval
You and I might disagree about cold ranges vs. hot ranges. I am O.K. with that disagreement and a difference of opinions can’t keep me from speaking up when things seem to be headed sideways. As an accomplished instructor, I know where the boundaries lie when it comes to safety and safe gun handling for me and it is imperative that I hold my ground related to these beliefs.
Mas’ actions were clearly outside my gun safety comfort zone. I don’t prefer to draw a gun from a holster in a gaggle of people. Instead, I prefer to have the person with the holster gun step to the firing line and when given the command draw to the low ready. I can then take the gun from the individuals hand and have the students assemble in a semi-circle around me to witness whatever demo I have planned. Why in the world would I allow another instructor to operate at a lower standard than I expect of myself when it comes to range safety?
I also require that any gun that will be used for a dry-fire demonstration be cleared by a minimum of two people directly before the demonstration. After the gun came out of the holster only one person cleared the gun. I didn’t stop the action. Instead, I let it ride.
On the range, I teach that there are two directions that can be considered “relatively safe” and are acceptable directions to point the gun; at the ground and at the backstop. The ground must be a relatively safe direction or we would never be able to draw a gun from a holster. The good news is that the ground is a relatively safe direction at our range with its soft sandy floor. The other “safe” direction is the backstop. Made of soft sandstone and 90 feet tall it is about as forgiving as it gets. Although there are times when muzzle up can be a relatively safe direction, on the range in our circumstances, it wasn’t.
I did not interfere when a hastily “cleared” gun was pointed skyward with the intent of pressing the trigger. It was an UNSAFE direction and an unsafe action.
Instead, I rolled the dice.
And I lost.
At any of these times I could have spoken up and potentially altered the course of events, but I did not. Was it the bystander effect? It seems to fit. Others have suggested that I didn’t speak because I was kneeling at the feet of my guru… I suppose that could be the case too, but I don’t really think so. I don’t think I held my tongue because I held Massad Ayoob in high regard. It is much more likely that I stayed quiet because I held my own beliefs in an unfortunately low regard.
We will never know what role the size of the group, their potential disapproval or what role the industry status of Massad Ayoob played in my failure to speak up. I do believe that all of these factors need to be considered the next time I host or attend a course so that I can be more prepared to act should a safety situation develop.
The negligent discharge took place at the halfway point of day 4 and there is no doubt that everyone involved was spent. Some may have been more fatigued than others. As we are learning more and more about fatigue it is becoming clear that being tired can significantly impair our motor skills and even our ability to make good decisions. As I look back on the incident I can’t help but wonder what role fatigue may have played.
I am a prime example of how fatigue may have been an issue. As the course host I had been awake late at night and up early each morning to make sure everything was in order for class. Although I am used to a hard schedule, when it is a class it is more intense than usual, but I don’t think that was the tough part. Remember our student with safety issues? I was his shadow making constant corrections and physically interacting to ensure safe trigger finger discipline and muzzle orientation when the gun was coming out of the holster and moving back in. Often I was dealing with both trigger and muzzle issues at the same time. This was mentally exhausting. When Mas was teaching and students were off the line, it was my time to grab a couple of deep breaths, a sip of water and get re-energized for the next experience at the line physically correcting this student’s trigger finger and muzzle direction.
The Environmental Push
The weather can have an unfortunate impact on firearms courses that are held outdoors. Unfortunately, the course was threatened with a severe thunderstorm watch throughout day 4 and as a result we pushed the course hard to avoid delays from the impending storm. To that end it was decided that we should skip lunch and continue shooting. In hindsight, that may not have been the best choice. The decision to skip lunch both intensified the pace of class and eliminated a rest period. Could these factors have an impact on the situation? No one will know for sure, but it certainly is plausible. If you have ever taught you will understand that it can be a particularly fatiguing activity and when that teaching takes place under a time crunch the fatigue can be intensified. I know that it was that way for me and my fatigue could have been a reason I didn’t speak up. I don’t presume to know how fatigue may have impacted others that were involved, but it doesn’t take much imagination to consider how it could have been a factor.
It is certainly possible that exhaustion played a role in the ND. Keep in mind, in the minutes preceding the ND 3 capable Massad Ayoob Group Instructors visually examined the gun to verify that it was unloaded (two instructors interacted with, checked and holstered the gun before we grouped up.) All three were incorrect regarding the condition of the gun. I suppose it may have been carelessness or simply a cursory check without the required attention for it to actually matter. Even if it was one of those situations, what contribution did fatigue have? We can’t ever answer the question, but we can and should factor fatigue in future safety related decisions.
As the saying goes, hindsight is 20/20 and in my opinion it is imperative that we take advantage of that clear vision so that we can cull the most important lessons and move forward toward a safer next time. To that end I want my final thoughts to include the most important lessons that I have learned from this incident.
The condition of your gun shouldn’t change how you handle it.
If you are a firearms instructor you have to decide what the best way is to run your range. I know what I believe to be the best way in most circumstances and that is a hot range where guns are loaded in the same condition they would be in if you were carrying them on the street. You may decide differently. If you run a cold range or you participate in events or courses on a cold range you must recognize that the “unloaded” condition of your gun should not effect the manner in which your gun is handled. If you find yourself with one set of rules when your gun is loaded and another set of rules when it is not, you are setting up yourself and those around you for a potentially tragic situation.
Factor in Fatigue.
When it comes to training, practice and handling of firearms you need to consider your level of rest. An increase in fatigue brings with it a compromise in your ability to perform physical skills and a decreased ability to make quality decisions. When you are tired you should consider significantly increasing your attentiveness to firearm safety and accept that getting rest prior to continuing your activity may be the safest choice even if it has inconvenient implications.
In General, Up is NOT the Safest Direction.
There are certainly times when the safest direction to point a firearm is up. In general, up is NOT the safest direction. On the range, performing a demonstration, especially one where the trigger is being pulled, up is a poor choice. On the range, the best direction for a gun to be pointed is at the backstop which is the specific place where we want bullets to impact. In Massad Ayoob’s blog post detailing the incident he comments,
“What prevented tragedy was Layer five: the gun pointed skyward, in an area where there was virtually no likelihood of a bullet fired straight up coming down anywhere it couldn’t be safely absorbed.”
I respectfully but firmly disagree with Mas on this point. The only thing that prevented tragedy in this situation is the luck that we have enjoyed because the slug doesn’t seem to have caused any harm.
The backstop is the best direction to point a gun regardless of it’s condition. Having an ND is nothing to laugh off, however, having an ND where a round leaves the range is significantly more dangerous than an ND where a round impacts the backstop. Taking the time to physically move students so they can safely see the demonstration, or taking the time to repeat the demonstration is well worth eliminating the real risk that EVERY round that leaves the range carries with it.
The most important lesson that I am taking away from this situation is the lesson that I need to take action and speak up. Throughout the course of the weekend I saw the problems stacking, but I didn’t think they would lead to the ND. Each problem on it’s own seemed manageable, but when they were all combined the outcome was unacceptable. I now have a frame of reference as to how important each individual problem can be and as a result I know how important it is for me as a shooter, a course host and a competent firearms instructor to take action and make my voice heard.
The simple article would have been to lay the blame at the feet of the man who pressed the trigger. Of course there is truth there. Massad Ayoob failed to properly ensure that a gun was unloaded and when he pointed it in the air and pressed the trigger the gun fired. In my opinion, that needs no clarification due to its obvious nature. The fact is these situations are more complex than the obvious shows. Placing the blame solely on Mas stifles the examination of the totality of the circumstances and it would be parallel to exclaiming that the cargo ship El Faro sank because it wasn’t strong enough to weather the storm. This type of oversimplification circumvents the opportunity for growth and learning and that is what I am after both personally, professionally and if possible for the industry as a whole. That growth requires difficult conversations, in-depth consideration, and relentless accountability all followed by an increase in expectations from all involved.
I hope that in reading this account you were able to take away some important lessons that make your next trip to the range to practice or train a safer experience for yourself, those that you love and others that are involved.
You can read Mas’ account of the event at his blog here and John Johnston’s thoughts here as he was also on the range at the time. Massad has requested that questions and comments be posted at his blog so that he may respond. I think it makes sense to carry on a conversation with Mas. At the same time, I would guess that Mas has already taken his lessons from this situation. For that reason I would ask that if you feel there are valuable lessons to be learned from what I have written spread the article and the conversation far and wide so that as many people as possible can benefit from those this unfortunate incident.