Three Spectacular In-The-Moment High-Stakes Decisions that Saved Lives – SDP#9

Lessons of Lower Manhattan

A Contrarian’s Perspective of the Unconventional, Exceptional Rescue of 500,000 People

By David Perrodin, PhD

Submitted for publication in School Business Affairs, February, 2017

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Anything You Want and Not Everything You Want

I worked with a school business manager who regularly reminded administrators and school board members that he could do anything that they wanted and not everything that they wanted.  His moniker was especially relevant amongst the cyclonic opinions that school safety must center expensive fortifications.

Regrettably, public perception about the issue is strongly influenced by field experts making recommendations often extremely disconnected from what has been revealed by empirical studies of the topic. Hysteria following the Sandy Hook massacre led to 450 school safety state-level legislative bills.  Some bills called for the elimination of windows in schools or arming staff even though such measures were not validated by research findings.  In fact, a large-scale study correlated the positive impact of natural sunlight in schools to students’ academic achievement.

The Colored Perception of School Safety

Business officials should know that investing in school safety has little to do with fancy surveillance cameras, expensive fortifications, thick crisis response binders or gruesome interagency active shooter simulations.

Surveillance is a forensic tool. Do not succumb to the passionate sales pitch that alleged real-time video monitoring of the school by responding squads will pinpoint a swift tactical nullification of the active shooter.  Likewise, fortifications are short-circuited by active shooters who can wait for children to spill across playgrounds.  Reliable locks and sturdy entrance and classroom doors are requisite items, but bullet-resistant glass panes are simply not worth the investment.  Crisis binders are either ignored or irrelevant in crisis situations as the authentic event doesn’t match a scripted contingency.

Interagency drills have become theatrical performances of adults and children “playing dead” in hallways and classrooms, resulting in a growing number of staff and students diagnosed with drill-induced stress disorders. If such a training method was ideal, then why don’t we litter hallways with burnt debris and pump artificial smoke into schools during fire drills?  Does anyone have a barn fan available for the tornado drill?  Beyond treating intruder drills with greater sensationalism than other sentinel events, we tend to overlook that the external people you drill with won’t be the same people responding to an all call of an active shooter at your school – even if that intruder event happens the very next day.

School Safety is Heuristics

School safety is about the process of identifying and maintaining heuristics.  It’s knowing your options and keeping as many options on the table as possible.  In most high-stakes safety situations, responders will be on scene within minutes and the incident command system will default to law enforcement.

Schools need to plan for about 8-minutes [into] any event. That’s it.  Regardless of your plans for offsite re-unification and such, those will all be shaped by the context and situation.  For example, you will have no idea of the perimeter that will be established by law enforcement or potential involvement and access to locations within the perimeter.  These will be fluid decisions.  Allowancing for adaptable decisions affords greater flexibility in responses to a sentinel event.

Distributed Leadership. Up until the past decade or two, we could reliably count on the inculcation of legacy knowledge to staff and students due to the predictable, paced turnover of staff and students. Today, school leaders maintain their posts for a scant 3 year span; teachers leave and enter the profession in droves and student cohort survival rates spiral downward in a transient society.  There’s much fluctuation in the administrative, staff and student rosters of contemporary schools.

I believe that we have crossed a threshold in which the constant churn of principals, teachers and students has brought the theoretical framework of distributed leadership to extinction in some districts and squared to the endangered list in remaining districts.

(James) Spillane (2005) defines leadership as a practice that unfolds among diverse leaders and followers in specific situations. He suggests that leadership is not only shaped by people interacting with one another, but also by certain tools and routines they employ in carrying out their work together (p. 146). Examples of tools of practice include safety flip charts and student assessment rubrics.  Instances of routines of practice include daily “walk-throughs”, weekly collaboration sessions and fire drills.

As found in Spillane and Orlina (2005, pp. 158-159), “Leadership refers to activities tied to core work of the organization that are designed by organization members to influence the motivation, knowledge, affect, and practices of other organizational members or that are understood by organization.”  These tools and routines are core, not peripheral, elements of leadership practice in many school situations.  Given that there appear to be few formal tools and routines of practice employed around leadership practices that prepare schools to be safe from low-incidence episodes of violence, the discretion that leaders use in this area emerges as an area of educational leadership research that is especially of note.  This in-the-moment discretion demarks an evolution from distributed leadership to sensemaking as the desired approach by which to situate school safety decision-making.  Wall-hanging flipcharts are artifacts of an ancient safety world.

Sensemaking.  First, we need to consider (Karl) Weick’s suggestion that in decision-making there is an important intersection between experience and learning.  Weick defines the process by which people give meaning to experience as “sensemaking. Per Weick, Sutcliffe, and Obstfeld (2005):

There are three main attributes of sensemaking. First, sensemaking occurs when a flow of organizational circumstances is turned into words and salient categories.  Second, organizing itself is embodied in written and spoken texts.  Third, reading, writing, conversing, and editing are crucial actions that serve as the media through which the invisible hand of institutions shapes conduct. (p.409)

I have found similar crossroads where people needed to draw from their experience and at the same time be open to doing new things.  This would be vital during an unfolding safety situation to ensure that contextual factors are continually processed and individuals’ responses are adjusted to match their environment—which the sailors in lower Manhattan did so successfully on September 11, 2001.

The Lessons of Lower Manhattan

I believe much can be learned from analyzing the improbable evacuation of Manhattan on September 11, 2001, as documented in the 11-minute film Boat Lift (Rosenstein, 2011).  Specific areas to study include discretion in decision-making, sensemaking, distributed leadership, and highly effective coordinated response without any planning, tools, or practice.  The underlying question is whether we should continue to prepare people to execute rote actions in situations we expect to be unpredictable, chaotic, and dynamic?  Note that this is the standard manner in which educational leaders prepare staff and students for high-stakes school safety situations.

Boatlift documents the maritime evacuation of Lower Manhattan on September 11, 2001—the largest water evacuation in American history.  Five hundred thousand (500,000) people were transported to safety in approximately nine hours by hundreds of vessels that answered a call from U.S. Coast Guard Admiral James Loy for anyone with a boat to assist in the evacuation of Lower Manhattan.  He had no protocols to follow, no flip charts or flow charts.  His instructions were simply for boat operators to assess the situation and do whatever they could safely do to rescue people.  In Loy’s words, “The real reality after I put out some direction was in the hands of commanders and captains who were the respective captains of the port and did what they needed to do, including all the stuff I told them to do and whatever else they felt was appropriate” (Rosenstein, 2011).

Such loose directives, especially in the context of the unprecedented chaos following the attack on the World Trade Center, seem like a guaranteed prescription for monumental failure, and yet the evacuation was accomplished without injuries or fatalities.  So, what were the factors that contributed to the success of this evacuation?

Success Factors

  1. Responders were given permission to exercise discretion.
  2. Responders were not attempting to match responses to scripts.
  3. Responders were effective in sensemaking in the midst of evolving, and uncertain contexts and situations.

Throughout history, the ability to exercise discretion in the best interest of others appears strongest in situations in which the person making the decision feels that the “greater organization” will vindicate the decision. It’s the “I’ve got your back” principle.  This was as apparent in the September 11, 2001 rescue as it was in the April 29-30, 1975 military evacuation of South Vietnamese citizens and American personnel from Saigon.

Code-named Operation Frequent Wind, the speed of the Saigon evacuation and number of people involved created an unforeseen scenario of ships overwhelmed with people and the helicopters that brought them. Some ships struggled to maintain buoyancy.  Orders were given to push surplus helicopters over the sides of the ships to make room for more people.  Some pilots dropped off passengers and then ditched their machines at sea.  Over 7,000 people were evacuated in Operation Frequent Wind.  Commanders that made decisions to plunge aircraft were not reprimanded.  In fact, all personnel who participated in Operation Frequent Wind were authorized the Vietnam Service Medal, Vietnam Cross of Gallantry, and Humanitarian Service Medal.

Practice Implications

Give Staff Permission to Make Decisions.  At first glance, this might appear to be a ridiculous directive.  One would assume that life preserving actions are primal.  Yet, (1) humans are conditioned to follow directives, and (2) we did not evolve to survive shooting rampages.  There are numerous documented instances of people overlooking near-obvious passages to safety as they awaited a directive from someone perceived to be in a position of authority.  Be overt in communicating the following points to all staff:

  1. Defend because you have the right to protect yourself.
  2. Be aggressive and committed to your actions.
  3. Do not fight fairly. This is about survival.

Balance Interagency Simulations with Less Invasive, Cerebral Tabletop Exercises. A tabletop exercise is a meeting to discuss a simulated emergency situation.  Participants review and discuss the actions they would take in a particular emergency, testing their emergency plan in an informal, low-stress environment.  Tabletop exercises are used to clarify roles and responsibilities and to identify additional mitigation and preparedness needs.

A significant benefit of a tabletop over an authentic full-scale simulation is that the tabletop more efficiently embraces variable interjects.  Hence, several “curve balls” can be introduced to the scenario in response to the real-time decisions of the participants.  For example, a tabletop drill that involves a decision to evacuate students from a school following the discovery of bomb threat could take an interesting twist if the person leading the exercise said, “Students are refusing to leave without their backpacks.”  OK, the drill can pause and participants can discuss options.

Following a completed tabletop drill, the participants should study the granular steps that were taken throughout the drill.  The purpose of reflection is often judged to be evaluative of the decisions.  However, decisions are contextual and situational and should only be assessed within those parameters.  Greater value is found in scrutinizing the heuristics of decision-making.  In other words, what were the available options at the time?  What other options could have been considered?  What was the process for determining the selected option?  Such decision reflection is commonplace to “military games” and readily generalizes to schools conducting tabletop exercises.

Analyses of decision-making in the military points to a specific procedure for understanding why and how decisions were made in a specific context. This popular method, which scrutinizes the process of decision-making, is known as applied decision analysis (ADA). Per Mintz and DeRouen (2010), “Applied decision analysis is an analytic procedure to recreate or ‘reverse engineer’ a particular decision-making process.  It is an effort to ‘enter the minds of decision makers in an attempt to uncover their decision rules’” (p. 80).  ADA is a two-stage process: the first step is to identify the matrix used by the leader, including the alternatives available and also the criteria for decision-making; the second step is to identify the options judged to offer maximized benefits and minimized risks.  ADA is an appropriate tool to study heuristics in decision-making.


The Lower Manhattan rescue taught us that one of the greatest challenges of contingency planning is making sure you don’t plan too much.  Having options offers flexibility and the ability to precisely align responses to developing contexts and situations.


Mintz, A. & DeRouen, K. (2010). Understanding foreign policy decision making. New York: Cambridge University Press, pp. 73 & 80.

Rosenstein, E. (2011). Boatlift [Motion picture]. United States: Eyepop Productions. Retrieved from

Spillane, J. P., & Orlina, E. C. (2005). Investigating Leadership Practice: Exploring the Entailments of Taking a Distributed Perspective. Leadership & Policy In Schools4(3), 158. doi: 10.1080/15700760500244728

Weick, K., Sutcliffe, K., & Obstfeld, D. (2005). Organizing the Process of Sensemaking. Organizational Science, 16(4), p.409.