Mass Violence Investigatory Board

Ceasefire Oregon Education Foundation Calls for A National Mass Violence Investigatory Board

In response to Senator Wyden’s July 2016 forum about gun violence research, Ceasefire Oregon Education Foundation (COEF) recommends the creation of a National Mass Violence Investigatory Board (MVIB) similar to the National Transportation Safety Board.

Currently, all deaths related to aviation, marine, pipeline, railroad and many highway accidents are investigated by the National Transportation Safety Board. COEF proposes a new MVIB be modeled after the NTSB. (MVIB would not replace NTSB.)

In 2013 alone, more than 84,000 people nationwide suffered a gunshot injury. More than 33,000 were shot to death. Approximately two-thirds of those deaths were suicides.

In the same year, the National Transportation Safety Board recorded 32,719 highway fatalities, 891 rail fatalities, 443 aviation fatalities, 615 marine fatalities and 10 pipeline fatalities.

Although transportation-related deaths are comparable to firearm-related deaths, the United States does not have a government agency dedicated to investigating and reducing shooting deaths. Based on the comparable death rate, COEF urges the creation of an agency dedicated to investigating shootings and making recommendations to reduce gunshot death and injury.

2012 Data Chart

The two overarching goals of the MVIB would be:

  1. To conduct objective, precise investigations and safety studies; and 
  2. To advocate and promote safety recommendations.

Benefits of a MVIB would be:

  • Improved, standardized, unbiased investigative techniques. 
  • Recommendations for building design and materials, firearm design, best practices for responding to and surviving active shooting situations.
  • Unbiased, professional data about gun-related deaths shared with gun violence prevention researchers.
    • Better data could allow researchers to identify patterns by observing a series of incidents.
    • Provide unbiased, professional recommendations to prevent future shootings.
  • Remove the financial burden of an extensive investigation from small towns and counties.

The NTSB works with many groups from airframe manufacturers to weather specialists. In a similar way, MVIB would work with trauma specialists, building designers, field medics, gun designers, psychologists, domestic violence experts and suicidologists.

A MVIB Team structure could parallel that of the NTSB:

  • A “Go Team” is lead by the Investigator in Charge (IIC) who is a senior investigator with experience. 
  • Each “Go Team” member is a specialist responsible for a clearly defined portion of the investigation.
  • OPERATIONS: The history of the shooting and the alleged shooter(s)’s activities for as many days prior to the shooting as appears relevant.
  • FIREARMS EXPERT: Documenting the firearm used, how it was accessed, and how lethality can be decreased. (Mechanisms like LCI or MDM, etc.)
  • ATF EXPERT: Assessing the purchase of the firearm and how the shooter accessed the firearm. (Did the shooter buy the gun? Did it belong to parents? Was the firearm secured? If so, how?)
  • STRUCTURES: Documenting the scene of the shooting including buildings and transportation to the shooting. (To determine if buildings can be made safer or if a shooter could have been stopped en route to the shooting.)
  • ON SITE VIDEO: Shootings or events leading directly to a shooting are often captured on video. Expert analysis of video can provide information about stopping a shooter or designing buildings to contain a shooter or provide better protection during a shooting.
  • HUMAN PERFORMANCE: Study of the shooter(s) prior to the shooting for factors that might be involved including medication, drug/alcohol use, medical history, prior convictions.
  • SURVIVAL FACTORS: Documentation of how people escaped the shooting, avoided being shot,  survived their injuries, as well as community emergency planning and first responder reaction. (For example, gunshot victims who enter a Level 1 Trauma Center increase survival chances by 25%. What can be done for shooting victims who are not close to a trauma center.)
  • MEDICAL DATA: Document the damage caused to the body by bullets. (Bullet size, type, velocity)
  • AFTERMATH: Document psychological and physical recovery of victims, survivors, community and the change in the local or national sale of firearms. (Why do firearm sales increase after a mass shooting?)
  • MEDIA EXPERT: One person provides information to the media to avoid speculation about the shooter(s)’s motive.

A significant difference between a MVIB and the NTSB is that the NTSB “…Board’s analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law.” The reasoning is to “…ensure that Safety Board investigations focus only on improving transportation safety…” In the case of suspected criminal activity, the FBI becomes the lead federal investigative body. Mass shootings, however, are criminal acts and therefore involve the FBI. Some single victim shootings, however, do not involve the FBI. Other agencies would need to be brought in for those cases or the new agency could implement a “report-only” requirement from local law enforcement officials.

Kristen Rand of the Violence Policy Center recommended:

  • a structured data system similar to NTSB,
  • sharing data (finished report) with the public,
  • implementing a report-only requirement for some shootings, 
  • implementing a holistic approach (e.g. include psychiatric evaluations of shooters), and
  • use domestic violence task forces as a model.

Of course, many questions must be answered, including:

  • How will a new agency be funded?
    • Currently, the costs of shooting investigations is borne by local law enforcement and the Federal Bureau of Investigation.
    • The cost can be transferred from local law enforcement to the new agency.
    • Ceasefire Oregon supports a tax on the sale of guns and ammunition. 
  • How will a “mass killing” be defined? (Current FBI definition is the murder of 4 or more people.)
  • What type of data will be collected?
  • Will this be implemented nationally, regionally or at a state level? 
  • What role will existing organizations play? (FBI, ATF, NVDRS, DV task forces, etc.)

The United States has an estimated 310 million guns in civilian ownership. Even if guns were never allowed to be manufactured or sold from this day forward, we will spend decades responding to shootings in our country. The United States must learn to protect our citizens from gunshot injury and death whether that is in the form of mass shootings, unintentional shootings or suicide. A national agency dedicated to investigating and preventing gunshot death will help drastically reduce the rate of gunshot death and injury in the United States.

About Ceasefire Oregon Education Foundation

The Ceasefire Oregon Education Foundation is a 501(c)(3) nonprofit organization committed to improving the health and safety of the community by reducing gun violence. We work to reduce the number of gun injuries and deaths in Oregon by educating the public and providing opportunities to dispose of unwanted firearms.

Ceasefire Oregon was founded in 1994 as a grassroots organization dedicated to staging an annual gun turn-in. We subsequently broadened our scope to include education programs to prevent gun violence.In 2001, we formed an alliance with a longtime legislative advocacy group, Oregonians Against Gun Violence (OAGV). The original Ceasefire Oregon became the Ceasefire Oregon Education Foundation, a 501 (c)(3) organization, and OAGV became Ceasefire Oregon, a 501 (c)(4) organization.

About the National Transportation Safety Board

The Board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents in the other modes of transportation – rail, highway, marine and pipeline. With about 400 employees, the Board accomplishes this task by leveraging its resources. One way the Board does this is by designating other organizations or companies as parties to its investigations.

The NTSB designates other organizations or corporations as parties to the investigation. Other than the FAA, which by law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as parties to the investigation. Only those organizations or corporations that can provide expertise to the investigation are granted party status and only those persons who can provide the Board with needed technical or specialized expertise are permitted to serve on the investigation; persons in legal or litigation positions are not allowed to be assigned to the investigation. All party members report to the NTSB.

Eventually, each investigative group chairman prepares a factual report and each of the parties in the group is asked to verify the accuracy of the report. The factual reports are placed in the public docket.

Safety Recommendations

Safety recommendations are the most important part of the Safety Board’s mandate. The Board must address safety deficiencies immediately, and therefore often issues recommendations before the completion of investigations. Recommendations are based on findings of the investigation, and may address deficiencies that do not pertain directly to what is ultimately determined to be the cause of the accident.

For example, in the course of its investigation of the crash of TWA flight 800, once it was determined that an explosion in the center fuel tank caused the breakup of the aircraft, the Board issued an urgent safety recommendation and three other recommendations in 1996, four years before completion of its investigation, that were aimed at eliminating explosive fuel/air vapors in airliner fuel tanks. The Board issued an additional recommendation in 1997 regarding the detection of explosives and six recommendations in 1998 to improve fuel quantity indication systems. When the Board issued its final report on the TWA 800 accident in 2000, four additional safety recommendations were issued that focused on the aircraft wiring systems.

Public Hearing

The Board may hold a public hearing as part of a major transportation accident investigation. The purpose of the hearing is two-fold; first, to gather sworn testimony from subpoenaed witnesses on issues identified by the Board during the course of the investigation, and, second, to allow the public to observe the progress of the investigation. Hearings are usually held within six months of an accident, but may be delayed for complex investigations.

The Remainder of the Investigation and Final Report

More months of tests and analysis eventually lead to the preparation of a draft final report by Safety Board staff. Parties do not participate in the analysis and report writing phase of NTSB investigations; however, they are invited to submit their proposed findings of cause and proposed safety recommendations, which are made part of the public docket. The Board then deliberates over the final report in a public Board meeting in Washington, D.C. Non-Safety Board personnel, including parties and family members, cannot interact with the Board during that meeting.

Once a major report is adopted at a Board Meeting, an abstract of that report – containing the Board’s conclusions, probable cause and safety recommendations – is placed on the Board’s web site under “Publications”. The full report typically appears on the web site several weeks later.