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Page 6 Schmidt et al. J Surveill Secur Saf 2020;1:1-15 I http://dx.doi.org/10.20517/jsss.2019.02

Since fault trees are hierarchical structures, where the top of the tree is the undesirable incident (the
disaster), and the bottom events are causal factors (root causes), there has been very little research on the
middle levels of the hierarchical structure, especially the level just below the top event. This is particularly
important as framing the problem dictates how the scope of the analysis will be developed into causal
factors and subsequent recommendations. It has been proposed that the middle part of the fault tree can
resemble the remit of the middle managers in humanitarian logistics organisations in terms of learning
[34]
from rare events . In addition, there has been a variation in terms of ways of classifying reasons of failure.
For example, the factors can be grouped into “direct” and “indirect” causes such as the work of Labib and
[1]
Read in the analysis of Hurricane Katrina disaster. The same approach is followed in this paper as it helps
to focus on both short and long terms recommendations. In addition, such taxonomy helps to realise both
single- and double-loop learning.

[11]
Argyris (p. 68) proposed the concept of single-loop learning, which can be defined as: “an error is
detected and corrected without questioning or altering the underlying values of the system”. It can be
[11]
argued that this is related to the “direct” causes in an FTA model. Conversely, Argyris (p. 68) defined
double-loop learning as: “mismatches are corrected by first examining and altering the governing variables,
and then reviewing the actions”. This can be attributed to be among the “indirect” causes in the FTA
modelling. Triple-loop learning has also been proposed in the literature, but this is beyond the scope of our
paper. Other variations to classify failures can be as sociological and technical, or human and technology
related issues.

3.2 Case study 1: Virginia Tech Shooting, USA, 2007
3.2.1 Background
One of the deadliest shootings in US history took place on 16 May 2007 at Virginia Tech University,
Blacksburg. The shooting comprised two attacks that took place in two different locations on campus,
[35]
which are illustrated in Figure 1 . The first shooting took place at 07:15 at West Ambler Johnston Hall
dormitory, killing two people. Since the police associated the shooting with a domestic incident and
assumed the attacker had already left campus, they did not shut down the campus . About two and a half
[35]
hours later, the gunman started the second shooting in Norris Hall building. Referring to witnesses, the
[35]
gunman entered various classrooms and started randomly shooting at everyone . As the gunman realised
that the police were rushing into the building, he shot himself.

3.2.2 Logic and technical cause of failure
As this incident has been fully investigated and to reduce biased information, the causes of failure identified
[36]
have been obtained from the amended Review Panel Report of the Virginia Tech Shooting (2009). The
failures have been identified as followed:
(1) Since his childhood, Cho exhibited mental health issues and received psychiatric treatment and
counselling for selective mutism and depression. His mental instability worsened during his junior year at
university as the university’s care team failed to provide support to Cho.
(2) After he mentioned suicidal remarks to his roommates, his mental health was evaluated by
psychologists. However, this was done inadequately resulting in insufficient treatment of Cho.
(3) With his history of mental health instability, he would not have been allowed by federal law to purchase
the two guns which he used in the shooting. However, his data were never entered into the federal database
used for background checks when purchasing firearms.
(4) There were communication errors among the university entities involved with Cho’s situation and the
incidents encountered by other students and faculty. Further, laws concerning the privacy of health and
education records have been misinterpreted.
(5) Students and staff were not notified of the first shooting due to a misinterpretation of the incident and
ineffective warning systems in place.