Editor’s note: Out of respect and sympathy for the officers involved in this tragic incident and in admiration for the agency’s courage in pursuing learning points that will help keep other officers safe, we have chosen to remove the actual names of the agents and the department associated with this event.
In Part 1 of this two-part series (click here), we recreated the fateful chronology that led to the fatal shooting of Agt. JD by his fellow officer Agt. DB during their response to a pre-dawn shots-fired call. Now, drawing on the findings of an independent Incident Review Board commissioned by the department that included a representative of the Force Science Institute, we explore some of the factors that put these two officers on a collision course of disaster.
You’ll recall the setting: JD, in uniform, was poking his head and his Glock 17 over the top of a privacy fence that enclosed the “pitch black” backyard of a residential property where an armed and dangerous suspect was believed possibly to be hiding. As DB and other officers entered the yard to search for the offender, the light on DB’s AR-15 illuminated JD’s face and hands. Mistaking his fellow agent for the suspect, DB shot and killed him when JD appeared to move his gun in a threatening manner.
Nearly 70 pages of the Review Board’s 144-page report are devoted to an unsparing analysis of big-picture, command-level errors made at the scene during the roughly 2? hours before DB pulled the trigger. Among the many shortcomings explored in detail are:
Poor command and control
From the beginning, the first patrol sergeant at the scene, who should have taken control of the operation, “failed to act as an effective incident commander,” the report says. Admittedly insecure about her tactical capabilities, she didn’t establish a CP, failed to set a decisive operational plan, allowed critical decisions to be made in an ad hoc manner by subordinates, and participated in tasks she should have delegated. A fellow sergeant on the scene also failed to take appropriate command.
JD’s location on the fence line could have been known and communicated if a periodic roll call of perimeter officers had been taken, but none was. No one asked about or conveyed his position. When DB arrived at the scene late in the incident, his briefing on the “situational awareness” necessary to conduct a safe search was “insufficient.” Indeed, a “buddy” officer who had been with JD earlier and was then with DB neglected to mention JD’s nearby location before the search team started to clear the backyard.
Dismissal of support resources
A helicopter from a neighboring agency offered assistance with its spotlight and infrared camera, but was dismissed early in the incident. Had it stayed, it could have been invaluable in clearing the backyard and identifying JD’s presence. Likewise, responding patrol officers from other agencies could have been used to fill gaps in the perimeter or to replace JD’s partner when he left JD alone to help deal with pit bulls inside the suspect residence prior to the backyard search.
Faulty risk management
With an armed suspect potentially barricaded alone and with no exigent emergency, SWAT should have been called to take over clearing the property, the Board said. This is a high-risk circumstance that “can be one of the most operationally sensitive situations faced by law enforcement,” the report explains, with “strict discipline” and “strong command…absolutely essential.” A highly trained SWAT team could likely have resolved the incident in the amount of time eaten up by the “ineffective” and “tactically questionable” procedures that surrounded the taking of JD’s life.
After addressing these and other macro elements that were largely beyond the control of DB and JD, the report then focuses on the actions, perspectives, and human performance factors of those two most intimate players in this ill-fated drama.
Obtaining post-incident reflections on what happened from JD was impossible of course, but with insightful input from the experts on the team the Board was able to draw reasonable conclusions about the shooting based on “the nature of human behavior and scientifically determined responses to stimuli.”
What DB saw and did
When DB stepped into the dark backyard, he told investigators, his attention was drawn to the fence line by a “conversational” voice that said, “Hey.” As he pointed his rifle in that direction, its light revealed a male head and hands above the top of the fence–with a semi-automatic pistol in one hand, angled “down and out.”
When DB yelled, “Police! Drop the gun!,” the subject raised the gun to a position that DB thought threatened his life. To defend himself, he fired a headshot that killed the subject, who was later identified as JD.
JD was wearing his uniform but there was nothing (such as a police-style hat) visible above the fence top to suggest his law enforcement affiliation. He said something after “Hey,” but DB found his speech “slurred” and unintelligible. And JD did not follow DB’s command to drop the gun.
DB, the survivor of another deadly force encounter earlier in his career, had seven critical actions to perform, some concurrently, within 1.5 to 2 seconds, the Board’s report points out: He had to identify himself as a cop…challenge the subject…remove his trigger finger from the “safe” position and disengage the safety on his rifle…observe the reaction/movement of the subject and the threatening firearm…access the rifle trigger…sight the gun…and press the trigger once he decided that the threat required an immediate life-or-death response.
All this left “little time to critically analyze the nature of the threat” and “very little time for facial recognition,” the report notes. He knew JD, but he had no idea he was even at the scene, much less positioned behind the fence. Plus, his primary focus instinctively would have swiftly been narrowed to the pistol and its movement.
Once his concentration shifted to his sights, “all of his attentional and visual resources [were] drawn away from the threat to [his] own action,” making recognition of the target even more difficult, the report explains.
As to the “incoherence” of whatever JD said, it’s “entirely plausible” that along with visual narrowing DB “also experienced associated auditory exclusion” or a distortion of JD’s speech as his attention zeroed in on JD’s gun. “Under conditions of high stress, humans tend to become visually dominant,” with their brain ignoring or suppressing “information coming in through other senses” so it won’t “interfere” with overridingly important visual input.
Dr. Lewinski elaborated in an interview with Force Science News: “In this type of blue-on-blue shooting, involving confusion or mistaken identity, time compression and a sense of life-or-death urgency are dominant factors.
“Either from a lack of pre-event information or because of erroneous information, the shooter doesn’t accurately understand the confrontation he’s about to enter into. He then encounters behavior by a subject that causes him concern and is easily misinterpreted as a direct threat.
“Because protecting himself seems urgent, he has no time to consider options or to negotiate. His only reasonable choice for his own defense as he understands it is to shoot. Only afterward is the encounter reframed in its accurate context–too late to prevent the tragedy.”
JD was fully vulnerable.
The position he had chosen–balancing on the side of a metal ladder that was leaning against the wooden fence so he could see into the backyard–was a poor one “tactically and for any protective reaction to an unfolding threat,” the report says. “[G]iven his limited visibility to others and no apparent police identification…almost any movement …would likely have been interpreted as an immediate threat to a challenging officer.”
Being challenged would have been unexpected to JD, who “undoubtedly regarded himself as part of the [response] team,” the report says. He vocalized his presence (“Hey”) “apparently to get the attention” of the other officers in a friendly manner. With only a dead flashlight, he had no way of “making others aware of his presence.”
From his position behind the fence prior to DB’s entry into the yard, JD was “likely fully visually dark-adapted,” dependent on his night vision, the report says. The sudden 200-lumen light from DB’s rifle directed at his face “would have produced ‘flashblindness,’ washing out his visual system and resulting in an inability to see.”
A bright light to the eyes “often results in involuntary movement…of the hands to shield the eyes.” This automatic “physical byproduct of a psychological recoil” may well have been what caused JD to move his gun up in a manner DB interpreted as threatening.
JD’s head wounds suggest that he was looking slightly to DB’s right when hit. It’s possible he was reflexively starting to look away from the light. This movement, too, could have caused “an inadvertent [sympathetic] movement of [his] hands,” including the hand with the pistol.
Why didn’t he comply and drop his gun? Again, thinking himself as one of the good guys, he “may have been confused as to whether or not the challenge was directed at him,” the report speculates. Perhaps he thought there was “a threat present between [DB] and himself.” Even that misinterpretation could have caused him to raise his gun as he began to search for the unseen adversary.
In any case, time would have been a critical factor. Generally, the report points out, it takes 1 to 1.5 seconds to cognitively process a command and began to comply. “With confusion surrounding the situation, perception, decision, and reaction time would take much longer.” In short, JD’s reaction would have been too slow to beat DB’s action of firing bullets his way.
“The underlying problem here,” Lewinski points out, “is that each of these two officers had a different mindset about what was going on. With his mindset, JD wouldn’t have understood why he was being challenged. The only thing he could have done to save himself when challenged would have been to freeze and comply immediately with DB’s command. Any other movement on his part could have been perceived from DB’s mindset as threatening.”
As part of its examination of relevant human behavior, the Board took special note of work hours and fatigue.
JD had worked 18 hours and 40 minutes before the fatal encounter, an “alarming” amount of time, the report states. DB had worked nearly 30 of the approximate 63 hours before the shooting. DB, the sergeant who failed to exercise proper command at the scene, and some other personnel involved in the call had also worked excessively in the days before the shooting, the Board determined, and the sergeant said she habitually averaged only 6 hours’ sleep on duty days.
For JD and others, fatigue may have diminished their “optimal cognitive performance during the incident,” the report says. Being awake for 17 hours “is the cognitive performance equivalent of having a blood alcohol concentration of .05%,” the report explains. And research has shown that being tired significantly lessens one’s ability to, among other things:
- “Comprehend complex situations that require processing a substantial amount of data within a short time frame”;
- “Manage events and improve strategies”;
- “Perform risk assessment and accurately predict consequences”;
- “Monitor personal performance”; and
- “Communicate effectively”–all of which were pivotal considerations in the case at hand.
“Given the totality of the circumstances,” the Review Board stated, “the tragic conclusion to the incident was almost predetermined…” But because the police department by commissioning the report courageously invited intense scrutiny that was “critical by its very nature,” substantial benefit may be reaped in the days ahead.
It is the Board’s hope that through the review “the department will arrive more quickly at the implementation of preventive measures in assuring that a repeat of this tragic incident does not happen to another police agent, his or her family, and the department itself.”
Beyond that, the Board notes, “there are lessons learned that should be reviewed by all law enforcement agencies, as this tragedy could have played out in almost any jurisdiction.”