Part 1 capstone - written analysis

Critical Incident Review Active Shooter at Robb Elementar y School

E X E C U T I V E S U M M A R Y

Critical Incident Review Active Shooter at Robb Elementary School

E X E C U T I V E S U M M A R Y

The internet references cited in this publication were valid as of the date of publication. Given that URLs and websites are in constant flux, neither the authors nor the COPS Office can vouch for their current validity.

The U.S. Department of Justice reserves a royalty-free, nonexclusive, and irrevocable license to reproduce, publish, or otherwise use and to

authorize others to use this resource for Federal Government purposes. This resource may be freely distributed and used for noncommercial and educational purposes only.

Photos by DOJ staff unless otherwise indicated.

Recommended citation: U.S. Department of Justice. 2024. Critical Incident Review: Active Shooter at Robb Elementary School. Executive Summary. Washington, DC: Office of Community Oriented Policing Services.

Published 2024

Content Advisory

The team took great care to be intentional about the words used in this report to convey the facts. Nevertheless, the descriptions may be activating for some readers due to the explanations of this mass

casualty incident, including the age of the victims.

The team deliberately does not name the subject to avoid glorifying the subject’s actions and out of respect for the victims’ families.

For resources, including free and confidential emotional support, please visit https://988lifeline.org/ or call/text 988 to reach the Suicide & Crisis Lifeline, available 24 hours a day, 7 days a week, 365 days a year.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Content Advisory iii

Dedication

This report is offered to honor the memories of the innocent victims—young students and teachers—

who were senselessly killed on May 24, 2022, at Robb Elementary School in Uvalde, Texas. To

memorialize those whose lives were taken, we created remembrance profiles to capture the spirit of each victim and to amplify their voices, which were silenced. These can be found in “Appendix A. Remembrance Profiles” and online at https://cops.usdoj.gov/uvalde.1

1 Placement of the Remembrance Profiles is based on requests from some of the families of the victims.

This report is also dedicated to the survivors—those who feared for their lives and the lives of their loved ones—who selflessly risked their own safety to call for help and to try to protect others and who witnessed the horror, watching in anguish as the event unfolded. To hundreds of survivors in this

community, we know the negative impacts, including physical, mental, and emotional injuries, will not end and that your grief remains very heavy. Many of you continue to bear the scars and pain you suffered from the loss of your loved ones and the loss of your sense of safety in your own community.

It is our intention to honor all of you by remembering your loved ones and representing your stories, sharing them here with the rest of the country. We hope that our review of the events of May 24, 2022, can provide answers to the remaining questions and lessons that may help others in the future.

The country mourned with the Uvalde community on that tragic day. While we remain heartbroken by

your loss, we are driven by the need to provide an authoritative accounting of the days and months leading up to that day, the response that transpired on May 24, and the events and actions that followed.

The following page lists the names of the victims.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Dedication iv

Below are the names of the innocent lives lost that day:

Nevaeh Alyssa Bravo, 10

Jacklyn “Jackie” Cazares, 9

Makenna Lee Elrod, 10

Jose Flores Jr., 10

Eliahna “Ellie” Amyah Garcia, 9

Irma Linda Garcia, 48

Uziyah Sergio Garcia, 10

Amerie Jo Garza, 10

Xavier James Lopez, 10

Jayce Carmelo Luevanos, 10

Tess Marie Mata, 10

Maranda Mathis, 11

Eva Mireles, 44

Alithia Haven Ramirez, 10

Annabell Guadalupe Rodriguez, 10

Maite Yuleana Rodriguez, 10

Alexandria “Lexi” Aniyah Rubio, 10

Layla Marie Salazar, 11

Jalilah Nicole Silguero, 10

Eliahna Cruz Torres, 10

Rojelio Fernandez Torres, 10

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Dedication v

Contents

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iii

Dedication iv

Acknowledgments vii

Executive Summary 1

Organization of the Report 2

Terminology and Treatment of Names 2

Overview of CIR Factual Observations 3

Overview of CIR Team Analysis 5

Chapter by Chapter Summary 7

Abbreviations and Acronyms 21

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Contents vi

Acknowledgments

The U.S. Department of Justice extends appreciation and thanks for the commitment and support of the

leaders of the Uvalde community, especially former Uvalde Mayor Don McLaughlin for reaching out to

the Associate Attorney General to request this review. It takes courage to voluntarily undergo an assessment, especially one of this magnitude.

The Justice Department thanks the City and County of Uvalde. In the midst of this tragedy and pain, the

people of Uvalde demonstrated kindness, hospitality, and openness.

The Justice Department extends deep appreciation to the family members, victims, responders, and

community members who agreed to speak with the review team through their discomfort and pain. The candid and often vulnerable conversations were invaluable to this report.

The Justice Department also acknowledges the agencies and organizations that were responsive to requests

for documents and data, in particular, the officials and personnel of the Uvalde Police Department; the Texas

Department of Public Safety; the Bureau of Alcohol, Tobacco, Firearms and Explosives; the Federal Bureau of Investigation; and U.S. Customs and Border Protection for their responsiveness.

The Justice Department acknowledges with gratitude the important contributions of the Critical Incident Review (CIR) subject matter experts who contributed to this review.

On behalf of the Office of Community Oriented Policing Services (COPS Office) team who led this review, we extend our appreciation to the COPS Office personnel who supported us throughout this project. In

particular, we acknowledge and thank the leaders and staff in the following divisions: Resources and Technical Assistance; Communications; Management Services; Finance; Budget; Information Technology; Facilities; Legal; and Publishing. We also thank the staff and contractors who provided transcription and

interpretation services throughout the project and the translation services for the report. We also share our appreciation for the staff of the Associate’s Office, Justice Management Division, DOJ Library, Bureau

of Justice Assistance, Office for Victims of Crime, Office of Justice Programs Publishing Team, Office of Privacy and Civil Liberties, Office of Information Policy, Office for Access to Justice, and particularly the U.S. Marshals Services Evidence.com Team for their substantial support and assistance.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Acknowledgments vii

Executive Summary

On May 24, 2022, a mass shooting at Robb Elementary School in Uvalde, Texas, shook the nation. With

just two days left in the school year, a former student armed with an AR-15 style assault rifle took the

lives of 19 students and two teachers, physically injured at least 17 others, and left countless families, friends, and a community grief-stricken for their unimaginable loss. In the aftermath of the tragedy, there was significant public criticism of the law enforcement response to the shooting. At the request of then Uvalde Mayor Don McLaughlin, the U.S. Department of Justice (DOJ) announced on May 29, 2022, that it would conduct a Critical Incident Review (CIR) of the law enforcement response to the mass

shooting. Recognizing that “[n]othing can undo the pain that has been inflicted on the loved ones of the

victims, the survivors, and the entire community of Uvalde,” the Attorney General stated that the goal of the CIR was to “assess what happened and to provide guidance moving forward.”

A full understanding of the response of local, state, and federal law enforcement agencies and personnel is critical for addressing many unanswered questions, identifying crucial lessons learned, enhancing

prevention initiatives, and improving future preparation for and responses to mass shootings in other communities. In providing a detailed accounting and critical assessment of the first responder actions in Uvalde, and the efforts since to ameliorate gaps and deficiencies in that response, the CIR is intended to

build on the knowledge base for responding to incidents of mass violence. It also will identify generally

accepted practices for an effective law enforcement response to such incidents. Finally, the CIR is intended to help honor the victims and survivors of the Robb Elementary School tragedy.

The CIR was led by the Office of Community Oriented Policing Services (COPS Office) with the support of a team of subject matter experts with a wide variety of relevant experience, including emergency

management and active shooter response, incident command, tactical operations, officer safety and wellness, public communications, and victim and family support (see “About the Team”). The CIR team

collected and reviewed more than 14,100 pieces of data and documentation, including policies, training

logs, body camera and CCTV video footage, audio recordings, photographs, personnel records, manuals and standard operating procedures, interview transcripts and investigative files and data, and other documents. The CIR team visited Uvalde nine times, spending a total of 54 days on site. The team

conducted over 260 interviews of individuals from more than 30 organizations and agencies who played a role in or had important knowledge or information about areas related to the review. Those interviews

included personnel from the law enforcement agencies involved in the response to the mass shooting, other first responders and medical personnel, victims’ family members, victim services providers, communications professionals and public information officers, school personnel, elected and appointed

government officials, survivors and other witnesses, and hospital staff.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 1

Organization of the Report

This report provides the results of the independent, comprehensive assessment conducted by the CIR

team. The period for collecting documents and data through this CIR was June 2022 until June 2023, defined throughout the report as the review period. To organize this comprehensive review, the team

established the following areas of focus:

 Incident Timeline Reconstruction. This chapter provides an authoritative account of pertinent facts leading up to, during, and immediately following the tragic mass shooting.

 Tactics and Equipment. This chapter examines tactical approaches and availability of special tools and equipment during the critical 77 minutes between the arrival of first responders on scene through the classroom entry and killing of the shooter.

 Leadership, Incident Command, and Coordination. This chapter examines the leadership, incident command, decision-making, and coordination actions that took place across responding agencies and law enforcement leaders.

 Post-Incident Response and Investigation. This chapter assesses the establishment of post- incident investigative command and activities, victim identification, and crime scene

management, as well as administrative investigations and after-action reviews.

 Public Communications During and Following the Crisis. This chapter examines communications activities and approaches with and between government entities

(including law enforcement) and the general public, family members, professional media, social media, and others.

 Trauma and Support Services. This chapter analyzes support and resources provided to

survivors, victims, responders, and other stakeholders.

 School Safety and Security. This chapter documents the school safety planning and assesses the security apparatus of the Uvalde Consolidated Independent School District (UCISD).

 Pre-Incident Planning and Preparation. This chapter assesses the training, agreements, and

procedures for law enforcement, other first responder agencies, and other relevant stakeholders in the critical areas of active shooter response, incident command, emergency

management, and other significant areas.

Terminology and Treatment of Names

Names are important. The team deliberated on the treatment of names and decided on the following:

 The subject’s name is not used to avoid glorification.

 Only elected officials and chief executives of agencies are named where appropriate. All other individuals are left unnamed.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 2

Additionally, this report refers to “victims” and “survivors” interchangeably to respect that some

people prefer to be referenced as survivors and others as victims. The CIR team was also cognizant of and attempted to avoid terminology like “triggered,” “targeted,” and other gun-related language as

well as time frame references (which typically convey celebrations, such as “anniversaries”), out of respect for the fact that these terms are often activating for some victims, survivors, responders, and family members.

Overview of CIR Factual Observations

At 11:33 a.m. on the morning of May 24, 2022, the subject entered Robb Elementary School equipped

with a high-powered AR-15 rifle. He immediately started shooting and within a minute entered

classrooms 111 and 112, which were connected via an interior door.

Within 3 minutes of the subject’s entry into the school, 11 law enforcement officers from the Uvalde

Consolidated Independent School District (UCISD) and Uvalde Police Departments (UPD), including

supervisors, arrived inside the school. Hearing continued gunfire, five of the responding first on scene

(FOS) law enforcement ran toward classrooms 111/112. The other six FOS did not advance down the hallway, including UPD Acting Chief Mariano Pargas, who was in the best position to start taking

command and control, and to start coordinating with approaching personnel. One of the officers said to

“line up to make entry” and within seconds shots were fired from inside one of the rooms. Two officers were hit with shrapnel, and all responders retreated to positions of cover.

After three attempts to approach the classrooms, the focus of the responders shifted from entering

classrooms 111/112 and stopping the shooting to evacuating other classrooms, attempting to negotiate

with the subject, and requesting additional responders and equipment. With this shift from an active shooter to a barricaded subject approach, some responders repeatedly described the subject over the

radio as “barricaded” or “contained.” Yet within four minutes from FOS arrival, 911 dispatch confirmed

that class was in session and reported that they had received calls from victims.

Chief Pete Arredondo of the UCISD Police Department (UCISD PD) directed officers at several points to

delay making entry into classrooms 111/112 in favor of searching for keys and clearing other classrooms. Occupants of other classrooms were at risk of further injury as a result of the high-powered nature of the shooter’s AR-15 style rifle and from possible crossfire once classrooms 111 and 112 were entered. At several points, UCISD PD Chief Arredondo also attempted to negotiate with the subject. Others called out over the radio for additional resources and indicated that they were waiting for a tactical team to

arrive, such as Uvalde special weapons and tactics (SWAT), the Texas Department of Public Safety

(TXDPS), and the U.S. Border Patrol Tactical Unit (BORTAC). Chief Arredondo, who became the de facto on-scene commander, was without his radios, having discarded them during his arrival, and

communicated to others either verbally or via cell phone throughout the response.

Over the course of the incident, overwhelming numbers of law enforcement personnel from different agencies self-deployed to the school. Leadership on scene, however, had not established command and control, to include an incident command post (ICP), staging area, or clear perimeter around the hallway

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 3

or the school. Thus, arriving personnel did not receive accurate updates on the situation or direction for how to support the response efforts. Many arriving officers—based on inaccurate information on the scene and shared over the radio or from observing the lack of urgency toward entering classrooms

111/112—incorrectly believed that the subject had already been killed or that UCISD PD Chief Arredondo was in the room with the subject. As leaders from additional law enforcement agencies arrived, including Uvalde County Sheriff Ruben Nolasco, the lack of clear communication and command

structure made coordination difficult. Emergency medical responders faced similar challenges as they

deployed. They struggled to identify who was in charge, and ambulances encountered streets blocked by law enforcement vehicles.

Concerned families were also arriving at the school. They likewise had difficulty obtaining information

about their loved ones’ status. Incorrect and conflicting information was also being shared on social media with the UCISD posting that all students and staff were safe in the building and later posting

messages about reunification that conflicted with the UPD posts.

At 12:21 p.m., 48 minutes after the subject entered the school, the subject fired four additional shots

inside classrooms 111/112. Officers moved forward into formation outside the classroom doors but did

not make entry. Instead, presuming the classroom doors were locked, the officers tested a set of keys

on the door of a janitor’s closet next to room 112. When the keys did not work, the responders began searching for additional keys and breaching tools. UCISD PD Chief Arredondo continued to attempt to

communicate with the subject, while UPD Acting Chief Pargas continued to provide no direction, command, or control to personnel.

After another 15 minutes, officers found a second set of keys and used them to successfully open the

janitor’s closet. With working keys in hand, the officers then waited to determine whether a sniper and a

drone could obtain sight of and eliminate the subject through the window. Those efforts were unsuccessful.

At 12:48 p.m., 27 minutes after hearing multiple gunshots inside classrooms 111 and 112, and 75

minutes after first responders first entered Robb Elementary, officers opened the door to room 111. A team composed of BORTAC members, a member of the U.S. Border Patrol Search, Trauma, and Rescue

Unit (BORSTAR), and deputies from two local sheriffs’ offices entered the rooms, and officers killed the

subject when he emerged shooting from a closet. The subject was killed at approximately 12:50 p.m., 77 minutes after the first officers entered the school and after 45 rounds were fired by the shooter in the

presence of officers.

There were 587 children and many other teachers and staff members present at Robb Elementary

School that fateful day. In the end, 19 children and two staff were killed, with at least 17 survivors

physically injured. Since not all the children and staff present at Robb Elementary at the time of the shooting were brought to the hospital or otherwise assessed for any medical concerns, it is unknown

how many in total sustained physical injuries as a result of this incident.

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Wounded and deceased victims were transported to Uvalde Memorial Hospital, while the majority of other victims were transported to the Uvalde Civic Center, where the Reunification Center was eventually established. At the hospital and the center, some families were reunited with their children. But other families received incorrect information suggesting their family members had survived when

they had not. And others were notified of the deaths of their family members by personnel untrained in delivering such painful news.

In the days, weeks, and months following the tragedy, survivors, families, and responders received

varying levels of support services. Many organizations arrived in Uvalde in the days that followed to

assist survivors and families in accessing mental health and other victim support resources. But since then, difficulties with tracking victims and transitioning service providers have meant that some victims, family members, and community members have not received services.

Public communications challenges continued throughout the response and in the aftermath of the

tragedy. Both impromptu and scheduled news conferences and media engagements contained

inaccurate and incomplete information. Victims, families, and community members struggled to receive timely and accurate information about what occurred on May 24. And although government officials

and school administrators hosted several family briefings and school board meetings over the weeks

and months after the shooting, those events offered limited information and few substantive responses from officials and, in some cases, exacerbated the distress of the families.

Overview of CIR Team Analysis

Based on these facts, the CIR team identified several critical failures and other breakdowns prior to, during, and after the Robb Elementary School response and analyzed the cascading failures of leadership, decision-making, tactics, policy, and training that contributed to those failures and

breakdowns. From the facts and analysis, the CIR team has been able to identify generally accepted

practices for an effective law enforcement response to similar mass shootings and offer recommendations in hopes that in the future, law enforcement would be able to act quickly, save lives, and prevent injuries to the greatest extent possible.

The most significant failure was that responding officers should have immediately recognized the

incident as an active shooter situation, using the resources and equipment that were sufficient to push

forward immediately and continuously toward the threat until entry was made into classrooms 111/112 and the threat was eliminated. Since the tragic shooting at Columbine High School in 1999, a

fundamental precept in active shooter response and the generally accepted practice is that the first priority must be to immediately neutralize the subject; everything else, including officer safety, is subordinate to that objective. Accordingly, when a subject has already shot numerous victims and is in a

room with additional victims, efforts first must be dedicated to making entry into the room, stopping the

subject, and rendering aid to victims. These efforts must be undertaken regardless of the equipment and personnel available to those first on the scene.

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 5

This did not occur during the Robb Elementary shooting response, where there was a 77-minute gap

between when officers first arrived on the scene and when they finally confronted and killed the subject. Several of the first officers on scene initially acted consistent with generally accepted practices to try to

engage the subject, and they moved quickly toward classrooms 111/112 within minutes of arriving. But once they retreated after being met with gunfire, the law enforcement responders, including UCISD PD Chief Pete Arredondo—who we conclude was the de facto on-scene incident commander—began treating

the incident as a barricaded subject scenario and not as an active shooter situation.

As more law enforcement resources arrived, first responders on the scene, including those with specific

leadership responsibilities, did not coordinate immediate entry into the classrooms, running counter to generally accepted practices for active shooter response to immediately engage the subject to further save lives. Instead, law enforcement focused on calls for additional SWAT equipment (which should not delay the response to an active shooter), requests for delivery of classroom keys and breaching tools

(which may not have been necessary to gain entry), and orders to evacuate surrounding classrooms prior to making entry into classrooms 111/112.

In addition to the overall failure to appreciate the active shooter nature of the situation, responders also

failed to act promptly even after hearing gunshots around 12:21 p.m., which should have spurred

greater urgency to confront the subject but instead set off a renewed search for keys.

There were also failures in leadership, command, and coordination. None of the law enforcement leaders at the scene established an incident command structure to provide timely direction, control, and

coordination to the overwhelming number of responders who arrived on the scene. This lack of structure contributed to confusion among responders about who was in charge of the response and how they could assist.

Communications difficulties exacerbated these problems. Per UCISD policies, Chief Arredondo was the

on-scene incident commander, but he lacked a radio, having discarded his radios during his arrival thinking they were unnecessary. And although he attempted to communicate with officers in other parts of the hallway via phone, unfortunately, on multiple occasions, he directed officers intending to

gain entry into the classrooms to stop, because he appeared to determine that other victims should first be removed from nearby classrooms to prevent further injury.

These failures may have been influenced by policy and training deficiencies. For example, recent training that UCISD PD provided seemed to suggest, inappropriately, that an active shooter situation can

transition into a hostage or barricaded subject situation. And while many of the FOS had sufficient active

shooter and incident command training, other key FOS responders lacked any active shooter training or incident command training. The vast majority of the officers from different law enforcement agencies had never trained together, contributing to difficulties in coordination and communication on the day

of the incident. The lack of pre-planning hampered even well-prepared agencies from functioning at their best.

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Chapter by Chapter Summary

As noted above, the CIR team organized the review of the Robb Elementary School response by focusing

on particular topics. A summary of the CIR team’s observations and recommendations for each of these chapters is provided below.

Chapter 1. Incident Timeline Reconstruction

This chapter provides an authoritative account of pertinent facts leading up to, during, and immediately

following the tragic mass shooting.

Chapter 2. Tactics and Equipment

Police active shooter response tactics have undergone significant changes and evolution over the years. Throughout most of history, the police response to an active shooter incident was to secure a perimeter and call out a SWAT team and, in some cases, negotiators. Most officers lacked specialized, advanced

training and preparation to handle such situations. The watershed moment in tactical changes occurred following the Columbine massacre in 1999. Following Columbine, law enforcement expert tacticians and

associations testified that the new paradigm for responding to crises like Columbine is rapid

deployment. Rapid emergency deployment puts significant responsibility on the first responding

officers, who may not be fully equipped or trained as a SWAT team member. First responders are instructed to go toward the violent offender, if necessary, bypassing injured victims and placing

themselves in harm’s way.

“Chapter 2. Tactics and Equipment” examines the tactics and pieces of equipment that were

contemplated, sought, and deployed over the course of the incident response at Robb Elementary School, beginning with the initial officers’ approach from outside the school and ending approximately

77 minutes later when the medical triage of victims inside classrooms 111/112 began.

Selected Observations

To see the full list of Observations, see “Chapter 2. Tactics and Equipment.”

 The first officers on scene immediately moved toward the sound of gunfire and into the West Building of Robb Elementary to stop the shooter, which was in adherence to active shooter response generally accepted practices. Once inside the building, five of the first officers on

scene continued to press down the hallway and toward a barrage of gunfire erupting inside of rooms 111/112. (Observation 1)

 After officers suffered graze wounds from shrapnel, the first officers on scene did not penetrate

the doors to rooms 111/112 and repositioned to a barricaded subject situation. This mindset permeated throughout much of the incident response, even impacting many of the later responding officers. Despite their training and despite multiple events indicating the subject continued to pose an active threat to students and staff in the building, including the likelihood

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 7

and then confirmation of victims inside the room, officers on scene did not attempt to enter the

room and stop the shooter for over an hour after they entered the building. The shooter was not killed until approximately 77 minutes after law enforcement first arrived. (Observation 3)

 The effort to clear and evacuate the entire West Building was intentional and directed by Chief Arredondo, to preserve and protect the lives of the children and teachers who remained in the hot zone, while the shooter remained an active threat with multiple victims in rooms 111/112. This was a major contributing factor in the delay to making entry into rooms 111/112. The time

it took to evacuate the entire building was 43 minutes, beginning at around 11:38 a.m., when Chief Arredondo realized there were occupants in room 109 that he could not access, and

ending at 12:21 p.m., when four shots were fired, and that same room was finally evacuated

through the windows. During this time and prior to 12:21 p.m., there were multiple stimuli indicating that there was an active threat in classrooms 111/112—including: the barrage of gunfire during the initial response; the children and teachers observed when evacuating the

classrooms; the single shot fired at 11:44 a.m.; the notification that class was in session; the notification from an officer on scene that his wife, a teacher, was inside classrooms 111/112 and

shot; and multiple radio broadcasts of a 911 call from a student inside the classroom. (Observation 6)

 Some officers on scene believed that they were waiting for more assets to arrive, such as shields

and a specialized tactical team, to make entry. (Observation 7)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 2. Tactics and Equipment.”

 Officers responding to an active shooter incident must continually seek to eliminate the threat and enable victim response. The shooter’s immediate past actions and likely future actions serve as “triggering points” that indicate the appropriate response should be in line with active

shooter response protocols.2

2 IACP (International Association of Chiefs of Police), Model Policy on Active Shooter (Alexandria, VA: International Association of Chiefs of Police, 2018), https://www.theiacp.org/resources/policy-center-resource/active-shooter.

An active shooter with access to victims should never be

considered and treated as a barricaded subject. (Recommendation 3.1)

 Law enforcement training academies and providers should ensure that active shooter training

modules include the factors in determining active shooter versus barricaded subject situations. (Recommendation 3.3)

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 Officers responding to an active shooter incident must first and foremost drive toward the

threat to eliminate it. In the event there are resources available and an opportunity to evacuate bystanders and victims from the hot zone, officers must balance the risk posed by evacuation

versus the risk posed by remaining in lockdown and potentially in the crossfire. Evacuations in

such circumstances must be conducted in the most expeditious manner, limited to those immediately in harm’s way, and not at the expense of the priority to eliminate the threat. In the

case of Robb Elementary, the CIR team concludes that the effort to evacuate was protracted and

should not have caused such significant delay in the eventual entry into rooms 111/112. (Recommendation 6.1)

 Officers responding to an active shooter incident must be prepared to approach the threat and

breach or enter a room using just the tools they have with them, which is often a standard-issue firearm/service weapon. (Recommendation 7.1)

Chapter 3. Leadership, Incident Command, and Coordination

Leadership in law enforcement is absolutely critical, especially in moments of a dire challenge, such as

the active shooter incident at Robb Elementary School. It requires courageous action and steadiness in a chaotic environment. Leadership can arise regardless of rank or title. Such moments require steady and

commanding actions and based on facts gathered for this report, this leadership was absent for too long

in the Robb Elementary School law enforcement response.

“Chapter 3. Leadership, Incident Command, and Coordination” describes key principles related to

leadership in an active shooter incident, including the need to direct an immediate response to the

active shooter threat and to establish a coordinated and collaborative command and control system. The chapter analyzes the actions of leaders from several law enforcement agencies, including UPD, UCISD PD, UCSO, TXDPS, and CBP in responding to the shooting at Robb Elementary School. The chapter discusses incident command and management; coordination with other law enforcement agencies, including mutual aid; self-deployment by other local, state, and federal law enforcement personnel; and

emergency medical services/fire medical response.

Selected Observations

To see the full list of Observations, see “Chapter 3. Leadership, Incident Command, and Coordination.”

 Leadership from UPD, UCISD PD, UCSO, and TXDPS demonstrated no urgency for establishing a command and control structure, which led to challenges related to information sharing, lack of situational statuses, and limited-to-no direction for personnel in the hallway or on the

perimeter. (Observation 4)

 Failure to establish a unified command led to limited multiagency coordination. (Observation 5)

 There was no uniformly recognized incident commander on the scene throughout the incident. (Observation 8)

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 UCISD PD Chief Arredondo was the de facto incident commander on the day of the incident. Chief Arredondo had the necessary authority, training, and tools. He did not provide appropriate leadership, command, and control, including not establishing an incident command structure

nor directing entry into classrooms 111 and 112. (Observation 9)

 On the day of the incident, no leader effectively questioned the decisions and lack of urgency of UCISD PD Chief Arredondo and UPD Acting Chief Pargas toward entering classrooms 111/112, including within their respective agencies and agencies with concurrent/overlapping jurisdiction

(e.g., Uvalde County Sheriff Nolasco, Uvalde County Constable Zamora, Uvalde County Constable Field, TX Ranger 1). (Observation 12)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 3. Leadership, Incident Command, and

Coordination.”

 Agency leaders must immediately determine incident status and the appropriate command

structure for the event. Leadership must continually assess and adjust as the threat and incident evolve. (Recommendation 4.1)

 As soon as possible and practical, the lead agency should establish a unified command that includes a representative from each primary first responder agency to facilitate communication, situational awareness, operational coordination, and allocation and delivery of resources. (Recommendation 5.1)

 The ICP should provide timely direction, control, and coordination to the agency leadership, other agencies, and other critical stakeholders before, during, and after an event or upon

notification of a credible threat. The ICP must also serve as an intelligence collection and dissemination node. (Recommendation 7.4)

 Agencies should create and train on a policy, and set an expectation that leaders will act in a

manner consistent with that policy during critical incidents. (Recommendation 12.1)

 A memorandum of understanding (MOU) or memorandum of agreement (MOA) needs to be

developed among agencies within a county or region that provides clarity on who is in

command, taking into consideration an agency’s training, experience, equipment, and capacity to take the lead during a multiagency response to a critical incident. (Recommendation 12.2)

 Agencies should use the Incident Command System (ICS) for more than large-scale tactical events. They should incorporate as many of the ICS principles as possible in response to varying levels of emergencies or planned events, so ICS becomes a regular component of the agency’s

culture. (Recommendation 13.1)

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Chapter 4. Post-Incident Response and Investigation

Establishing investigative command after a multiagency response to a mass casualty incident is critical to

ensuring effective control and coordination of the scene and responsive resources, assignment of investigative assets, collection of information and intelligence, and external and internal communication. In the wake of a critical incident involving a law enforcement response, multiple

investigations and reviews will often occur. In addition to a criminal investigation of the subject, critical incidents often result in one or more administrative investigations of officer conduct during the incident.

The “Post-Incident Response and Investigation” chapter centers around criminal and administrative

investigations and associated activities and processes that took place at Robb Elementary School, such

as management of the crime scene, evidence collection, and interagency coordination in such efforts. Additionally, it describes several critical incident reviews that were initiated following the tragedy.

Selected Observations

To see the full list of Observations, see “Chapter 4. Post-Incident Response and Investigation.”

 The involvement of local agencies in the hallway during the incident led the district attorney, in consultation with the TXDPS, to assign Texas Rangers to solely investigate the incident. (Observation 1)

 Body-worn camera (BWC) video captures officers walking into the crime scene without an investigative purpose or responsibility in the immediate aftermath of the incident. Furthermore, in

the days that followed, crime scene preservation was compromised, and the crime scene team

had to continually stop and start their important work when non-investigatory personnel entered the hallway and classrooms 111/112 for the purpose of viewing the scene. (Observation 4)

 The Texas Rangers Crime Scene Team processed and exhaustively documented an incredibly challenging crime scene that put their training, policies, and procedures to the test. The team

conducted an after-action review to examine their efforts and learn as an organization. (Observation 9)

 Among the agencies with the most involved personnel, most have not completed administrative

investigations into their officers’ actions on May 24. (Observation 11)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 4. Post-Incident Response and Investigation.”

 Agencies should have a formal agreement or understanding on investigative command after a

multiagency response. (Recommendation 1.1)

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 Leaders must respect the integrity of the crime scene and only access it with a declared and

documented legitimate purpose. Crime scenes need to be held without contamination until completed. The crime scene team should be permitted to do their methodical work without continuous interruptions by VIPs who want to enter the crime scene but have no probative need

to do so. (Recommendation 4.1)

 Agencies in regional proximity to each other should conduct multiagency tabletop exercises for complex investigations that may necessitate mutual aid and support from each other. Doing so

will build greater interagency coordination in activities like evidence collection as well as understanding of jurisdictional boundaries, capabilities, processes, and expectations among

partner agencies. The tabletop exercises should include local, state, and federal agencies, as

appropriate, and be designed to exploit weaknesses, uncover strengths, and develop solutions. (Recommendation 7.1)

 Agencies should adopt parallel investigations policy for criminal and administrative

investigations, including for major incidents, while taking diligent steps to ensure that information derived from compelled administrative interviews are completely walled off from

any criminal investigation into the officer’s or agent’s actions. (Recommendation 11.1)

 Agencies that engage in after action/critical incident reviews should adequately resource the effort to ensure high-quality and timely reports of lessons learned and areas for organizational improvement. (Recommendation 12.1)

Chapter 5. Public Communications During and Following the Crisis

Public communications during and after a disaster, emergency, or mass violence event is itself an

intervention that can help victims and community members prepare and respond effectively. Communications from trusted leaders who exude a sense of calmness, competency, control, and

compassion that integrate trauma-informed information can also help those impacted manage their stress and distress reactions to these events. Thus, both internal and external communications are

vitally important in every disaster, emergency, and mass violence incident. These communications must be timely and accurate and provide as much information as appropriate at any given time, providing the community with a sense of trust and confidence during a time in which many are learning the most devastating news that anyone can receive.

The “Public Communications During and Following the Crisis” chapter describes critical components

for coordinated communication during and after a tragedy, including the identification of a public information officer (PIO) and the establishment of a Joint Information System (JIS), housed by a Joint Information Center (JIC). The chapter canvasses the public communications in the days, weeks, and

months following the shooting at Robb Elementary School and describes how inaccurate and untimely information combined with inconsistent messaging created confusion and added to the

victims’ suffering.

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Selected Observations

To see the full list of Observations, see “Chapter 5. Public Communications During and Following the Crisis.”

 Inaccurate information combined with inconsistent messaging created confusion and added to

the victims’ suffering, both on the day of the incident and in the days after the mass shooting. (Observation 1)

 Family members encountered many obstacles to locating their loved ones, getting access to the

hospital, and getting information from leadership, law enforcement, and hospital staff in a

timely manner. This includes initial information posted by UCISD on the reunification site followed by a series of contradictory posts between UPD and UCISD on reunification. This added

to the confusion, pain, and frustration. (Observation 5)

 Spokespersons for UCISD and TXDPS, the only agencies speaking publicly, did not coordinate their messaging during the afternoon of the incident. Some conflicting information was shared

by the two agencies. (Observation 11)

 All social media public messaging was posted only in English. The one exception to this was the FBI San Antonio Field Office’s messaging starting on May 25. (Observation 15)

 The extent of misinformation, misguided and misleading narratives, leaks, and lack of communication about what happened on May 24 is unprecedented and has had an extensive, negative impact on the mental health and recovery of the family members and other victims, as

well as the entire community of Uvalde. (Observation 18)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 5. Public Communications During and Following

the Crisis.”

 To establish leadership and a sense of order, the lead agency must be swift, proactive, accurate, and transparent in its messaging. Relevant information that is not law enforcement-sensitive

should typically be released as soon as it is confirmed. However, speed must be balanced with the need for accuracy. It is critical that information is verified before it is released even when

there is tremendous pressure to release information quickly. (Recommendation 4.3)

 When reunification is complete and the victims’ families have been notified, the lead agency should release that information to the community. This is a crucial step in unifying the

community to start the healing process. (Recommendation 6.2)

 The lead agency should institute incident command and establish a JIC for coordinating the release of all public information, including victim information from all medical facilities that can

be incorporated into coordinated news briefings. (Recommendation 7.1)

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 When an organization recognizes that an error has occurred, it should admit the mistake and

share what actions it is taking to rectify the problem and prevent it from happening again. Even when the mistake is egregious, an agency can maintain or seek to regain public trust by being

open and holding itself accountable to the community. In these moments, a law enforcement agency can build community trust by holding itself to the highest possible standard. (Recommendation 13.1)

 In a community with a large population with limited English proficiency, officials should post emergency information in English and in other predominant languages. This inclusive approach will help ensure that critical public safety messages reach a larger audience and will help boost trust. (Recommendation 15.1)

 Intentional transparency is needed for the victims, survivors, and loved ones who are seeking answers about what happened; however, authorities need to provide information in a trauma- informed, victim-centered, and culturally sensitive manner. (Recommendation 24.1)

Chapter 6. Trauma and Support Services

Support services for individuals who are exposed to tragedies like a mass casualty incident, including

victims, family members, the broader community, and responders, are essential. Helping those affected

understand that they can access crisis counseling, learn good coping skills, reach out to social supports, and access their innate strengths to build their resilience, can protect against people developing a mental illness as a result of their exposure to a traumatic event and its aftermath. Adequate support, services, and resources all contribute to recovery and healing.

“Chapter 6. Trauma and Support Services” assesses the support and resources provided to survivors, victims, responders, and others involved in the shooting at Robb Elementary School. This chapter describes the acute services provided in the first 24–72 hours following the shooting, including during

the evacuation process and the establishment of the Reunification Center for families and survivors. It also describes intermediate and long-term survivor and victim family support; support services for law enforcement and other responders; and management of emotional/trauma support for the broader Uvalde community following the tragic incident at Robb Elementary School.

Selected Observations

To see the full list of Observations, see “Chapter 6. Trauma and Support Services.”

 Once the children and adults were rescued from their classrooms during the evacuation process, they received limited instruction and direction on where to proceed. Due to the chaotic nature of the evacuation, children and school personnel were not adequately evaluated medically prior to being transported to the Reunification Center. As such, injured victims had delayed medical care and were at risk of further injury. (Observation 1)

 The establishment of a Reunification Center was delayed and chaotic. Families and next of kin received conflicting instructions on the location of the center. (Observation 6)

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 The death notification process was disorganized, chaotic, and at times not conducted in a

trauma-informed manner. (Observation 9)

 Responders were not provided timely, immediate access to trauma and support services, and

many reported feeling abandoned and unsupported in the weeks and months following the critical incident. Others reported being aware of the services but electing not to use them. (Observation 14)

 Shared trauma is a concern for the Uvalde community due to compounding factors, including the size of the community and its interrelatedness. For the hundreds of law enforcement, medical, behavioral health, and government personnel who responded to this incident, shared

trauma can make what happened even more overwhelming. Law enforcement’s trauma is also exacerbated by the backlash from the community–as the community’s trauma is exacerbated by

the lack of an adequate response from law enforcement. (Observation 16)

 The Uvalde community continues to need support and guidance as it struggles with the negative impacts of the failed response, a lack of accountability for those implicated in this failure, and

remaining gaps in the information about what happened to their loved ones. (Observation 43)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 6. Trauma and Support Services.”

 Officials should ensure all victims of a mass violence incident are screened medically and

assessed for mental health concerns soon after evacuation and no later than 24-48 hours post- incident. (Recommendation 2.1)

 In the weeks and months following an incident, victims and family members should receive

follow-up or continued monitoring to ensure they are receiving the necessary mental health care and other services. (Recommendation 2.2)

 Victim advocates should be assigned to communicate with and assist families. Each family

member of a deceased person and each injured victim should be assigned a victim advocate who works with that family/victim consistently throughout the treatment and recovery period, having frequent communications to ensure the family/victim is aware of and able to access

needed services and supports. (Recommendation 9.4)

 Local officials engaging in trauma and death notifications should consult national resources and

ensure best practices are followed when providing these notifications. Preparedness and

planning can help a locality identify areas where they have fewer trained or experienced staff, thus the areas where they need mutual aid supports. (Recommendation 11.1)

 Leaders from responder agencies need to provide services to all personnel involved in a mass casualty incident (MCI), which for some agencies means everyone on their staff. These services

should include resources on post-disaster behavioral health and secondary traumatic stress, referrals to health care providers, and peer support. (Recommendation 14.5)

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 15

 As part of disaster preparedness planning, communities—including law enforcement—need to

plan for the aftermath of a critical incident. This planning should include generally accepted practice processes, education and training, support, and resources. A trauma-informed, culturally sensitive approach should be applied to the victims, survivors, and impacted

community members, as well as responders and their families. (Recommendation 16.3)

 A family assistance center(FAC) should be established within 24 hours of an incident with a

security plan that includes external law enforcement presence and a process for internal vetting

of providers and those seeking services. (Recommendation 18.1)

 The definition of responders should be expanded, consistent with generally accepted practices, to include disciplines other than law enforcement, fire, and rescue staff, such as dispatchers, EMTs, health care providers, ambulance drivers, behavioral health providers, and faith-based

leaders. This should be reflected in all support services provided by resiliency centers, nongovernmental and governmental entities, and other support service providers. (Recommendation 31.2)

Chapter 7. School Safety and Security

While the primary goal of school districts across the United States is to educate, they must also prepare

for myriad threats to school safety and security, ranging widely in scale and seriousness. In addition to

certain safety functions maintained at the school district administration level, such as threat assessment teams, school safety committees, student counseling services, and physical security maintenance and

upgrades, many school districts throughout the nation partner with local law enforcement agencies to

establish school resource officer programs, and some create their own police departments. Among the 1,207 independent school districts in Texas, 309 (about 26 percent) have their own police department, including the UCISD.

“Chapter 7. School Safety and Security” reviews the safety and security apparatus of UCISD on May 24, 2022, including UCISD policies and procedures on active shooter response and incident command and their policies on locked doors, use of an emergency alert system, history of drills and exercises, establishment of its police

department, and district-wide and campus planning processes around school safety.

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Selected Observations

To see the full list of Observations, see “Chapter 7. School Safety and Security.”

 UCISD’s campus safety teams met infrequently, and annual safety plans were based largely on

templated information that was, at times, inaccurate. (Observation 5)

 UCISD had a culture of complacency regarding locked-door policies. Both exterior and interior doors were routinely left unlocked, and there was no enforced system of accountability for these policies. Door audits were conducted, but not done systematically, nor were they

documented. On May 24, all of the exterior doors and at least eight interior doors of the West Building, where the incident took place, were unlocked. (Observation 8)

 Law enforcement arriving on scene searched for keys to open interior doors for more than 40 minutes. This was partly the cause of the significant delay in entering to eliminate the threat and

stop the killing and dying inside classrooms 111 and 112. (Observation 10)

 Four years into its existence, the UCISD PD was functioning without any standard operating procedures. A range of UCISD employees, including administrators, faculty, support staff, and

police officers, told the CIR team they had no knowledge of, nor had they been informed about, their school police department’s policies and procedures. The UCISD PD has recently drafted standard operating procedures. (Observation 18)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 7. School Safety and Security.”

 School district police departments should enter into MOUs that establish mutually agreed upon clear jurisdictional responsibilities with other neighboring agencies that are likely to respond to

a critical incident on school property. The MOUs should account for not only routine criminal activity, but also critical incidents. The MOU should address the issue of unified command, in

addition to incident command, and account for the capacity and capabilities of the respective

agencies. (Recommendation 2.1)

 Law enforcement, first responders, emergency management, and other municipal government agencies should coordinate with school districts to conduct multiagency preparedness exercises

on at least an annual basis. Exercises should operate in accordance with the state and local regulations regarding active threat exercises. The exercises should be incorporated into the

emergency operations plans and Campus Safety Plans. (Recommendation 3.1)

 Communities should adopt a multidisciplinary approach to school safety that includes school police, law enforcement, school officials, mental health professionals, and other community

stakeholders. It is especially important that all voices in the school community be heard, including faculty, staff, administrators, counselors, nurses, resource officers, parents, and

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students. Every stakeholder must feel empowered to play a role in reducing fear and raising the

level of safety in and around schools. Each campus should establish and train school safety committees that will meet at least monthly for this purpose. (Recommendation 4.2)

 School districts should invest in upgrading or replacing all doors (or locks) throughout its campuses

to remedy this issue, so that doors can be locked from the inside. (Recommendation 9.1)

 School districts should implement universal access boxes. A universal access box refers to a

locked box that contains master keys, located near the entry points of school buildings, that can

be accessed by authorized emergency first responders and school district staff. (Recommendation 10.1)

 School districts should ensure that emergency alert systems are well-understood by all staff. In the case of UCISD, district leadership should issue a district-wide clarification on the use of PA systems

in conjunction with Raptor emergency alerts. (Recommendation 11.1)

Chapter 8. Pre-Incident Planning and Preparation

Pre-incident planning is crucial in preparing for and responding to mass violence incidents, as it enables

agencies and organizations to develop strategies and procedures to respond quickly and effectively to such incidents. The planning process involves identifying potential risks and hazards, assessing the

likelihood and potential impact of incidents, and creating plans and procedures to respond to them. When a mass violence incident occurs, a community’s response is not limited to one agency, but falls to multidisciplinary stakeholders, including law enforcement, fire, emergency medical services, hospitals, victim service providers, prosecutors, emergency management, government and civic leaders, media, businesses, and individual community members. The planning process—coordinating routinely among all relevant stakeholders, developing agreements, and conducting multidisciplinary trainings, exercises, and drills—is foundational, as are relationship- and trust-building.

Most failures in response can be traced back to failures in pre-incident planning and preparation, and

this is true of the mass casualty incident at Robb Elementary School. “Chapter 8. Pre-Incident Planning and Preparation” describes the policies and procedures, training, mutual aid agreements, and other formal coordination efforts in Uvalde prior to May 24, 2022, and explains how those pre-incident processes impacted the response at Robb Elementary School.

Selected Observations

To see the full list of Observations, see “Chapter 8. Pre-Incident Planning and Preparation.”

 Responding agencies lacked adequate related policies and, in most cases, any policy on responding to active attackers. (Observation 1)

 The Uvalde emergency operations center (EOC) developed an adequate emergency

management plan. However, not all the relevant agencies and organizations actively participated in the process, drills, and exercises which ultimately contributed to a failed

emergency response on May 24, 2022. (Observation 2)

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 The MOU between UPD and UCISD PD that was active the day of the incident failed to

adequately outline the expectations and authorities for a response to a mass violence event. The agencies failed to exercise the MOU, nor cross-train in preparation for a critical incident. (Observation 3)

 Responding agencies had minimal exposure to incident command system (ICS)/National Incident Management Systems (NIMS). Of those serving in top leadership positions within the primary

responding agencies, only UCISD PD Chief Arredondo and the TXDPS regional director had taken

training in ICS/NIMS. (Observation 6)

 Responding officers had levels of active shooter training that varied in terms of their length of time and quality, leading to failures in operationalizing the training. (Observation 7)

 Personnel from responding agencies rarely trained and exercised in a multiagency environment. (Observation 8)

Selected Recommendations

To see the full list of Recommendations, see “Chapter 8. Pre-Incident Planning and Preparation.”

 Every agency must have a clear and concise policy on responding to active attacker situations. (Recommendation 1.1)

 Agencies should regularly review after-action reviews (AAR) with other regional agencies to plan

as a region for a coordinated and collaborative response to possible similar events. (Recommendation 1.2)

 Agencies should consider obtaining state- or national-level accreditation to adopt and maintain

standardized policies and procedures. This process also ensures accountability and transparency

that can enhance confidence and trust in law enforcement among the communities they serve. (Recommendation 1.3)

 Regional public safety partners should plan, train, and exercise unified command for complex incidents. This includes federal, state, and local law enforcement, fire, EMS, and emergency

management as well as other governmental and non-governmental agencies that would

respond to a critical incident. (Recommendation 2.9)

 Elected officials should establish a Multi-Agency Coordination (MAC) Group to provide policy

guidance to incident personnel and support resource prioritization and allocation. Typically, these groups are made up of government agency or private sector executives and administrators whose organizations are either impacted by, or provide resources to, an incident. MAC Groups enable decision-making among senior officials and executives, and delegate

command authority to the incident commander to cooperatively define the response and recovery mission and strategic direction. Additionally, MAC Groups identify operational priorities and communicate those objectives to the Emergency Operations Center and the

pertinent functions of the Incident command system and the joint information center. (Recommendation 2.11)

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 Interagency training, drills, and exercises help to build relationships at the front-line officer level and, if attended by law enforcement supervisors, can further strengthen relationships and the efficacy of a multiagency response to a mass casualty incident. Though policies may differ slightly among agencies, overarching commonalities are the same in an active attacker incident. (Recommendation 8.1)

 Each PIO should draft a crisis communication plan and practice it at least four times a year with

smaller events. This will help identify problem areas and solutions and ensure everyone is

familiar with the plan and knows their role instead of trying to figure that out during a crisis. (Recommendation 12.2)

We hope the observations and recommendations in this report will improve the preparation and

response by those law enforcement agencies assessed during this review, as well as other law enforcement agencies throughout the country. We also provide this independent review of what transpired as a measure of dedication not only to those who lost their lives on May 24, but also to the

surviving victims, family members, and others deeply and forever affected by this tragedy.

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Abbreviations and Acronyms

Acronym Definition

AAR after action review

BORSTAR Border Patrol Search, Trauma, and Rescue

BORTAC Border Patrol Tactical Unit

BWC body-worn camera

CBP U.S. Customs and Border Protection

CCTV closed-circuit television

CIR Critical Incident Review

COPS Office Office of Community Oriented Policing Services

DOJ U.S. Department of Justice

FOS first on scene

IACP International Association of Chiefs of Police

ICP incident command post

ICS Incident Command System

JIC Joint Information Center

JIS Joint Information System

MAC Group Multiagency Coordination Group

MOA memorandum of agreement

MOU memorandum of understanding

PIO public information officer

SWAT special weapons and tactics

TXDPS Texas Department of Public Safety

UCISD Uvalde Consolidated Independent School District

UCISD PD Uvalde Consolidated Independent School District Police Department

UCSO Uvalde County Sheriff’s Office

UPD Uvalde Police Department

Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary | Abbreviations and Acronyms 21

U.S. Department of Justice Office of Community Oriented Policing Services 145 N Street NE Washington, DC 20530

To obtain details about COPS Office programs, call the COPS Office Response Center at 800-421-6770.

Visit the COPS Office online at cops.usdoj.gov.

e072326061 Published 2024