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Letter from the COPS Office

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This project was supported by cooperative agreement number 2016-CK-WX-K021 awarded by the Office of Community Oriented Policing Services, U.S. Department of Justice. The opinions contained herein are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice. References to specific agencies, companies, products, or services should not be considered an endorsement by the authors or the U.S. Department of Justice. Rather, the references are illustrations to supplement discussion of the issues.

Cover Photo: Orlando Police Department.

I don’t think any of us will forget the horror of the Pulse Nightclub attack in June of 2016. This terrorist act claimed the lives of 49 innocent people and injured 58 others, making it at the time the worst attack in our country since September 11, 2001. Nor should we forget the bravery, strength, and professionalism of the Orlando Police Department (OPD) and the other first responders who responded to the incident. They performed with great heroism and skill in the midst of chaos and carnage.

The OPD’s response, which was appropriate and consistent with national guidelines and best practices, saved lives. But the department also learned important lessons from this event, which can be of great value to other law enforcement and public safety organizations. To share them and identify best practices for effective response to similar attacks and mass casualty events, OPD Chief John W. Mina asked the COPS Office to conduct a critical incident review.

This report, which details all aspects of the event and its aftermath, underscores the need for a national conversation about law enforcement policies, practices, and training for handling acts of mass public violence and terrorism. This discussion is especially important now, in an era when we face coordinated events, multisite attacks, explosive devices, and other unforeseen threats.

The report also stresses the fact that developing partnerships before an event occurs is critical to a successful response. In addition, it notes the vital role that communication to the public plays and highlights the importance of meeting the mental health needs of officers who have been involved in mass casualty incidents.

I applaud Chief Mina for requesting this comprehensive review and thank the Police Foundation and its technical team for developing the report. Its findings and recommendations will not only benefit the OPD but can also help other agencies prepare for similar situations.

As threats of terrorism persist and our law enforcement officers and first responders continue to put themselves in harm’s way to protect us, efforts such as this can help save many lives.

Sincerely,

Russ Washington
Acting Director
Office of Community Oriented Policing Services

As I write this letter on October 2, 2017, the country is learning of yet another deadly shooting that occurred last night in Las Vegas, Nevada. It now has the dubious distinction of the worst mass murder on American soil since 9/11. At this moment, Las Vegas first responders are responding to a scene where at least 58 people were killed and hundreds wounded by a gunman who fired on a large crowd at a concert.

It is unfathomable to me how frequently our first responders are confronted with responding to horrific incidents such as this one and the one that occurred at Pulse on June 12, 2016. In recent years, there have been countless domestic and international mass casualty and terrorist attacks that highlight both the worst of humanity and the best—such as the bravery and resilience demonstrated by communities like Orlando.

Like many across the nation on June 12, 2016, my heart broke as I watched the news that Sunday morning. As the sun rose, it became apparent that Orlando was at that time the site of the deadliest terrorist attack on American soil since September 11, 2001. More than 100 innocent people were shot—leaving 49 dead and 53 with gunshot wounds, as well as five people with other injuries—as part of a vicious and senseless attack at the Pulse nightclub.

The challenges confronting the principal public safety agencies responding to this incident included: transitions in the operational and tactical strategies from active shooter to barricaded suspect with hostages to terrorism; the dark and difficult layout of the nightclub; the safety and well-being of countless hostages and officers; multiple local, state, and federal agencies arriving with sometimes overlapping roles and responsibilities; and agencies with differing policies and practices using different communications systems and protocols. In addition, the constant threat of secondary attacks and explosions required decisive action with little conclusive information under extremely grisly and difficult circumstances.

While our assessment team confirmed that the Orlando Police Department’s (OPD) tactical response was consistent with the its policies, procedures, and training as well as nationally recognized promising practices, the current and evolving threat environment demands that our nation’s public safety agencies better prepare command personnel and first responders to prevent and respond to the next attack. It is imperative that our national homeland security, law enforcement, and public safety communities coordinate, debate, and create guidelines on the police response to acts of mass public violence and terrorism that meet this increasing and evolving threat.

Bringing new advances to policing lies at the core of the Police Foundation’s mission. Central to our research and work with law enforcement agencies is the idea that it is imperative to honestly examine, analyze, and study police-involved incidents to identify “lessons learned” to continually advance the profession. The increased frequency of these incidents and the continual evolution of the challenges faced mandate that public safety agencies must continue to evolve and adapt their training and responses to meet these challenges. Certainly, that is true of this incident.

Those who responded to the Pulse that night are some of the bravest and most dedicated of public servants. Undoubtedly, their well-trained and decisive actions saved lives. It is because of the efforts of all involved in the response on June 12 that the suspect was neutralized before he could inflict more damage and devastation. This assessment—and the lessons learned—are not designed to “Monday morning quarterback.” Rather, they are intended to provide a basis for careful study of the tactics used by the terrorist and the actions taken by Orlando-area public safety agencies that day. It is an effort to enhance the safety of first responders and the public at large and further aide in preparing for, responding to, and recovering from mass casualty and terrorist incidents like the one that occurred last night.

I am grateful to Orlando Police Chief John W. Mina and the OPD for their cooperation with our review. Not only were they willing to answer our questions, provide us access to their department and vital information, and provide us unwavering support but they also invited our team and our examination of the response to this attack in an effort to help advance policing response to terrorist attacks. Deputy Chief Robert Anzueto provided our team with exceptional access and support throughout the project. In addition, I am grateful to the hundreds of interviewees who generously gave us their time. They answered questions candidly, and we are forever thankful for their willingness to tell us the story of their experiences and rehash traumatizing moments. It was only through their eyes that we were able to gain a true understanding of the complexities involved. It is extremely important to acknowledge the dedication and professionalism of the many law enforcement and first responder agencies involved in this incident. In addition to the Orlando Police Department, the individuals from 26 additional agencies that responded all performed their duties valiantly.

I would like to express my gratitude for the hard work of our assessment team: Chief Frank Straub (ret.), PhD; Jack Cambria; Chief Jane Castor (ret.); Ben Gorban; Dr. Brett Meade; David Waltemeyer, and Jennifer Zeunik. In addition, I would like to thank our Police Foundation staff, including Blake Norton, James Burch, Rebecca Benson, Joyce Iwashita, and Siobhan Scott for their hard work and support throughout the review.

Finally, we offer this work as a tribute to the memory of the victims and survivors of the attack on Pulse, and to the resiliency of the City Beautiful. May we remember them and honor them by diligently applying the lessons learned.

Chief Jim Bueermann (ret.)
President
Police Foundation

On June 12, 2016, what began as an active shooter incident when a lone gunman entered the Pulse nightclub in Orlando, Florida, and began shooting innocent clubgoers transitioned into a barricaded suspect with hostages incident and ended as the deadliest terrorist attack on American soil since September 11, 2001. One hundred two innocent people had been shot: 53 injured and 49 killed.

The decisions made and actions taken by the men and women of the Orlando Police Department (OPD) and Orlando’s other law enforcement agencies embody the bravery, strength, and professionalism of our nation’s law enforcement and public safety first responders as well as the strength of the Orlando community.

The following pages of this E-report detail the multiple phases of the OPD response to the incident and describe the public safety response more generally to provide context. The report also provides observations and lessons learned from the response, identified through an independent, objective, and comprehensive analysis. The report is designed to benefit OPD and the Orlando community as well as to provide law enforcement and public safety agencies across the nation with critical guidance and recommendations to inform the response to an increasingly complex and violent threat environment. The E-Report format allows you to further explore important topic areas through interactive story maps: The Incident; Emergency Medical Care; Media & Public Information; Officer Safety & Wellness; Equipment & Training; and Remembering Victims & Supporting Survivors. For more information, view the full technical report, interactive timeline, and critical incident review library.

As the time approached 2:00 a.m., approximately 300 people—many from the Orlando-area LGBTQ and Hispanic communities—were still packed into the 4,500-square foot Pulse nightclub, enjoying the last 30 minutes of the Latin Night event. At each of the club’s three bars, patrons lined up to get their drinks for last call. Others were dancing and watching live entertainment in the three sections of the club. Rotating strobe lights ran as music blared. A different type of music came from each DJ in the club.

Armed with an assault rifle, handgun and ammunition, an almost six-foot tall male wearing a plaid dress shirt and tan cargo pants parked at the neighboring car shop and walked along the fence line towards the front entrance. The suspect had been to the club before.

At 2:02 a.m., the suspect entered the club and immediately began firing a Sig Sauer MCX semi-automatic .223 caliber rifle and a Glock 17 9mm as fast as he could pull the triggers. Some rounds struck the first victims at close range; other rounds ricocheted off the cinderblock and stucco walls, the reception desk, and the chandelier, pockmarking the walls and hitting victims. Deeper inside the club, some patrons were not immediately startled by the shots. Some believed the sound was part of the music or a special sound effect employed by a DJ; to others it sounded like a BB gun. One of the three DJs in the club turned his music down and listened closer. Realizing that it was not a special effect but something much more real, the DJ turned the music off and yelled, “Run! Get out! There’s a guy with a gun!”

Outside, in the Pulse parking lot, an OPD detective who was working extra duty at the club—to provide outside security and to provide assistance to security personnel inside the club if needed—heard the shots that were being fired; at 2:02:17 a.m., he broadcast over the radio, “Shots fired, shots fired, shots fired,” and requested additional officers to respond. OPD Dispatchers broadcast a Signal 43 (officer needs immediate assistance). Recognizing that his Sig Sauer P226 9mm handgun was no match for the suspect’s .223 caliber rifle, the detective moved to a position that afforded him more cover in the parking lot. Two patrons attempted to flee through an emergency exit on the south side of the club. When the detective saw the suspect shoot them, he fired at the suspect.

Around the time the shots began, the first 911 calls began to come in. Call takers and dispatchers could hear the shots being fired and the chaos inside Pulse as they answered calls or held open lines with people who had been shot. They tried to gather information from callers inside Pulse and relayed the information to responding officers while attempting to calm the callers.

Once clubgoers recognized the sounds as gunfire, the club became chaotic. An employee kicked a hole through the eight-foot patio fence, which allowed 22 patrons to escape. Patrons ran for exits; hid in dressing rooms, closets, and restrooms; or ducked behind the bars. Many of them were already wounded. During this time, crammed into these hiding places, people hugged one another; screamed and yelled for help; and made calls to 911, friends, and family. The first calls indicated the confusion and chaos inside the club regarding what was happening and the number of shooters.

After the detective fired at the suspect, the suspect doubled backed through the club and walked deeper into the main dance area called the Jewel Box, indiscriminately firing both his rifle and handgun. Patrons continued to escape or find a place to hide. Others fell to the ground, took cover, pretended to be dead, or had been shot. According to survivors, as the suspect moved through the Jewel Box at this time, he stood over the individuals lying on the floor and fired additional rounds into them at point-blank range without regard for whether they were alive or already dead. The suspect then continued to make his way toward the patio, continuously firing his weapons as he moved. According to OPD estimates, the suspect fired approximately 200 rounds in less than five minutes, stopping only to reload.

Listen to some survivors recount their personal stories of that night.

A few minutes after the shooting had begun, three additional officers arrived and formed a contact team with the detective. The team was staged outside trying to determine the status and location of the suspect when the shooting suddenly paused. The team, now led by an OPD sergeant, entered the club through the patio. At just more than six minutes after the shooting began, the contact team immediately began rescuing people. They were followed approximately one minute later by a second contact team led by the OPD special weapons and tactics (SWAT) commander—a lieutenant who was also the on-duty watch commander. The second contact team broke a large window to enter the reception area and headed toward the Jewel Box area to locate the suspect and assist in the rescue efforts.

According to officers who entered the building, what they saw in the largest room of the club was a scene unlike any they had ever seen before. Bodies were piled up on the stage and across the dance floor; individuals with devastating wounds and deceased victims were everywhere. A disco ball and colored lights were the only source of light in the otherwise dark room. There was an “eerie quiet”—broken only by occasional gunfire, cries for help, and ringing cell phones strewn across the floor or in the pockets of victims as friends and family tried to reach those inside the club. While they were tending to individuals in the Jewel Box, the contact team led by the OPD SWAT commander responded to gunshots in the Adonis Room. Just as quickly as the shooting began, it stopped. The OPD SWAT commander recalled that at this time, he believed they had contained the suspect in one of the two restrooms located at the end of the narrow hallway. The SWAT commander directed the team to take up positions to cover the hallway and prevent the suspect from advancing down the hallway.

View the full video of first responders recounting their stories of the response.

Meanwhile, the OPD Communications Center continued to receive emergency calls, several from people inside Pulse. Call takers and dispatchers held on to calls even when victims grew silent or were unable to speak.

Victim and survivor calls provided vital information to responders. At approximately 2:10 a.m., one caller told a 911 operator that he was hiding in the handicapped-accessible stall with at least 10 other people, that he was shot in the leg and the knee, and that there were several other people who had been shot multiple times. The injured hostage was also able to provide the operator with a key piece of information referring to the suspect: “He’s in the bathroom. He’s in the bathroom.”

The chaos and horror extended well beyond the nightclub. Dispatchers occasionally muted their phones to compose themselves before continuing with panic-stricken, and sometimes critically wounded callers inside the club. The dispatchers relied on their training to keep callers calm so they could obtain critical information regarding the suspect, the location of persons hiding in the club, or the bomb vests the shooter claimed to have and relay that to officers and command personnel at the scene.

Listen to some 911 calls from the incident:

Relying on Training When it Matters Most: An OPD communications center employee was returning from her break, heard the commotion, and realized something big was happening. She returned to her duty station and began taking 911 calls from victims. As she was speaking to one victim, the employee heard gunshots and realized the victim had just been killed as she was talking with her. She then received a call from another victim. Relying on her extensive training, she was able to keep the victim calm on the phone and was instrumental in his eventual rescue. Several employees were distraught and the emotional toll was apparent, but because of their training, they were all able to provide a calming presence to the victims and relay important information to officers on scene. Supervisors immediately requested department chaplains respond to assist call takers and dispatchers dealing with emotional trauma. Read more on supporting responders.

At 2:14 a.m., while the second contact team remained in the Adonis Room containing the suspect, the first team—joined by additional officers and deputies—began clearing the patio, the Jewel Box, and any other areas they could access. As one team provided security, the other triaged the injured and started rescuing those with the most critical injuries. More than 20 patrons were rescued from the restroom on the southeast corner of the Jewel Box.

At 2:18 a.m., the OPD SWAT commander initiated a full SWAT call-out as the suspect was contained in the restroom with hostages. The SWAT commander also requested that a triage team be formed to remove injured people from the club.

As the triage team—consisting of officers from agencies including the Apopka, Belle Isle, Eatonville, Maitland, Winter Garden, and Winter Park Police Departments, the Orange County Sheriff’s Office (OCSO), and the Seminole County Sheriff’s Office—rescued the injured survivors, others pulled on the legs of officers and begged for help. One officer, responding to a number of severely wounded or deceased victims, told survivors, “If you’re alive, raise your hand,” as he continued to rescue victims. Many of the victims were too severely injured or in shock and unable to move by themselves, so officers and deputies carried them to the makeshift triage center, located behind the Einstein Bros. Bagels store approximately 200 feet from the club. Between 2:18 a.m. and 2:28 a.m., officers rescued 14 victims from inside the club.

When the triage area became too crowded to handle the number of critically injured persons and responders administering first aid, officers and deputies loaded injured individuals into their vehicles and transported them to Orlando Regional Medical Center (ORMC), the Level 1 Trauma Center less than half a mile away. Between 20 and 25 gunshot victims were transported by law enforcement to ORMC in their vehicles.

At 2:20 a.m., as the club was being secured and people were being rescued, another individual—this time from inside the restroom with the suspect—called 911. The hostage advised the call taker that the suspect was reloading his weapons and that although he was no longer firing, there were injured hostages who needed medical attention. One minute later, a hostage escaped from one of the bathrooms down the hallway.

At 2:30 a.m., 11 more persons—five who had been hiding in the drink preparation and kitchenette room behind the main bar in the Jewel Box and six who had been hiding in an upstairs office area above the main dance floor—were rescued by an OPD sergeant and a team of officers. By approximately 2:35 a.m., all the critically injured individuals in the club except the hostages and the survivors in the Adonis Room area, the restrooms, and the dressing rooms—had been rescued.

At 2:35 a.m., another 911 call was answered in the Communications Center: a call that would change the nature of the incident from a barricaded suspect with hostages to a terrorist event.

Rapid Victim Transportation: On July 12, 2012, the city of Aurora, Colorado experienced a mass shooting at Century 16 Theatre movie complex when a lone gunman shot 70 people while 12 other people suffered injuries from fleeing the scene. As the number of police, fire, and emergency medical services responders increased, the theater quickly became a site of chaos and confusion, with no coordinated response. An unintended consequence was that police vehicles blocked ambulances from triage and treatment locations to pick up victims and transport them to local hospitals. In a creative improvisation, police officers decided to transport victims in their own vehicles, which was unprecedented and unplanned but saved lives. This practice was beneficial in the responses to Pulse and the San Bernardino terrorist attack. For more lessons learned from the Pulse response, view the Lessons Learned page in this E-Report.