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Police Foundation Critical Incident Reviews

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Letter from the COPS Office

Letter from the Police Foundation

Bringing Calm to Chaos – A San Bernardino Attacks Summary

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This project was supported by grant number 2015-CK-WX-K005 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: Officers from San Bernardino and the surrounding area respond to a shootout with suspects on San Bernardino Avenue. Francine Orr/Los Angeles Times via Getty Images.

Letter from the COPS Office

As many of us watched events unfold after the terrorist attack in San Bernardino in December 2015, there was one source of reassurance in those dark hours: the exemplary response of the police department, sheriff’s department, probation department, emergency services, and FBI, who all came together to prevent additional deaths and injuries.

There is much to be learned from the response to this tragic event. One important takeaway is that the responding agencies were well prepared. Many responders noted that their preparation was due in large part to lessons learned from previous critical incident reports. This acknowledgement highlights the importance of documenting lessons learned, which can be of great value not only to the agency which experienced the event but to other agencies as well. For this reason, the Police Foundation, in coordination with the COPS Office, conducted a critical incident review of the shooting and surrounding events. By examining the public safety response of the December 2015 attack, this report provides additional lessons learned from all aspects of the event, including the aftermath.

As was demonstrated in San Bernardino, a detailed review can be of great value to a law enforcement agency, enabling significant improvement of policies, procedures, systems, and relationships. It can also help other public safety agencies prepare for mass casualty incidents. Through after action assessments such as these, the U.S. Department of Justice and its partners can disseminate critical lessons learned to the entire field, enabling comprehensive preparation and response and potentially saving lives.

Our thanks go out to the many organizations whose members responded so bravely at the time of the attack, especially to those who willingly relived this painful event to share their experiences and offer recommendations that can help other agencies in the future. All of them are to be acknowledged for their valuable contributions to public safety.

I encourage all law enforcement and public safety leaders to consider the lessons learned in San Bernardino and how they can be applied to their own agencies. Terrorist activities and other mass casualty events are rare, but as we have seen in Orlando, Paris, and other locales, they are unfortunately becoming more common—almost always without warning. And as we saw in San Bernardino, advance preparation can be of enormous help in the midst of tragedy and chaos.


Ronald L. Davis
Office of Community Oriented Policing Services

Letter from the Police Foundation

As the retired Chief of Police of the Redlands (California) Police Department, I understand the impact critical, high-profile incidents have on a community and a police department. The terrorist attack in the City of San Bernardino on December 2, 2015, was unlike anything I experienced during my 33 years in the Redlands Police Department. On that day, the city of San Bernardino was the site of the world’s most recent terrorist attack—and the first on American soil since the bombings at the Boston Marathon in 2013.

Two individuals opened fire indiscriminately—shooting 36 (killing 14 and injuring 22) innocent people—as part of a vicious and premeditated terrorist attack at the Inland Regional Center before escaping and then returning to San Bernardino to engage in a final shootout that ended their lives.

The challenges confronting the principal public safety agencies that responded to this attack were monumental: three crime scenes; multiple local, state, and federal agencies arriving with sometimes overlapping roles and responsibilities; hundreds of victims and witnesses; differing policies and practices, different organizational cultures, using different communications systems and protocols; and a nation and world watching and waiting for answers. The fluidity of every aspect of the attack and its aftermath required decisions to be made on the spot, in less than opportune situations, with the media—and social media—broadcasting every move in real time.

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 examine, analyze, and learn from police-involved critical incidents in an effort to continually improve. Certainly, that is true of this incident.

Those who responded on that day did so with the utmost bravery and dedication, and their well-trained and disciplined actions undoubtedly saved lives. It is because of the efforts of all involved in the response on December 2, 2015 that there were not more victims and that the two terrorists were killed before they could inflict more damage and devastation. In fact, many of the lessons learned in this report are based on policies, procedures, and protocols that responding agencies followed on that day. This review is not meant to assign fault to any individual or agency where improvements are suggested but to apply lessons to enhance the safety of first responders and the public at large and to further aide in bringing calm to chaos.

I am grateful to San Bernardino Police Chief Jarrod Burguan and the professionals at the San Bernardino Police Department and to San Bernardino County Sheriff John McMahon and the professionals at the San Bernardino County Sheriff’s Department for their cooperation. Not only were they willing to answer our questions, provide us access to their departments and information, and provide us unwavering support but they also invited our team and our investigation into the response to these attacks in an effort to help advance policing and specifically the response to terrorist attacks.

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 San Bernardino Police Department and the San Bernardino County Sheriff’s Department, the Redlands Police Department, San Bernardino County Probation, Inland Valley Regional SWAT, San Bernardino City Unified School District, Ontario Fire Department, San Bernardino City Fire Department, Inland Counties Emergency Medical Agency, California Highway Patrol, Fontana Police Department, Colton Police Department, Rialto Police Department, San Bernardino County District Attorney’s Office, FBI, ATF, DHS all performed their duties valiantly.

In addition, I am extremely grateful to the hundreds of commanders, supervisors, detectives, officers, deputies, other first responders, and victims and witnesses who generously gave us their time. They answered all questions candidly, and I am forever thankful for their willingness to relive their stress and heartbreak through the retelling of their experiences and the rehashing of traumatizing moments. It was only through their eyes that we were able to gain a true understanding of the complexities involved throughout that fateful day.

I would like to express my gratitude for the hard work of our review team: Sheriff Rod Hoops (ret.), Chief Rick Braziel (ret.), Chief Frank Straub (ret.), PhD, and George Watson. In addition, I would like to thank our Police Foundation staff, including Program Director Jennifer Zeunik for driving the activities of this effort as well as Blake Norton, James Burch, Ben Gorban, Rebecca Benson, Joyce Iwashita, and Maria Valdovinos. They worked tirelessly to present this critical incident review in a compelling and useful manner.

Finally, this review is dedicated to the victims and families of the victims affected by this terrible attack and to victims of terrorism worldwide. It is offered in memory of Robert Adams, Isaac Amanios, Bennetta Bet-Badal, Harry Bowman, Sierra Clayborn, Juan Espinoza, Aurora Godoy, Shannon Johnson, Larry Daniel Kaufman, Damian Meins, Tin Nguyen, Nicholas Thalasinos, Yvette Velasco, and Michael Wetzel. May we remember them and honor them by diligently applying the lessons learned.


Chief Jim Bueermann (ret.)
Police Foundation

Bringing Calm to Chaos

A Summary of the San Bernardino Attacks

First Responders

First Responders
Photo: Gina Ferazzi/LA Times via Getty Images

On December 2, 2015, San Bernardino County employees at the Inland Regional Center (IRC) in San Bernardino, California, were gathering for a training meeting. Syed Rizwan Farook, a county environmental health specialist, was in attendance but left the building during the meeting. He and his wife, Tashfeen Malik, later returned to the building dressed in dark tactical military-style gear and unleashed terror on his coworkers and others along the way. In a matter of minutes, the couple fired over 100 .223 rounds, wounding 22 and killing 14 before they fled in a rented SUV.

Within four minutes of the first 9-1-1 calls, first responders began to arrive. Four hours later, the couple engaged officers in a gun battle that ended the the assailants’ lives. In those chaotic hours, multiple local, state, and federal law enforcement agencies, firefighters, and medical personnel responded to three separate scenes (the IRC, the officer-involved shooting scene, and the assailants’ residence). They collectively sought to secure the scenes, treat and transport the injured, investigate the incidents, address the media and the public, and identify and locate the assailants, all while facing threats of secondary attacks and possible explosive detonations.

The preliminary investigation that followed revealed that the assailants planned, targeted, and attacked Farook’s coworkers in an act of terrorism.

On all accounts, the public safety first response to the shooting was exemplary. First responders acted with courage and discipline – using their training and skills to act quickly and decisively in a horrifying situation. The challenges that they faced were immense. Just as the response to the Christopher Dorner attacks did years earlier, looking at all the moving pieces to this horrifying event and the responses to it reveals many important lessons both for San Bernardino public safety agencies and for agencies nationwide. This report is intended to inform other departments and cities as they train, prepare, and respond to critical events. Key ‘Lessons Learned’ are summarized in this E-Report and further detailed in the technical report.

This abbreviated interactive E-Report and linked Story Map captures the pivotal points of the event and shares lessons with other departments, cities, and the public to limit impacts of future active shooter or other hostile events. We hope that they adequately acknowledge the valiant efforts put forth by first responders, and honor the victims of that horrible day.

A Normal Start to a Traumatic Day

Inland Regional Center – December 2, 2015

December 2, 2015 began as normal training day taking place at the Inland Regional Center for San Bernardino County Health workers. Employees were seated at tables throughout the conference room. It did not seem particularly unusual that County Health Inspector Rizwan Farook got up from his chair and left the room after checking his phone. He had a six-month old baby at home, a baby for whom his co-workers had months earlier thrown him a shower. During a break shortly before 11 a.m., normal became chaos as the room erupted with bullets. A masked man dressed in black tactical attire swung the door open, spraying the room with bullets. Moments later, a second shooter in similar attire appeared and calmly began firing. A round hit the fire sprinkler system, causing water to pour out of the ceiling’s shattered pipe. The water, the smoke, and the darkness of the room made it difficult for anyone to see. Three male county workers tried to stop the shooters by rushing one of the gunmen but all three were shot. The shooters walked between tables throughout the room firing shots at anybody who moved or made a sound. After firing over 100 .223-caliber rounds, the shooters hastily disappeared in a black SUV parked just outside the conference room in Building 3.

The First to Respond

“That was the hardest part, stepping over them.” – San Bernardino Police Department Patrol Officer

The first 9-1-1 call regarding the shooting came into dispatch at 10:59 a.m. The first officer arrived on-site within four minutes of receiving the call. The officer was a San Bernardino Police Department (SBPD) lieutenant who immediately called for three officers for back up so they could enter the building in a trained formation. The second to arrive, a patrol officer, had a community service officer in the vehicle with him who he ordered to find a safe hiding spot. The third was a homicide detective who had just gassed up the cruiser on a break from a patrol assignment. The fourth, a motorcycle patrol officer, had spotted the aerial helicopter while at lunch and rushed to aid. All four had been through active shooter training. After conferencing for about 20 seconds, “…it just seemed like we knew what our roles were and what we were supposed to do…”

Diagram of IRC Buildings

Diagram of IRC Buildings
Photo: San Bernardino County Sheriff’s Department

Rounding the southeast corner of the building, the team of four encountered three deceased victims. The first was a woman lying on the ground outside of the double glass doors, which had been shot out. The second was a man sitting on a bench. His cell phone was still in his hand, and at first the officers thought he was alive until they saw the extent of his wounds. Finally the team saw a man who appeared to have been eating his lunch sitting at a picnic table.

The officers were stunned as they entered the conference room. It looked like a bomb had gone off. Bodies were strewn across the floor. Many had devastating wounds. Blood was everywhere. The smell of gunpowder filled their nostrils and the sprinklers sounded like they were hissing. As trained and necessary, the officers moved in formation through the room. “It was the worst thing imaginable – some people were quiet, hiding, others were screaming or dying, grabbing at your legs because they wanted us to get them out, but our job at the moment was to keep going,” the patrol officer said. “That was the hardest part, stepping over them.” The team encountered several people hiding in hallways, closets, and under furniture as they moved deeper into the building, eventually meeting up with a second team of officers. The two teams quickly organized a plan to clear the building.


More Help Arrives

“You never lack for people, you just need to figure out what to do with them all.” – David Bowdich, then-FBI Assistant Director in charge of the Los Angeles Field Office

San Bernardino County Sheriff and Probation officers rush to the scene

San Bernardino County Sheriff and Probation officers rush to the scene
Photo: Frederic J. Brown/AFP/Getty Images

San Bernardino Police Chief Jarrod Burguan headed straight to the scene when he was informed of the active shooter incident. “It was complete and total chaos when I got there,” the chief recalled. “There were already a lot of emergency vehicles there. Initially, you are just trying to get a handle on what is going on because the (police) radio is overwhelmed.” Having so many emergency vehicles would eventually create problems. Vehicles were parked randomly as officers sprinted to the IRC while fire engines and ambulances staged as close as possible. As the incident continued to unfold, this disorganization became more and more problematic as entry and exit lanes were blocked.

SWAT Armored Vehicle

SWAT armored vehicle
Photo: Marcus Yam/LA Times/Getty Images

San Bernardino Sheriff John McMahon quickly reached out to Chief Burguan, offering his resources and experience, having led the Dorner search in 2013. Soon after, the FBI was on scene as well.

Members of the San Bernardino County Probation Department, which is headquartered just 2.9 miles from the IRC, also arrived quickly. The first two probation officers pulled into the parking lot and found many victims hiding, leading them to quickly realize they would need additional help.

Also nearby, SBPD’s Special Weapons and Tactics (SWAT) team was conducting active shooter drills at a local hotel. As they were concluding a drill, members heard the active shooter call over the radio. They immediately made appropriate equipment changes and headed to the IRC.

Clearing the Building

Helicopter outside the IRC

Helicopter outside the IRC
Photo: Luis Sinco/LA Times/AP

Law enforcement encountered victims hiding in any space they could find. They worked to get people out of the building as quickly and safely as possible, all the while unsure of the location of the suspects. The suspects’ identities and whereabouts were still unknown, so people were asked to exit the building with their hands visible. Officers tried to ease tensions by reassuring employees while keeping the evacuation process moving.

Units had arrived or were arriving from multiple agencies, each with their own uniforms and procedures. Officers were trying to clear the building but had limited access to spaces that were protected by specific key cards and/or heavy metal doors. They used several employees’ cards; however the varying security levels made this inefficient. They had to wait for breaching equipment to reach certain areas. Further complicating the building search, they lacked a uniform way to mark areas that were cleared. The teams were frustrated when they cleared the buildings but had not located the suspects.

“I’ll take a bullet before you do.” – Officer evacuating employees

IRC Buildings

IRC Buildings. Conference room where shooting occurred is in Building 3 on the far right
Photo: San Bernardino County Sheriff’s Department

Triage and Safety

“That’s why so many people are still alive. We couldn’t have done it without the police department, fire department. Everyone.” – San Bernardino tactical medic

IRC victim

IRC victim
Photo: David Bauman/AP

As officers searched for the suspects, others helped the wounded. A San Bernardino tactical medic triaged the injured inside the conference room using tape to mark the victims’ status. Victims were then transported using anything the officers could find – tables, blankets, chairs – to carry out the wounded soaked with blood and water from the sprinklers. A probation sergeant found a woman hiding between two cars, fearful she was going to die, with a large hole in her leg and and a smaller wound to her arm. Had officers not taken immediate action, she would not have survived. “Everybody worked together, and those people are alive because of it,” the tactical medic said. “That’s why so many people are still alive. We couldn’t have done it without the police department, fire department. Everyone.”

Loma Linda University Medical Center

Loma Linda University Medical Center
Photo: Patrick T. Fallon/AFP/Getty Images

Some victims were picked up by officers in vehicles for immediate transport to hospitals while others were taken to a safer area near the San Bernardino Golf Course entrance. At that secondary triage location, firefighters and paramedics treated victims, binding wounds and doing whatever they could to assist the injured. Tarps were put out, designating the different levels of trauma. Ambulances continued to arrive to take the wounded to local hospitals. Medical transport helicopters also landed on the golf course and transported a couple of the victims. Altogether, it took 57 minutes to get 22 wounded survivors, some critical, out of the IRC and to a hospital.

In the medical community, it’s believed that if injured or wounded people can be transported to a hospital in under an hour – known as the Golden Hour – their likelihood of survival grows significantly. On that day, every victim taken to a hospital survived.

IRC witnesses on golf course

IRC witnesses on golf course
Photo: Micah Escamilla/LA News Group via AP

At the same time, authorities led uninjured county employees and IRC staff to a nearby spot on the golf course and told them to stay there. Hundreds of people waited, sharing grief and tears and wondering what had just happened.

By 1 p.m., the San Bernardino City Unified School District (SBCUSD) issued a lockdown at all of its school sites and offices, requiring all gates and entrances to be secured. After-school activities were canceled and the lockdown remained in place into the afternoon during the investigation. All schools were back in session the next day.

Read the Police Foundation’s after action review analysis for the SBCUSD in the technical report, appendix B.