The state commission investigating what led to the massacre at Marjory Stoneman Douglas High School and how law enforcement responded is criticizing both the school system and the sheriff’s office, according to draft findings and recommendations being debated by the panel Wednesday in Tallahassee.
The report lists security failures, including the school leaving outer fence gates open and building doors unlocked, which allowed the killer to walk on campus with an AR-15 in a rifle bag, and walk into a building where he would kill 17 people on Feb. 14.
It says the failure of the school system to mandate safe areas, including hard corners — taped off areas in classrooms out of line of sight from a potential shooter locked out of the classroom — was a “safety breach.”
When it came to the Broward sheriff’s office, the commission lays primary blame on now-former school resource officer Scot Peterson, who they say was “derelict in his duty” for fleeing from just outside the 1200 building while others were killed, retreating to his own safe area.
The draft, portions of which will be modified before being forwarded to the governor and legislature by Jan. 1, also criticizes six deputies who arrived near campus, heard gun shots and did not immediately move toward the gun fire. That response, the document states, was “unacceptable.”
School monitors were also singled out for criticism for not immediately calling a Code Red, active shooter warning, when they saw on campus someone they believed was either armed or a potential school shooter.
That delay likely cost lives, commissioners said, because no one died or was wounded in any of the second-floor classrooms where teachers, hearing gunshots, acted as if a Code Red had been called.
On the third floor, where some assumed a fire drill was taking place after dust loosened by gunfire on the first floor set off the alarm, six people were killed and many others filing into hallways were at risk.
Here are some of the key findings, subject to change:
- Cruz entered the MSDHS campus through an open and unstaffed pedestrian gate that had been opened by Campus Monitor Andrew Medina for afternoon dismissal. Cruz exploited this open and unstaffed gate and it is what allowed him initial access to the campus. This open and unstaffed gate was a security failure.
- Unlocked and opened gates were regularly left unstaffed for long periods of time on the MSDHS campus. School administrators cited a lack of personnel as the explanation for the unstaffed and open gates. This explanation is unacceptable as leaving open perimeter gates unstaffed is a breach of effective security protocols.
- The school district does not allow Broward County law enforcement live, real time access to its school camera systems. Law enforcement’s inability to live- view cameras in the building 12 hindered the law enforcement response and caused officer safety issues because law enforcement was unable to determine whether Cruz had departed the building.
- The fire alarm caused confusion among students and staff in building 12. Some treated the event as a fire alarm (evacuation) and some treated it as an active shooter situation (hiding in place). As set forth in section 5.2, the lack of a called Code Red contributed to students and staff not treating this incident as an active shooter event and that put students and staff at risk because they used evacuation protocols, not active assailant response protocols.
- The glass windows in the classroom doors allowed Cruz line of sight access to target his victims and there were no pre-designated window coverings for teachers to quickly cover their classroom door windows.
- Only 2 of the 30 classrooms in the building 12 had marked hard corners. To the extent that students attempted to hide in the classrooms’ hard corners they were mostly inaccessible due to teachers’ desks and other furniture occupying the space. There was inadequate space in many classrooms’ hard corners and some students were squeezed out of the hard corners. Because classrooms lacked effective hard corners and/or students were not directed to hard corners, some students were forced to seek cover in an area visible to Cruz. Cruz only shot people within his line of sight and he never entered any classroom. Some students were shot and killed in classrooms with obstructed and inaccessible hard corners as they remained in Cruz’s line of sight from outside the classroom. The District’s failure to mandate and implement hard corners or safe areas in every classroom was a safety breach that contributed to students being shot.
- Some bullets traveled through the drywall and the metal doors. Had Cruz intentionally shot through the walls or doors, the amount of casualties could have been greater. Drywall and easily penetrable doors are a safety vulnerability.
- The storm resistant glass on the third floor teacher’s lounge mitigated the number of people shot because the rounds fragmented and prevented Cruz from effecting his sniper position. Despite trying to shoot from his sniper position, Cruz had 180 rounds of ammunition left when he abandoned his gun and fled the school.
- The lack of a formal Code Red or similar active assailant response policy in the Broward County Public Schools led to school personnel not knowing or clearly understanding the criteria for calling a Code Red, who could call it, or when it could be called. The lack of a called Code Red on February 14, 2018, because there was no policy, little training and no drills, left students and staff vulnerable to being shot, and some were shot because they were not notified to lockdown. This was most evident on the third floor of building 12.
- There were no Code Red drills at MSDHS in the year preceding the shooting.
- Campus Monitor Andrew Medina was the first school employee to observe Cruz walk onto the MSD campus. Medina saw Cruz carrying a bag that was obviously a rifle bag—Medina admitted on video that he recognized the bag Cruz was carrying was a rifle bag and Medina identified Cruz as a threat. Medina failed to act appropriately by not calling a Code Red and that failure allowed Cruz to enter the 1200 building without the building’s occupants being notified to implement an active assailant response (Code Red). Further, even after hearing gunshots Medina failed to call a Code Red. There are veracity issues with Medina’s post-incident statements regarding what he knew and what he did and did not do.
- Medina notified Campus Monitor David Taylor via school radio that Cruz was entering the 1200 Building. Taylor saw Cruz enter the building but Taylor did not call a Code Red. Taylor was inexperienced with guns and recognized Cruz when he entered the 1200 building as someone they had previously discussed as being a potential school shooter. Taylor’s inaction by not calling a Code Red was inappropriate and delayed notification to others of the active shooting.
BROWARD SHERIFF'S OFFICE
- Former Deputy Scot Peterson was derelict in his duty on February 14, 2018, failed to act consistent with his training and fled to a position of personal safety while Cruz shot and killed MSDHS students and staff. Peterson was in a position to engage Cruz and mitigate further harm to others and he willfully decided not to do so. There is overwhelming evidence that Deputy Peterson knew that the gunshots were coming from within or within the immediate area of building 12. Furthermore, there is no evidence to suggest that Peterson attempted to investigate the source of the gunshots. In fact, the statement of Security Specialist Greenleaf confirms Peterson did not attempt to identify the source of the gunshots and by all accounts – including surveillance video - Peterson retreated to an area of safety.
- On February 14th, the BSO law enforcement response to MSDHS was hindered in part by MSDHS School Resource Officer Scot Peterson’s erroneous directions and other improper information he relayed over BSO’s main radio channel 8A to include, directing responding deputies to shut down nearby intersections and requesting no pedestrian traffic anywhere on nearby roads.
- Peterson instructed deputies to stay at least 500 feet away from the 12 or 1300 buildings. These instructions conflict with current law enforcement response procedures to active shooter situations. Law enforcement officers should try to eliminate any immediate threat even if that requires approaching gunfire and danger.
- Deputy Peterson responded to the area of building 12 within approximately 1 minute 39 seconds after the first shots were fired. Prior to his arrival 21 victims had already been shot, 9 of which were fatally wounded. This makes clear that seconds matter and that SRO’s cannot be relied upon as the only protection for schools. Even if there is a rapid response by an SRO, it is insufficient in and of itself to safeguard students and teachers. One SRO per campus is inadequate to ensure a timely and effective response to an active assailant situation and some campuses require additional armed personnel.
- Several uniformed BSO deputies were either seen on camera or described taking the time to retrieve and put on their ballistic vests, sometimes in excess of one minute and in response to hearing gunshots. Deputy sheriffs who took the time to retrieve vests from containers in their cruisers, removed certain equipment they were wearing so that they could put on their vests, and then replaced the equipment they had removed all while shots were being fired, or had been recently fired is unacceptable and contrary to accepted protocol under which the deputies should have immediately moved towards the gunshots to confront the shooter.
- Several BSO deputies arrived on Holmberg Road, just north of building 12 while shots were being fired and most of them heard the shots. These deputies have been identified as Kratz, Eason, Stambaugh, Perry, Seward, and Goolsby. These deputies remained on Holmberg road and did not immediately move towards the gunshots to confront the shooter. The deputies’ actions appear to be a violation of accepted protocol under which the deputies should have immediately moved towards the gunshots.
- The Broward County Public School’s decision not to allow law enforcement live and real time direct access to the school camera systems in Broward County, including the system at MSDHS, adversely affected law enforcement efforts to locate Cruz and it hampered victim rescue efforts.
- Sergeant Miller was the first responding supervisor and he arrived on Holmberg Road at least by 2:27:03. By his own statements he heard 3 to 4 shots upon arrival. Miller was not wearing his ballistic vest and took time to put it on. Miller was on scene for approximately 7 minutes before BSO’s radio throttling began; therefore, radio capacity issues did not exist at the time of Miller’s arrival. Miller failed to coordinate or direct deputies’ actions and did not direct or coordinate an immediate response into the school. Miller was observed behind his car on Holmberg Road and he did not initiate any radio transmissions until approximately 10 minutes after arriving on scene. Sergeant Miller’s actions were ineffective and he did not properly supervise the scene.
- Captain Jordan failed to timely establish an incident command and was ineffective is her duties as the initial incident commander. While Capt. Jordan experienced radio problems that hindered her ability to transmit, nobody reported receiving command and control directions from Jordan in person. Jordan spent approximately the first 7 minutes after her arrival in the building 1 office and then transitioned to a position of cover in the north parking lot behind a car with Deputy Perry.
- BSO deputies had some level of knowledge and familiarity with their active shooter policy. Several of them referenced that their policy states that they "may" enter a building or structure to engage an active shooter. The use of the word “may” in the BSO policy is ambiguous and does not unequivocally convey the expectation that deputies are expected to immediately enter an active assailant scene where gun fire is active and neutralize the threat.
- Some deputies could not remember the last time they attended active shooter training. Some deputies could not recall what type of training they received. CSPD officers had a high level of knowledge and familiarity with their active shooter policy. Many reference that the policy sates they “shall” engage the threat. All CSPD officers remembered their active shooter training because they attend the training on an annual basis. Many of the officers praised the quality of their training and the equipment which they are provided.
FIRE AND MEDICAL RESPONSE
- There is no evidence that any victims at MSDHS did not receive appropriate medical care.There is no evidence that law enforcement commander’s decision to not authorize rescue task forces affected anyone from receiving appropriate and timely medical care. Rescue task forces are only appropriate to operate in the “warm zone,” and not the “hot zone”; the building 12 was a “hot zone.” The decision not to use RTFs at MSDHS was the correct decision.
- There is no evidence that any medical personnel (doctors, etc.) who arrived at the scene were inappropriately denied access to the building 12 to provide medical care or that victims were not timely and appropriately removed so they could receive medical care.
- The TAC-medics followed the standard procedures of a MCI to identify, assess and tag the patients within building 12.
- The first responding law enforcement officers acted appropriately and consistent with their training when they first removed victims who were verbal and/or conscious during the initial 7 to 14 minutes.
- Radio communication problems, including the lack of interoperability and throttling affected the tactical operations inside of building 12, including the medical response.
- The 911 system on February 14, 2018, and the current 911 system in Parkland that has all Parkland 911 calls from cellular phones routed to Coral Springs, hinders a swift and effective police response by BSO. All Parkland 911 callers from cell phones who need police assistance have to explain their emergency to the Coral Springs dispatcher who then tells the person to standby while Coral Springs calls Broward County Regional Communications. The Coral Springs dispatcher then tells the BSO dispatcher that they have a caller on the line with a police emergency and the 911 caller repeats the reason for needing the police all over again to the BSO dispatcher. In many instances the original 911 caller hangs up before being transferred to BSO by Coral Springs and this hinders the BSO dispatcher because they are unable to speak directly to the caller needing police help in Parkland. This also creates an officer safety issue for Parkland deputies because they cannot obtain updated information while responding to the emergency because the caller hung up and the dispatcher cannot reestablish contact with the caller. Many callers also become frustrated because they have to explain their emergency a second time and they do not understand the necessity of the redundancy. This call transfer system prohibits BSO from receiving direct 911 calls from its service area in Parkland and creates a situation, as it did on February 14, 2018, where there is an information void adversely affecting an effective law enforcement response.
- The system is designed for Coral Springs to transfer all 911 law enforcement calls it receives from Parkland to BSO. On February 14, 2018, Coral Springs transferred very few calls it received and this resulted in BSO, as the primary response law enforcement agency, not knowing all the information known to Coral Springs. This hindered BSO’s response.
- On February 14, 2018 the Coral Springs 911 communications center initially treated the MSDHS shooting solely as a fire/EMS event because it provides fire and emergency medical services to Parkland, not police response. Coral Springs waited 4 minutes and 22 seconds from the time it received the first call of shots fired at MSDHS until it dispatched its first Coral Springs police officer. Coral Springs could not effect a quicker response by BSO because it had to transfer the call to BSO and Coral Springs could not directly communicate via radio with BSO Parkland deputies.
- The decision to route all Parkland 911 calls that originate from cell phones to Coral Springs and not Broward Regional Communications (BSO) was made by the City of Parkland. The call transfer process delayed the law enforcement response to MSDHS on February 14, 2018. The City of Parkland has the authority to decide where its 911 calls are routed and the City can change the routing process at-will.
- BSO brought the Parkland 911 call workflow issues to the City of Parkland in 2014 but there have no discussions resulting in a resolution since that time.