Executive Summary

April 15, 2008

On August 16, 2005, Mayor Antonio Villaraigosa announced the formation by Chief William Bratton of a Board of Inquiry (BOI) to study the LAPD’s Special Weapons and Tactics team (SWAT) in the wake of the death of Suzie Peña, a 19-month-old child who died during a SWAT operation on July 10, 2005. While the Peña case occasioned the inquiry, the purpose of the BOI was not to reinvestigate that case but rather to take a comprehensive look at all aspects of SWAT operations.

The BOI conducted an 18 month study and delivered its confidential report to the Chief. This Board of Inquiry was unique in that most of its members were from outside the LAPD. Chief Bratton’s decision to include both sworn and non-sworn outsiders represented a sea change from the LAPD’s historically closed and isolated stance. The members of the Board were: Richard Aborn, Merrick Bobb, William Geller, LASD Lieutenant Phil Hansen, Gregory M. Longworth, Chief Bernard Melekian of the Pasadena Police Department, LAPD Assistant Chief Sharon K. Papa, Assistant Chief Linda Pierce of the Seattle Police Department, and Eugene Ramirez. The unanimously adopted report represented the extraordinary success of the BOI in reaching consensus harmoniously and with respect for individual viewpoints.

The BOI found SWAT personnel to be dedicated professionals who train arduously, take their responsibilities seriously, and, by and large, discharge them ably. The LAPD pioneered SWAT operations, and within the tactical officers’ community, LAPD SWAT is widely regarded as one of the best. Overall, SWAT has been a net positive contributor to public safety and security in Los Angeles. There are many SWAT successes to celebrate. There are many dedicated and courageous individuals working in SWAT now and in the past. SWAT’s successes flow from a tradition of excellence.

While acknowledging SWAT’s record of solid achievement, all BOI members, including SWAT’s strongest proponents, favored change. The BOI’s recommendations have been given serious consideration in the months since the report was presented to the Chief. The Chief adopted most of the recommendations in whole or in part and rejected only a few. This Memorandum will describe the recommendations and the Chief’s decisions with respect to them.

By way of background, there were a total of 3371 SWAT activations from 1972-2005, the period examined by the BOI, and suspects were apprehended without untoward incident in 83% of them. A total of 3196 of the 3371 activations involved tactical incidents. Of these, 174 involved hostages. Although there were incidents in which hostages died at the hands of suspects, only one incident—Peña—resulted in a hostage fatality apparently caused by SWAT. Of 134 fatalities among the 3371 SWAT activations, 80 incidents, or 60% represent suicides. In 31 incidents, or 23%, suspects were killed by SWAT. In 22 incidents, or 16%, suspects were killed by patrol officers prior to SWAT’s arrival.

Underlying the need for change in SWAT was the view of the BOI that SWAT had become insular, self-justifying, and resistant to change. While acknowledging that in most routine matters SWAT performs ably and often admirably, there were incidents and trends suggesting an over-reliance on tactical operations over negotiated solutions and rigidity about changing tactics and strategy as circumstances change. The BOI also found that SWAT was often uncritical of its own.

In records provided to the BOI concerning use of force by SWAT members, there were 696 reported uses of force between the mid-1980’s and the present. Of these, 15 have not yet been adjudicated. In 679 reported uses of force between the mid-1980’s and the present, barring two accidental discharges, the use of force in question was always held to be in policy.

According to the disciplinary matrix provided by the LAPD, only three members of SWAT have ever been disciplined for unauthorized force. Two officers received discipline in 1988; one

received a four-day suspension, and the other got a written reprimand. A third officer received an official reprimand in 1995. No officer has been disciplined for unauthorized force in the last 11 years.

Many Board members were struck by these statistics and believed that it stretches credulity past the breaking point that no member of SWAT has ever engaged in an out-of-policy use of force, save for the two accidental discharges.

I. Pool of candidates for SWAT.
The Board concluded that the absence of women as team members in SWAT needed to be addressed and dealt with through reasonable, newly validated, nondiscriminatory, yet rigorous performance standards. The Board also concluded that a greater diversity of views, perspectives, talents, and life experiences would be a benefit to SWAT. How best to achieve that needed diversity focused principally on the values and drawbacks of using Metro as the selection pool. The BOI recommended Department-wide selection for SWAT.

The Chief has concluded that the pool for selection of SWAT will be expanded to become department-wide. No longer will membership in Metro be the sole way for interested persons to join SWAT.

Action taken.
On August 23, 2007, Metropolitan Division hosted a SWAT/Divisional Open House at the Elysian Park Academy. The event had as its goal to cultivate interest among the 23 women in attendance in pursuing a position within Metropolitan Division and SWAT. At the direction of Chief Bratton, Metropolitan Division is currently developing and designing a revised SWAT selection process that will ultimately allow for Department-wide selection. In the meantime, the next four to six openings in SWAT will be filled pursuant to an interim selection plan. A department-wide selection process may raise labor relations issues and collaborative efforts are underway with the Los Angeles Police Protective League which insists that there must be a Meet and Confer process before such a change can be made.

Metropolitan Division is responsible for implementing this recommendation. Metro initially estimated that an interim selection process waiving the one year requirement in Metropolitan would be in place by the end of 2007, and it was. The full implementation of a department wide application process will begin upon the completion of the labor relations procedures.

II. Selection Criteria for SWAT.
The BOI noted that SWAT’s selection criteria have not been validated in the last 10 years. The BOI concluded that existing selection criteria under-emphasized negotiating skills, patience, empathy, and flexibility while over-emphasizing physical prowess and tactical acumen. The Board thought it important to consider whether selection of individuals for SWAT should be made in whole or in part by persons outside of Metro in order to avoid an appearance that selection for SWAT amounted to a search for the like-minded.

Accordingly, the BOI concluded LAPD should rethink its selection criteria and minimum standards. SWAT should continue to seek out the most qualified candidates in order to continue its tradition of excellence, but gender and other diversity need not and should not be sacrificed in any selection process.

While the Board of Inquiry was meeting and considering its recommendation, the Department had already begun the revision of the selection criteria. The Department is presently using an interim process which includes some modification in the prior selection criteria. The Department believes this process is more extensive and better reflects the actual skills necessary.

III. Rotation.
The BOI saw SWAT’s insular culture as self-perpetuating. SWAT members seemed to believe they had career tenure, absent a major deterioration of skills. A majority of the BOI concurred with those members of SWAT’s leadership who advocated that mandatory rotation on balance is beneficial. A few members of the Board were convinced that the benefits to SWAT of experienced personnel outweighed any countervailing arguments for limited tenure. Those members argue that retention in SWAT should be based upon proficiency, productivity, and the
successful completion of periodic performance tests, believing that the sophistication of
contemporary SWAT techniques demand unusually high levels of experience to assure high probabilities of success.

The BOI recommended mandatory rotation of police officers, team leaders, sergeants, and lieutenants after 10 years in SWAT. If the Chief of Police concurs, one five year extension could be tacked on that individual’s tenure.

After that, the BOI concluded that the wealth of experience should be spread across the Department as a whole, reasoning that the highest and best use of experienced SWAT officers in their post-SWAT years is training and upgrading patrol officers and their supervisors.

The Chief has concluded their rotation within SWAT should be considered in the context of rotation for all specialized units and the Department as a whole. The LAPD and the Police Commission are considering the wider rotation issues.

IV. Dealing with the mentally ill and persons in an overly excited state.
The BOI found that SWAT, in common with nearly all law enforcement agencies in the United States, needs to change how it deals with persons who are mentally disturbed, under the influence of drugs or alcohol, in a heightened emotional state, or simply uncooperative, as contrasted to aggressive and combative. The BOI found that unless SWAT had reason to believe an individual is suicidal, more often than one might like, but by no means always, SWAT concluded that negotiations are or would be fruitless in instances where the optimal time for a negotiated resolution had not passed. To the BOI, SWAT appeared at times to accelerate a tactical intervention or to have exacerbated the volatility of persons in an overly excited state, rather than negotiating or waiting for them to calm down or come off the effects of alcohol or drugs.

The BOI concluded that SWAT officers need substantial training on dealing with individuals in heightened emotional states. The BOI recommended the development of active training scenarios where SWAT members confront and must deal with actors playing the role of persons with a variety of mental illness and substance abuse problems, recommending that SWAT personnel should undergo rigorous and frequent training in conflict resolution, negotiation, psychology, dealing with persons who are under stress or are otherwise volatile, violent, difficult to predict, or incapacitated. The platoon should have one or more psychologists permanently assigned and specifically trained in defusing tense situations by conflict resolution.

The Chief has concluded that SWAT negotiators and the balance of the SWAT membership shall receive Critical Incident Training (CIT), a methodology already in use in the LAPD and in many other law enforcement agencies to train individuals in the knowledge and skills necessary to deal safely and effectively with persons who are mentally ill or in an overly excited state. The Chief has further concluded that the LAPD’s SMART teams should continue to roll out to all situations involving barricaded suspects. SMART is a unit of the LAPD trained to assist others in dealing with individuals demonstrating signs of mental illness or impairment. The SMART team determines if their services should be employed. The Chief also concludes that LAPD psychologists should continue to be actively assisting in negotiated resolutions of such confrontations.

Actions to date.
As of early 2008, 40% of the SWAT personnel had received CIT training.

Metro Division estimates that all SWAT personnel will receive CIT training by mid-2009. A timetable for implementing the balance of the Chief’s conclusions will be presented on or before July 1, 2008.

V. Negotiations.
The BOI presented statistical data tentatively suggesting that SWAT may proceed to a tactical resolution before the optimal time for negotiation has occurred. Inadequate data collection by SWAT precluded more definitive conclusions. Nonetheless, the data suggest that where negotiation is the singular component in resolutions, negotiation times run from three-to-six hours. The data also tentatively suggest that the decision for tactical entry is occurring before the optimal negotiating time has passed. The data tend to show that in a significant number of cases, SWAT tactical response, canine search, contact with a suspect, and even the use of a chemical agent, may be occurring prior to negotiations. The data appear to demonstrate a substantially lower amount of force is used when negotiations take place, either in tandem with other methods of resolution or alone. Injuries, shots, and uses of force appear to be lowest when negotiators are given about three hours. This suggests further that when negotiators are used, the need for force and other tactical options is reduced. The data seem to suggest that more shots are fired the less time is allotted for negotiation. The BOI accordingly recommended that policy be developed that requires greater exhaustion of non-tactical solutions before force is used. Negotiators and SWAT members should be on separate teams, in the opinion of nearly all Board members. This model is commonly associated with the FBI, NYPD, other East Coast law-enforcement agencies, as well as Seattle on the West Coast. The BOI further recommended Compstat-like accountability should be instituted on a regular and recurring basis for SWAT, not only to account for SWAT effectiveness in crime control but also for achievement of negotiated resolutions and avoidance of unnecessary tactical solutions and strategic and tactical errors.

The Chief has concluded that it is not necessary to create wholly separate teams given the potential of the current model if refined to achieve the desired result of greater exhaustion of non-tactical solutions before force is used. The data relied upon by the BOI on this issue was tentative and not definitive, principally because SWAT had not systematically collected data bearing upon the key questions. As described below, the Chief has ordered the rigorous collection and ongoing analysis of data regarding every SWAT operation. As this data is created, computerized, and analyzed, it will become clearer whether the desired results are being achieved. The Chief adopts the BOI Compstat recommendations.

Action to date.
SWAT has revised its reporting requirements and has begun to collect data bearing on these issues. SWAT has begun to create a database from the ground up in furtherance of these recommendations.

It is anticipated that the Compstat recommendations will be implemented by the end of 2008. Further Department support is necessary in order to create a meaningful database for risk management analysis and reporting.

VI. Criteria for SWAT negotiators.
In the view of the BOI, any negotiator working for or with SWAT should possess:

• Demonstrated capacity to establish a working relationship with persons who are volatile, violent, or in a heightened emotional state, including individuals who are mentally ill, suicidal or seriously depressed, on drugs or alcohol, or are physically or mentally disabled or otherwise impaired in their ability to respond to police commands.
• Demonstrated abilities to negotiate and establish rapport with people, including a record of resolving arrests and other tense situations verbally and without use of force.
• Dedication to peaceful resolution of conflict regardless of time or discomfort and having as the overriding priority preservation of human life, be it of suspects, hostages, third parties, or law enforcement personnel.

A willingness to serve all of Metro and selected patrol assignments where necessary, not just serving SWAT.

SWAT personnel receive negotiation training and those individuals who express a desire to become a negotiator and who fulfill the criteria stated above are selected to serve in that capacity. It should be noted that all SWAT personnel are dedicated to the peaceful resolution of all conflicts.

VII. Data Deficiencies.
Following a report of a study conducted by Richard Aborn, the BOI concluded that SWAT’s data deficiencies are deep. SWAT’s inability to provide complete and reliable data for analysis demonstrates that SWAT is not capably managing risks. The BOI adopted all recommendations in the Aborn report and therefore recommended that the LAPD:

• introduce rigorous risk management, trend analysis, data analysis, and accountability measures in SWAT, including focused data collection and use of computers in connection with foregoing;
• institute Compstat-like accountability on a regular and recurring basis for SWAT, not only to account for SWAT effectiveness in crime control and operationally, but also for achievement of negotiated resolutions and avoidance of unnecessary tactical solutions and strategic and tactical errors;
• supplement current debriefings with regular critical analysis in writing for each significant SWAT incident,
• Revise After Action Reports to include a full discussion of response time, time to set up, debriefing by SWAT of first-responding officers, tactics and strategy, use of negotiators and possible use of personnel who were making progress before SWAT arrived, avoidance of unnecessary tactical resolutions, and command-and-control issues. After Action Reports and search and arrest warrant summaries should be expanded to include a full narrative description and a critical analysis of the foregoing topics.

The Chief adopts the BOI recommendations.

Action taken.
An After Action Report, which summarizes every SWAT call-up, is prepared and submitted within 48-hours to the Commanding Officer of Special Operations Bureau. This report has been augmented to include additional information (e.g., risk management considerations) in order to identify and capture the substantive points presented in this recommendation. A SWAT lieutenant now participates in the involved Area’s debrief immediately after an incident. With the concurrence of the involved commanding officers, a SWAT lieutenant will attend the
concerned Area’s next patrol roll call(s) after an incident, in order to provide feedback and fully debrief the incident in greater detail. Moreover, debriefs are now summarized and included in the After Action Report, along with the other information outlined in this recommendation. Furthermore, Department personnel are currently working on the creation of a software program/database from the ground-up, which will capture detailed information and allow for identification of trends, risk management concerns, and provide a solid foundation for detailed analysis of SWAT responses. Metropolitan Division’s Compstat profile is being refined to include additional data. The After Action Report submitted within 48-hours to the Commanding Officer of Special Operations Bureau has been modified to include additional information. The balance of the other recommendations has not yet been addressed.

Information and Communications Services Bureau (ICSB) has the primary responsibility of developing the software/database needed to fully implement this recommendation. Once the software has been created, ICSB will be tasked with providing the hardware/computer system. On October 11, 2007, a formal meeting was held between ICSB, Use of Force Review Division, and SWAT personnel to determine the feasibility of this concept and creating a model, which would capture all of the pertinent information. It is anticipated that this recommendation will be fully implemented by the second quarter of 2008. The balance of the recommendations that the Chief has ordered implemented will be addressed and fully implemented by the second quarter of 2008.

VIII. Coverage.
The BOI analyzed the days and times of the week in which SWAT was called out during the period 2002 – 2004. It found that more often than not, SWAT was off-duty when the call came in. In 2002, 52 of 83 callouts, or 62 percent, happened off-duty; in 2003, 76 of 128 callouts, or 53 percent, occurred off-duty; and in 2004, 26 of 48, or 54 percent were off-duty. SWAT was generally slower to arrive and set up during off-duty periods. The Board learned that a SWAT officer called out off-duty had to go pick up his partner before proceeding to the location of the call, thereby losing precious time. The Board therefore unanimously concluded that at
minimum, all “on call” SWAT officers should have take-home cars. The Board further recommended on-duty coverage 24 hours a day, seven days a week, or as close to that as is feasible.

The Chief has adopted the recommendation that on call SWAT officers should have taken-home cars. Current fiscal and budgetary realities preclude the expansion of SWAT personnel by approximately 60 officers necessary to accomplish 24/7 on-duty coverage.

Action taken.
Regarding take-home cars, Motor Transport Division (MTD) provided the bulk of the additional vehicles needed and Metropolitan Division allocated the remaining vehicles required.

IX. Time Allocation.
The BOI found that SWAT officers had an overwhelming preference for training over other activities when not actively engaged in a SWAT operation. The Board agreed with SWAT that more attention should be paid to reducing activities such as ceremonial duties and answering phones. It disagreed with SWAT officers who think training others in the department is unnecessary. To the Board, it is one of the best uses that can be made of SWAT. A substantial number of instances where SWAT is called out are resolved by patrol before SWAT arrives.

It is important that patrol officers, supervisors, and incident commanders be trained in and be ready to act, if absolutely necessary, before SWAT is ready to go.

SWAT should be involved in preparing patrol resources and incident commanders to address rapidly evolving high risk incidents in order to give them the highest chance for a successful outcome.

The Chief concurs with these recommendations.

Action taken.
Chief Bratton believes that through leadership and the full implementation of the recommendations contained in the BOI report, the culture within SWAT can be positively influenced. Metropolitan Division developed a contemporary crime suppression model for SWAT, which strikes a balance between crime suppression efforts and fulfilling SWAT’s mission in an ever- changing environment. The new crime suppression model will include the following:

• Target-specific apprehension missions focused on individuals posing a significant risk of violence (e.g., high-risk fugitives, high-control parolees or probationers, violent gang members, or anyone wanted by an Area/specialized investigator who could potentially jeopardize officer or public safety);

X. Command and Control.
A. The transition of operational control from patrol to SWAT.
The Board found instances of uncoordinated and unsupervised transitions when SWAT arrives piecemeal and replaces patrol. The Board recommended that essential decisions be made at a higher level pursuant to an operational plan keyed to the specific incident. Contingencies should be identified and addressed at the planning stage so that officers are not forced to respond ad hoc to changed circumstance.

The BOI concluded that SWAT should reduce the circumstances under its control that cause officers to act without due supervision, including not having adequate resources and on-duty personnel to deploy quickly, not having the SWAT lieutenant and supervisors present at the scene from the inception, not having adequately worked out a strategy in advance, not changing strategy in light of changed circumstances, and placing too much discretion in the hands of a team leader.

Concededly, in the exceptional case, the dynamism, unpredictability, and fluidity of a situation may preclude the step by step approach under a supervisor’s direction that is advocated above.

The BOI did not discount the benefits of empowering SWAT personnel to take action when windows of opportunity occur to resolve a situation. These opportunities may present themselves in different forms, which may or may not involve the employment of deadly force. Opportunities sometimes exist for brief periods, and officers must be empowered to act. This empowerment comes from those in command, and can be justified on the basis of training and a full understanding by all parties of the law, policy, and protocols associated with a given type of incident. Empowerment or delegation of authority should be distinguished from abdication of responsibility. Officers must be empowered to act and then be held accountable for their actions, right or wrong.

It was the Board’s perception that too much power, authority, and discretion has been reposed in team leaders and operators and too little authority is exercised by lieutenants and sergeants. Board members found troubling the degree to which individual team leaders and team members were reported to hold supervisors in low regard or resist the notion that supervisors should actively participate in operations and in fact supervise them.

The Board recommended that greater emphasis needs to be placed on the role of command and control, transfer of responsibility, and the creation of specific yet flexible operational plans for each SWAT deployment. The overall role of sergeants and lieutenants in SWAT operations generally, and in entries specifically, needs to be enhanced. They should be actively in charge. Conversely, boundaries and limits on the discretion of team leaders need to be thoughtfully considered and articulated. The respective roles of the lieutenant, the captain, the incident commander, the chief overseeing Metro, and other executives and managers on the scene need to be thought through and defined with precision.

The Chief endorses the development of appropriate protocols governing the subjects described above, however he does not believe it is necessary to reduce to writing protocols as the protocols for SWAT operations and the command and control of the operations are extensively covered in the initial and on going training.

Action taken.
The role of SWAT sergeants has been expanded to include being in charge of entry teams, which was formally the responsibility of the team leader (Police Officer III+I), during tactical operations. Generally, during SWAT operations the proposed tactics and strategies are forwarded to the SWAT Commander (Metropolitan Division Commanding Officer) and Incident Commander for approval prior to taking action. Moreover, the Commanding Officer of Metropolitan Division directed that supervisory personnel be trained in the supervision of the various tactical operations that they would be involved in within Metropolitan Division (e.g., dive operations, entry teams, etc.). Chief Bratton approved modifications to the current system in order to reinforce command and control at SWAT call outs. Those modifications include the Commanding Officer of Metropolitan Division responding to all SWAT call outs and acting as a bridge between the Incident Commander and the tactical commander balancing the perspectives of each. This Crisis Negotiating Team (CNT) now responds to certain calls involving potential suicide in terms as a stand-alone unit. If no tactical considerations are apparent, the remainder of SWAT’s tactical resource does not respond. In addition, the Commanding Officer of Metropolitan Division is acting as an intermediary between the Incident Commander and Tactical commander.

B. The Incident Commander.
The BOI recommended that LAPD should create a specially trained cadre of individuals with a track record of seasoned judgment to act as Incident Commanders in all SWAT operations. BOI also recommended that the LAPD institute a certification process for those who will act as Incident Commanders. In addition to completing the certification course to be instituted by the LAPD, those Incident Commanders should, among other things, be familiar with, or willingness to become familiar with, SWAT strategy, tactics, and methodology, including, if advisable, cross training with SWAT. BOI further recommended that these Incident Commanders have demonstrated in their careers a dedication to peaceful resolution of conflict regardless of time or discomfort and having as the overriding priority preservation of human life, be it of suspects, hostages, third parties, or law enforcement personnel.

The BOI noted a substantial number of instances where SWAT is called out but the incident is resolved by patrol before SWAT arrives. The BOI underscored the importance of patrol incident commanders being trained and ready to act, if necessary, before SWAT is ready to go. Deployment of SWAT and replacement of patrol should be governed by good intelligence developed as—or preferably before—SWAT arrives.

The Chief determined that the creation of a specially trained cadre to become the Incident Commander for all SWAT situations would not be necessary. The Incident Command shall remain with the local Area.

Action taken.
Command Development School now includes training for new commanding officers relative to command and control of SWAT incidents. In 2006 all commanding officers received training in Critical Incident Management which included SWAT operations. Lastly, both SWAT lieutenants will be attending monthly Bureau meetings with command officers to discuss best practices for first responders and recent incidents, in order to provide ongoing training.

Metropolitan Division and Training Division are both responsible for ensuring that the mandated training is provided.

XI. Weapons.

The BOI was disinclined to make specific recommendations about which weapons SWAT should use. Their investigation did not turn up errors of judgment in weapons selection.

Some Board members concluded that certain weapons have been used in an unnecessarily risky way. More specifically, allowing automatic weapons to be set at fully automatic is neither

necessary nor desirable. The strongest argument for that position was made by a LAPD SWAT manager, who noted that neither the British nor the Israelis allow the weapons to be on full automatic setting. The Board recommended disallowing fully automatic settings, at least on the M4, unless specific supervisory approval for the fully automatic setting is given for a particular incident.

Action taken.
The Commanding Officer of Metropolitan Division issued a Divisional Order in approximately September 2006 on this very issue. Currently, full automatic settings on the M4 can only be utilized with the approval of a SWAT lieutenant or the Commanding Officer of Metropolitan Division, unless SWAT officers are spontaneously confronted with exigent circumstances.

XII. The Board recommended the assignment of a second lieutenant to SWAT and an additional captain to Metropolitan Division. The Board further recommended augmentation of SWAT’s intelligence gathering capacity. While the Board was meeting and finalizing its recommendations, the Chief authorized an additional Captain and the Metropolitan Commanding Officer added a second Lieutenant.

Action taken.
A second lieutenant has been added to SWAT and there is now an additional captain in Metropolitan Division. Two detectives have been temporarily assigned to Metropolitan Division. One of these detectives responds to all SWAT call outs and is tasked with gathering intelligence and providing it to the CNT and the SWAT Commander. The detectives also assist with interviewing victims/witnesses/suspects, warrant support/advice, conducting follow-ups in support of Area prosecution efforts, and providing legal updates and training to personnel. In order to fully implement this recommendation, the two detectives, currently on loan, need to be permanently assigned to Metropolitan Division. This responsibility rests with the Office of Operations.