Sheriff Ponders Mistakes In Fatal Deputy Shooting

An investigation into the shooting death of an Orange County (Fla.) sheriff’s deputy found a series of procedural, tactical and performance errors by an anti-crime task force and sheriff’s dispatchers, but determined that none of the mistakes were directly responsible for the deputy’s death. Dep. Brandon Coates was shot and killed last December by the driver of a truck he pulled over as part of a anti-crime unit operation. In a report issued today by sheriff Jerry Demings, investigators learned the task force was using a radio channel that wasn’t monitored by dispatchers or other patrol units. After the shooting, the first notification came from neighbors near the vehicle stop who heard gunfire. The report also noted that dispatchers who fielded 911 calls reporting the incident did not immediately dispatch units to the scene, but instead skeptically questioned the callers, and tried to confirm by radio if any patrol units were on a car stop. Task force members had heard Coates call out the car stop, but since they were not monitoring the patrol channel, they did not hear the dispatchers’ inquiries. The questioning process added about three minutes to the response, investigators determined, and at least four patrol units were nearby the shooting scene and could have quickly arrived. Coincidentally, the comm center’s computer-aided dispatch (CAD) system crashed during the incident, further complicating the handling of the incident.

Shortly after the incident, Demings ordered the task force to work in twos, and to always use a radio channel monitored by a dispatcher. He also ordered re-training for the dispatchers, who the report said “demonstrated a lack of ability to cope with critical incidents of this type.” The report noted that dispatchers, “would benefit by providing wide-ranging scenario training drills resulting in a more consistent response.” Download (pdf) a copy of the 106-page report here., and read a news story about the report here.

In the review of the comm center staff, the report noted that concerns were raised about the timeliness of the transfer of the 911 information. But the investigation concluded, “Units were dispatched to the scene. Other agencies were notified via Intercity and started to respond.”

However, early in the incident, “Dispatchers started to experience difficulty with the Computer Aided Dispatch (CAD) system and deputies also experienced problems with their mobile computers. There was a rapid and continuous increase in manpower. Soon almost 300 responders from numerous law enforcement agencies were inthe area. Suspect information was obtained by the first units on the scene and broadcast over the radio.”

The county’s Information Management Services (IMS) unit determined that the CAD shut-down was caused by three separate CAD server events related to the incident:

• a problem with the way the Tiburon CAD software handled messages from the CAD server to the Mobile Comm in-vehicle units that were assigned as backup units to the call
• deputies not assigned to the call viewing the call notes on their Mobile Comm
• a flood of deputies that were not logged on the Mobile Comm, logging on to view the call notes

The investigation found, “These three actions combined to cause an overload on the system which could only be resolved by restarting the Tiburon application.”

On the personal side, the investigation also noted that, “During a catastrophic event, employees personally affected because of relationships should be identified and triaged away from the work area.” The report also recommended that television sets in the comm center be turned off during critical incidents to limit the dispatchers exposure to stressful information.