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Aurora Century 16 Theater ShootingAfter Action Report for theCity of Aurora, ColoradoCONFIDENTIALSubmitted to:City of Aurora15151 East Alameda ParkwayAurora, CO 80012Submitted by:TriData Division, System Planning Corporation3601 Wilson BoulevardArlington, VA 22201(703) 351-8300April 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALTable of ContentsFOREWORD . IACKNOWLEDGMENTS . IIIEXECUTIVE SUMMARY .XWhat Went Well .xAreas for Improvement . xiiiConclusion .xvCHAPTER I. AURORA AND ITS EMERGENCY DEPARTMENTS. 1Aurora Police Department .2Aurora Fire Department .5Public Safety Communications Department .7Hospitals .9CHAPTER II. THE SHOOTING . 10Attack Starts .12Audience Reaction .14Recommendations .14CHAPTER III. POLICE RESPONSE TO THEATER . 16Initial Dispatch and Command .16Apprehension of Suspect .20Search of Theaters .21Emergency Medical Assistance .22Crowd Management .25Police Incident Command .27Mutual Aid .31Key Findings .33Recommendations .34CHAPTER IV. PARIS STREET APARTMENT. 40Evacuation and Security .40Inside Suspect’s Apartment .42Render-safe Plan .43Inter-agency Cooperation .45Key Findings .46Recommendations .46CHAPTER V. EMERGENCY MEDICAL SERVICES . 48Casualty Count .48Aurora EMS System .48Overview of EMS During the Incident .49Initial EMS Dispatches and Transports .51Triage in the Theater .51TriData Division,System Planning CorporationApril 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALIncident Command for EMS .53Ambulance Access .54Medical Groups.61Victim Transportation .67Treatment on Scene .73Medical Direction .74Hospital Care .74Key Findings .78Recommendations .79CHAPTER VI. PUBLIC SAFETY COMMUNICATIONS . 88Role of Communications Center.88Communications Center Staffing.88Call-taking Volume.89Request for Mutual Aid .89Personnel Notifications .90Police-Fire Communications .91Key Findings .93Recommendations .94CHAPTER VII. PUBLIC INFORMATION . 98Public Information and Media Relations .98Key Findings .104Recommendations .104CHAPTER VIII. INCIDENT COMMAND SYSTEM AND EMERGENCYOPERATIONS CENTERS . 106Incident Command System .106National Incident Management System .108Single or Unified Command .110General Staff .113Key Findings – ICS.116Recommendations – ICS .116Operations Centers .117Key Findings – EOC .118Recommendations – EOC .119CHAPTER IX. DEALING WITH THE AFTERMATH . 120Victim Services Unit .120Mobilization of Victim Services .122Family Reunification Center .123PIOs for Victim Families .126Assessment of Victim Services by Victims and Families .128Office of the Coroner .130Prayer Vigil .131Presidential Visit .134Assistance to City Personnel.136TriData Division,System Planning CorporationApril 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALSupport Services for the Community.137Aurora Strong Resilience Center .140Key Findings .140Recommendations .141APPENDIX. CENTURY 16 THEATER SHOOTING INCIDENT TIMELINEOF NOTABLE EVENTS . 144TriData Division,System Planning CorporationApril 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALFOREWORDThe City of Aurora chose to conduct an independent after action review (AAR) of itsresponse to the July 20, 2012 mass shooting at the Century 16 Theater movie complex, and theassociated threat of explosive devices at the shooter’s apartment on Paris Street. The Citycompetitively selected TriData Division, System Planning Corporation, to undertake the review.TriData had completed over 50 after action reviews of major emergency incidents, includingprevious mass shootings at Virginia Tech, Northern Illinois University, and Columbine HighSchool in Littleton, Colorado.ScopeThe After Action Review started in May 2013, almost a year after the incident. The delaywas due to a court-imposed gag order on information connected with the case, which had not yetcome to trial. The case still had not yet come to trial during this review, which confined thescope to the response, and not the investigation or background of the shooter.The review focused primarily on the response of the City’s emergency forces during thefirst three days, including actions by police, fire and emergency medical services (EMS), privateambulances, hospitals, public safety communications, and public information personnel. Alsoincluded was the first week of family and victim assistance, assistance to first responders, andhealing support for the community. The roles played by regional and national agencies and othercity departments were reflected in the review.The investigation of the crime itself was largely outside the scope of the review, exceptfor initial steps taken to gather and organize theater witnesses, and the actions of the coroner.The shooter’s background and motivation were outside the scope, as was the issue of preventingthese types of incidents.The charge to the team was to first describe the event and actions taken by the City’semergency personnel, then to evaluate what was done, draw lessons learned, and makerecommendations for the future. The project team was also to review measures taken by the Cityafter the incident to improve future emergency responses.The report attempts to make a reasonable compromise between level of detail andreadability. The goal was to provide a sufficiently detailed description of events so that readerswould understand the key aspects. In some cases, details were withheld out of concern that theymight be too useful to future perpetrators.Some timeline information is provided in each chapter to help the reader understand theflow of events. The Appendix has a detailed combined timeline developed by the Aurora PoliceDepartment that is based largely on radio transmissions, telephone recordings, the automatedvehicle location system, and interviews of participants.TriData Division,System Planning CorporationiApril 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALSources of InformationThe City of Aurora gave the project team access to the personnel involved in the incidentand its aftermath. Over 180 interviews were conducted with city and emergency leadership,police, fire and ambulance responders, hospital personnel, coroner’s office staff, public safetycommunicators, family assistance personnel, mutual aid responders, federal and state agencies,and others. The project team could not interview every first responder involved, but we obtainedmore than a representative sample. A few victims and victims’ family members also agreed to beinterviewed.The project team reviewed a large amount of written and video information the city hadgathered, including police and fire reports, reports from investigators who interviewed theaterpatrons, dispatch recordings, and pictures and diagrams provided by the police. We alsoreviewed videos of the event, news broadcasts, news articles, and other sources. We consideredstandards and guidelines on widely accepted practices, and background information on thevarious organizations involved from their websites.Some individuals are mentioned by name in the narrative for clarity, to avoid pedanticrepetition of positions, and in some cases to give credit for innovative actions. For the most part,however, the report describes actions of groups or individuals by rank, unit, or radio call sign.Organization of the ReportThe report begins with background on the city and the organization of its emergencyforces. Next are chapters describing the theater shooting and police response, followed by achapter on the response to the improvised explosive hazards found at the suspect’s Paris Streetapartment. The report then cycles back to discuss in separate chapters the medical response bythe fire department, ambulances, and hospitals; the public safety communications center role;public information; and incident command. The last chapter discusses the aftermath—actionstaken to reduce consequences and unite the community. There is some redundancy acrosschapters that is intended to help the reader understand the context without having to rereadearlier chapters.Each chapter after the first ends with a summary of key findings and recommendationspertinent to the area discussed. In total, there are 84 recommendations for the future based on thelessons learned. Many should be of interest beyond Aurora.In the time since the Aurora Century 16 Theater shooting, mass shootings have takenplace in the Sandy Hook Elementary School in Connecticut, Santa Monica College in California,and at the Washington Navy Yard in the District of Columbia. By addressing what worked welland what could have been improved, we hope the report will contribute to the body ofknowledge on how best to deal with such incidents in the future.TriData Division,System Planning CorporationiiApril 2014

After Action Report Aurora Century 16 Theater ShootingCONFIDENTIALACKNOWLEDGMENTSThe authors wish to thank the many City of Aurora personnel and those in the local, stateand federal agencies who shared their experiences in dealing with this incident with the projectteam.We would like to especially thank Police Commander James Puscian, the city’s principalcoordinator for the project. He was extremely helpful throughout the project, including arrangingthe myriad of interviews, and handling many sensitive issues. Special thanks also to Officer FaithGoodrich, who assisted Commander Puscian and provided invaluable assistance in research,scheduling, and many other tasks supporting the review. Unless otherwise credited, thephotographs and diagrams in this report were provided by the city.Deputy Fire Chief Tony Cito was instrumental in coordinating the fire service aspects ofthe review. Nanette Coats and Marena Lertch were instrumental in expediting the interviews forthe Public Safety Communications staff.Most of the people interviewed individually or in groups are listed below. For privacy,we excluded names of victims and their family members who graciously allowed us to speakwith them. We greatly appreciated everyone’s time and candor. We apologize if we inadvertentlymissed anyone. The positions listed are those held at the time of the incident, in July 2012.While we received much assistance from the city and those listed, the findings andrecommendations are those of the project review team, whose members are listed at the end ofthe list below.City of AuroraGeorge “Skip” NoeMichelle WolfeNancy FreedKim StuartJason BatchelorNancy SheffieldBarbara Shannon-BanisterJan HadenSuzanne HahnChanell ReedHeath WalterTriData Division,System Planning CorporationCity ManagerDeputy City Manager, Administrative ServicesGroupDeputy City Manager, Operations GroupDirector, CommunicationsDirector, FinanceDirector, Neighborhood ServicesCommunity Relations ManagerHuman Resources SpecialistBenefits/HR SpecialistMayor/City Council DivisionStreet Maintenance SupervisoriiiApril 2014