Report to City of Portland 

 
 

PORTLAND POLICE BUREAU
OFFICER-INVOLVED SHOOTINGS
Sixth Report / January 2019

OIR GROUP
Michael Gennaco
Robert Miller
Julie Ruhlin

 323-821-0586
7142 Trask Avenue   Playa del Rey, CA 90293

OIRGroup.com

 Table of Contents
Foreword .......................................................................... 1
SECTION ONE

Officer-Involved Shootings.............................................. 7
June 12, 2014 ◦ Nicholas Glendon Davis .............................. 7
March 22, 2015 ◦ Christopher Healy ................................... 15
July 5, 2015 ◦ David Ellis ..................................................... 23
November 6, 2015 ◦ Michael Johnson ................................ 29
May 24, 2016 ◦ Timothy Bucher .......................................... 41
December 5, 2016 ◦ Steven Liffel........................................ 53
February 9, 2017 ◦ Quanice Hayes ..................................... 61
February 9, 2017 ◦ Don Perkins .......................................... 75
May 10, 2017 ◦ Terrell Johnson .......................................... 83

SECTION TWO

Common Themes and Issues .................................... 95
Police Review Board Issues ............................................... 95
Tactical Retreat .................................................................. 99
Officers Involved in Multiple Shootings ............................ 101
Timeliness of Investigations .............................................. 103

SECTION THREE Recommendations ..................................................... 105
APPENDIX Table of Cases Reviewed by OIR Group

  Foreword

T

his is OIR Group’s Sixth Report on Portland Police Bureau critical
incidents. Counting the nine incidents we review in this report, we have
examined a total of 50 officer-involved shootings and in-custody deaths
during our work with the City over the past eight years, occurring as early
as March 2004 and as recently as May 2017. We provide some basic facts about
these 50 critical incidents in a table attached as an Appendix to this report.
As laid out in the table, subjects died in 27 of the 47 officer involved shootings.
Over half of the 50 subjects at whom officers fired or who died in police custody
had a history of mental health issues or were experiencing some type of mental
health crisis (29 total). In 22 of the officer-involved shootings, subjects carried
operable firearms; in eight they were armed with knives or other edged or
potentially deadly weapons (crowbar or machete). Beginning with a shooting
incident in December 2010, seven subjects have brandished realistic-looking
replica handguns. Thirteen of these 50 critical incidents involved AfricanAmerican subjects; three involved Latinos; and the remainder (34) involved white
subjects. All of the involved subjects were men.
While it is useful to see this information compiled in a table, our reviews focus on
the details of an event that cannot neatly be encapsulated on a chart or described
by a set of data. We delve deeply into each critical incident to examine each
decision that the officers made, their level of planning and communication with
each other, willingness to consider alternative plans, and the effectiveness of onscene supervisors to manage and direct resources and control the scene. More
significantly, we examine the Bureau’s internal investigations – for thoroughness,
timeliness, and effective identification of officer decision making that falls below
the Bureau’s expectations and standards. And we evaluate how effectively
internal reviewers develop and implement action plans to address individual
officer performance as well as broader systemic issues. Our review is focused on

 how the Bureau performs these critical internal assessments, as the agency has
ultimate responsibility for effectively using investigation, analysis, review,
accountability, and remediation to meet the overarching goal of reducing future
use of deadly force events.
While there is no one broad unifying theme of this report, the cases we review
here share similarities. In three of the nine incidents, subjects advanced on
officers with potentially deadly weapons (in two cases a knife and in one, a
crowbar) and officers stumbled or fell while trying to back away, placing them at
a tactical disadvantage that resulted in officers believing that deadly force was the
only option. In two of these incidents, subjects were armed with realistic-looking
handguns that turned out to be replica firearms, not capable of doing great
damage. And in three incidents, officers were fired upon by subjects prior to
returning fire.
In four of these nine officer-involved shootings, there is evidence to suggest the
subject intended to engage police with the goal of ending his own life. This was a
theme of a past report (Fourth Report, January 2016), where a startling seven of
11 incidents involved suicidal individuals apparently intent on provoking a deadly
force encounter with police. We were critical in that report of the use of the term
“suicide by cop” to describe this phenomenon suggesting that the shooting was
inevitable, and officers powerless to change the outcome. We were pleased to
note that the Bureau did not use this language in connection with these more
recent cases, and that, in one incident in particular, officers showed patience in
dealing with an armed, apparently mentally ill subject, even as he fired his
weapon into the ground. (Unfortunately in that case, involving Michael Johnson,
officers ultimately shot and killed the subject when he fired his weapon at them.)
Nonetheless, we did see articulated in review documents the persistent notion that
there was nothing officers could have done to change the course of events that
ultimately led to the officers’ use of deadly force. While the reality may be that
an officer had a reasonable fear for his life or safety as the result of a subject’s
actions at the moment the officer fired his weapon, it is rarely true that officers
and their supervisors had no alternative courses of action in the time leading up to
the shooting that are worth consideration. In its internal review of these incidents,
it is critical that the Bureau consider these alternative scenarios. A thorough and
constructive review demands that those examining the incident – in the Training
Division, Bureau management, and at the Police Review Board – critically assess
ways that personnel might have altered their response as a way to promote
continuous growth and learning.
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 The Bureau has a positive record in recent years of conducting criminal and
internal affairs investigations that are thorough and fair, although as detailed
below, we were concerned in one case about witnesses who were identified
during the internal affairs investigation but not interviewed. Its internal review
mechanisms – Training Division Reviews and Commander’s Memoranda –
generally identify and document some significant performance issues, though we
identify additional issues in this report that were not raised.
Unfortunately, even when performance issues are identified by Training or
management earlier in the review process and recommendations are advanced for
improvement, it apparently is the rare case when those internal recommendations
are subsequently formally considered, let alone implemented. The Police Review
Board is a unique feature of the Bureau’s administrative review process,
particularly in its inclusion of community members. But its current makeup,
orientation, or structure does not appear to be serving as effective an independent
check on officer performance or systemic improvement as initially envisioned. In
recent years, we have not seen a Review Board finding that recommends formal
discipline, and few systemic recommendations made earlier in the review process
are formally considered and advanced by the Board for the Chief’s consideration.
As we did in our last report, we make additional structural and training
recommendations designed to make the Review Board process more robust.
However, if tangible results are not achieved, a more significant overhaul of the
Review Board may be an issue for future discussion.
One of the cases we review here – the officer-involved shooting of Quanice
Hayes – engendered protests and strong reactions in segments of the Portland
community who responded to the shooting in the context of notorious recent
events nationwide involving the deaths of young African-Americans at the hands
of the police.
It is undeniable that currently nearly every negative interaction between the police
and African-Americans, both in Portland and nationwide, evokes heightened
apprehension and concern. As the new Chief expressly recognized in remarks
made at the beginning of her tenure, the historical role of police officers as agents
of segregationists in the South, and the City’s own history of racial inequality and
displacement provides an important perspective in explaining the reserve of
distrust among some in order to inform the Bureau’s current efforts to establish
trust with the African-American community.
That long history of injustice understandably frames the public analysis of cases
like the Hayes shooting. This deep-seated distrust undermines confidence in

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 findings that excuse officers while providing neither consolation nor satisfaction
to frustrated observers and grieving loved ones. And there is understandable
frustration – on both sides – when long-simmering tensions prevent effective
communication and constructive engagement.
These dynamics are unlikely to be resolved in the immediate future. The history
behind them extends beyond law enforcement matters to economic, educational
and structural dynamics that contribute to persistent inequality. None of these
factors, of course, are within the control of current Bureau officers and
executives.
But to ignore them overlooks a critical element fueling the criticism of the
shooting of Mr. Hayes as well as other recent incidents. For their part, perhaps
the best response police agencies can provide is to endeavor to build a reservoir of
goodwill through honest dialogue, receptivity to feedback, transparency, and a
demonstrable willingness to evolve and improve. Of course, such efforts cannot
preclude the possibility of future controversial incidents. They can, however,
enhance confidence in the legitimacy and appropriateness of the Bureau’s
responses – both systemically and in terms of individual accountability.
The Bureau’s newest Chief has spent time engaging with Portland’s communities
in atypical law enforcement settings – skipping rope with youngsters or moving to
the beat of contemporary music. Some dismiss the outreach as a public relations
ploy, casting the efforts in a negative light as if somehow “public relations” was
not an important part of the mission of a public service agency. More
significantly, the media reports of these events show the impact of such leadership
where other command staff members model the Chief’s initiative. The Chief’s
willingness to engage with Portland communities on their terms is an important
first step toward strengthening bridges throughout the City.

We make 40 total recommendations in this report. This number should not be
seen as a suggestion that the Bureau is in crisis or in need of significant overhaul.
Rather, we view our recommendations in the context of an attentive police agency
continually striving to improve. The Bureau’s systems and processes function at
a high level and many of the types of recommendations we make to other
agencies we review are remedial by comparison – the types of things that Portland
officers, investigators, and executives have been doing for many years. Our

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 recommendations for the Bureau can be seen as “graduate-level” work, if you
will, intended to put the Bureau at the upper echelons of American policing.
One circumstance that has been most consistent over the eight years we have
reviewed critical incidents in Portland is the level of cooperation we have
received from Bureau members – from the Chief’s office, through the entire
executive staff, to Captains and Lieutenants, to Sergeants and Officers – who have
been uniformly candid, helpful, and generous with their time. They have
provided us documents when we needed them, responded to phone calls and
emails quickly and substantively, opened their offices for meetings and training
facilities for observation, and been willing to engage with us in meaningful
discussions about Bureau practices, training, national best practices, and a host of
other subjects relevant to our work. While we do not always agree on significant
issues and are often pointedly critical of Bureau actions or practices, our dialogue
with Bureau members has always been constructive and respectful. That is not a
statement we can make about every law enforcement agency with which we have
worked, and we appreciate the relationship we have been able to build with the
Bureau.
It is also important to recognize the support, insight, and perspective we continue
to receive from the Auditor, the Independent Police Review Director and staff,
and the Mayor and Commissioners. Each has been gracious with their time, and
have contributed to our work by strengthening our knowledge of the
interrelationships between the Bureau and other City functions. Finally, the level
of engagement and discourse from Portland’s public in connection with our
presentations also provides critical perspective from those directly impacted by
the actions of the Police Bureau and we appreciate that dialogue and insight.

Scope of Review
With this report, we have examined all officer-involved shootings and in-custody
deaths for which the investigation and administrative review was complete by the
end of 2017. As we have done for each of our prior reports, we reviewed all of
the Bureau’s investigative materials for each of the nine critical incidents we
evaluate here, including the Detectives’ and Internal Affairs’ investigations, as
well as grand jury transcripts where available. We also read and considered the
Training Division Review and materials documenting the Bureau’s internal
review and decision-making process connected with each incident. We requested,
received, and reviewed relevant training materials, referred back to training
materials we reviewed for our prior reports, and interviewed current Training

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 Division personnel. We talked with Bureau executives regarding questions that
were not answered in the initial materials provided and requested additional
documents that were responsive to those questions.
Our analysis centers on the quality and thoroughness of the Bureau’s internal
investigation and review of each of the incidents presented. We look at relevant
training and policy issues, and corrective actions initiated by the Bureau. We do
not focus on whether any particular shooting, or related tactic or use of force, is
within policy, but do point out where we see officer performance that appears to
be inconsistent with Bureau directives and expectations. We also identify issues
that were not identified, addressed or thoroughly examined by the investigation
and review process that could have impacted the Bureau’s findings on the
appropriateness of the force or other tactical decision making or resulted in a lost
opportunity for remediation or improvement.

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 SECTION ONE

Officer-Involved
Shootings
Summary and Analysis

June 12, 2014 ◦ Nicholas Glendon Davis
On the date of the incident, in the early morning hours, two officers were
dispatched to a strong-arm robbery in a wooded area within the city limits of
Portland. The complainant told officers that he was traveling in the area on his
bicycle, and looking for metal scraps that could be turned in for recycling. The
complainant further said he encountered a subject, later identified as Nicholas
Glendon Davis, who confronted him and told him to leave because he was
trespassing. When the complainant asked if he could retrieve his bicycle that he
had laid down while scavenging for metal, Davis told him no. The complainant
said Davis started swinging his fists at him and he started to run away. The
complainant indicated that he fell which allowed Davis to catch up to him and
punch him a couple times in the forearm before he was able to push him away and
escape. As the complainant left the area, he said he saw Davis walk with his
bicycle off the trail and into the woods.
Officer Robert Brown and another officer arrived at about the same time to the
dispatched location. They located Davis walking in a wooded area and Brown
called out for him to stop and walk over. Mr. Davis did so and told officers that
he was the real victim in that the complainant had attacked him while he was
trying to sleep. Officer Brown asked the person for his name, and the subject

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 identified himself as Nicholas Glendon Davis. Officer Brown ran a computer
check and found an outstanding third-degree theft misdemeanor warrant for his
arrest. The complainant (who talked with officers later) said he did not want to
press charges but just wanted his bicycle back. The officers instructed the
complainant to retrieve his bicycle.
While talking with the officers, Davis vacillated from agitated to calm and again
agitated. During the conversation, Mr. Davis articulated irrational thoughts. At
some point, without warning or provocation, Davis lifted his shirt and pulled out a
three-foot long crowbar that he held up over his head as he advanced toward
Officer Brown. As Officer Brown backed up, he tripped over a guy-wire causing
him to fall. As Davis continued to approach, Officer Brown fired two rounds at
Davis who staggered back and fell into the wooded area off the trail. The partner
officer had observed Davis procure the crow bar and advance on his partner and
said he was about to fire when he heard Officer Brown discharge his weapon.
While Officer Brown initially proceeded to check on Davis, his on-scene partner
instructed him to wait for additional officers to arrive. Davis was motionless and
not following commands. Eventually, back up officers arrived who handcuffed
Davis. Paramedics were allowed on scene and pronounced Davis deceased.
The grand jury determined that the shooting was justified. The Police Review
Board convened and recommended that the Chief find the shooting to be within
policy.

Timeline of Investigation and Review

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6/12/2014

Date of Incident

7/1/2014

Grand Jury concluded

7/22/2014

Internal Affairs Investigation completed

9/9/2014

Training Division Review completed

10/21/2014

Commander’s Findings completed

12/3/2014

Police Review Board

12/17/2014

Case Closed

 OIR Group Analysis
Tactical Planning and Communication
Failure to Frisk or Search the Subject
The Training Division Review opined that because officers had no information or
made no observations that Mr. Davis might have been armed, circumstances did
not meet the legal threshold for frisking Mr. Davis. The Training analysis does
not consider alternative legal bases for executing a search or frisk, namely, that
eventually officers discovered an outstanding warrant for Mr. Davis and the fact
that he may have just been involved in a strong-arm robbery. A search incident to
arrest or detention would likely have been justified. Alternatively, the analysis
suggests that the officers could have requested Mr. Davis’ consent to search his
person for weapons. The Training analysis concluded that while the officers’
actions were consistent with training they were not the most effective method or
tactic but failed to consider whether there were other legal bases to support a stop
or frisk.
In our Fifth Report (January 2016 – after the date of this incident and subsequent
investigation), we recommended that when a Constitutional legal issue arises, The
Bureau should consult with an attorney who has a legal background in Fourth
Amendment jurisprudence. We renew that Recommendation here.
RECOMMENDATION 1: When a legal issue arises
regarding the Fourth Amendment, the Training Division
should consult with an attorney with a legal background in
Constitutional jurisprudence.

Failure to Communicate a Plan
The Training Division Review noted that after Officer Brown notified Mr. Davis
that he had an active misdemeanor warrant for theft, Davis started to become
anxious. Officer Brown stated that he tried to de-escalate the situation by
explaining to Mr. Davis that the warrant was not a big deal and the complainant
only wanted his bicycle back.
Officer Brown stated that he had not yet decided if he was going to take Mr.
Davis into custody or whether he was going to let him go. Officer Brown said
that he was planning on calling for backup assistance if he decided to effectuate

9

 an arrest but wanted to deal with the recovery of the bicycle first. Officer Brown
said he believed that it was going to require a fight to take Mr. Davis into custody
but had not discussed a plan with the other on-scene officer. The Training
Division Review opined that Officer Brown should have communicated his plan
to the other on-scene officer on whether to take Mr. Davis into custody and found
that while the officer’s actions were consistent with training they were not the
most effective method or tactic.

Implementing Training Division Recommendations
The Training Division Review made the following systemic recommendations
about officer training based on its review of the Davis officer-involved shootings:
•
•
•
•

Emphasis in scenario-based training that a relatively routine encounter can
quickly lead to a high-risk situation
Emphasis on good communication during tactical events
Firearms program should instruct on shooting from positions other than
standing such as from a kneeling or prone position
Defensive tactics program should continue to instruct officers on ground
fighting and recovering to a stable platform

However, there is no indication that these recommendations advanced by Training
were implemented or even further considered. There is no documentation
suggesting that the Police Review Board discussed these recommendations. As
we note in Section Two, below, any systemic recommendations from Training
should be a routine part of all Police Review Board discussions and should be
advanced to the Chief for consideration and a Review Board recommendation
regarding implementation. The Chief should note in her closing memorandum
whether she accepts any of the systemic recommendations and direct a plan for
implementation of those she accepts.
In addition, the Training Division Review identified two tactics or methods that
were not effective: the officers’ failure to frisk or search Mr. Davis and Officer
Brown’s failure to communicate a plan regarding whether Davis was going to be
arrested. However, there is no documentation from the Police Review Board that
these issues were considered, discussed, or addressed. Certainly, no action item
was derived by the Board to address these identified issues; there is no
documentation that they were even used to debrief the involved officers. As we
discuss later in this report, the Police Review Board should consider each of the

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 tactical performance issues identified in the Training Division Review and
formulate action plans designed to address them.

Delay in Providing Medical Attention
As noted below, after deadly force was used, Officer Brown moved toward the
embankment down which Mr. Davis had fallen to examine him and provide
medical attention. However, the witness officer instructed him to wait until
additional personnel arrived. Once backup officers did arrive, an arrest team was
formed, Mr. Davis was handcuffed, and paramedics were allowed on-scene. It
took over five minutes from the time of the shooting before paramedics were able
to tend to Mr. Davis, and by that time he had expired.
The Training Division Review noted that after the shooting, both officers
holstered their weapons and maintained a position of advantage above Davis. He
noted that a sergeant arrived and formed a custody team that gave numerous
commands to Mr. Davis prior to its approach. During the approach, the team had
lethal cover, handcuffed him, and medical professionals were permitted on scene
to treat Mr. Davis.
What the Training analysis did not discuss is whether it would have been
appropriate and consistent with training for the on-scene officers to approach Mr.
Davis immediately and render medical aid. Factors cautioning against such a
move were:
•
•
•

Officer Brown was not sure whether he had struck Davis with his rounds;
The location where Davis fell was down an embankment; and
Officers had not yet located the crow bar.

However, factors suggesting such a decision would have been appropriate were:
•
•
•

There was no evidence that Davis was armed with a firearm;
Davis was exhibiting no signs of movement or aggression; and
Davis was non-responsive to commands.

Perhaps the best evidence of risk assessment that the officers perceived was that
they felt safe enough to no longer cover Mr. Davis and holstered their weapons
while they waited for backup to arrive. The Training analysis does not discuss
whether the two officers could have cautiously approached Mr. Davis with one
officer providing lethal cover to make an earlier assessment of his condition and
render first aid more quickly.

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 In evaluating whether the Bureau optimally provided medical attention to an
injured individual, the Training Division Review should evaluate whether it
would have been consistent with training for initial on-scene officers to approach
and render medical aid prior to the arrival of paramedics.
RECOMMENDATION 2: In evaluating post-shooting
performance, the Training Division Review should evaluate
whether there were alternative strategies that on-scene
officers could have used to render medical aid more quickly.

Investigative Issues
Decedent Information in Detective File
For officer-involved shootings, the Bureau’s detective investigations prominently
feature at the beginning of the file multiple pages of information about the person
who was shot. That information primarily sets out in detail the individual’s
criminal history and mug shots. Placing that information at the front of the file –
before the facts of the incident are even discussed – unnecessarily emphasizes this
minimally relevant information.
In an officer-involved shooting, the criminal history of a person shot is usually of
little or no relevance to an analysis of its justification, particularly if the shooting
officer(s) had no knowledge of it. Rather, as we have stated in earlier reports,
focusing on the decedents’ “rap sheets” gives this information outsized
importance. For these reasons, the Bureau should consider rearranging its
detective file organization in officer-involved shootings to place appropriate
emphasis on what happened on the date of the shooting as opposed to prior crimes
and misdeeds of the decedent.
RECOMMENDATION 3: The Bureau should not place
detailed criminal histories at the beginning of its detective
file, to emphasize that the facts of the incident are the
appropriate and primary focus of the investigation.

Time Line of Incident
In this case and to their credit, Bureau detectives prepared a detailed time line of
events beginning from the 911 call to the paramedics’ evaluation of Mr. Davis.
The availability of such a time line is extremely helpful in understanding the
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 length of any interaction between the involved officers and the subject and postincident decision-making. Many of the Detectives’ files we reviewed for this
report contained these timelines, but some did not. This investigative analysis
should be routinized and prepared for every officer-involved shooting.
RECOMMENDATION 4: The Bureau should prepare and
include in the investigative file a time line setting out
relevant events from the initiation of the call for service or
initial police contact to the time paramedics initiate
evaluation of the person shot.

Timeliness of Officer Interview
Detectives did not interview the officer who used deadly force in this case until
six days after the incident. Until recently, if an officer involved in a shooting
declined to provide a voluntary statement to criminal investigators, the Bureau
was prohibited from obtaining any account of the incident for at least 48 hours,
pursuant to an agreement with the officers’ union. However, as a result of
concerns about the implications of this delay voiced in a number of our reports, as
well as by the U.S. Department of Justice and community advocates, the City
eliminated the so-called “48 hour rule.” Current language now instructs internal
investigators to obtain a statement from involved officers “as soon as practicable,
but no later than within 48 hours of the event, unless the member is physically
incapacitated and unable to provide a statement.”
The most serious concern about a delay in obtaining a statement is that it
compromises the Bureau’s ability to obtain a pure statement about the officer’s
actual observations and state of mind. Officers’ recollections degrade over time.
More significantly, either consciously or unconsciously, officers’ versions will be
contaminated as a result of exposure to external information from third parties or
media accounts. Bureau protocols chaperone and segregate officers immediately
after a shooting so that this potential for contamination is eliminated in the
immediate aftermath. However, if an officer is allowed to go off duty before
providing a statement, the Bureau has no effective mechanism to prevent outside
sources from influencing an officer’s statement.
While the new language is a significant improvement over the “48 hour rule,” we
will be interested to learn how the Bureau implements the “as soon as practicable”
language. Generally, following an officer-involved shooting, attorneys for the
involved officers respond to the location. Thus, it would seem “practicable” that

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 a statement could be obtained from the officers prior to them being released from
their shift. If, however, the new directive is interpreted to allow that an involved
officer is interviewed 47 hours after the incident, the same risk of contamination
exists and the process would suffer the same infirmities as the initial rule.
Because we have yet to review a shooting in which the new policy language was
interpreted and implemented, we will refrain from making a formal
recommendation at this juncture. However, we are hopeful that the Bureau will
interpret “as soon as practicable” to mean prior to the end of an involved officer’s
duty shift.

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 March 22, 2015 ◦ Christopher Healy
On the date of the incident, Officer Thomas Clark was dispatched to a radio call
indicating that the complainant had caught a subject inside his house. Officer
Royce Curtiss was also dispatched and both responded with emergency lights and
siren.
When Officer Clark arrived he observed the subject, later identified as
Christopher Healy, across the street from the dispatched location. Officer Clark
observed a man holding onto Healy, later identified as the 911 caller. Clark
waited a matter of seconds for Officer Curtiss to arrive and then started his
approach to the two persons.
The officers gave several commands to the two men and they separated from each
other. Officer Clark later reported that a black shirt being held by Mr. Healy was
now covering up his hands. Officer Clark ordered Healy to show him his hands
but he failed to comply. At some point, Mr. Healy dropped the black shirt
covering his hands and Officer Clark immediately observed him holding a knife.1
According to Officer Clark, Healy then lunged at his throat. Officer Clark moved
back away from the knife and used his hand to slap Healy’s hand downward.
Officer Clark felt an impact on his chest and immediately backed away from
Healy to create distance. Officer Clark drew his firearm as he was backing away
while Mr. Healy began to wave the knife2 in a figure eight motion. Officer Clark
repeatedly ordered Healy to drop the knife.
Officer Clark reported that Healy then lunged at him a second time. Officer Clark
fired two rounds at Healy. Officer Clark reported that Healy stopped his advance
but was still standing. Officer Clark gave Mr. Healy repeated commands to get
on the ground but he did not comply. Officer Curtiss, who was positioned nearby,
then used his Taser on Healy, which caused him to go to the ground.

1

Officer Curtiss did not report that Mr. Healy’s hands were concealed by his shirt but did
indicate that after the men separated, Healy immediately produced a knife and advanced
on the officers.
2

Officer Clark said he was familiar with the type of knife, which was specially designed
for knife fighting.

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 A third officer arrived as the shooting occurred. The three officers developed a
plan to take Healy into custody and he was handcuffed. Medical aid was
summoned and the third officer monitored Mr. Healy’s breathing. Another
responding officer applied a trauma dressing to Mr. Healy moments before
medical arrived. Mr. Healy was transported to a local hospital but succumbed to
the two gunshot wounds, one to his arm and another to his chest and abdomen.
While Officer Clark was not injured in the chest area, his vest showed defects that
may have been caused by the knife.
The matter was presented to a grand jury, which found that the use of deadly force
was justified.

Timeline of Investigation and Review
3/22/2015

Date of Incident

4/22/2015

Grand Jury concluded

5/13/2015

Internal Affairs Investigation completed

5/14/2015

Training Division Review completed

6/23/2015

Commander’s Findings completed

7/29/2015

Police Review Board

8/9/2015

Case Closed

OIR Group Analysis
Tactics and Communication
Failure to Accurately Communicate Arrival On-Scene
As noted above, a third officer arrived at about the time of the shooting and after
the two initial officers had been on scene for at least several minutes. However,
PPB’s computer records show him arriving first at the location. This is because
the third officer was several blocks away from the call when he placed himself
“on scene” via his in-car computer. More significantly, the incident timeline
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 prepared by the Bureau does not indicate that Officer Clark, who arrived first on
scene, ever communicated via either radio or computer that he was on scene.
In modern day policing, it is essential that officers communicate through their
radio or in-car computers when they arrive at a call. It is equally important that
they communicate accurate information. In this case, Officer Clark failed to alert
communications that he ever arrived on scene, and the third officer inaccurately
placed himself at the location minutes prior to actual arrival. Although identified
in the investigative file, these issues were neither addressed nor remediated during
any aspect of the Bureau’s review process. The Bureau directives on radio or incar computer use do not include any apparent expectations that an officer will
accurately communicate when she or he is on scene to a dispatched call.
Consistent with other similarly situated police agencies, such directives should
exist.
RECOMMENDATION 5: The Bureau should devise
directives requiring officers to accurately communicate when
they are on-scene at a dispatched call.

Disavowal of the 21-Foot Rule
In our Fourth Report (January 2016), we discussed the origins of the so-called
“21-foot rule.” Based on one trainer’s unscientific “experiments” that concluded
an armed attacker could clear 21 feet in the time it took most officers to draw,
aim, and fire their weapon, officers came to see the “rule” as legal justification for
shooting a person with a knife that is less than 21 feet away. A preferred way of
addressing this concept, though, is as a warning to officers to think defensively
when confronting a subject with an edged weapon – to seek distance and cover to
buy time and create additional options for dealing with the threat. When
interviewed as part of this investigation, Officer Clark referred to the 21-foot rule
when describing his perceived threat: “…with that 21-foot rule he can literally
come to me and kill me before I can even draw my weapon.”
We understand that the Bureau does not train its officers on the “21-foot rule” but
the statement of Officer Clark is evidence that its impact still existed within the
Bureau, at least as late as 2015.3 When an officer-involved shooting demonstrates
that an officer has some lingering attachment to the 21-foot rule, it is incumbent

3

We note that in other, more recent incidents involving edged weapons we reviewed for
this report officers made no mention of the 21-foot rule.

17

 upon the Bureau to debrief the issue with the specific officer so that they have a
clearer understanding of principles of distance, cover, and other officer safety
tactics consistent with actual Bureau training doctrine.
RECOMMENDATION 6: When an officer-involved
shooting reveals statements by officers referencing a
disregarded tactical principle such as the 21-foot rule, the
Bureau should debrief the officer regarding its preferable
tactical philosophy.

Post-Incident Decision-Making
The Training Division Review found the on-scene officers’ tactics, decisionmaking, and uses of force consistent with training. It also found post-scene
decisions consistent with training. The analysis noted that inconsistent with
Critical Incident Management protocols, no officer was assigned to ride in the
ambulance with Mr. Healy when he was transported away from the scene. While
opining that best practice would have been for an officer to accompany Mr.
Healy, the analysis noted that supervisors were concerned with security at the
scene due to several hostile witnesses and did not feel they had sufficient
resources available at the time in order to accomplish this mission. Instead,
supervisors instructed an officer to meet the ambulance at the hospital as a
reasonable and next best available option.
Certainly, the transport of Mr. Healy should not have been delayed due to a lack
of Bureau personnel to ride with him in the ambulance. And while the decision
not to follow Critical Incident Management protocol may have been appropriate
in this incident, the investigation revealed a concern regarding supervisor
awareness of the directive.
When the on-scene officer in charge was interviewed and asked about whether
there was a directive that an officer travel with the subject in the ambulance, he
indicated he was not sure if there was and thought it was an advisement as
opposed to a directive.
The Training analysis recommended that the Training Division needed to
continue to instruct supervisors on the concepts delivered in the Critical Incident
Management Response Class. Based on the on-scene supervisor’s lack of
certainty about the directives, this recommendation should have been accepted
and implemented. There is no documented evidence that it was.
18

 RECOMMENDATION 7: The Training Division should
continue to instruct Bureau supervisors on the directives
required during the management of a critical incident.

Investigative Issues
Identified Witnesses Not Interviewed
The Portland Police Bureau, per agreement with the United States Department of
Justice has agreed to complete the investigative and review process within 180
days. In this case, the investigation was “completed” in 149 days but the
following identified witnesses were not interviewed:
•

Investigators traveled to an alleged eyewitness’ home to attempt to
interview her. The witness’ mother indicated that the witness was home
but she declined to be interviewed. Investigators left business cards but
the witness did not contact investigators.

•

Investigators also attempted contact with four identified juvenile
eyewitnesses by leaving voice mail messages on cell phones. None of the
juvenile witnesses replied to the messages.

•

Investigators traveled to a residence to re-interview the individual who had
called 911 and was holding onto Mr. Healy when officers arrived.4 They
knocked on the door but received no response, left a business card, but
received no reply.

•

Investigators called the private ambulance service to attempt to interview a
paramedic who responded to the location. A representative for the
company indicated that a subpoena would be required before the
paramedic could be interviewed.

•

Investigators attempted to interview a Portland Fire Bureau firefighter
who responded to the scene but was informed that the firefighter was not
available until the subsequent week.

After the investigation was completed and during the review process, the
Independent Police Review division of the City Auditor’s Office reminded
4

Fortunately, PPB detectives had initially interviewed the witness on the date of the
incident.

19

 Internal Affairs that it had subpoena authority that could assist in having
witnesses cooperate.
The litany of witnesses who were identified but not interviewed raises concerns
about the completeness of the investigation. While reluctant witnesses sometimes
make it difficult for investigators to obtain a full account of an incident, in
Portland investigators can use IPR’s subpoena authority to gain cooperation.
Certainly, the rescue witness could have been interviewed by the simple issuance
of a subpoena and the civilian witnesses may have agreed to cooperate if
subpoenas had been issued. And most concerning, the unavailability of the fire
fighter for less than a week should not have resulted in a determination to close
the investigation without interviewing him.
One question raised by this is the degree to which the internal deadlines imposed
for completion of the investigation due to the PPB and Department of Justice
agreement may be causing investigators to forego interviews for the sake of
meeting the artificial time line. Clearly, the thoroughness of an officer-involved
shooting investigation cannot be sacrificed so that an internal deadline can be met.
Internal Affairs managers must ensure that the pressures of completing an
investigation “on time” do not impede the more compelling interests in
thoroughness and completeness.
RECOMMENDATION 8: The Bureau should use IPR’s
subpoena authority when necessary to achieve cooperation
from witnesses.
RECOMMENDATION 9: Internal Affairs should ensure
that all reasonable efforts are made to interview identified
witnesses even if doing so might impact the deadline for
completion of the investigation.

Recording Interviews of Involved and Witness Officers
As a matter of protocol, PPB investigators audio record and transcribe all
interviews of involved and witness officers. In many instances, an interview of an
officer will result in the officer making movements or gestures to explain his
shooting motion or other tactical movements leading up to the shooting. In cases
like Ellis, Davis, and Healy – reviewed in this report – where movement of the
various actors proves critical, a video recording of the interview would provide
the officer a better medium to demonstrate the movements that he/she made and
20

 observed. Video recording would also relieve the interviewer of the oftenneglected task of describing gestures made by the officers during their interviews.
The Bureau should consider instituting the routine video recording of the
interviews of involved and witness officers.
RECOMMENDATION 10: In officer-involved shooting
investigations, the Bureau should video record interviews of
involved and witness officers.

Witness Interviews Not Recorded
Detectives reported interviewing several witnesses but did not make audio
recordings of the interviews. The Bureau’s general practice is to record
interviews in officer-involved shooting investigations. Sometimes witnesses will
agree to be interviewed but object to the interview being recorded. There may be
other impediments to recording, especially in the field when batteries may die or
recording devices malfunction.
While we recognize that there may be a reasonable explanation for not recording
all witness interviews, the investigative reports should include that explanation for
why there was a deviation from PPB practice.
RECOMMENDATION 11: When a witness objects to the
recording of an interview or recording the interview proves
impracticable, the investigative reports should provide an
explanation.

Police Review Board Findings
The Police Review Board found that the use of deadly force and the subsequent
use of the Taser were within policy. It also found that all post-incident decisions
were consistent with training and policy.
The Police Review Board recommended that a crime scene diagram or map be
included in the case file for review by members in advance of a Review Board
meeting. The Review Board found that use of a map or diagram of the incident
scene to show relative distances would help Board members better understand the
context of the actions taken by Bureau members, subjects, and witnesses.
The Chief accepted the recommendation and assigned implementation to the
Detectives Division.

21

 Timeliness of Officer Interview
In this case, Officer Clark was not interviewed until four days after the incident.
As discussed above, we look forward to the time when we will be able to review a
case in which the officer was interviewed on the date of the incident pursuant to
subsequent improvement in investigation protocols.

22

 July 5, 2015 ◦ David Ellis
While on duty in an unmarked car, Officer Scott Konczal and his partner officer
observed a man, later identified as David Ellis, near a Portland Police Bureau
contact office. The officers later reported that they suspected Mr. Ellis was either
considering burglarizing the office or publicly urinating on the building when
they first observed him. When the officers drove up to him and attempted to
speak with him, he walked away. The partner officer then stepped out of the
passenger side of the police car to further engage with Mr. Ellis while Officer
Konczal drove parallel to them. Officer Konczal then drove ahead of the two to
position his vehicle to block Mr. Ellis.
When the partner officer ordered Mr. Ellis to stop, Ellis reached into his pants
pocket, retrieved a folding knife with an approximately four inch blade that was
now open and then turned and stepped toward the partner officer. The partner
officer quickly backpedaled and fell backwards, breaking his right wrist. Mr.
Ellis continued to advance until he stood over the top of the partner officer and
began stabbing him, puncturing the officer’s left palm with one of the knife
thrusts. Officer Konczal observed Ellis advancing on his partner and alighted
from the vehicle. By then Ellis was on top of his partner and Officer Konczal was
concerned that shooting at the subject could result in his partner being
accidentally struck. As a result, Officer Konczal holstered his weapon and
withdrew his collapsible steel baton intending to use it on Ellis.
At that point, Mr. Ellis suddenly stood up, turned the knife towards Officer
Konczal and appeared as if he was going to advance on him. Officer Konczal
started to back up. Mr. Ellis moved as if he was going to stab his partner again.
Officer Konczal then put away his baton and fired his handgun once, striking Mr.
Ellis in the arm, and causing him to drop his knife.
When uninvolved officers arrived on scene, Officer Konczal and his partner were
appropriately removed from their immediate duties. The partner was transported
to the hospital for medical attention. Officers formed a custody team, which gave
commands to Mr. Ellis to move away from the knife. Ellis somewhat complied
but was having difficulty moving. Eventually, Mr. Ellis moved far enough away
from the knife so that the custody team believed they could safely approach. The
custody team took Mr. Ellis into custody without the use of additional force.

23

 Besides the broken wrist, the partner officer did not suffer additional significant
injury. Mr. Ellis survived the gunshot wound to his arm.
The District Attorney found that the use of deadly force was justified. The grand
jury indicted Mr. Ellis for attempted murder. The Police Review Board found that
the shooting was within policy and that all post-incident procedures were
appropriate.

Timeline of Investigation and Review
7/5/2015

Date of Incident

8/25/2015

Internal Affairs Investigation completed

9/13/2015

Training Division Review completed

9/21/2015

Commander’s Findings completed

11/4/2015

Police Review Board

11/23/2015

Case Closed

OIR Group Analysis
Officers’ Decision to Split from Partner
Initially the two officers remained in their unmarked car while talking with Mr.
Ellis. Officer Konczal said he did so because he wanted to approach Mr. Ellis in a
“low key” manner. Officer Konczal pulled up alongside Mr. Ellis as he continued
to walk away on the sidewalk. Mr. Ellis did not acknowledge Officer Konczal
and proceeded to cut through a parking lot, which Officer Konczal interpreted as
evasive.5

5

One fact not discussed in the Training analysis is that on the date of the incident the
officers, while in uniform, were in an unmarked car. That fact, coupled with the decision
to remain in their car, may have provided less clarity to Mr. Ellis initially about whether
they were, in fact, police officers. While Mr. Ellis made spontaneous statements about

24

 The Training Division Review noted that officers are trained on the advantages
and disadvantages of making contacts from the patrol vehicle. Some of the
advantages stated by Training were the ability to initiate and maintain a
conversation and the ease with which officers can chase or contain a person if
they flee. The disadvantages include the inability to readily go “hands on” and
the fact that it places officers in an inferior tactical position.
As noted above, once Ellis declined to engage with the officers and continued to
walk away, the partner officer alighted from the patrol car while Officer Konczal
drove past the two to try to cut Mr. Ellis off. As a result, the partner officer was
forced to engage with Mr. Ellis alone. It was during this engagement that Ellis
eventually reached into his pocket, pulled out a knife and moved toward and
stabbed the partner officer. At this time, Officer Konczal was apparently still in
the car and had to get out to assist his partner. By the time he was able to do so,
Ellis had stabbed his partner and was on top of him.
The facts suggest that Officer Konczal’s decision to split from his partner,
however briefly, left his partner at a tactical disadvantage once Ellis attacked him.
The partner officer was forced to defend against a now violent subject while
Officer Konczal was in the patrol car. The Training Division Review did not
discuss this questionable tactical decision-making, but instead found that all onscene officer decisions demonstrated sound and effective tactics. The
Commander’s Memorandum likewise did not discuss the officers’ decision to
separate, nor did the Police Review Board address it.
RECOMMENDCATION 12: The Training Division
Review, Commander’s Memorandum, and internal review
process should identify any tactical decision making that
results in partners being separated and required to detain
subjects alone.

Implementing Recommendations
As we discuss in more detail in the “Common Issues” section, the Training
Division Review recommended reinforcement through training of tactics intended
to be safer than backpedaling away from an advancing, armed subject, and the
reviewing Commander concurred with this recommendation. Unfortunately, there
is no indication that this recommendation was embraced or implemented.
the shooting after he was detained, he was largely uncooperative in providing a detailed
account of the incident.

25

 The Commander’s Memorandum here further recommended that the Training
Division create a video reenactment6 of the incident along with development of a
lesson plan by defensive tactics instructors. The Commander stressed that the
incident could be used as a platform to discuss two-on-one officer control tactics7
along with contact and cover techniques and strategies for patrol officers to think
about and apply when in the field.
The Commander also recommended that the Training Division reinstitute
defensive tactics and ground fighting skills during annual in-service training and
continue to train on such skills at least annually.
As with the Training Division Review recommendations, there is no evidence that
the recommendations made by the Commander were ever considered by either the
Police Review Board or the Chief’s Office. As we recommend more broadly
below, the Bureau should create protocols to ensure that all recommendations
coming out of the internal investigation and review process are considered by
both bodies.

Providing Medical Treatment
When uninvolved officers arrived on scene, Officer Konczal and his partner were
appropriately removed from their immediate duties. The partner was transported
to the hospital for medical attention.
A custody team was formed and commands were given to Mr. Ellis to move away
from the knife. Ellis somewhat complied but was having difficulty moving.
Eventually, Mr. Ellis moved far enough away from the knife so that the custody
team believed they could safely approach. The custody team took Mr. Ellis into
custody without the use of additional force.
In this case, unlike others we have reviewed in prior reports, the custody team was
formed and responded quickly to provide medical attention to the downed
individual. While all risk had not been eliminated, the custody team found that
they had appropriate resources to move toward Mr. Ellis to bring him into custody
and provide him timely medical aid.
6

We are aware that other officer-involved shootings in Portland have resulted in the
production of training videos. The use of real-life scenarios for training purposes is
consistent with best training practices.
7

As discussed above, because the officers decided to split, the situation with Mr. Ellis
became a one-on-one encounter when he decided to aggress the officer.

26

 Timeliness of Officer Interviews
Office Konczal was not interviewed until two days after the incident. Subsequent
protocols now require officers involved in deadly force incidents to be
interviewed as soon as practicable but no later than 48 hours after the incident.
We look forward to reporting on the Bureau’s compliance with that new standard
with the hope that officers will routinely be interviewed before they go off shift.

27

 28

 November 6, 2015 ◦ Michael Johnson
Just after 5:30 in the morning, a man later identified as Michael Johnson walked
into the emergency room at Good Samaritan Hospital in Northwest Portland and
told the woman working the registration desk that there was a man with a gun
outside and that they should call the police. She called hospital security, and the
on-duty unarmed guard responded and walked outside with the employees who
had seen Mr. Johnson come into the hospital. They identified the man they had
seen earlier, standing in an employee parking lot, and did not see anyone else
other than some physicians heading into work.
The security guard called the Bureau of Emergency Communications nonemergency dispatch and officers quickly responded as security moved to lock
down the hospital. The first responding officers established a staging area from
which they could coordinate their efforts to locate and monitor the subject as well
as coordinate a perimeter and make efforts to block access to the area. These
tasks were complicated by the fact that, even in the pre-dawn darkness, people
were arriving at the hospital for work or early morning appointments from various
directions by car, bicycle, and on foot. Officers focused on “getting eyes on” the
subject and confirmed that he did, in fact, have a gun (a .38 caliber revolver). The
handling officer requested an Enhanced Crisis Intervention Team8 member to
respond.
Acting Sgt. Robin Dunbar and Sgt. Robert Quick arrived shortly after the original
call and initially shared supervisory responsibility. Officers made a plan to get
closer to the subject, utilizing a ballistic shield and moving a police SUV into
place ahead of them for cover. This group included the Enhanced Crisis
Intervention Team member, who took the lead in attempting to communicate with
Mr. Johnson. She called out to him to put down the gun, telling him they wanted
to help him. He refused, telling them he was not going to put it down.
Throughout this time, he was pacing back and forth, sitting down then standing
up, pointing the gun at his head, into the air, or down at the ground. Officers
continually reevaluated their positioning as additional resources arrived,
attempting to maintain verbal and visual contact with Mr. Johnson while
8

All Bureau officers receive basic Crisis Intervention training, but some officers elect to
go through additional, specialized training in handling mental health crisis calls. These
“Enhanced Crisis Intervention Team” officers work regular patrol assignments and are
dispatched to crisis calls as needed.

29

 maximizing officer safety. Because Mr. Johnson appeared to be fixated on the
police vehicle, officers at some point changed their positions, using a different
vehicle for cover.
Eventually the officers attempting to communicate with Mr. Johnson moved out
of the ground level parking lot, and up into a parking structure across the street,
where they could maintain a better view of the subject and where they had hard
cover in the form of concrete barriers.
For the most part, Mr. Johnson was not engaging with the officers who tried to
talk to him. He did provide his name, and a series of numbers that officers
thought might be a driver’s license number or social security number, and officers
attempted to use this information to gather background information on the subject.
He also told them he was bi-polar and was “going to end it.” They checked with
the hospital to see if he had been a patient or associated with a current patient.
They attempted to locate an address or names of family members to gain some
insight in their efforts to communicate with Mr. Johnson but did not get far with
any of these efforts.
Acting Sgt. Dunbar requested a Crisis Negotiation Team9 to respond, and eight
minutes later, the Special Emergency Reaction Team (SERT)10 was activated. A
short time later, then-Captain Mike Marshman arrived and assumed the role of
Critical Incident Commander. They made the decision to instruct precincts to
respond to only priority calls in other parts of the City and to send all available
officers to respond to this scene to bolster containment efforts. Over the next
roughly 40 minutes, a Crisis Negotiating Team officer attempted to communicate
with Mr. Johnson while regularly providing dispatched updates regarding his
status. Mr. Johnson for the most part continued his disengagement – variously
walking around, crouching, lying down, plugging his ears, and at times pointing
the gun to his head or cheek while at other times pointing it down or sweeping it
9

The Crisis Negotiation Team is made up of negotiators, technical experts, and mental
health professionals who respond to situations involving hostages, armed and barricaded
suspects, and mental health crises where the subject is considered armed and dangerous.
Their role is to communicate with the subject in these situations as well as gather
information that may assist in successful communication and resolution.
10

SERT is a tactical response team that is activated to handle hostage, active shooter, or
barricaded suspect incidents, as well as service of high-risk warrants. SERT officers
receive specialized tactical training and have access to weapons and equipment that
general patrol officers do not have. SERT is not a full-time assignment, but SERTtrained officers respond from their regular assignments when activated.

30

 around. At one point, officers heard him repeatedly saying, “I love you,” but he
otherwise was not communicating. Negotiators believed that Mr. Johnson likely
was responding to some internal stimuli.
As reflected in their subsequent interviews, officers and supervisors had
significant concerns for the bystanders in the area. There were windows into
office buildings around the parking lot and, despite efforts to shut down all forms
of traffic into the vicinity, people still were walking or bicycling in relatively
close proximity to Mr. Johnson. Just past 7:00 a.m., Mr. Johnson fired one round
from his handgun into the ground. Officers did not respond, but generally
reported how knowing Mr. Johnson was willing and able to fire his weapon
heightened their apprehension.
Eight minutes later, as SERT officers and others continued to arrive on scene, Mr.
Johnson fired a second round into the ground. SERT officers, including Officers
Russell Corno and Chad Daul, re-positioned patrol officers while taking over key
positions. Corno and Daul relieved the officers who had been providing lethal
cover to the negotiating team.
SERT had deployed its armored vehicle to the scene, but supervisors decided
initially to keep it out of Mr. Johnson’s view because they were concerned it
would agitate him and escalate the situation. After he fired the second shot into
the ground, however, they decided to move the vehicle into a position where the
crisis negotiator could get closer to Mr. Johnson and communicate with him from
inside the protection of the vehicle.11 The negotiating officer attempted to explain
to Mr. Johnson that the vehicle was not coming to hurt him but only to facilitate
communication.
Just after he told Mr. Johnson about the armored vehicle, the negotiating officer
said Mr. Johnson raised the gun, pointed at the level of the parking structure
where he and other officers were positioned, and fired one round.12 The SERT
rifle operators both made the same observation (as did several other officers on
scene), and returned fire because they concluded that Johnson’s actions threatened

11

The negotiating team was positioned about 50-60 feet away from Mr. Johnson, behind
a 40-inch high concrete wall. In order to sufficiently project his voice to address Mr.
Johnson, an officer had to stand up and expose his head.
12

Investigators found a flattened bullet that could have come from Mr. Johnson’s gun in
the parking structure where the negotiating team and Officers Corno and Daul were
positioned.

31

 the lives of the officers on scene. Officer Daul fired his rifle four times, and
Officer Corno fired three rounds. Mr. Johnson went down.
Because Mr. Johnson was still holding a gun in his hand and officers observed
some movement from him, they did not immediately approach. The armored
vehicle was already moving toward Mr. Johnson, so the SERT team decided to
utilize it for cover. SERT Sgt. Tom Forsyth directed an officer to fire a less-lethal
sponge round to see if Mr. Johnson would respond. That round struck Mr.
Johnson’s leg and did not prompt any additional movement, so officers
approached along with a SERT medic, within about seven minutes of the shooting
by Daul and Corno. They began lifesaving efforts, but paramedics declared Mr.
Johnson deceased approximately five minutes later, and about an hour and 40
minutes after the initial call.
Mr. Johnson suffered five gunshot wounds – four in his torso and abdomen, and
one in his lower leg. The medical examiner also noted “hesitation marks,” or
superficial incisions on Mr. Johnson’s wrists, indicating tentative suicide efforts.
He also found what he described as a suicide note written in blue ink up and down
his hands and arm. Investigators also found a number of notes with Mr. Johnson,
essentially saying goodbye to specific people. The medical examiner deemed the
cause of death to be multiple gunshot wounds, but the manner of death to be
suicide.
Despite the suicide finding, the District Attorney presented the incident to a grand
jury, which concluded the shooting was legally justified. The Police Review
Board convened and determined all aspects of the incident to be within policy, but
also recommended a Debriefing/Performance Analysis for two involved sergeants
stemming from the delay in activating SERT.

32

 Timeline of Investigation and Review
11/6/2015

Date of Incident

12/3/2015

Grand Jury concluded

12/28/2015

Training Division Review completed

1/6/2016

Internal Affairs Investigation completed

2/22/2016

Commander’s Findings completed

4/6/2016

Police Review Board

4/14/2016

Case Closed

OIR Group Analysis
Tactical Issues
This situation presented a number of tactical challenges. Officers understood
from the outset that they were likely dealing with a person in some sort of mental
health crisis who was possibly suicidal. At the same time, they were in an open
setting that was difficult to contain and presented substantial risks to uninvolved
individuals in the area. In many ways, the tactical performance here can be
viewed as indicative of the ways the Bureau has learned from past incidents, in
that officers did not replicate decisions that have been the subject of past
criticism.
The initial responding officers took their time, designated a staging area, and
made a deliberate, tactical approach. Sergeants arrived on scene quickly and
appropriately assumed command. The two sergeants initially on scene agreed that
Acting Sgt. Dunbar was officially in charge, but Sgt. Quick stayed with her as a
sort of mentor. As the Training Review noted, Acting Sgt. Dunbar did not
broadcast that she was the incident commander, but this did not create confusion
for officers on scene, who clearly understood she was in charge. Throughout the
incident, the sergeants communicated with each other in a productive, cooperative
way.

33

 The initial responding officers had requested response from an Enhanced Crisis
Intervention Team member, and Acting Sgt. Dunbar requested a Crisis
Negotiation Team response. Sgt. Quick did a phone consult with SERT, but the
official request for SERT activation came eight minutes after the crisis negotiators
were activated. Typically – though not required by policy at the time – SERT is
activated whenever the Crisis Negotiation Team is requested, because negotiators
often need SERT resources to effectively do their job.13 While neither Training
nor the reviewing Commander found the eight-minute delay to be significant, the
failure to activate SERT at the same time as the negotiation team was the subject
of a Debriefing with both involved sergeants.
Throughout the incident, officers and supervisors maintained effective overall
communication, with the negotiating team providing regular updates about the
subject’s movements and actions. They made efforts to learn about Mr. Johnson
so they might better be able to engage with him. He gave them his name, which
unfortunately was too common to provide meaningful leads. He also gave a
series of numbers to them, which turned out not to be associated with a driver’s
license or social security number. They checked with the hospital, to see if he had
been a patient or was associated with anyone currently admitted and located
records on a car in the parking lot that they thought might have been connected to
him. While the Bureau should be credited with these attempts at intelligence
gathering, none of these efforts resulted in any helpful information.
Most importantly, officers attempted to find a cell phone number for Mr. Johnson.
Communicating with him from a distance that provided safety and cover for the
officers was challenging, and officers hoped they might be able to communicate
by phone. Officers could not locate a number for Mr. Johnson. While there was
some discussion of trying to get a phone to him that they could then use to call
him, that was ultimately not a tactic they pursued.
The issue of communication was significant, particularly in light of a fatal officerinvolved shooting of a suicidal man that had occurred in 2012, in which officers
opted not to communicate with the subject by telephone, and left positions of
cover in an attempt to build rapport and talk more freely with the young man to
convince him not to jump to his death, but in disregard of reports that he was
armed. He ultimately drew and pointed a replica firearm at officers, who felt
13

A SERT response generally takes much longer, because the negotiators simply have to
get themselves to the scene, while SERT operators have to retrieve specialized gear
before responding.

34

 compelled to fire – just 20 minutes after arriving on scene – because they had
placed themselves in such a vulnerable position.
Here, officers sacrificed the ability to more easily communicate with Mr. Johnson
in order to remain behind cover, effectively slowing the incident down and giving
officers time to try to find a way by which they could effectively but safely
communicate with Mr. Johnson. That distance and cover meant officers could
exercise restraint even when Mr. Johnson twice fired his weapon into the ground.
Unfortunately, even the available cover and distance was not enough to overcome
officers’ concerns for their own and others’ safety when Mr. Johnson fired at
them, and this event came to the same tragic end as the earlier incident.
One tactical option considered by those in command was use of the armored
vehicle deployed by SERT. That would allow a negotiating team to get closer to
Mr. Johnson and communicate from the safety of that vehicle, which is designed
to defend against ballistic weapons more powerful than Mr. Johnson’s. It also
might have given officers the flexibility to utilize a less-lethal weapon in response
to Mr. Johnson’s actions, because the armored vehicle could move within the
effective range of these weapons systems and would provide protection from the
.38 caliber revolver they knew Mr. Johnson possessed.
SERT officers began arriving on scene roughly 20 minutes before the shooting
and the Critical Incident Commander was weighing how to use available
resources. There was a concern expressed that the armored vehicle might agitate
Mr. Johnson, and therefore escalate the situation, so they did not immediately
move it to within his sight. After he fired his weapon the first two times,
however, the commander decided to utilize the vehicle. The shooting occurred
just after the negotiating officer advised Mr. Johnson that officers would be
bringing in the armored vehicle.

Investigation Staffing
The detective who served as the primary investigator of this incident had first
responded to the scene as a member of the SERT team, prior to the shooting. As
soon as the shooting occurred and the incident stabilized, he informed the Critical
Incident Commander that he would take over the scene as the handling Detective.
His assignment with SERT is in an intelligence position, coordinating resources
and relaying information between other SERT members and the incident
commander. During this incident, he played a peripheral role and was not a
witness to the shooting itself or any of the communication efforts with Mr.

35

 Johnson. Nonetheless, his dual role transitioning from being a SERT responder to
handling the crime scene and subsequent investigation raises potential concerns.
When the detective testified before the grand jury, he first testified about events
surrounding the shooting of Mr. Johnson that he observed, heard, or experienced
first-hand, and also described what he learned as a result of his investigative
work. It was not clear from his testimony what he knew because he was present
when it happened, and what he later learned from interviewing other witnesses
while wearing his investigative hat. While the detective’s testimony likely did not
impact the grand jury’s ultimate decision (particularly in light of the medical
examiner’s determination about suicide), his dual role in this case created an
unnecessary lack of clarity in the testimony.
Also, because the criminal investigation focused on the actions of his fellow
SERT responders in an incident during which he was on the scene at the time of
the events being reviewed, the detective’s role as primary investigator raises
concerns about objectivity and potential conflicting roles. While we saw nothing
in the investigative materials that causes us to question the investigation’s fairness
or impartiality, even the possibility of creating this perception is not in the
Bureau’s best interest.
Most importantly, the concerns created by the detective’s dual role were
avoidable. The Detective Division makes assignments on a rotation basis. The
involved detective knew at the time he responded as part of the SERT team that
he was the “next up” for an assignment. He could have notified his supervisor at
that point of the possibility of a conflict, should the incident result in an officerinvolved shooting, and the supervisor could have notified whoever was next in
rotation to be prepared to handle this incident. Indeed, the Detective Division has
an informal protocol for handling situations such as this in a way that in most
cases avoids overlapping assignments, but the Bureau should create a formal
policy to avoid having detectives investigate incidents in which they were
involved, however minimally.
RECOMMENDATION 13: The Bureau should adopt a
policy or protocol prohibiting a member who was even
minimally involved in a critical incident from being part of
the investigative team.

36

 Equipment and Resource Issues
There was some concern through this incident about officers being able to
effectively communicate with Mr. Johnson while remaining in a safe position,
with distance and cover. The lead officer on scene for the Crisis Negotiation
Team believed that Mr. Johnson could hear him but chose not to respond or
engage because of the internal dialogue he appeared to be struggling with. He
was concerned, though, that other members of the negotiating team could not
project their voices sufficiently for Mr. Johnson to hear. One option not discussed
in the investigative or review materials was the availability of a megaphone or a
patrol car’s loudspeaker system to attempt to communicate with Mr. Johnson. We
understand there may be reasons to question the utility of that equipment in this
scenario, but consideration of its use would have added constructively to this
review, particularly given the fact that the shooting officers expressed concern
about the vulnerability of the negotiator every time he exposed his head above the
concrete barrier that served as cover.
Also, the investigation noted that the supervising sergeants requested a K-9 to
respond to this incident, to maximize available resources in the event the subject
attempted to flee the area. No K-9 officers were available, but no further
information is provided as to why, or how frequently this valuable resource is
unavailable to officers14. As this incident unfolded, there was no obvious
opportunity to use the K-9, but that should not deter scrutiny of the issue.
Similarly, as noted in the Training Division Review, none of the uniform patrol
officers on scene wore their ballistic helmets, which is part of the standard gear
officers are required to carry in their patrol cars. Given the concerns about the
limitations of available cover, and how officers sometimes had to expose their
heads in order to communicate with Mr. Johnson, donning helmets would have
been wise. Training recommended that operations branch members be reminded
that ballistic helmets (generally thought of as crowd control gear) can also be used
in tactical incidents like this one. Training should also push these reminders out
to supervisors as part of their critical incident training.

14

Supervisors had inquired about the possibility of getting a K-9 officer from another
jurisdiction to respond, but it was unclear how that inquiry was resolved.

37

 RECOMMENDATION 14: The Training Division should
prepare briefings and/or a Training Bulletin to remind
officers and supervisors about the usefulness of ballistic
helmets in tactical incidents and should include this
information in the curriculum for its critical incident training.

Training Division Recommendations
The Training Division Review made several important recommendations. First,
the review noted that Acting Sgt. Dunbar had been in that “acting” capacity for
over a year but had not yet attended the full Sergeants’ Academy that those
formally promoted to the rank are required to complete. Though Acting Sgt.
Dunbar’s performance here largely met Department expectations, Training
recognized that it is unfair and potentially unwise for the Bureau to put its
personnel in command of critical incidents without providing them access to all of
the tactical leadership training included in the Sergeants’ Academy, and
accordingly recommended that the Bureau provide basic supervisory training for
all of the officers on each sergeant promotional list.
Training also recommended training updates regarding the use of ballistic
helmets, referenced above, and a review of SERT directives to consider
mandating SERT activation any time the Crisis Negotiation Team is called out.
There is no written documentation that the Police Review Board or the Chief’s
Office considered or adopted any of these recommendations. As we discuss
below, the Review Board should formally address every recommendation from
Training during its deliberations of an incident and make documented
recommendations to the Chief regarding any the Board supports.

Timing of Interviews
Officers Corno and Daul both provided voluntary interviews to Detectives, but
not until four days after the shooting. We expect that recent changes to
Department policy will result in more timely interviews of involved officers.

Concerns about “Suicide by Cop”
The coroner ruled the manner of death here to be “suicide.” He testified to the
grand jury about this decision, stating that most deaths following an officer38

 involved shooting would be deemed homicides, which is defined as death at the
hands of another. However, he stated that when he sees a clear indication that the
person intended to get the police to kill him or her, he considers it a suicide. In
this case, he said the suicide notes found in Mr. Johnson’s pockets, as well as
written on his arms and hands, along with what he learned about Mr. Johnson’s
history of mental illness and seemingly intentional efforts to precipitate a police
response were enough to convince him this was a suicide.
In our Fourth Report (January, 2016), seven of the 11 officer-involved shootings
we analyzed involved subjects who made statements or took actions indicating an
intent to precipitate the deadly force encounter. We cautioned against referring to
those cases as “suicide” because it suggests inevitability of the subject’s death and
invites a less rigorous analysis of the officers’ actions. Here, we did not find that
the Bureau shortcut its investigation or review process as a result of Mr.
Johnson’s evident intent to die (despite the fact that the Commander’s
Memorandum regarding the use of deadly force begins with the observation:
“This use of deadly force . . . was driven by Mr. Johnson’s desire to end his
life.”).15
Also, as noted above, we found that officers here seemed to employ much of the
training developed and re-emphasized following those incidents we reported on in
2016. That training stresses the importance of maintaining distance, seeking
cover, deploying in a manner where officers remain out of the subject’s sight, all
with the goal of making it more difficult for subjects to force a confrontation,
even when that may be their intent.
We question the decision of the Medical Examiner to rule Mr. Johnson’s death a
suicide. While he may have made his desire to end his life clear through his
notes, there is evidence (the hesitation marks on his wrists) to suggest that, left to
his own devices, he may not have been able to fulfill his suicidal intent. Through
his actions, Mr. Johnson did seem intent on provoking a deadly force encounter
with officers, but as with many deaths that are deemed “suicide by cop,” Mr.
Johnson was not necessarily someone who would have killed himself regardless
of the officers’ actions. And even if he were intent on provoking the police to
shoot and kill him, the dynamic of an officer-involved shooting is not the same as
a person actually taking his own life.

15

We have repeatedly made the point that the Bureau should not consider incidents or
outcomes to be “driven” by the will of the subject, but instead should focus on whether
officers used all reasonable means to “drive” the outcome.

39

 Moreover, a finding of “suicide” by the Medical Examiner could imply that
officers’ use of deadly force need not be examined by a grand jury for criminality.
If, in fact, there was no “homicide” as a result of the officers’ use of deadly force,
the homicide statutes in play under Oregon law would arguably not even apply.
Even, as in this case, where there is a grand jury proceeding, when a Medical
Examiner opines before the grand jurors that an event was a suicide, any question
of potential criminal culpability for the officers is effectively obviated.
RECOMMENDATION 15: The Bureau should initiate a
dialogue with the Medical Examiner regarding the potential
legal and accountability implications of a finding that a use
of deadly force by police officers constitutes a suicide.

40

 May 24, 2016 ◦ Timothy Bucher
The Bureau of Emergency Communications received a 911 call on the evening of
the incident. The caller put the phone down but left the line open. The dispatcher
could hear arguing between a man and a woman, including verbal ranting, a slap,
threats to “kill people who were going to kill him,” and mention of a gun. A male
voice said he had a gun and is going to kill someone as well as that the police
were “his ticket out,” and that he had the answer right here in his hand. The
operator could also hear a second woman in the house.
Seven minutes later, two uniformed officers arrived at the location, a mobile
home park, and began to walk toward the subject residence when they saw a man
in front of a residence point a gun at them, then turn and run into the house. The
officers later stated they were too far away from the man to shoot at him when he
pointed his gun. They called for backup. A field sergeant arrived and quickly
requested that the Special Emergency Response Team (SERT) and the Crisis
Negotiation Team respond to the location.
Dispatch learned from listening to the open phone line in the mobile home and
fielding calls from neighbors and friends that the subject’s wife and mother were
in the residence with him and the mother was elderly and had difficulty walking.
The subject was identified as Timothy Bucher.
Officers requested that TriMet send a bus to assist with evacuation of residents
from mobile homes around the subject’s residence. SERT officers and sergeants
began to arrive and scout the containment positions around Mr. Bucher’s
residence. A few minutes later officers received word from dispatch that a caller
said he had just talked with Mr. Bucher who said, there are “cops surrounding the
place and he is going to shoot them.” The caller also said Bucher was “off his
meds” and did not usually act this way. Several attempts by the negotiation team
personnel to get Bucher on the telephone failed because the residence telephone
was off the hook.
At around 8:23 p.m., officers heard shots fired from Mr. Bucher’s residence that
sounded like handgun rounds. Two minutes later, another volley of shots was
fired from inside the trailer. Two minutes after that, officers saw and heard more
shots coming out of a window of Mr. Bucher’s residence. Then two SERT
armored vehicles arrived at the mobile home park.

41

 Over the open line the dispatcher heard Mr. Bucher say that the police will shoot
him and “death is on its way.” A few minutes later, officers heard more shots
coming from Mr. Bucher’s trailer “going in the direction of officers.” A caller
from a nearby major street said a bullet just whizzed past her head. Bucher was
audible over the phone line continuing to argue with his wife. Shortly afterward,
Mr. Bucher’s wife left the trailer and provided information to SERT supervisors
that Bucher had a revolver and a .22 caliber rifle inside.
A few minutes later, Mr. Bucher’s mother came out of the mobile home and
approached PPB personnel. Bucher yelled that if any officers shot at her, he
would kill them. The mother was walked to the Crisis Negotiation Team van
where she confirmed that there was no one left in the mobile home other than Mr.
Bucher and that he had a second rifle inside that she described as looking like “a
war rifle.”
With both family members now out of the trailer, SERT’s tactical approach
shifted. They no longer had to plan for a possible hostage rescue and focused
their attention on the threat to unevacuated neighbors posed by Bucher’s
intermittent gunfire. Reports from neighbors confirmed that some of the bullets
were passing through their trailer walls. As one SERT sergeant put it, the “focus
is to get armor in front of the location to protect the officers, to have him focus on
the armor so he stops shooting through the other trailers.” Mr. Bucher’s
unpredictable gunfire had curtailed the evacuations.
Meanwhile, SERT finalized plans to launch gas into Bucher’s mobile home and
slowly pulled the two armored vehicles closer to the residence, with officers and a
sergeant walking along beside each vehicle using it as cover. Sergeant Jim Darby
supervised the group of officers in and around the smaller armored vehicle; a
second SERT sergeant, Tom Forsyth, supervised the group with the larger
armored vehicle.
As SERT armor approached the Bucher residence, officers were reminded over
the air that many neighbors had not yet been evacuated and a SERT member
broadcast to other SERT officers and supervisors at the scene, “I just want you to
understand that if he comes outside again we are going to use deadly force to
prevent him from going back in.”16 A lieutenant at the scene acknowledged the
statement by saying, “Copy that.”

16

This comment reflected a brief discussion among SERT officers and supervisors over
the radio suggesting that if Mr. Bucher came out of his house unarmed then changed his

42

 While using the smaller armored vehicle “as a moving shield,” Sgt. Darby heard
more gunfire coming from the trailer. He was not sure where it was directed but
recognized it as larger caliber than a .22. Sgt. Forsyth’s team was also rolling into
position near the mobile home. He said it was “obvious to me” from the
distinctive crack of the gunfire that “we were taking fire from an assault rifle.”
Other officers saw some of those rounds strike the ground near the armored
vehicles.
Sgt. Forsyth hesitated to signal officers to launch gas into Bucher’s residence
because the gas operators would have to leave cover to do so. Then Officer Chad
Gradwahl, who was also walking along behind the larger armored vehicle, asked
for authorization to apply cover fire to the window. Sgt. Forsyth authorized the
use of cover fire to protect the officers about to launch gas. Officer Gradwahl
fired several rounds from his rifle toward the top of the window and the wall just
above the window. After a moment, Mr. Bucher fired four or five rounds from
inside his trailer. Officer Gradwahl continued with a second volley of cover fire.
When cover fire commenced, a SERT officer standing alongside the armored
vehicle launched one gas canister into a window on the side of the residence near
the street. At the same time another SERT officer inside an armored vehicle had
launched twelve smaller gas rounds into a second window. A third officer on
another side of the residence launched four gas rounds into a third window of the
residence. A fourth officer on another side of the residence launched two
canisters into a window on that side. The simultaneous launching of gas into all
four sides of the mobile home was intended to stop Mr. Bucher from continuing
to fire bullets and to drive him to leave the residence.
Meanwhile, the smaller armored vehicle stopped in position a few yards from Mr.
Bucher’s front doorway. Sgt. Darby became concerned that the officers inside the
armored vehicle were vulnerable to Bucher’s rifle fire. He yelled at the officer in
the turret on top of the armored vehicle to come down out of the turret and then,
to protect the officers, he moved forward so he could see over the lower front
hood of the vehicle. As his team members were putting on their gas masks, he
illuminated the doorway with his flashlight and saw Mr. Bucher just inside the
open doorway of the residence holding a rifle, pointing it at officers and appearing
mind and went back in, it would be dangerous to allow him to regain access to his
weapons. When SERT officers asked for direction on this issue before the wife and
mother were out of the house, the Lieutenant at the scene had told them to allow Mr.
Bucher to return inside. It is not clear from the recordings whether there was any further
discussion from supervisors on this hypothetical question after the two women left the
residence.

43

 to manipulate the weapon in some fashion. Sgt. Darby fired four rounds at Mr.
Bucher through the door frame which partially obscured him, but the sergeant
could not tell if he hit Bucher. The gun barrel was lowered, then came back up.
Sgt. Darby fired one more round.
He observed Bucher disappear briefly, then yell from inside, “I’m giving up. I’m
giving up.” This was broadcast to officers present just before Bucher walked out
his front door, laid down on his front porch and said he couldn’t move. While
Bucher’s hands were visible and empty, officers could not see if he had any
weapons on him. Recently deployed gas coming out of the trailer further
obscured the officers’ view of Mr. Bucher. Supervisors approved sending the K9
in first before approaching to handcuff Mr. Bucher.
The dog was given a bite command and approached Mr. Bucher and bit him. Mr.
Bucher immediately started fighting with the K9 punching it and putting it in a
head lock. The arrest team moved in to handcuff Mr. Bucher. One of the arrest
team officers was told by Sgt. Darby to use his Taser because Mr. Bucher was
still wrestling with the dog and had his back to the approaching officers, and it
was still unclear whether he had any weapons. An officer fired his Taser once at
Mr. Bucher’s back, causing Bucher to release the dog and give up. He was
handcuffed without further incident and transported to a hospital.
Mr. Bucher fired a total of 14 rounds from his assault-style rifle. They were fired
in many directions, some hitting trailers and two to three striking the armored
vehicles. Some of the surrounding trailers had multiple bullet strikes penetrating
their walls that appeared to have been fired from Mr. Bucher’s assault rifle.
Sgt. Darby fired five rounds from his rifle, intending but failing to hit Mr. Bucher.
Officer Gradwahl fired eleven rounds from his AR-15 rifle in cover fire mode, the
authorized intent of which is to keep an armed subject from continuing to fire or
threatening to fire a gun from a particular area of the building. Mr. Bucher was
not wounded by these rounds. Four SERT officers fired gas into all sides of Mr.
Bucher’s trailer. The K9 was biting or trying to bite Mr. Bucher for several
seconds. The Taser probes hit Mr. Bucher in the back and the officer activated
the Taser for one standard five-second cycle.
Mr. Bucher had no direct gunshot wounds but a small fragment of a bullet jacket
was removed from his arm at the hospital. He also sustained lacerations on his
arms from the dog bites, but recovered from his wounds.

44

 The matter was presented to a grand jury, which found that the use of deadly force
was justified under criminal law.
The Police Review Board found that the shooting as well as the uses of less lethal
force – the K9 and the Taser – were within policy and that all post-incident
procedures were appropriate. The Review Board recommended that the SERT
acting captain and two sergeants be given an organizational review debriefing
regarding the early operational planning and supervision aspects of the incident.
The Bureau Chief completed the debriefings with each of the three supervisors.

Timeline of Investigation and Review
5/24/2016

Date of Incident

6/7/2016

Grand Jury concluded

7/11/2016

Internal Affairs Investigation completed

7/19/2016

Training Division Review completed

8/9/2016

Commander’s Findings completed

10/17/2016

Police Review Board

10/21/2016

Case closed

OIR Group Analysis
Tactical Issues
Use of Cover Fire
Officer Gradwahl’s use of deadly force was in “cover fire” mode. The Bureau’s
definition of cover fire is firing a firearm to:
neutralize the use of deadly force. Cover fire is not intended to
strike a subject but is meant only to prevent subjects from taking
action against police or others or entering or occupying locations.

45

 Cover fire can be dangerous and must be used with extreme
caution.
The use of cover fire in this incident appeared to be in line with this language.
Sgt. Forsyth, who approved the use of cover fire, pointed out that this definition
used to appear in the Bureau’s use of force policy but was removed.
Nevertheless, the tactic is still permitted and Training Division trains this
definition. The Independent Police Review also noted cover fire, while an
approved use of force, is no longer addressed in the Bureau’s main use of force
policy, Directive 1010.10, and should be reinstated. Currently, a definition for
cover fire appears in the PPB policy manual but has the more ambiguous
character of a general guideline rather than policy. It also no longer carries the
“use with extreme caution” language.
RECOMMENDATION 16: The Bureau should reinstate its
prior “cover fire” policy expressly in the Directives
including the “use with extreme caution” language.

Use of Less Lethal Force
SERT operators used three “less lethal” weapons during the incident: gas, a K9
and a Taser. While three less lethal techniques are rarely used in overlapping
succession, Mr. Bucher’s demonstrated willingness to use firearms on the officers
and his unknown physical state supported SERT’s level of extreme caution.
Bucher had stopped shooting and given up when his house filled with gas but then
it became unclear whether he was attempting to cooperate or using a ruse to draw
officers in while he was still able to access a weapon. His attempts to fight the K9
further fueled this concern.
A SERT operator fired his Taser at Mr. Bucher while he was still wrestling with
the K9. At first blush, this may seem like a redundant use of less lethal weapons
but it was reasonably well calibrated to end the struggle with the dog, keep Mr.
Bucher from pulling a weapon out of his clothing, and hasten officers’ efforts to
secure Mr. Bucher. The Taser was activated for one automatic five-second cycle,
the K9 handler called off the dog, and Mr. Bucher was immediately handcuffed.

Officer Safety and Equipment Concerns
The objective of the SERT plan to fire gas into the house was to get Mr. Bucher to
stop shooting and come out of his residence, presumably through his front door.
The subject’s appearance at the front door, therefore, was not an unpredictable
46

 outcome of launching gas into the residence. The SERT teams also knew before
then that Bucher had an “assault-type” rifle, and not just a .22.17
The SERT plan called for using armored vehicles to provide cover and safety
while allowing officers to get close enough to the house to effectively launch the
gas into the home and ultimately apprehend Mr. Bucher. However, as the
operation unfolded, Sgt. Darby decided suddenly that the officers in the armored
vehicle were in danger and he came forward, partially leaving cover and exposing
himself to gunfire from the chest up. He stated that at that moment he needed to
be the one to stop the subject.
At this critical juncture in this incident, the two SERT sergeants, each with an
armored vehicle team in similar positions working toward the same objective
made strikingly different conclusions about their cover. Sgt. Darby, with the
smaller armored vehicle, concluded on the spot that the officers inside the armor
were vulnerable and must be protected by an officer outside the vehicle, namely
himself. Sgt. Forsyth made statements later expressing his conclusion that the
officer inside the armor was protected but that the officers outside the vehicle
should not chance exposing themselves in order to launch gas until cover fire had
suppressed Mr. Bucher’s gunfire.
Sgt. Darby’s use of deadly force was scrutinized and deemed in policy by the
reviewing commander and the Police Review Board. His decision to move away
from full cover and take a position where he eventually felt obliged to use deadly
force was not scrutinized. According to the sergeant’s statements, this decision
was sudden and based on the realization that the subject had a high-powered
weapon that could possibly penetrate the armored vehicle windows. The
sergeant’s sense of urgency was avoidable. The “confirmation” that the subject
had an assault-type rifle had been broadcast 20 minutes earlier, before the
armored vehicles had moved into place. The sergeants could have weighed and
discussed concerns about the extent to which the vehicles were capable of
protecting officers from Mr. Bucher’s weapon earlier and adjusted the plan
accordingly. They could have positioned the armored vehicle farther away or
assigned another officer to provide lethal cover from a position of greater distance
and safety.

17

The sergeant in charge of the other armored vehicle team a few yards away from Sgt.
Darby’s vehicle team stated that it had been “clarified and confirmed” that Mr. Bucher
was firing an assault rifle about 20 minutes before Sgt. Darby decided his officers were in
danger and fired at Bucher.

47

 It is not clear from the record why the two sergeants reached different conclusions
about the vulnerability of officers inside the armored vehicles to assault rifle fire
and significantly different decisions about how best to address these
vulnerabilities. It may signal a difference in assumptions about the capabilities of
the armor, or an actual difference between the armor of one vehicle versus the
other, or a fundamental difference in defensive doctrines. Any of these
possibilities calls upon SERT and the Training Division to clarify the facts or
make a policy decision that would put all supervisors facing similar challenges on
the same page.
RECOMMENDATION 17: The Bureau should ensure that
its training message and any written protocols concerning the
capabilities of its armored vehicles to provide cover against a
variety of weapons is clear, consistent and fact-based.

Tactical Engagement by On-Scene Sergeant
Our prior reports have repeatedly addressed the role of on-scene sergeants,
emphasizing the need for them to maintain a supervisory perspective and avoid
tactical involvement, delegating these roles to officers in their command. The
Bureau has responded to our frequent recommendations in this area with
agreement and the assurance that current practice and training emphasizes this
supervisory role for sergeants.
Here, Sgt. Darby was one of the two main SERT supervisors at the center of the
scene. He was responsible for the inner perimeter, placing and commanding other
SERT officers on one of the armed vehicle teams, and approving deployment of
gas rounds launched into Mr. Bucher’s trailer. Rather than maintaining that
supervisory posture, however, at a critical juncture, Sgt. Darby took a position
near the front of the armored vehicle, put himself in the lead for the likely
confrontation of Mr. Bucher and partially left his hard cover.
While we can appreciate that the sergeant was concerned about the safety of the
officers under his command, his primary concern should have been supervision of
the incident, directing officers to positions of greatest safety and deploying
resources as necessary. By taking an active hands-on part, he lost focus of this
important role. Indeed, because he placed himself at the front of the action
without having donned his gas mask (as his officers had) and was thus himself
physically compromised by the gas that was deployed, he needed assistance from

48

 an officer to move to safety, was briefly unable to perform his supervisorial tasks,
and had to call upon a different officer to check on the welfare of other officers.
In addition, a few seconds before Sgt. Darby began shooting, he looked over and
saw Officer Gradwahl shooting from behind the other armored vehicle but
candidly stated that he did not know what the officer was shooting at. This was
despite SERT radio broadcasts referring to cover fire and then the announcement
“cover fire away,” as Officer Gradwahl began to shoot. This may be simply a
vivid reminder of how confusing an incident of this nature can be, especially once
police rounds and gas canisters are fired. But it may also indicate that the
sergeant had immersed himself so deeply into the action that he found it difficult
to stand back and supervise the execution of the plan. Under these circumstances,
it is inherently difficult to switch back and forth between actions as an operational
officer and as a supervisor.
Despite the Bureau’s past assurances regarding the importance of sergeants
maintaining supervisory positions, neither the Training Division nor the reviewing
commander identified or addressed these concerns with Sgt. Darby’s tactical
engagement.18 In our Fifth Report, we recommended that the Bureau adopt a
policy that reinforces the messages taught by training in the Sergeant’s Academy
and Critical Incident Management Class. We restate that recommendation here
and add another recommendation to reinforce it.
RECOMMENDATION 18: The Bureau should develop
specific policy that instructs sergeants on the need to
maintain their supervisory perspective and avoid tactical
involvement in incidents when officers are available to
perform those roles and should hold supervisors accountable
for violating those directives.
RECOMMENDATION 19: Whenever a supervisor becomes
tactically involved in a deadly force situation, the
Commander’s Memorandum, the Training Analysis, and the
Review Board should all opine on whether such involvement
was consistent with Bureau directives.

18

This is in contrast to another case we review in this report, involving Mr. Hayes, where
a sergeant who had been acting as an incident commander then engaged as a back-up rifle
operator was subject to a formal debrief regarding his role.

49

 Breadth of Review
This incident involved dozens of officers and supervisors, working both patrol
and SERT assignments. The Bureau’s review process was a multifaceted
evaluation of uses of deadly force, use of gas, uses of a K9 and a Taser, planning
and supervision of the operation by a captain and two sergeants and post-shooting
procedures and preservation of evidence at the scene. The Commander’s
Memorandum raised a new issue that had not been identified by Internal Affairs
or Training. The commander was critical of the SERT lieutenant’s decision to
initiate assignments without first seeking approval from the Critical Incident
Commander, who was en route to the scene. Bureau policy does not directly
address this issue.
The Police Review Board followed up on this point and recommended that the
Critical Incident Commander and two of the sergeants receive debriefings on the
issue from the Chief. Perhaps the greater value of the Commander’s highlighting
of ambiguities in the policy was to initiate a dialogue within the Bureau regarding
command and control during critical incidents. We are informed that the Bureau
further considered the issue and refined its policy concerning supervisory
authority prior to the arrival of a Critical Incident Commander, issuing a
clarification of that policy in March 2017. We are encouraged that the
commander’s comments helped promote this process despite the fact that the
issue had not been previously identified in this case as an area of concern.

Timeliness of Interviews and Review Process
Both officers who used deadly force in this incident declined to be interviewed by
detectives during the criminal phase of the investigation. Each testified at the
grand jury proceedings. Each was interviewed by Internal Affairs three days after
the incident. We have stated consistently in prior reports that this time lag
between incident and first interview is not consistent with best practices.
Since the time of this incident, Portland has enacted a directive that requires an
officer to submit to an administrative interview as soon as practicable, but no later
than within 48 hours of the event unless the involved officer is physically
incapacitated. We look forward to reporting on post shooting procedures that
comply with this new standard.

50

 Use of Air Support Surveillance Video
The day after the incident, the video footage recorded from the air support
helicopter was shown to at least one roll call briefing group. Some of the officers
and supervisors who witnessed the incident saw it before their interviews by
Internal Affairs. We acknowledge that viewing such a video as a group at roll call
can be highly beneficial to any discussion of tactics or officer safety and we
generally encourage their use to provide real life examples for training purposes,
but that purpose could have been equally well served by waiting a few days until
after all witness employees had been interviewed. Showing such a video to some
witnesses but not others undermines the communication restriction memos
typically given to witness employees at the scene and would conflict with the
Bureau’s current policy prohibiting involved officers from viewing videos of an
incident prior to being interviewed.
RECOMMENDATION 20: The Bureau should continue to
use surveillance footage of Bureau operations for training
purposes but should develop handling procedures for
recently recorded videos that ensure investigators have
interviewed Bureau witnesses about the incident before
videos are shown.

51

 52

 December 5, 2016 ◦ Steven Liffel
Late in the evening on the date of the incident, an anonymous call to 911 reported
hearing shots fired in a residential neighborhood and gave a tentative address. An
officer went to the area described, found nothing amiss and departed. Several
minutes later, the officer was dispatched again based on another 911 call that
reported shots fired and a woman appearing to hide outside near an apartment
building.
The officer joined Officer Lawrence Keller and another officer and Sergeant John
Holbrook at the scene and they approached the apartment building. The officer
interviewed the woman outside when he arrived at the scene and was informed
that the subject, her boyfriend Steven Liffel, was located in a nearby apartment
building. He had woken her up and been threatening and incoherent and told her
to leave. Soon after she went outside, she heard him come out yelling and heard
gunshots. She believed he had shot at his own truck but gave no information
about Liffel’s firearms, drugs or mental health status. Officers shortly discovered
the truck with apparent gunshot damage and heard yelling from Mr. Liffel’s
apartment.
The sergeant, who had taken command of the scene, requested more backup units
and assigned positions to the officers at the scene behind cover. Sgt. Brian
Hughes arrived and had a patrol vehicle with reinforced ballistic panels brought
up close to the building to act as potential cover for officers. Officer Keller was
assigned a position behind the reinforced police vehicle approximately 100 feet
from Mr. Liffel’s front door to provide lethal cover to other officers. Sgt.
Holbrook directed officers to stop traffic around the apartment called Mr. Liffel’s
telephone six times, but the calls were not answered. Officers then heard a shot
fired from the windows or doorway of the subject’s apartment, heard a bullet pass
overhead and concluded that Liffel was shooting in their direction.
After the shot was fired, Sgt. Holbrook called out the Special Emergency
Response Team (SERT) and the Crisis Negotiation Team and instructed
emergency communications to stop the commuter train outside the vicinity of the
scene. Officers tried loud hailing Liffel using a patrol vehicle loudspeaker, also
without a response.
Officers at the scene observed Mr. Liffel come out of his residence several times,
yell at them, and then go back in. On one occasion, he appeared to attempt to

53

 light toilet paper as part of a possible makeshift Molotov cocktail. On another, he
had a pistol in his hand. On one or more occasions he yelled, “kill me” to officers
and “come get me.” Officers at the scene then heard another shot fired from
inside the apartment. They began to evacuate nearby residents who had been told
earlier to “shelter in place.”
A few more shots at brief intervals came from Mr. Liffel’s apartment though their
direction was not clear to officers. Lieutenant Anthony Passadore arrived at the
scene, was briefed by Sgt. Holbrook and took over as incident commander.
Other officers observed Mr. Liffel walking around his apartment with a revolver
in his hand and yelling. Shortly thereafter, about an hour and 15 minutes after
officers first arrived at the scene, Mr. Liffel stepped out his front door carrying a
rifle and moved toward the street, ignoring commands to drop the gun. Officer
Keller observed Liffel walking at “a steady pace with purpose” carrying the rifle
at a “port arms ready position”19 and inferred that Mr. Liffel was in a hunting
mode.20 Officer Keller fired one round, which struck Liffel in the hip. Liffel
bent, tossed the rifle a short distance, then fell down and rolled on the ground and
yelled, but did not fully respond to orders to crawl away from the rifle, which was
nearby. He appeared to have an object in his right hand, came to rest on his
stomach and tucked both hands under his stomach.
After the shooting, Lt. Passadore requested medical assistance. SERT officers
arrived a few minutes after the shooting, formed an arrest plan and approached
using an armored vehicle as protection with a beanbag shotgun and lethal cover.
They handcuffed Mr. Liffel and called for medical personnel who were now
staged nearby. Before they arrived less than a minute later, a SERT medic
checked for signs of life and found none. The medical personnel pronounced Mr.
Liffel dead at the scene 16 minutes after officers shot him.
The matter was presented to a grand jury, which found that the use of deadly force
was justified. The Police Review Board found that the shooting was within policy
and that all supervisory decisions and post-incident procedures were appropriate.

19

Held close to the front of the body with the barrel pointed generally upward.

20

While Officer Keller did not report observing a change in the angle of the initially
vertical barrel, another officer standing next to him did perceive that Mr. Liffel turned
toward him and Officer Keller and begin to lower the rifle barrel toward them. Another
officer reported seeing Mr. Liffel carry the rifle down the walkway at a 45-degree angle.

54

 Timeline of Investigation and Review
12/5/2016

Date of Incident

1/18/2017

Grand Jury concluded

2/2/2017

Training Division Review completed

3/9/2017

Internal Affairs Investigation completed

4/3/2017

Commander’s Findings completed

5/24/2017

Police Review Board

5/26/2017

Case Closed

OIR Group Analysis
Review and Tactical Issues
When Officer Keller was assigned to provide lethal cover with his rifle, another
AR-15 operator was similarly assigned. Officer Keller’s view of the front door
was partly obstructed. He could only see the top few inches of the screen door
and had to rely on broadcasts from another officer, positioned with the second
AR-15 operator, who described the movements of Mr. Liffel until Liffel walked
several feet down the walkway in front of his door where Officer Keller could see
him. The other AR-15 officer had a clear view of the entire front door area. That
officer stated to detectives he was about 75 yards away but he or his partner at this
location were looking through binoculars and observed and broadcast Mr. Liffel’s
actions both inside and outside the apartment. He too saw the rifle with the barrel
pointed up. He said he was prepared to shoot and that if the subject lowered the
angle of the rifle, that would cross the “line in the sand” and he would have fired
his AR-15. Officer Keller also stated that he was very concerned with the
backdrop to his line of sight to the subject, should he have to shoot, because it
contained a window of an apartment that was not yet confirmed evacuated. For
this reason he intentionally fired his round “low.” The obscured view of the
doorway and the need to fire low potentially restricted his effectiveness in
providing lethal cover.

55

 There is no ideal terrain for the use of deadly force, but some positions found by
other officers at the scene did not share these drawbacks. Additionally, the
Bureau’s newly acquired patrol vehicles with ballistic panels provide other
options to strive for a flexible vantage point without compromising officer safety.
In this case, however, the original cover vehicle for the assembled arrest team –
for which Officer Keller was providing lethal cover – was parked facing north in
the street that ran in front of Mr. Liffel’s front door. The ballistic panel vehicle
that was moved in for extra cover was placed parallel to the first vehicle. Officer
Keller and other officers took a position on the west side of the reinforced vehicle;
Liffel’s apartment was on the east side. When Mr. Liffel came out his front door
with a rifle, Officer Keller could not see him until he was a good way down his
walkway walking toward the street. Thus, by the time Liffel did clear the side of
a truck parked in his driveway and became visible to Officer Keller, he had only a
few more feet to go before he might be standing in the street looking straight at
Officer Keller and several colleagues, who would no longer be on the safe side of
their cover. Officer Keller stated that he felt he only had a couple of seconds to
determine whether to fire to defend himself and his team. This imminent prospect
of officer vulnerability was concerning enough to the lieutenant who had just
taken over as scene commander and was observing from behind Officer Keller
that he stated he had instinctively begun to take his pistol out of its holster before
realizing that, as incident commander, he should maintain a big picture and not
focus on aiming his firearm at the subject.
In effect, when Mr. Liffel began to move out from the doorstep of his apartment
for the first time, each of the two designated officers providing lethal cover for the
rest of the many officers in the area were either too close and accessible (Officer
Keller) or so far away (the other AR-15 operator) that he could not confirm that
the object in Mr. Liffel’s hand was a rifle without the aid of his partner on
binoculars. With the benefit of hindsight,21 it appears that the arrangement of
officers and police vehicles was inflexible once the subject began to move
forward out his front door.
The Training Division recognized this as an area of concern and discussed this
scenario and the ways to use on-scene vehicles to maximize defensive

21

Hindsight and the opportunity to consider a dynamic situation from many different
angles are useful tools for training and debriefing purposes. Considering alternatives is
not equivalent to rendering harsh judgments of decisions made in the field under time
pressure. It is a hallmark of a learning institution that it is willing to try to extract tactical
lessons from every critical incident.

56

 opportunities in its 2018 in-service training. We encourage the Bureau to make
this topic a standard part of tactical training.

Timing of SERT Activation
The sergeant in charge of the scene requested SERT activation after Mr. Liffel
fired one round in the direction of officers. The parameters for requesting SERT
are broad and great discretion is given to the incident commander. In this
situation, due to efficient information gathering, the scene commander, Sgt.
Holbrook, knew within a few minutes that the subject had a gun, had fired it
outside of the apartment (hitting his truck), displayed mental distress and erratic
behavior, did not respond to police communications, and was taunting police.
Still, he did not call in SERT until about 35 minutes into the incident.
It is also notable that Sgt. Holbrook did not call to the scene an Enhanced Crisis
intervention Team officer who would have extended training in communicating
with subjects in mental health crisis and likely would have been available to
respond more quickly than SERT or the Crisis Negotiation Team. Although there
were early indications that Mr. Liffel was undergoing a mental health crisis, the
sergeant elected to initiate communication himself, but he could not reach Mr.
Liffel by telephone. Later, he delegated field officers to try getting through to Mr.
Liffel by loudspeaker, also to no avail.
The Training Analysis deemed the sergeant’s decision to activate SERT
appropriate but did not address the timing of it or discuss the potential benefits of
an earlier request.
Some of the tactical concerns we address above may have been alleviated by an
earlier SERT response. SERT officers and supervisors do extensive training in
just these types of scenarios and are the Bureau’s recognized experts at tactical
positioning and responding to barricaded subjects. They also bring specialized
tools that can be crucial to successful resolution. SERT resources such as
armored vehicles can also assist with the problem that proved so crucial in this
incident -- finding hard cover close to the subject location. A more thorough
discussion and examination of the timing of the decision to activate SERT by both
Training and the Commander’s Memorandum would have been a valuable
component of a comprehensive review process.

57

 RECOMMENDATION 21: The Bureau should evaluate the
practicality of streamlining and standardizing the incident
commander’s decision factors for activating SERT.

Delay in Providing Medical Care
The delay in providing medical care to Mr. Liffel after he was shot raised
important issues, some of which were examined at length by investigators. After
being shot, Mr. Liffel rolled in pain and crawled a little before lying face down
with his hands under his torso and the rifle close by on the ground. He lay still
and did not respond to commands to crawl away from the rifle. The lieutenant
who had taken over the scene just prior to the shooting, determined that it was not
safe for patrol officers to approach the subject because he had previously used a
handgun and may be concealing it under his torso. The lieutenant instructed
officers to wait until SERT arrived to secure the subject. When SERT did so,
medical personnel were allowed in and pronounced Mr. Liffel dead at the scene.
A total of 16 minutes passed between the shooting of Mr. Liffel and his
examination by medical personnel.
Training addressed the relatively late staging of medical personnel nearby and
recommended a standardized medical staging procedure that would ensure that
medical personnel are close by at the earliest reasonable stage.22 While we agree
that this is an important issue relevant to many critical incidents, the late staging
of medical personnel in this case would only have been relevant had SERT been
activated earlier. Sgt. Hughes had prepared a small team to approach Mr. Liffel
with ballistic shields and a less lethal beanbag shotgun to secure him and get
medical aid to him. But because of Mr. Liffel’s proximity to his rifle and the fact
that he had crawled forward but then hidden his hands, Lieutenant Passadore
elected to take the cautious approach and wait for SERT instead of using field
officers to try to secure the subject. When SERT personnel assembled, they
quickly made a plan to approach and handcuff Mr. Liffel to address his medical
needs with their own medically trained officers and ambulance personnel.
Thus, Training did not acknowledge the main reason for delayed medical
attention in this particular incident – the decision to wait for SERT to assemble,
make a plan and approach and secure Mr. Liffel so that medical could be allowed
into the scene, particularly given the fact that the specialized team was not
activated early in the incident. Mr. Liffel was responsive to some commands after
22

The reviewing commander did not adopt Training’s recommendation.

58

 he was shot. He crawled forward as instructed but then stopped. As it turned out,
the nature of Mr. Liffel’s fatal injury – a severed major artery in the groin – may
have rendered medical intervention at the scene ineffective, but the severity of his
injury was not known until medical personnel could physically contact him.
RECOMMENDATION 22: All of the Bureau’s reviewers –
Training, Commander, and Police Review Board – should
consider all contributing causes in their analysis of a delay in
providing medical care.

Timeliness of Interviews and Review Process
The investigation and review were appropriately broad-based, taking up important
issues beyond the use of deadly force, including supervision and management of
the active scene, post-shooting procedures, and medical care. This is in keeping
with best practices and with the Bureau’s current procedures.
The investigation and review were completed within the 180-day internal time
limit agreed to by the Bureau. The interview of the officer who used deadly
force, however, was not timely. Officer Keller was interviewed by Internal
Affairs seven days after the shooting. Since he had declined to be interviewed by
detectives at the scene, this was the first opportunity the Bureau had to learn about
the officer’s perceptions and thinking before he shot Mr. Liffel. This is too long
for the Bureau to wait before interviewing the central involved officer. Since the
time of this incident, Portland has enacted a procedural standard that requires an
officer to submit to an internal affairs interview as soon as practicable but no later
than 48 hours after an incident. We look forward to reporting on post-shooting
procedures that comply with this new standard and, as discussed above, hope the
Bureau will routinely obtain statements from involved officers before the end of
their shifts.

59

 60

 February 9, 2017 ◦ Quanice Hayes
At 7:24, 7:26, and 7:35 in the morning, on a cold day with heavy rain, dispatch
received three separate calls about crimes apparently involving the same suspect.
The first was from a man who was the victim of an attempted carjacking. He was
asleep in his car when the subject knocked on the window, displayed a gun, and
eventually got into the car. The victim described the subject as a young black
man, in his 20s, wearing a dark colored hoodie with the hood up and black jeans.
The victim said the subject had held a gun to him that he described as a .45 that
looked like a military gun, with desert camouflage. After a little more than 30
minutes, frustrated that the victim’s car was out of gasoline, the subject got out of
the car and walked away. The victim reported to the dispatcher that the subject
put the gun into his waistband as he left.
The second call was from a woman who reported that her car had been broken
into in a parking lot. She confronted the subject, who was still in her car, and he
got out of the car and fled on foot. She described the subject as a young black
man in his teens or early 20s, with shoulder-length dreadlocks wearing a blue or
black shirt, jeans and a white belt, with a black rolling suitcase. As she was on
the phone with dispatch, she walked around the corner to see the name of a crossstreet, and again saw the subject.
The third call came from a woman who said there was a stranger banging on her
door, who would have had to hop a fence to get into her backyard. She described
the subject as a young black man in his teens or 20s, wearing a green or black
hoodie, with the hood up, carrying something like a suitcase.
Two officers responding to this third call confronted the subject in the driveway at
the caller’s residence at around 7:45. Noting that he matched the description of
the subject of the call – young black male with dreadlocks, dark hoodie, and
jeans, standing over a suitcase – they ordered him to put his hands up, intending
to detain him. The subject partially complied but continued dropping his hands
while he talked to officers, claiming that he lived in the house. Officers
communicated via radio that the subject was not complying, and additional
officers began responding.
While one officer continued to detain the subject, the other went to the door of the
residence to ask the 911 caller if she knew the subject. When she said “no,” the
subject took off running. As he began to run, officers stated that he grabbed at his

61

 front waistband in a manner they associated with an effort to secure a weapon (as
opposed to a move to pull up one’s pants, for reasons they describe in detail).
Believing that this likely was the subject wanted for the robbery who was armed
with a handgun, officers made a decision not to pursue the subject around a blind
corner and over a fence. Instead, they communicated with other officers about the
subject’s location and direction of travel, helping to focus the containment effort.
The Bureau of Emergency Communications dispatcher coordinated with the
numerous responding officers, who were beginning to set a perimeter around the
location of these three calls. Two sergeants – Kyle Nice and Jeffrey Helfrich –
responded and assumed supervisory roles. Officers requested a K-9 officer and
an AR-15 rifle operator.23 A K-9 officer responded and began tracking the
subject from the location he had last been seen. Officer Andrew Hearst responded
to the request for an AR-15 operator and, with his partner, who armed himself
with a less-lethal beanbag shotgun, joined the team tracking the subject. Sgt.
Helfrich attached himself to the K-9 team and supervised the search, while Sgt.
Nice assumed command of the overall incident.
The dog followed the subject’s scent and eventually alerted to a backyard and a
house in the area. Officers noticed signs that someone may have entered the
house through a rear window and perhaps tried to kick in a nearby door and did
some follow-up investigation relating to seemingly fresh footprints in the mud
and a handprint on a railing. Sgt. Nice asked dispatch to contact the alarm
company (for which there were signs at the house) to see if there had been prior
alarms at the location that day and learned there had been none. Officers called
all available phone numbers for the owners of the home to determine if the
damage to the window and door was recent but could not reach anyone.
Officers held perimeter positions while the supervisors discussed whether to
activate the Special Enforcement Response Team. They decided to hold off on
that call and conduct some further investigation and tracking to see if they could
determine whether the subject was in the house or had left the area.
As officers were examining the door into the basement at the rear of the house
and pushing on it to determine if it had been breached, an audible alarm went off
23

The K-9 is routinely used as a tool for tracking, searching, and the apprehension of atlarge suspects. The AR-15 rifle fires high-velocity rounds with distinctive accuracy,
giving officers an opportunity to address potential threats from a safer distance if
necessary while minimizing the chances of hitting an unintended target. One
disadvantage of an AR-15 rifle is it can be cumbersome when officers are on the move.

62

 inside the house, and officers assumed it was the result of their activity. Because
there had been no prior alarms, on-scene officers and supervisors reached the
conclusion that the subject had not entered the house. Shortly thereafter, an
officer who had moved toward the front of the house noticed a screen on the
ground outside an open window that had previously been shut. As he looked
around the area, he saw the subject crouching in the back of a narrow alcove
between the house and garage.
The officer immediately gave the subject a command to put his hands in the air
and alerted other officers in the area that he had located the target of their search
as he drew his weapon and attempted to move to a less exposed position while
still maintaining a view of the subject. The K-9 officer moved to the driveway at
the front of the house, along with Officer Hearst, the less-lethal shotgun operator,
Sgt. Helfrich, and one other officer. Sgt. Nice, who along with Lieutenant
Richard Deland and Commander Bryan Parman had gathered around patrol
vehicles across the street with several other officers, retrieved his AR-15 from his
car and moved up to the side of Officer Hearst to serve as a secondary rifle
operator. Other than Officer Hearst and Sgt. Nice, none of the other officers had
firearms drawn. Two were providing less lethal options (K-9 and beanbag
shotgun), Sgt. Helfrich was standing behind the others in a supervisory role, and
the remaining officer was prepared to approach and handcuff the subject, so kept
his hands free.
Officer Hearst had his rifle pointed at Mr. Hayes at the back of the alcove and had
officers on either side of him. None of these officers in the driveway had
positions of cover, as the angle of the alcove was such that maintaining visual
contact with Mr. Hayes required them to be in the open driveway, but all describe
their efforts to stay on the periphery of Mr. Hayes’ lateral shooting range and to
maintain some distance from the mouth of the alcove in accordance with their
tactical training.
Because the alcove was too narrow to permit officers to safely go in toward the
subject, the plan was to have Mr. Hayes come out into the driveway in a
controlled manner, have him move to a prone position (lying flat on his stomach
with his hands extended out), and then have a custody team approach and
handcuff him.
Officer Hearst addressed him initially, instructing him to put his hands in the air,
and, with greater specificity, told him that officers believed he was armed and that
if he reached for his waistband, he would be shot. All of the witness officers
describe Mr. Hayes as being somewhat – but not fully – compliant with officers’

63

 commands. He put his hands up, but only part way, in a manner that officers took
as a signal he was not 100% acquiescent but testing them and thinking about his
options or formulating a plan.
The K-9 officer then began addressing Mr. Hayes, instructing him to get on his
knees and then to crawl out of the alcove. Mr. Hayes immediately stood up and
kept his hands partially up. The officer again instructed him to get on his knees
and crawl out, and this second time he followed the instructions. However, when
he was just out of the alcove at the edge of the driveway – about 10 or 15 feet
away from the officers – he stopped crawling and raised his torso up while
remaining on his knees.
The K-9 officer described this as unusual, because he said subjects generally want
to demonstrate compliance when confronted with a barking dog and the fear of
being bitten. Other officers also noted his failure to completely comply as
unusual, because it would have been clear to Mr. Hayes that he was surrounded
by officers and had no chance of escape, and because subjects in these
circumstances generally give up and are taken into custody. In their interviews,
all stated that it seemed Mr. Hayes understood the commands given to him,
evidenced by his partial compliance and seeming reaction to what officers were
saying.
Mr. Hayes then reached one hand behind his back, but then put it back up in the
air. Officer Hearst described this as a moment that took his breath away, because
he had nearly fired his weapon in response to this movement. A witness officer
also observed this movement and remembered being surprised that no officer had
shot in response. The K-9 officer – standing next to Officer Hearst – was
preparing to release his dog with a command to bite the subject in response to Mr.
Hayes’ hand movement.
A second later, however, officers describe seeing Mr. Hayes drop his hand again –
this time to the front of his waistband – and Officer Hearst fired his weapon three
times. Mr. Hayes fell forward into the driveway and made no further movements.
Officers quickly assembled a custody team, retrieved a ballistic shield from one of
the sergeants’ cars, approached Mr. Hayes and secured him. Mr. Hayes had
sustained three bullet wounds – two to the chest, and one to the forehead.
Paramedics arrived but pronounced Mr. Hayes dead at the scene at around 9:30,
nearly two hours after the first call relating to this incident.

64

 There was a gun found within a few feet of Mr. Hayes’ body, similar to the one
described by the initial carjack victim. However, none of the officers on scene
reported seeing the gun at any time prior to the shooting.
The District Attorney presented this case to the grand jury, which determined
Officer Hearst’s use of deadly force to be legally justified. The administrative
review process culminated in a Police Review Board decision to find the shooting
within policy, though the Board recommended a formal debrief for Sgt. Nice for
stepping out of his supervisory role and assuming the role of secondary lethal
cover.

Timeline of Investigation and Review
2/9/2017

Date of Incident

3/21/2017

Grand Jury concluded

4/4/2017

Training Division Review completed

4/14/2017

Internal Affairs Investigation completed

5/24/2017

Commander’s Findings completed

6/29/2017

Police Review Board

7/3/2017

Case Closed

OIR Group Analysis
Tactical Considerations
Time, Distance, and Cover
We regularly emphasize the principle that tactics to improve officer safety also
are less likely to leave officers in a vulnerable position from which they feel
compelled to use deadly force. Here, the Bureau got many of these tactics “right”
– officers who initially spotted Mr. Hayes did not get drawn into a risky foot
pursuit but instead assisted in coordinating a containment and a K-9 track;

65

 supervisors arrived on scene, coordinated resources, and made thoughtful,
deliberative decisions; and officers maintained regular communication with each
other and supervisors.
Nonetheless, officers did find themselves in a vulnerable position as they
attempted to take Mr. Hayes into custody. They had strong reason to believe the
subject they were confronting was armed but placed themselves in a position with
no available cover. The Training Division Review addresses this, reached the
conclusion that “rapidly [e]volving circumstances” left them with no options. Lt.
Deland had directed officers to move a patrol vehicle with ballistic doors into a
position at the end of the driveway to give officers a position to which to retreat if
needed, but officers only used this option after the shooting, while determining
whether Mr. Hayes continued to pose a threat.
What the Training analysis does not address is whether officers could have done
anything to alter the rapidity with which this event unfolded. The tempo of events
like this can become contagious. Officers had been searching for Mr. Hayes for
nearly two hours, and once they had him literally cornered, it is not hard to
understand that officers were eager to take him into custody. The role of the
supervisors, however, is to manage that instinct and control the pace of the
encounter.
Upon discovering Mr. Hayes crouched in the alcove, officers almost immediately
began giving him commands to crawl out. An alternative would have been to
hold Mr. Hayes at gunpoint in the alcove while conferring with each other about a
plan for taking him into custody. The plan could have included moving a car into
the driveway to create cover, or bringing the ballistic shields from the sergeants’
cars as a source of protection, or backing out to the end of the driveway, where
they could have still seen into the alcove but from a greater distance, out of easy
range of the weapon they assumed the subject still possessed. These options were
utilized after the shooting, when officers remained concerned about the subject’s
weapon; slowing the incident down could have given officers the opportunity to
use these tools prior to the shooting. With the protection of cover, officers may
have felt less vulnerable, and the less-lethal options might have been viewed as
reasonable alternative responses to Mr. Hayes’ lack of cooperation. Evaluation of
these options and their applicability, including potential risks and downsides,
would have made for a more thorough and constructive review.
As it was, the officers deploying less-lethal options were operating in a gray area
because Mr. Hayes was partially following commands. Unambiguous defiance of
66

 their orders that did not involve reaching for a weapon would have likely
prompted use of the less-lethal tools available. For example, the K-9 officer was
clear that if Mr. Hayes had simply refused to come out of the alcove or had taken
off running, he would have unleashed the dog with a command to “take” the
subject, but releasing the dog on a subject who was generally following
instructions – if with some level of defiance – was not plainly justified. Similarly,
the officer with the less-lethal shotgun said he would have fired had the subject
tried to run, but the usefulness or appropriateness of a less-lethal deployment
sooner than that was not obvious, and might have precipitated a use of deadly
force if it caused Mr. Hayes to make a sudden movement. Both the less-lethal
shotgun and the K-9 could have been deployed when Mr. Hayes dropped his hand
to his waistband the first time, but he brought his hand back up quickly and then
dropped it again, leading to the use of deadly force.

Clarity of Commands
Delaying the subject’s move out of the alcove also would have given officers time
to coordinate who would be giving him commands. While Officer Hearst and the
K-9 officer recalled a clear demarcation between who was giving commands at
which time, the statements from different witness officers painted a more
confusing picture, with varying accounts of who was giving commands and when.
Sgt. Nice stated that he gave the subject commands just before the shooting, and
others reported hearing these commands from the sergeant, though Hearst and the
K-9 officer did not mention this in their interviews. At a critical point, just
moments before the shooting, the K-9 officer testified that he was the only one
giving commands and that the subject rose to his knees on his own, not pursuant
to any directions from officers. But a different witness officer gave an account to
Detectives and to the grand jury that was confusing in light of all the other
officers’ recollections of these moments. He said the subject was arguing with
officers over what may have been confusing orders to “keep his hands up” and to
“crawl forward,” noting that he couldn’t crawl with his hands in the air. This
officer remembered that someone had told the subject to “walk” forward on his
knees.
Inconsistencies in the details of different witnesses’ accounts of a critical incident
are understandable and even anticipated, given the ways in which memory
operates and the speed with which these events unfold. (Indeed, stories that
match too closely can be suspect.) But these varying accounts point to what
might have been a very significant issue. If officers on scene have differing views
of what the subject is supposed to be doing in order to demonstrate compliance,

67

 officers may develop different impressions of the subject’s level of cooperation
and have correspondingly different reactions. And if the subject is confused
about officers’ expectations, that creates another obvious set of problems. Here,
the potential confusion the varying accounts portray might have been avoided had
officers slowed their response and given themselves additional time to plan and
coordinate. Unfortunately, these conflicting accounts were not explored in the
administrative investigation and were not addressed in the Training Division
Review.
All the witnesses were clear, however, that officers gave repeated warnings to Mr.
Hayes, to the effect of: “We believe you have a weapon. If you reach for it, you
will be shot.” There are some potential downsides to this type of warning: It may
commit an officer to a particular course of action, regardless of how the incident
develops, or may encourage other officers on scene to fire, regardless of their own
independent assessment. And it may signal to a suicidal person exactly what he
or she needs to do to prompt the officer to fire.
The Bureau trains its officers that such a warning can be given when officers
confront subjects, depending on the particular circumstances, but should be
tailored to the nuances presented. Here, the officers had specific information
about Mr. Hayes’ possession of a handgun, and that he may be carrying it in his
waistband. Further, when ordered to put his hands up, all the witness officers
stated that Mr. Hayes did not put them all the way up, to signal surrender, but
instead held them part way up, and raised and lowered them throughout the
encounter.
While the warnings given to Mr. Hayes may have been appropriate in these
circumstances, the Training Division should continue to weigh the tactical
advantages and disadvantages of such explicit messages. Like the question of the
need to immediately order Mr. Hayes out of the alcove and the confusion
surrounding some of the specific commands that were given, the wisdom of these
particular warnings should have been a point of discussion in the administrative
review of this incident.
RECOMMENDATION 23: The Training Division, Internal
Affairs, and Commanders should identify, analyze and assess
all of the tactical considerations surrounding a given
incident, including the effectiveness of particular commands
and warnings officers gave to the subject.

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 Action-Reaction Principle
The grand jury determined that Officer Hearst was legally justified in firing his
weapon at Mr. Hayes. The relevant legal standard in adjudging potential
criminality of deadly force is objective reasonableness, meaning that officers are
authorized to use deadly force to protect themselves or others from what they
reasonably believe to be a threat of death or serious injury.24
Under current criminal law, seeing a subject reach for what officers have reason
to believe is a concealed weapon has often been considered sufficient to justify
deadly force because of what is commonly known as the action-reaction principle.
The principle, based on human physiology, holds that an initiator of an action has
an advantage in a contest of time over a person who is trying to react to that
action. As applied to police activity in this context, it means that an individual
who draws a gun will be able to fire before the officer has time to perceive the
action and react to it with deadly force. PPB officers receive training on this point
in several contexts. One is to instruct officers that if they believe a subject is
reaching for a weapon, it may be reasonable to use deadly force even before
24

While the Constitutional standard instructs that the use of deadly force be considered
through the prism of “objectively reasonable,” PPB’s use of force policy places
additional requirements on its police officers. For example, the Directives requires the
use of disengagement and de-escalation:
1.1. Members shall use disengagement and de-escalation techniques,
when time and circumstances reasonably permit. De-escalation
techniques provide members the opportunity to stabilize the scene or
reduce the necessity for or intensity of force so that more time, options
and resources are available to resolve the confrontation. Members shall
take proactive steps to eliminate the immediacy of the threat, establish
control and minimize the need for force.
1.1.1. De-escalation techniques include, but are not limited to: 1) using
verbal techniques to calm an agitated subject and promote rational
decision making; 2) allowing the subject appropriate time to respond to
direction; 3) communicating with the subject from a safe position using
verbal persuasion, advisements, or warnings; 4) decreasing exposure to a
potential threat by using distance, cover, or concealment; 5) placing
barriers between an uncooperative subject and an officer; 6) ensuring
there are an appropriate number of members on scene; 7) containing a
threat; 8) moving to a safer position; and 9) avoiding physical
confrontation, unless immediately necessary.

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 seeing the weapon, because it may be too late if they wait for visual confirmation
before firing.
Officer Hearst referred several times to the action reaction doctrine in his
testimony before the grand jury. He also stated, “[w]ith all of the information I
knew up to that moment, there was no doubt in my mind he had a gun.”
This statement raises the all-important context of the shooting – what officers
knew or believed about the subject and what alternative tactics that knowledge
should suggest. One pitfall of law enforcement’s reliance on the action-reaction
principle is that it can easily be misconstrued by officers who may believe they
have a mandate to shoot anyone holding a gun, or someone who might have a gun
and makes a sudden movement, regardless of other tactical alternatives or threat
assessment. We have seen in some agencies where “action-reaction” has become
the justification for almost any use of deadly force. Therefore, it is important for
reviewers to unwind these situations and consider the totality of the circumstances
and the specific threat to which officers were responding. Most significantly, it is
critical for Bureau reviewers to determine, consistent with the Bureau’s
disengagement and de-escalation dictates as set out in the Directives, whether
officers and on-scene supervisors did all they could to slow the incident down,
keep themselves safe in positions of cover, develop a plan where each officer has
a clear understanding of his or her role, communicate effectively and clearly with
the subject, and not place themselves in a vulnerable situation where they felt
constrained to use deadly force.
When evaluating incidents where the action-reaction principle is cited, we employ
three basic guidelines:
•

•

•

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The action-reaction principle may be a useful cautionary component of
training but it should not be applied as a catch-all defense to every lethal
force decision that turns out to be misinformed or misguided.
The implications of this principle are not to justify using deadly force but
instruct officers of their own physical limitations and the need to do all
they can to keep themselves from a position of vulnerability and where
deadly force then ends up being the outcome.
There are often available engagement tactics that reduce or eliminate the
need to use deadly force when a subject makes a movement suggesting a
reach for a weapon.

 An analysis of this incident compelled by these precepts produces a more exacting
evaluation of the events. We do not suggest that the Bureau engage in exotic or
newfangled theorizing but rather insist on some fundamental principles that have
guided force training for decades: Cover, Time and Distance are the vital tools
that police officers must employ whenever possible to slow the situation down,
reduce danger to themselves and others, and place greater control of the outcome
in the hands of the officers.
In fact, to the Bureau’s credit, new officers receive precisely this message at the
Bureau’s Advanced Academy. In the classroom, the mat room, and in shooting
scenarios, trainers convey the principle, “action beats reaction so do something to
change that” by, for example, moving to cover or ordering the subject into a
disadvantageous position.
Most significantly, then, it is similarly critical for reviewers of these events to
determine whether officers and on-scene supervisors did all they could to
demonstrate their implementation of this training. Unfortunately, in this case,
none of the Bureau’s review mechanisms sufficiently explored the question of
whether the on-scene officers and supervisors performed consistently with the
training that accompanies the action-reaction principle, and instead reached the
fatalistic conclusion that Mr. Hayes’ actions drove the outcome. As we discussed
above, a more thorough and constructive review would have assessed questions
about how personnel might have altered the tempo of their response, allowing
them to weigh options for providing cover, to better coordinate commands, and to
consider safer ways to take Mr. Hayes into custody.
In this case, we raise the following questions about whether the on-scene officers
performed consistent with the training accompanying the action-reaction
principle:
•

•
•

Were there other options that officers could have deployed for cover (as
they did after the shooting) such as utilizing the patrol car with ballistic
doors that was on scene?
After redesigning the scene to provide cover could the Bureau have
slowed the incident down to consider other tactical options?
Would slowing down the incident have provided an opportunity to better
plan who was going to give the commands to order Mr. Hayes out, what
those commands would be, and when they would occur?

71

 The Bureau’s review process did not sufficiently address these critical issues.
When analyzing Bureau performance, it is imperative, consistent with the
Bureau’s de-escalation policy, to conduct a more exacting review.
RECOMMENDATION 24: The Bureau and Police Review
Board should ensure that officer-involved shooting reviews
do not begin and end with a citation to the action-reaction
principle but must critically assess other tactical options that
might have driven a different result.

Supervisory Issues
Sgt. Nice was acting as the incident commander during the search for Mr. Hayes.
As attention focused on the house outside of which officers ultimately found him,
however, he believed that the situation called for a secondary AR-15 operator, and
he armed himself with his rifle. He put it away for a time during which he was
conferring with Lt. Deland and Commander Parman, but then took it out of his car
again and stood near Officer Hearst while they confronted the subject. We have
frequently commented in prior reports about the disadvantages of sergeants
assuming tactical roles during a critical incident. Training, the Commander, and
the Police Review Board, all recognized that Sgt. Nice should have remained the
incident commander and not inserted himself into the role as secondary lethal
cover. This became the subject of a formal debrief.

Grand Jury Concerns
The District Attorney convened a special session of the grand jury the day after
the shooting to capture the testimony of the victim of the incident that initiated
officers’ search for Mr. Hayes. His testimony came five weeks before the
remainder of the grand jury proceedings because the prosecutor was not certain
the witness would still be living in the area at the time the criminal investigation
was complete.
The witness identified Mr. Hayes as the person who robbed him at gunpoint,
threatened his life, and held him hostage in his car for an extended period. He
described a sequence of events that unfolded during the time Mr. Hayes was in his
car, and identified items stolen from him that were later found in Mr. Hayes’
possession. The prosecutor asked him to describe the gun Mr. Hayes brandished
and at the end of his detailed response, which included him recounting how the
72

 gun was pointed at his face, he said, “I’m glad he’s dead. It still bothers me
because the way everything happened, but I’m glad he’s dead.” With that
statement, the prosecutor concluded the proceedings.
This highly prejudicial statement, while not elicited by the prosecuting attorney,
should have prompted the prosecutor to request it be stricken and to instruct the
jury to disregard it.

Timing of Interviews
This incident happened during the period of time after the City had eliminated the
so-called “48-hour rule” from its contract with PPB officers (and before it was
effectively reinstated after intervention from the District Attorney and then again
eliminated by action of City Council). In this case, Internal Affairs investigators
interviewed Officer Hearst – a compelled administrative interview – about 25
hours after the shooting incident. Officer Hearst declined to give a voluntary
statement to Detectives conducting the criminal investigation but did testify
before the grand jury 47 days later.

73

 74

 February 9, 2017 ◦ Don Perkins
In the evening on the date of the incident, Don Perkins called 911 twice and
reported that he had taken 30 pills and would take 30 more if he could not contact
his doctor. He said, “I’m killing myself,” and refused to answer questions about
his location. This and other remarks caused the Bureau of Emergency
Communications to deem this a suicide call and to dispatch officers as a priority
welfare check. Officer Roger Walsh was assigned to the call and requested that
an Enhanced Crisis Intervention Team (ECIT) officer be assigned as well.
Officer Bradley Clark heard the request and indicated that he was ECIT trained
and would respond. Emergency Communications provided a rough location for
the caller based on the GPS signal from the cell phone.
The officers were unable to find anyone in the vicinity of the location and
requested that dispatch “ping” the cell phone for a more precise location. After
continuing their search a few blocks away, they received an updated location
based on the ping results and drove there. After a few minutes of searching in the
new area, the officers approached a parked van with fogged windows and called
out for Mr. Perkins.
When there was no response, the officers opened the back door of the van. Mr.
Perkins was sitting in the back of the van with a pill bottle and pills on the floor
near him and nothing in his hands. Officer Clark told Mr. Perkins they were
concerned about the pills and wanted to get him some help, then moved to the
van’s side door, which Officer Walsh had just opened. As Officer Walsh looked
into the van he saw a black object in Mr. Perkins’ hand and heard a metallic click,
which he associated with firearms. Officer Clark likewise heard the click and
shared his partner’s concern.
Both officers unholstered their guns and quickly backed away to crouch behind
the back of Officer Clark’s patrol car parked a few yards away. Officer Clark
retrieved his AR-15 rifle while Officer Walsh broadcast that they had found Mr.
Perkins and that he might have a gun. Dispatch began the process to stage
medical personnel nearby. The officers requested another rifle operator and
another Enhanced Crisis Intervention Team officer.
Mr. Perkins opened the side door of the van and threw a small object out that
looked like a pill bottle then tossed another object, black in color, and sat in the
door screaming at the officers that he had just thrown a gun out and that the

75

 officers should approach him. They remained behind the cover of the patrol car
and tried to talk to Mr. Perkins, whereby Mr. Perkins began yelling, “It’s your
call. Shoot me, bitch. Kill me. Come get me,” and “Everybody here don’t go for
the gun.”
Officer Clark instructed Mr. Perkins to show his hands and walk back to them.
Mr. Perkins would not and yelled profanities. The officers had concluded that the
black colored object that Mr. Perkins threw out of the van was a gun and told Mr.
Perkins not to reach for it or he would be shot. Mr. Perkins said he had another
gun in the van. The officers agreed with each other that they would fire if Mr.
Perkins attempted to pick up the gun on the ground.
A third officer arrived who had heard the incident developing over the radio and
joined Clark and Walsh. Sergeant Jerry Cioeta arrived and walked up to the three
officers behind the patrol car. The sergeant instructed the third officer to get a
beanbag shotgun from her patrol car. The sergeant observed a black object in the
grass three or four feet from where Mr. Perkins was sitting facing out of the side
door of his van. Mr. Perkins bent down and reached out toward the black object.
Officer Clark fired one round from his rifle and Officer Walsh, who had begun to
pull the trigger of his pistol, desisted, hearing the round from the rifle.
Mr. Perkins jumped to a nearby tree and hid behind it, yelling at officers to shoot
him. It was not clear to the officers or the sergeant whether the rifle round had hit
Mr. Perkins or whether he had retrieved his weapon from the ground. He then
reached down to the grass for the black object again and Officers Clark and Walsh
both fired rapidly. Officer Clark fired another three rounds from his AR-15 rifle
and Officer Walsh fired his service pistol six times. They wounded Mr. Perkins
in the abdomen and the right elbow. The shooting occurred approximately nine
minutes after the officers first made contact with Mr. Perkins. The officers and
Sgt. Cioeta spent this time retrieving a beanbag shotgun from a patrol vehicle,
calling for additional back up including another rifle operator and another ECIT
officer, observing the actions of Mr. Perkins and considering what level of threat
he posed.
Mr. Perkins moved out of sight behind the front of the van. The sergeant called
for the Special Emergency Response Team (SERT) and the Crisis Negotiation
Team to come to the scene. Officer Clark yelled to Mr. Perkins who said he was
hurt. He complied with commands to come out in the street with his hands up.
Mr. Perkins followed other commands and was handcuffed without further

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 incident. Officers observed a black metal pistol lying on the grass by the open
side door of the van.
Medical assistance had been staged nearby, but before the ambulance arrived, the
sergeant observed Mr. Perkins’ wounds in his abdomen and elbow. He put a
tourniquet around Mr. Perkins’ wounded arm.
Mr. Perkins made statements in the ambulance on the way to the hospital that he
had a “BB gun” that looked like a real gun and pointed it at the police when they
opened the door to his van so that they would go away. He said he later threw a
pill bottle and the gun out of the van so that the police would know it was a fake
gun, but also told the officers to “go ahead and shoot” him. He stated that he
realized that when he picked up the gun the police would shoot him and that is
what he desired at the time.
Mr. Perkins recovered from his wounds. The object Mr. Perkins threw was later
identified as a BB gun made to replicate a handgun.
The matter was presented to a grand jury, which found that the use of deadly force
was justified under criminal law.
The Police Review Board found that the shooting was within policy and that all
post-incident procedures were appropriate.

Timeline of Investigation and Review
2/9/2017

Date of Incident

3/15/2017

Grand Jury concluded

4/3/2017

Training Division Review completed

3/21/2017

Internal Affairs Investigation completed

5/11/2017

Commander’s Findings completed

6/21/2017

Police Review Board

6/27/2017

Case Closed

77

 OIR Group Analysis
Consideration of Tactical Options
When officers opened fire on Mr. Perkins, it was the result of a decision based on
the accumulated evidence that Perkins had thrown what resembled a gun on the
ground, that he asserted it was a gun, that he was belligerent and taunted them to
kill him yet tried to get them to leave cover and approach him. The officers had a
conversation in which they had concluded that, if Mr. Perkins tried to pick up the
presumed thrown gun, they would shoot to defend themselves. They later stated
that they even considered the safety to possible bystanders provided by the
backstop area behind Mr. Perkins.
Both the Training Analysis and the Police Review Board concluded that the
officers’ use of force was justified under the circumstances. Training, however,
added the following:
Mr. Perkins… due to his suicidal mind set and his unwillingness or
inability to de-escalate he left the officers with no other option
than to fire their weapons to stop him as a threat when he reached
for the gun.
Unfortunately, Training did not discuss or analyze other alternatives that the
officers might have considered. Indeed, implicit in the officers’ quick though
rational and deliberate process was the consideration of other options. Even
Officer Walsh’s release of pressure on his trigger just after his partner fired his
rifle shows a trained field officer considering options in real time. This makes
sense because there are virtually always other options to consider.
Here, for example neither the Training Division Review nor the Commander’s
Memorandum addressed the following possibilities, including some that look
back to the circumstances that led up to the incident:

78

•

Officers perhaps could have found improved cover using other patrol cars,
ballistic shields or trees in the area. This may in turn have allowed the
officers to delay use of firearms, if only for a very short time.

•

Officers might have considered activating SERT and the Crisis
Negotiation Team and attempted to hold Mr. Perkins in place until a

 negotiating team arrived. The incident documentation does not reflect any
consideration of activating SERT before shots were fired.
•

If dispatch had asked Mr. Perkins whether he had any weapons, officers
might have been better prepared for the scenario they ultimately
encountered.25 Even if less lethal weapons, ballistic shields or other
defensive equipment were not available on scene, this consideration of the
early phase of the incident might stimulate consideration by Bureau
leadership of whether they should be more widely available.

For the Training division to intone the formula of “no alternatives,” especially in
circumstances where officers anticipate encountering a suicidal subject, is
inaccurate and counter-productive. Incidents where persons in mental crisis act
belligerent and attempt to taunt and provoke officers into killing them have
become all too common. They are rightly perceived as potentially dangerous to
peace officers, but they also raise a question fundamental to engagement with
determined subjects: what can officers do to influence the outcome rather than let
the subject determine the outcome? We considered these questions in detail in
our Fourth Report.
Acknowledging that there are always alternative scenarios that are worth
considering, even if it may move the discussion into the realm of the hypothetical,
does not undermine a finding of justifiable use of force. But wrapping up a
Training analysis with “he left the officers no other option than to fire their
weapons” effectively ends any further discussion. It relegates critical incidents
that receive that verdict from the training experts useless for training purposes and
reinforces tactical thinking about inevitable outcomes that discourage innovation
and creativity.
It is important to acknowledge that these officers and their sergeant did make
attempts at de-escalation, including retreating from the van and taking cover;
calling for another ECIT officer and trying to communicate with Mr. Perkins;
retrieving a less lethal weapon; declining to fire upon hearing a partner fire a
round. Training nevertheless implied that these attempts at de-escalation were a
failure because “they were not reciprocated by Mr. Perkins.” This view relegates
de-escalation to just one of a number of techniques that field officers may pull out
of their quiver when circumstances are favorable. It should instead be viewed as
25

While Mr. Perkins was belligerent, uncooperative and hung up abruptly when
questioned about his location during both 911 calls that he made, dispatch operators
possibly had the opportunity to try a new topic and ask him about weapons. It is
impossible to know whether he would have answered the question.

79

 an evolving framework of analysis that helps law enforcement agencies improve.
Every critical incident should be reviewed as a learning opportunity to keep
stimulating that analysis and improving opportunities for effective de-escalation.
RECOMMENDATION 25: The Bureau’s Training Division
should eliminate the phrase “left the officers with no other
option…” from their analyses.

Delay in Locating 911 Caller
Officers encountered a significant delay in locating Mr. Perkins. They discovered
him in a van 45 minutes after he first made a suicidal 911 call. They had been
searching in the general area for 35 minutes. Because he had called 911 from a
cell phone without providing his exact location, officers originally only knew
where he was within a 300-yard radius. This circumstance has become very
common because of the ubiquity of cell phones. Officers are encountering the
extra challenge of finding the caller’s locale because cell phones cannot be traced
as precisely as land lines. Nevertheless, the “pinging” process – triangulating the
location of the cell phone from nearby cell broadcasting towers – can narrow
down the possible locations to a 25-yard radius and significantly shorten the
search process for officers in the field. Initiating this procedure immediately after
the Bureau of Emergency Communications receives any urgent call with an
unknown address would allow dispatchers to guide officers in a more timely and
precise way.
RECOMMENDATION 26: The Police Bureau should work
with the City to evaluate the practicality of procedures that
would require the Bureau of Emergency Communications to
initiate locating technology early in the dispatch/assignment
process so that officers can expend less time searching for
911 callers who raise a credible threat of suicide or other
source of imminent death or injury.

Timeliness of Interviews and Review Process
The investigation and review process were completed well within the 180-day
internal time limit agreed to by the Bureau. The great majority of the process up
to and including the Commander’s review and findings was completed in a
commendably short three months.
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 Both officers who used deadly force in this incident declined to be interviewed by
detectives during the criminal phase of the investigation. Each testified at the
grand jury proceedings. Each was interviewed by Internal Affairs two days after
the incident. We have stated consistently in prior reports that this time lag
between incident and first interview is too long, especially when the Bureau has
had no previous opportunity to obtain a statement from the officers who used
deadly force. It did, however, comply with the Bureau’s standard procedures at
the time of the incident. Since the time of this incident, Portland has enacted a
procedural standard that requires an officer to submit to an internal affairs
interview “as soon as practicable” after an incident. We look forward to reporting
on post shooting procedures that implement this new standard.

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 82

 May 10, 2017 ◦ Terrell Johnson
Just before 7:00 in the evening, a woman called 911 from a MAX platform to
report that an individual later identified as Terrell Johnson had approached her
and her companions as they waited for their train to ask for a cigarette. They told
him “no” and then, “out of nowhere,” he began chasing their 17-year-old neighbor
who had just gotten off the train and stopped to talk to them. They described the
subject as a white man,26 with a hooded sweatshirt and knit cap, who appeared to
be homeless. When the dispatcher asked if the subject had any weapons, the
caller responded that she did not see any.
The young man who was chased off the platform later reported that Mr. Johnson
had pulled a knife on him. He was able to run away from the subject, then called
his father and ran the short distance home, where he retrieved a kitchen knife and
gathered some friends before returning to the area and confronting Mr. Johnson.
They had a brief standoff with their knives drawn and exchanged words before
the boy’s father arrived and, as tempers were cooling, they saw the police arriving
in the area. The young man, his father, and his friends all left abruptly and
returned home without officers even noticing them. Officers only put together
this piece of the story later, when witnesses came forward after the shooting.
Officer Samson Ajir and his brother, a Clackamas County Sheriff’s Deputy,27
picked up the call.28 Both are assigned to Transit Division and regularly work
together as partners. The initial call voiced to Officer Ajir made no mention of
any weapons, but when he read the call on the in-car computer, it said “now
weaps.” Officer Ajir believed this was strange, vague, and somewhat ambiguous
26

Mr. Johnson was in fact biracial, with an African-American mother and white father.

27

Transit Division is staffed by officers from various local law enforcement agencies
throughout Multnomah, Washington, and Clackamas Counties – all the areas serviced by
TriMet.
28

Because officers assigned to Transit Division regularly move between precincts and
jurisdictions, calls are dispatched via text message to a Bureau-issued cell phone. The
text provides a brief summary of the call and the jurisdiction in which it originated.
Officers can then switch to the radio net for that jurisdiction to get further details and
updates on the call. Within the City of Portland or Gresham, officers can get information
on a call via their in-car computer system. In all other cities and county areas serviced by
TriMet, officers must use the radio to voice in their responses because they do not share
the same Computer Assisted Dispatch system.

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 because it is not how information about weapons would normally be
communicated and contained no detail about any particular type of weapon.
Officer Ajir stated he did not have time to request further information about
weapons during the short drive to the location of the call but interpreted the
information to mean that the subject had a weapon of some sort.
A West Linn Police Department officer also assigned to Transit was close by and
attached himself to the call as an assist unit. He was the first to arrive on scene
and was quickly able to identify the subject based on the description provided by
the original caller. He approached Mr. Johnson, who at the time was talking to
another individual, and began questioning him about the alleged threatening
behavior. He asked Mr. Johnson whether he had any weapons, and the subject
told him he had a knife in his pocket. The West Linn officer cautioned him not to
reach for that knife. He asked Mr. Johnson if he could pat him down and take the
knife, and he refused. The officer said Johnson seemed fidgety and kept looking
over his shoulder as if planning to run, so the officer asked him to sit down, but he
refused. The officer planned to wait until Officer Ajir and his partner arrived
before making physical contact with Mr. Johnson.
When Officer Ajir and his brother reached the location, within minutes of the
West Linn officer’s initial contact with Mr. Johnson, the subject took off running
almost as soon as the two exited their patrol car. As he got out of the car, Officer
Ajir heard the West Linn officer say, “warrant,” and saw the West Linn officer
begin to chase the subject. Officer Ajir joined the chase as the Clackamas deputy
went back to the car with the plan to drive ahead and cut off the subject’s path.
The officers did not communicate with each other about this plan, and the West
Linn officer did not tell Officer Ajir that the subject had a knife.
Officer Ajir is a fit and experienced runner, and his plan was to chase the subject
until he was tired and eventually gave up. He ran faster than the West Linn
officer, and quickly got out ahead, without any knowledge of specifically where
his partners were. As the West Linn officer fell behind the chase, he considered
trying to run toward the deputy in the car so he could ride with him but then he
saw the foot chase change course and head into an area of tracks where a car
would not be able to go, so he continued running in that direction. He reported
seeing Officer Ajir catching up to the subject, close enough to grab hold of him,
but then lost sight of them. When he caught up again, he saw that Mr. Johnson
had turned and was facing Officer Ajir with a knife in his hand. The West Linn
officer was still 60-70 feet away. The Clackamas deputy was navigating the
terrain and monitoring the subject’s course, trying to find a way to cut him off.
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 He could see the subject and the pursuing officers, but had an obstructed view and
was approximately 150 feet away when he heard the first gunshot. He quickly got
out of his car and ran to assist.
The chase crossed uneven terrain and required Officer Ajir to hop over the tracks
and curbs. As Mr. Johnson slowed to a stop, Officer Ajir closed the distance,
thinking that he was going to surrender. He was surprised when the subject
turned around with a knife in his hand, slashing at the officer.29 He unholstered
his weapon as he tried to back up to distance himself from the subject, who at the
time was only around seven or eight feet from him. As he moved back, his heel
hit a curb and he started to fall backward. According to Officer Ajir’s statement,
he fired one shot as he was falling, and the subject continued to slash out and
move toward him. From the ground,30 Officer Ajir fired three more rounds at Mr.
Johnson, who fell forward.
This incident, including the shooting, was captured on TriMet video, which is
generally consistent with officers’ accounts.
Mr. Johnson fell on top of the knife, and officers were concerned he may try to
use it as they approached to handcuff him. They called for a code-3 medical
response, and then requested a ballistic shield to use as a barrier when they
contacted him. Within minutes, other arriving officers had secured Mr. Johnson,
and two Clackamas County deputies were administering emergency first aid until
paramedics arrived. The paramedics declared Mr. Johnson deceased at 7:21,
approximately six minutes after Officer Ajir had broadcast the shooting. He was
struck three times, in the chest, side, and hip or buttocks. The fourth round
appears to have passed through Mr. Johnson’s jacket without striking him and
was not recovered.

29

The knife is what is referred to as a utility knife or box cutter. Officer Ajir recognized
the knife as what he said is referred to on the streets as a “slasher.”
30

Officer Ajir remembered his buttocks hitting the curb, and said he used his left hand
and a rocking motion to quickly push himself back up to his feet, while simultaneously
firing at the subject. The video pretty clearly depicts Officer Ajir being on the ground at
the time he fires all rounds, providing an interesting example of the ways in which
normal human memory may differ from recorded video in significant – but not
necessarily nefarious– ways.

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 Timeline of Investigation and Review
5/10/2017

Date of Incident

6/22/2017

Grand Jury concluded

8/14/2017

Internal Affairs Investigation completed

8/25/2017

Training Division Review completed

10/16/2017

Commander’s Findings completed

12/18/2017

Police Review Board

12/20/2017

Case Closed

OIR Group Analysis
Tactical Issues: Foot Pursuits
When a person runs from officers attempting to detain him, the officers’
instinctive reaction may be to immediately give chase and catch the subject at all
costs. This common scenario, however, creates untenable safety risks to officers,
the public, and subjects being pursued.
The dynamic of most foot pursuits is inherently unsafe for the officer. Some of
the factors are simple ones. For instance, a long foot pursuit can place physical
strains on officers that compromise their effectiveness in various ways. Here,
Officer Ajir’s plan was to chase the subject until he was tired enough to surrender.
After about 200 yards at what he described as a sprint, though, while Mr. Johnson
may have been tired and therefore ready to turn around and fight, the officer was
also “gassed.” It is impossible to know exactly how that may have affected the
officer’s agility in backpedaling over difficult terrain, but fatigue almost certainly
played some factor.
Other potential problems arise from the reality that the subject determines the path
of the pursuit, and can therefore readily establish a tactical advantage through
maneuvers that cause the officer to lose visual contact and become more
susceptible to sudden aggression. Awareness of this danger heightens officer
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 adrenaline and perception of threat in obvious ways – thereby increasing the
likelihood that ambiguous gestures (such as turning or grabbing at a waistband or
carrying an object) will be interpreted as lethal aggression. When it turns out that
the person being chased was simply trying to escape, or was not armed at all, this
gap in perception can have devastating consequences.
It is important for officers and members of the public to remember that the
decision to not engage in a foot pursuit does not equate to letting the “bad guy”
go. Rather, it is an acknowledgment that usually there are safer, smarter ways to
apprehend suspects than chasing them down. As well-regarded policies and
accompanying training emphasize, an officer who is chasing a suspect and
properly communicating can continue to follow without closing the distance
unsafely. Coordinating the response of fellow officers and establishing a
containment are regarded by tactical experts as more sound and effective
approaches.
Guidance to police agencies and their officers on when and how to pursue has
evolved over the years, and many agencies – including PPB – have adopted
comprehensive foot pursuit policies in an attempt to provide guidance to officers
to mitigate these risks. The Bureau foot pursuit policy provides guidance to
officers on the dangers of foot pursuits, factors to consider in deciding whether to
initiate or continue a pursuit, and how to balance officer safety considerations
with the objective of apprehending a subject.
The effectiveness of PPB policy and training on these points was evident in
another incident we discuss in this report, where officers who initially confronted
Mr. Hayes more than an hour before the eventual shooting decided not to pursue
him because of the inherent risks. Here, unfortunately, there were gaps between
the dictates of PPB policy and Officer Ajir’s performance and disparities in the
application or interpretation of the policy by Training and the Bureau reviewers.
Specifically relevant here, the directive states:
Sworn Member Responsibilities (630.15)
a. Once the foot pursuit has been initiated, the pursuing sworn
member should notify BOEC and attempt to broadcast the
following information:
1. The suspect’s direction of travel.
2. Whether the suspect is armed, if known.
3. Number of fleeing suspects.
4. The reason for the pursuit.

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 5. If known, the identification of the suspect, or a physical
description.
b. Generally, the pursuing sworn member should not attempt to
overtake the fleeing suspect but keep the suspect in sight until
sufficient cover is available to take him/her into custody.
The following are techniques to consider:
1. Following and maintaining a safe distance.
2. Paralleling the suspect.
3. Cover/contact pursuits (two sworn members).
4. Following a different route then the suspect (i.e., wide corners).
5. Using Available cover (i.e., parked cars).
c. The primary sworn member should attempt to immediately
coordinate with secondary sworn members to establish a perimeter
in the area to contain the suspect. Secondary sworn members may
assist with the coordination if the primary sworn member is unable
to do so.
Foot Pursuit Restrictions (630.15)
a. … Sworn member should not engage in or continue foot
pursuits in the following circumstances:
1. Armed suspects unless, in extreme circumstances, no other
alternative strategy is feasible and a delay in the apprehension of
the suspect would present a threat of death or serious physical
injury to others.
The Training Division Review and the Commander’s Memorandum both
addressed the foot pursuit, but focused more on the decision to pursue than on the
inherent risk factors and the officer’s responsibilities during the pursuit. Both
documents ignore or mischaracterize some facts in order to minimize those risks.
For example, the Training analysis states that Ajir knew the West Linn officer
was “close behind him” and the Commander’s Memorandum states Ajir knew his
cover officers were “on his heels.” In fact, the West Linn officer was 60 to 70
feet away at the time, and the deputy was at least 150 feet away, with only a
partial view of the subject. Neither was in a position to help Officer Ajir in
immediately defending against Mr. Johnson’s aggression.
Both documents also say that Officer Ajir “maintain[ed] distance or “kept a
buffer” between himself and the subject. While Officer Ajir stated in his
interview and grand jury testimony that he was intending to keep his distance, the
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 reality was that he had closed the distance enough so that when Mr. Johnson
turned to come back towards him, they were only seven or eight feet apart. The
TriMet video supports this statement. The fact that the subject was able to turn
and advance so quickly that Officer Ajir was immediately in fear for his life
suggests there was not an effective buffer between the two as the officer pursued.
Nor did the reviewing documents discuss the lack of any meaningful
communication about the foot pursuit. Officer Ajir broadcast that he was in
pursuit but did not give his location or direction of travel. Rather, he said since he
was in the lead, he counted on the other two involved officers to handle the
broadcasts. Neither of them did. Regardless, PPB policy is clear that the
pursuing sworn member has a responsibility to notify the Bureau of Emergency
Communications and provide specific information about the subject and the
pursuit. Neither the West Linn officer nor the Clackamas deputy share this same
responsibility, as each is trained in and held accountable to the requirements of his
agency’s policies, not PPB directives.
We addressed concerns about the multi-jurisdictional nature of Transit as early as
2010, when we issued a report on the death of James Chasse. In that report, we
noted that because Transit officers are all trained differently and work under
divergent policy expectations, there is a potential that those officers will react
differently in dynamic situations. We recommended then and reiterate now that
The Bureau should work with other agencies to develop a core set of policies and
key tactical training doctrines to promote consistency in the responses of various
protected entities.
RECOMMENDATION 27: The Bureau should identify key
operational and tactical policies and training doctrines and
develop a focused training program to provide all Transit
officers an understanding of these core concepts.
Finally, both the Training Division Review and Commander’s Memorandum
discuss the significance of the fact that Mr. Johnson was pumping his arms and
looking straight ahead, not reaching for his pocket or waistband or turning around
to see the officer’s position. The former is consistent with a subject who simply
wants to get away, while the latter movements may be indicative of an intent to
acquire a weapon and attack the officer. However, neither discussed the
significance of the fact that Officer Ajir believed that the subject had some sort of
weapon based on the original call information. PPB policy generally prohibits
foot pursuits of armed subjects except in “extreme circumstances” that do not
seem to have been present here.

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 Consistent with the findings of Training and the Commander that Officer Ajir’s
actions were consistent with training and complied with the Foot Pursuit
Directive, the Police Review Board did not have any substantive discussion of the
issues surrounding this foot pursuit and made no contrary determination.
Here, for formal findings of the Police Review Board, the Foot Pursuit Directive
was grouped into an “Area of Review” that included the Application of Deadly
Force, creating the implication that if the foot pursuit is found out of policy, then
the deadly force may likewise be out of policy. While it may be true that a
tactically unwise foot pursuit may lead to a use of force that was not, in the
strictest sense, necessary or unavoidable, an out-of-policy pursuit does not
necessarily mean the force was out of policy. Tying the two findings together
may lead to a less-than-rigorous review of the foot pursuit in an effort to avoid a
conclusion that the force was out of policy. In deadly force cases involving a foot
pursuit, the pursuit should be reviewed independently.
RECOMMENDATION 28: In officer-involved shootings
and other critical incidents involving a foot pursuit, Internal
Affairs, Commanders, and the Police Review Board should
consider whether officers’ actions complied with the Foot
Pursuit Directive as an Area of Review separate from the
review of the application of deadly force.

Communications Issues
Information about Possible Weapons
The initial 911 caller indicated that she did not see a weapon on the subject. The
West Linn officer knew before Officer Ajir and his brother arrived on scene that
the subject had a knife in his pocket but did not communicate that information
before Mr. Johnson ran and the officers pursued. The initial call voiced to Officer
Ajir made no mention of any weapons, but when he read the call on the in-car
computer, it said “now weaps.” Officer Ajir believed this was vague and
ambiguous but said he did not have time to request further information about
weapons during the short drive to the location of the call. Nonetheless, he
interpreted the information to mean that the subject had a weapon.
The Training Division Review critiqued the officer’s assessment and suggested he
should have contacted dispatch to clarify why the call listed “now weaps.”
Though the Training analysis concluded this was not the most effective tactic, the
90

 Commander’s Memorandum neglected to discuss this issue. There was no formal
finding on this matter from the Police Review Board.

Dispatching Transit Division Officers
There is no single dispatch system for Transit Division officers. The Division is
divided into districts, and officers are responsible for calls relating to the rail and
bus lines in all areas serviced by TriMet within each district, throughout Portland
and the surrounding cities and county areas. An officer in Transit South, for
example, will respond to calls from dispatchers in Portland, Milwaukie,
Clackamas County, and Oregon City, among others. All of these dispatch
systems operate independently of each other, so that a Portland dispatcher does
not necessarily know when a Transit officer handling a call in Clackamas will be
available for a new call.
Calls to Transit officers are dispatched via text message to a Bureau-issued cell
phone. The text provides a brief summary of the call and the jurisdiction in which
it originated. If available, a Transit officer will respond and notify dispatch to
assign the call to him or her. The officers then switch to the radio net for that
jurisdiction to get further details and updates on the call. Within the City of
Portland or Gresham, officers can get information on a call via their in-car
computer system. In all other cities and county areas serviced by TriMet, officers
must use the radio to voice in their responses because they do not share the same
Computer Assisted Dispatch system.
There are significant technological challenges in managing a dispatch system over
an area as large as that covered by Transit Division, involving officers from many
different jurisdictions. There may be no better solution than the current use of
cell phones to alert officers to Transit-related calls. However, the lack of
uniformity in how calls are dispatched and how individual officers respond can
and does create difficulties.
For example, here Officer Ajir and his partner did not know the West Linn officer
had assigned himself to the call, and had no idea he had arrived and was talking to
the subject. The West Linn officer knew that the other officers were on the way
but did not communicate with them regarding his status. The West Linn officer
involved in this incident is not subject to formal review by the Bureau
administrative investigation, and the Training analysis did not evaluate this
communications issue. Despite the Bureau’s lack of formal authority over this
officer, though, the issue could have and should have been flagged as a subject for
debriefing of this officer and training for all Transit Division officers.

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 RECOMMENDATION 29: The Bureau should ensure that
all Transit Division officers, regardless of which agency they
work for, are included in debriefings to address any potential
performance issues and are adequately trained in the
importance of effective communications.
RECOMMENDATION 30: The Training Division should
formally consider and critique the tactical decision making
of all officers involved in a joint operation with Bureau
officers, regardless of which agency they work for, so that
these issues can be included in post-incident debriefings.

Family Members Working as Partners
Officer Ajir regularly works in a two-person car partnered with his brother, a
Clackamas County deputy. This is by choice and by design, as the brothers each
sought assignments in Transit Division so they could work together. While there
is nothing about the conduct of either brother in this case to suggest a problem
with this arrangement, there are significant potential disadvantages to having
family members work together in such close circumstances. Close family
relationships (including spouses, parents, children, or siblings) can create
conflicting loyalties and may impact officers’ ability to function independent of
their unique emotional ties. In addition, their testimony also may be vulnerable to
attempts at impeachment based on an inference of bias due to familial ties. For
these reasons, many agencies restrict the ability of family members to work on the
same assignment. The Bureau currently has no such directive, either for its own
officers or for those working assignments (such as Transit) where they regularly
partner with officers from outside agencies.
RECOMMENDATION 31: The Bureau should prohibit the
assignment of close family members to the same patrol team
or specialized assignment.

Timing of Interviews
Officer Ajir declined to provide a voluntary statement to Detectives after the
shooting. Following advice from the Multnomah County District Attorney,
Internal Affairs investigators did not interview Officer Ajir until June 23 –
following the conclusion of grand jury proceedings and nearly a month and a half
92

 after the incident. The officer had testified to the grand jury the day before his
interview, but had otherwise not provided a substantive statement about his role in
the incident, his observations, or his state of mind, meaning that the Bureau
waited 44 days to hear from the only living witness to the event his rationale for
decisions he made prior to the use of deadly force and the decision to fire his
weapon.
The District Attorney took the position that compelling officers to provide
statements in an administrative interview would immunize those officers against
criminal liability, effectively preventing an officer from being prosecuted for his
or her role in an officer-involved shooting. The Director of the Independent
Police Review challenged this legal conclusion, and the City ultimately pressed
ahead with its decision to require officers to submit to administrative interviews
shortly after an incident. As frequent advocates of the elimination of what was
referred to as the “48-hour rule,” we welcome this change and look forward to
reviewing more timely interviews in future investigations.

93

 94

 SECTION TWO

Common Themes
and Issues

Police Review Board Issues
Formal Review of Tactical Decision Making
In our Fifth Report, we recommended that the Bureau modify its protocols so that
the review of every officer-involved shooting includes an explicit review of preshooting tactical decision making, and express findings from the Commander and
Police Review Board on whether officers’ tactical performance was consistent
with training and policy. We noted that this change could be made consistent
with the way the Bureau has added review of “Operational Planning and
Supervision” and “Post Shooting Procedures” to its formal review mechanism.
While we appreciate that the Bureau has recognized the need to assess tactics
leading up to a deadly force incident longer than many other agencies, and
specifically tasks the Training Division to identify and address any lapses in
tactical decision making, the reviewing commanders and the Police Review Board
should focus more consistently on these issues.
For example, in cases reviewed for this report, we found concerns about the way
the review process handled issues surrounding a foot pursuit (Terrell Johnson);
officers’ decision to separate and leave one officer alone with a subject (Ellis and
Terrell Johnson); concerns about cover and concealment (Hayes, Liffel, and
Bucher); the ways in which officers could have better controlled the pace of an

95

 incident (Hayes and Perkins) and more clearly communicated with a subject
(Hayes).
We have repeatedly discussed the ways in which tactical decisions that keep
officers safe also reduce the likelihood that officers will find themselves in a
position where they feel the need to use deadly force. We know that the Bureau
embraces this principle through its training, planning, and expectations for officer
performance, but its review process does not always reflect this emphasis. We
therefore reiterate the recommendation we made in our last report – that the
Bureau should add a separate area of review for pre-shooting tactical decision
making to its administrative investigations of officer-involved shootings and
require both the reviewing Commander and the Police Review Board to make a
finding on the appropriateness of tactics leading up to every incident.31
RECOMMENDATION 32: The Bureau should ensure that
the administrative investigation of every officer-involved
shooting includes an explicit review of pre-shooting tactical
decision making and require express findings from the
Commander and Police Review Board on whether officers’
tactical performance was consistent with training and policy.
Similarly, when the training Division identifies officers’ actions as being anything
other than “sound and effective,”32 the Review Board has not always addressed
these potential concerns. For example, following the shooting of Mr. Davis, the
Training analysis identified two tactics or methods that were not “most effective,”
but there was no documentation to suggest that the Police Review Board
considered these or developed any plan to address the tactical performance issue.
To be most effective, the Board should formally discuss each of these training
concerns.

31

We acknowledge that all of the incidents discussed in this report pre-date the release of
our last report but note that in the one Police Review Board hearing we attended
(covering an incident that occurred since the time of our last report), tactical decision
making was not a formal part of the analysis.
32

Training employs a four-part rating scale in which officers’ actions are deemed to be:
(1) “not consistent with training or create an unnecessary or serious risk;” (2) “generally
acceptable but create identifiable risks;” (3) “consistent with training, but are not the most
effective method or tactic;” or (4) “demonstrate sound and effective tactics.”

96

 RECOMMENDATION 33: The Police Review Board
should expressly consider all actions rated by the Training
Division to be anything other than “sound and effective” and
should develop an action plan to address these issues.

Consideration of Systemic Recommendations
We have noted throughout this report valuable recommendations made by
Training or a reviewing Commander that did not find their way into any formal
findings by the Police Review Board or, ultimately, the Chief.
For example:
•

In its review of the incident involving Mr. Davis, Training expressed
concerns about training gaps raised by that incident and made several
recommendations emphasizing scenario-based training and modifying the
content of firearms and defensive tactics training.

•

Following the shooting of Mr. Ellis, the reviewing Commander
recommended that Training develop a lesson plan based on this incident to
discuss control tactics and contact and cover techniques. The Commander
also recommended that Training regularly include defensive tactics and
ground fighting skills during annual in-service training.

•

Following the shooting of Michael Johnson, the Training Division
recommended that the Bureau provide supervisory training to all officers
on sergeants’ promotional lists, consider reviewing the SERT directive on
mandatory activation, and issue training updates on the use of ballistic
helmets.
RECOMMENDATION 34: The Bureau should develop
protocols to ensure that any recommendations made by the
Training Division or the reviewing Commander are
considered by both the Police Review Board and the Chief.
RECOMMENDATION 35: The Chief should formally
accept or reject any systemic recommendations made by the
Police Review Board, and for those recommendations
accepted, should direct a plan to ensure they are fully
implemented in a timely way.

97

 Training for Police Review Board Members
A critical aspect of Portland’s officer-involved shooting review process is the role
to be played by the Police Review Board. In that forum, members of the Board
who have had an opportunity to review the investigative file and the Bureau’s
initial analysis are able to meet and discuss issues arising from the incident. The
Board is entrusted with making recommendations about whether the use of deadly
force was within policy and the propriety of post-incident conduct, including the
provision of medical attention to injured subjects. We recommend above (and in
prior reports) that the Police Review Board should make determinations regarding
the propriety of tactical decision making leading up to the use of deadly force and
formally consider any individual or systemic recommendations advanced by
either the Training Division or the Commander.
What makes Portland’s Review Board relatively unique among internal review
mechanisms of police agencies is that it includes members of the public. Because
we have recommended an increased role for the Review Board in the way it
holistically considers incidents, it is important for the City to consider ways to
ensure that Board members (particularly the civilian members) are prepared for
this role.
The Bureau and the Independent Police Review division facilitate fairly extensive
training for community member volunteers who serve on the Citizen Review
Committee and the Police Review Board. The 40-hour training (only some of
which is relevant specifically to Police Review Board issues) covers topics such
as types of force, the use of force policy, the action-reaction principle, how to
prepare for a Review Board hearing, and includes some scenario-based training.
This training is essential but may not be sufficient. Because police practices have
become increasingly complex, and the skills needed to read a police investigative
file and identify issues with the investigation and performance of involved
officers are relatively esoteric, we think it is critical for the community member
volunteers to be trained in these tasks. In addition, it would be helpful
periodically (at least annually) to have all Review Board members involved in
joint training to work on strategies so that the expertise and experience of Bureau
members and the important outside perspective of civilian members are combined
in a productive and healthy discussion of the issues arising from these incidents.
This additional training that we envision for the Review Board should not be a
Bureau training initiative. It should be independently facilitated and involve a
98

 session with only civilian members of the Board that focused on issue spotting
and general police practices followed by a session with the entire Board. The
training should be scenario-based and independently facilitated.
RECOMMENDATION 36: The City should develop
additional training components for its Police Review Board
to ensure members are sufficiently prepared for the task of
identifying investigative and performance issues associated
with their review of critical incidents.

Tactical Retreat
In three of the nine cases we reviewed in this report – Davis, Ellis, and Terrell
Johnson – officers fell while backing away from individuals who were advancing
on them with potentially deadly weapons. In all three cases, the stumble or fall
while backpedaling put the officers in a position of disadvantage as the subjects
continued to advance. In the Davis case, the tactical disadvantage the officer
found himself in after he stumbled likely contributed to his decision to use deadly
force. In Ellis, the fall caused the partner officer to break his wrist, allowed the
subject to stab the officer, and made further retreat impossible. And in the
incident involving Terrell Johnson, the officer tripped over a curb and fell
backward, then fired his weapon from his position on the ground because he was
unable to further retreat from the subject, who continued to move toward him with
a knife.
In its review of the Ellis shooting, the Training Division recommended
reinforcement through training of the tactic of moving “off line” rather than
backpedaling when attempting to avoid a sudden attack. The “off line” technique
is a sideways move that avoids the direct line of attack and reduces the likelihood
of the officer stumbling or falling. Some trainers also teach a side step approach
that increases distance, allows the officer to maintain visual contact with the
individual as well as assess his or her direction of travel, while also remaining
more surefooted. The reviewing commander in Ellis concurred with Training’s
recommendation and emphasized that the Training Division should discourage
backpedaling and teach dynamic lateral movement techniques in its course of
instruction on tactical defensive maneuvers.
It is unclear whether Training followed up on its own recommendation, but there
is no record of it being addressed, let alone formally adopted, by the Police

99

 Review Board or advanced to the Chief. To the extent it has not incorporated an
emphasis on alternative techniques for backing away from an armed, advancing
subject in its tactical maneuvers classes, Training should adjust its curriculum to
adopt its own 2015 recommendation.
RECOMMENDATION 37: The Training Division should
examine and adjust its curriculum on tactical defensive
maneuvers to include an emphasis on lateral movement
techniques that allow officers to move away from armed,
advancing subjects while minimizing the chance of
stumbling or falling.
Further, it is notable that the Training analysis of the Terrell Johnson incident did
not include any reference to specific training on defensive maneuvering
techniques that could minimize the risk of falling, despite the fact that the
shooting officer was put at such a tactical disadvantage as a result of tripping
while backpedaling, and the fact that this had been an issue identified by the
Training Bureau in two other relatively recent incidents. The Johnson shooting
occurred nearly two years after the Ellis incident and three years after Davis.
While the circumstances in each were somewhat different, the basic scenario in
each shared similarities that should draw the attention of Bureau managers and
trainers. Informally, there is some indication that the Training Division does take
note of such similar fact patterns and includes lessons learned as it develops new
training scenarios and curricula for in-service training. Recent changes to
Training Division practices will result in this effort becoming more formalized.
A critical incident shines a spotlight on Bureau practices and procedures and
provides an opportunity to examine training and performance issues in a
meaningful way. Proactive supervisors and executives can and should look
beyond the facts of a single incident and think more broadly about other recent
incidents to identify patterns and craft possible solutions. Many incidents –
critical and non-critical – within the experience or knowledge of supervisors and
executives may involve tactical problems or officer safety issues relevant to such
patterns. The Bureau should seek ways to encourage and incentivize its members
to take initiative and consider critical incidents in this way.
RECOMMENDATION 38: The Bureau should encourage
its managers and trainers to examine critical incidents more
broadly, looking beyond a single incident to identify
similarities and patterns among all recent incidents.
100

 Officers Involved in Multiple Shootings
Two of the officers involved as shooters in cases we review in this report –
Officers Corno and Hearst – have been involved as shooters in cases we reviewed
in prior reports. We have twice previously addressed a similar issue in our Third
and Fourth Reports (November 2014 and January 2016). Indeed, Officer Corno's
prior two shootings were the specific subject of discussion in our Third Report.
We recommended in both prior reports that when reviewing an officer-involved
shooting, the Training Division Review and the Police Review Board should
examine any prior shootings by involved officers to consider whether there are
significant parallels between the officer’s tactical decision making in the
incidents. We noted in both reports:
Every incident is different in its details and in the precise decisions
that an officer makes based on those details. Nevertheless, officerinvolved shootings are revealing events that show how the Bureau
as a whole and its individual officers operate under high-risk
conditions in the field. In this regard, it is appropriate and
necessary to consider whether two shootings involving the same
shooter officer reveal any patterns or parallels that could help
inform corrective action or other reforms or remediation.
The fact that an officer has engaged in multiple shootings does not necessarily
point to a problem or concern, but given the high stakes involved in a use of
deadly force, it is a fact that should be considered and evaluated as part of a
thorough review. Therefore, we reiterate verbatim the recommendations we made
in our January 2016 report (where they were numbered Recommendations 29 and
30):
RECOMMENDATION 39: When an officer uses deadly
force, the Bureau’s review of that incident – by the Training
Division, Commander, and Police Review Board – should
consider any prior uses of deadly force and evaluate whether
there are significant parallels between the officer’s tactical
decision making in the incidents.

101

 RECOMMENDATION 40: When an officer has been
involved in more than one use of deadly force the Bureau
should engage that officer in a command-level debrief of the
incidents to help both the Bureau and the officer identify any
patterns or parallels between the multiple events that should
be addressed through training or other corrective action.
In its response to our 2014 report, the Bureau indicated that because the Review
Board’s primary purpose is to provide a recommendation to the Chief whether or
not the member’s use of force was within policies, it would not be appropriate to
discuss prior shootings until the Board evaluated the present case on its own
merits. An officer’s prior shooting history would only be provided if the Board
reaches a finding that an officer’s conduct was out of policy.
Interestingly, the investigative file provided to the Review Board routinely
contains the entire criminal history of any individual shot by an officer, without
concern for its potential relevance. More significantly, and consistent with our
themes in recent reports, the Review Board should be more expansively
considering the entire incident, rather than merely whether an officer’s actions
were within policy. And as the Bureau itself has recognized, a finding that an
officer’s use of deadly force is in policy does not preclude debriefing or other
remedial measures intended to address tactical decision making or other
performance. While not presumptive, a careful analysis of the instant shooting in
light of the prior shooting(s), might identify a pattern of conduct that justifies
more tailored training or even reassignment of the officer.
It is fact that most police officers never use deadly force in their careers and only
the smallest percentage of officers are involved in multiple shootings. To keep
any prior history from the Review Board necessarily precludes further discussion
of remediation where the shooting is found to be in policy. As a result, the
Review Board is incapable of considering any possible pattern of performance
issues presented when an officer has two, three or even more prior shootings. We
reiterate the Recommendations made four years ago and urge the Bureau to
reconsider their position.

102

 Timeliness of Investigations
The settlement agreement between the City of Portland and the Department of
Justice was finalized and accepted by the federal judge in August 2014. The
settlement agreement established, among other things, a 180-day time limit for the
Bureau to complete all internal investigations and review processes following an
officer-involved shooting. The Bureau complied with this deadline in all but two
of the nine incidents we review in this report (and one of those was overdue by
just eight days). The table below includes two additional cases commenced after
the implementation of the settlement agreement (discussed in our previous report)
and shows that investigators completed 11 out of 13 within the 180-day time
limit.
In the one significantly overdue case covered in this report – the incident
involving Terrell Johnson on May 10, 2017 – a number of factors were at play.
The Detectives’ investigation took six weeks longer than its allotted time, largely
because of the coordination with TriMet over a sizeable number of videos from
various trains and platforms that had to be gathered, copied, and reviewed. This
likewise set the Internal Affairs investigation and Training Division Review back
a bit, as did complications over the timing of the interview of the involved officer
as a result of the District Attorney’s intervention (as covered in our individual
discussion of the Terrell Johnson case, above). Finally, the case was delayed in
getting to the Police Review Board, presumably because of the Thanksgiving
holiday. These factors were principally outside of the Bureau’s control, and the
fact that the remaining eight cases were completed within the 180-day timeframe
demonstrates that this case was an anomaly and not a cause for great concern.33
The following table depicts all of the incidents that have occurred since the
Bureau’s agreement with the DOJ to complete its investigation and review
process within 180 days, plus the incident involving Mr. Davis, which occurred
just prior to finalization of the agreement. The shaded rows are the officerinvolved shootings covered in this report.

33

However, as discussed in detail in Healy, a potential greater cause for concern is the
decision not to interview identified witnesses so that the case can be timely completed.
Even though in Healy the Bureau had an additional fifty days under the DOJ agreement
to complete the investigation, it chose not to interview witnesses who had been identified
as having potential evidentiary value. The thoroughness of investigations cannot be
sacrificed to meet an internal deadline.

103

 Timing to Completion of Investigation and Review
Time to
Case
Closure

Subject’s Name

Date of
Incident

Terrell Johnson

5/10/2017

224 days

Don Perkins

2/9/2017

138 days

Quanice Hayes

2/9/2017

144 days

Steven Liffel

12/5/2016

172 days

Timothy Bucher

5/24/2016

150 days

Michael Johnson

11/6/2015

160 days

David Ellis

7/5/2015

141 days

Alan Bellew

6/28/2015

143 days*

Michael Harrison

5/17/2015

116 days*

Christopher Healy

3/22/2015

140 days

Ryan Sudlow

2/17/2015

321 days*

Denoris McClendon

9/1/2014

163 days*

Nicholas Davis

6/12/2014

188 days

* These times are calculated based on the date of Review Board hearing, per our practice in prior
reports. Because the DOJ deadlines are based on the date the case was formally closed, the newer
cases use this date, which includes time for the Review Board’s recommendations to be sent to
and considered by the Chief, after which the administrative case can be “closed” via official notice
to the reviewed members.

104

 SECTION THREE

Recommendations

1

When a legal issue arises regarding the Fourth Amendment, the
Training Division should consult with an attorney with a legal
background in Constitutional jurisprudence.

2

In evaluating post-shooting performance, the Training Division
Review should evaluate whether there were alternative strategies
that on-scene officers could have used to render medical aid more
quickly.

3

The Bureau should not place detailed criminal histories at the
beginning of its detective file, to emphasize that the facts of the
incident are the appropriate and primary focus of the investigation.

4

The Bureau should prepare and include in the investigative file a
time line setting out relevant events from the initiation of the call for
service or initial police contact to the time paramedics initiate
evaluation of the person shot.

5

The Bureau should devise directives requiring officers to accurately
communicate when they are on-scene at a dispatched call.

6

When an officer-involved shooting reveals statements by officers
referencing a disregarded tactical principle such as the 21-foot rule,
the Bureau should debrief the officer regarding its preferable tactical
philosophy.

7

The Training Division should continue to instruct Bureau supervisors
on the directives required during the management of a critical
incident.

8

The Bureau should use IPR’s subpoena authority when necessary to
achieve cooperation from witnesses.

105

 9

Internal Affairs should ensure that all reasonable efforts are made to
interview identified witnesses even if doing so might impact the
deadline for completion of the investigation.

10 In officer-involved shooting investigations, the Bureau should video
record interviews of involved and witness officers.

11 When a witness objects to the recording of an interview or recording
the interview proves impracticable, the investigative reports should
provide an explanation.

12 The Training Division Review, Commander’s Memorandum, and
internal review process should identify any tactical decision making
that results in partners being separated and required to detain
subjects alone.

13 The Bureau should adopt a policy or protocol prohibiting a member
who was even minimally involved in a critical incident from being part
of the investigative team.

14 The Training Division should prepare briefings and/or a Training
Bulletin to remind officers and supervisors about the usefulness of
ballistic helmets in tactical incidents and should include this
information in the curriculum for its critical incident training.

15 The Bureau should initiate a dialogue with the Medical Examiner
regarding the potential legal and accountability implications of a
finding that a use of deadly force by police officers constitutes a
suicide.

16 The Bureau should reinstate its prior “cover fire” policy expressly in
the Directives including the “use with extreme caution” language.

17 The Bureau should ensure that its training message and any written
protocols concerning the capabilities of its armored vehicles to
provide cover against a variety of weapons is clear, consistent and
fact-based.

106

 18 The Bureau should develop specific policy that instructs sergeants
on the need to maintain their supervisory perspective and avoid
tactical involvement in incidents when officers are available to
perform those roles and should hold supervisors accountable for
violating those directives.

19 Whenever a supervisor becomes tactically involved in a deadly force
situation, the Commander’s Memorandum, the Training Analysis,
and the Review Board should all opine on whether such involvement
was consistent with Bureau directives.

20 The Bureau should continue to use surveillance footage of Bureau
operations for training purposes but should develop handling
procedures for recently recorded videos that ensure investigators
have interviewed Bureau witnesses about the incident before videos
are shown.

21 The Bureau should evaluate the practicality of streamlining and
standardizing the incident commander’s decision factors for
activating SERT.

22 All of the Bureau’s reviewers – Training, Commander, and Police
Review Board – should consider all contributing causes in their
analysis of a delay in providing medical care.

23 The Training Division, Internal Affairs, and Commanders should
identify, analyze and assess all of the tactical considerations
surrounding a given incident, including the effectiveness of particular
commands and warnings officers gave to the subject.

24 The Bureau and Police Review Board should ensure that officerinvolved shooting reviews do not begin and end with a citation to the
action-reaction principle but must critically assess other tactical
options that might have driven a different result.

25 The Bureau’s Training Division should eliminate the phrase “left the
officers with no other option…” from their analyses.

107

 26 The Police Bureau should work with the City to evaluate the
practicality of procedures that would require the Bureau of
Emergency Communications to initiate locating technology early in
the dispatch/assignment process so that officers can expend less
time searching for 911 callers who raise a credible threat of suicide
or other source of imminent death or injury.

27 The Bureau should identify key operational and tactical policies and
training doctrines and develop a focused training program to provide
all Transit officers an understanding of these core concepts.

28 In officer-involved shootings and other critical incidents involving a
foot pursuit, Internal Affairs, Commanders, and the Police Review
Board should consider whether officers’ actions complied with the
Foot Pursuit Directive as an Area of Review separate from the
review of the application of deadly force.

29 The Bureau should ensure that all Transit Division officers,
regardless of which agency they work for, are included in debriefings
to address any potential performance issues and are adequately
trained in the importance of effective communications.

30 The Training Division should formally consider and critique the
tactical decision making of all officers involved in a joint operation
with Bureau officers, regardless of which agency they work for, so
that these issues can be included in post-incident debriefings.

31 The Bureau should prohibit the assignment of close family members
to the same patrol team or specialized assignment.

32 The Bureau should ensure that the administrative investigation of
every officer-involved shooting includes an explicit review of preshooting tactical decision making and require express findings from
the Commander and Police Review Board on whether officers’
tactical performance was consistent with training and policy.

33 The Police Review Board should expressly consider all actions rated
by the Training Division to be anything other than “sound and
effective” and should develop an action plan to address these issues.

108

 34 The Bureau should develop protocols to ensure that any
recommendations made by the Training Division or the reviewing
Commander are considered by both the Police Review Board and
the Chief.

35 The Chief should formally accept or reject any systemic
recommendations made by the Police Review Board, and for those
recommendations accepted, should direct a plan to ensure they are
fully implemented in a timely way.

36 The City should develop additional training components for its Police
Review Board to ensure members are sufficiently prepared for the
task of identifying investigative and performance issues associated
with their review of critical incidents.

37 The Training Division should examine and adjust its curriculum on
tactical defensive maneuvers to include an emphasis on lateral
movement techniques that allow officers to move away from armed,
advancing subjects while minimizing the chance of stumbling or
falling.

38 The Bureau should encourage its managers and trainers to examine
critical incidents more broadly, looking beyond a single incident to
identify similarities and patterns among all recent incidents.

39 When an officer uses deadly force, the Bureau’s review of that
incident – by the Training Division, Commander, and Police Review
Board – should consider any prior uses of deadly force and evaluate
whether there are significant parallels between the officer’s tactical
decision making in the incidents.

40 When an officer has been involved in more than one use of deadly
force the Bureau should engage that officer in a command-level
debrief of the incidents to help both the Bureau and the officer
identify any patterns or parallels between the multiple events that
should be addressed through training or other corrective action.

109

  Appendix

  Table of Critical Incidents Reviewed by OIR Group
2004 – 2017

Subject’s
name

Date

# of
# of
involved/ rounds
shooting fired
officers

Officers’
Hit/
weapon(s) nonhit

Fatal/
non-fatal

Subject
weapon?

Subject’s
Race

Mental
health
issues

Officer(s)
disciplined?

James Jahar
Perez
Marcello Vaida

3/28/04

1

3

9mm

Hit

Fatal

Unarmed

No

No

10/12/05

2

38

9mm

Hit

Non-fatal

Handgun

No

No

Raymond
Gwerder
Dennis Lamar
Young

11/4/05

1

1

AR-15

Hit

Fatal

Handgun

AfricanAmerican
AfricanAmerican
White

Yes

No

1/3/06

1

2

9mm

Hit

Fatal

White

No

Yes

Timothy Grant

3/20/06

1

N/A

N/A

N/A

White

No

No

Jerry Goins
Scott Suran
James Chasse

7/19/06
8/28/06
9/17/06

1
1
3

4
2
N/A

9mm
AR-15
N/A

Hit
Hit
N/A

Handgun
None
N/A

White
White
White

Yes
No
Yes

No
No
No

David Earl
Hughes
Dupree Carter

11/12/06

3

15

Hit

None

White

Yes

No

12/28/06

1

2

9mm (2);
AR-15 (1)
9mm

In-custody
death
b
Fatal
Non-fatal
In-custody
death
Fatal

None (subject
drove vehicle
at shooting
officer)
N/A

No

No

Steven Bolen
Leslie Stewart

5/22/07
8/20/07

2
1

10
1

No
No

No
No

Jeffrey Turpin
Jason Spoor

10/5/07
5/13/08

1
2

Yes
Yes

No
No

Derek Coady

5/15/08

Handgun

AfricanAmerican
White
AfricanAmerican
White
AfricanAmerican
White

Yes

No

Osmar
LovainaBermudez
Aaron
Campbell
Jack Dale
Collins

Non-fatal

Handgun

9mm; AR-15
AR-15

Nonhit
Hit
Hit

Fatal
Non-fatal

Shotgun
None

4
2

9mm
9mm

Hit
Hit

Fatal
Fatal

Handgun
Handgun

1

2

9m

Fatal

8/24/09

1

3

AR-15

Nonhit
Hit

Non-fatal

Handgun

Latino

No

No

1/29/10

1

1

AR-15

Hit

Fatal

None

Yes

Yes

3/22/10

1

4

9mm

Hit

Fatal

Knife

AfricanAmerican
White

Yes

No

d

a

e

 Table of Critical Incidents Reviewed by OIR Group
2004 – 2017

page 2

Subject’s
name

Date

# of
# of
involved/ rounds
shooting fired
officers

Officers’
Hit/
weapon(s) nonhit

Fatal/
non-fatal

Subject
weapon?

Subject’s
Race

Mental
health
issues

Officer(s)
disciplined?

Keaton Otis

5/12/10

2

19-21

9mm

Hit

Fatal

Handgun

Yes

No

Craig Boehler

11/23/10

1

3

AR-15

Hit

Fatal

No

No

Darrryll
Ferguson

12/17/10

2

20

9mm

Hit

Fatal

White

No

No

Marcus
Lagozzino
Kevin Moffett

12/27/10

1

4

AR-15

Hit

Non-fatal

Handgun and
rifle
Replica
handgun/ BB
gun
Machete

AfricanAmerican
White

White

Yes

No

1/1/11

1

1

9mm

Non-fatal

Handgun

No

1/2/11

2

12

9mm

Fatal

Knife

AfricanAmerican
White

No

Thomas
Higginbotham
Ralph Turner

Nonhit
Hit

Yes

No

3/6/11

2

9mm; AR-15

Nonhit

Non-fatal

Rifle, shotgun,
and handgun

White

Yes

No

William Kyle
Monroe

6/30/11

1

4-5;
then
cover
fire
4

Hit

Non-fatal

None

White

Yes

Yes

Darris
Johnson
Brad Lee
Morgan
Jonah Aaron
Potter

7/9/11

3

N/A

Less-lethal
shotgun
loaded with
lethal
rounds
N/A

N/A

N/A

No

2

5

9mm

Hit

AfricanAmerican
White

No

1/25/12

In-custody
death
Fatal

Yes

No

3/26/12

4

7

9mm (2); M4
(1); M16 (1)

Hit

Non-fatal

White

Yes

No

Juwan
Blackmon
Billy Wayne
Simms

7/17/12

1

1

9mm

Hit

Non-fatal

No

No

7/28/12

1

6

AR-15

Hit

Fatal

AfricanAmerican
White

No

No

f

Replica
handgun
Replica
handgun/ BB
gun
Handgun
Handgun
(unloaded)

 Table of Critical Incidents Reviewed by OIR Group
2004 – 2017

page 3

Subject’s
name

Date

# of
# of
involved/ rounds
shooting fired
officers

Officers’
Hit/
weapon(s) nonhit

Fatal/
non-fatal

Subject
weapon?

Subject’s
Race

Mental
health
issues

Officer(s)
disciplined?

Michael Tate

8/21/12

1

2

9mm

Nonhit

Non-fatal

Latino

Yes

No

Joshua Baker
Merle Hatch

9/29/12
2/17/13

2
3

17
19

9mm; AR-15
9mm (2)
AR-15 (1)

Hit
Hit

Non-fatal
Fatal

White
White

Yes
Yes

No
No

Santiago
Cisneros
Kelly Swoboda

3/4/13

2

22

9mm

Hit

Fatal

None (subject
raised hand
holding cell
phone)
Rifle
None (subject
pretended
telephone
receiver was a
handgun)
Shotgun

Latino

Yes

No

3/12/14

1

4

9mm

Hit

Fatal

Handgun

White

No

No

Paul Ropp

4/16/14

2

15

9mm

Hit

Non-fatal

Rifle

White

No

No

Nicholas Davis

6/12/14

1

2

9mm

Hit

Fatal

Crowbar

White

Yes

No

Denoris
McClendon

9/1/14

1

2

Shotgun

Hit

Non-fatal

AfricanAmerican

Yes

No

Ryan Sudlow

2/17/15

1

1

9mm

Non-fatal

White

No

No

Christopher
Healy
Michael
Harrison
Alan Bellew

3/22/15

1

2

9mm

Nonhit
Hit

Replica
handgun/ BB
gun
None

Fatal

Knife

White

Yes

No

5/17/15

1

7

9mm

Hit

Non-fatal

Knife

White

Yes

No

6/28/15

2

14

9mm

Hit

Fatal

White

No

No

David Ellis

7/5/15

1

1

9mm

Hit

Non-fatal

Replica
handgun/
starter pistol
Knife

White

Yes

No

Michael
Johnson

11/6/15

2

7

M4 rifle

Hit

Fatal

Handgun

White

Yes

No

 Table of Critical Incidents Reviewed by OIR Group
2004 – 2017

page 4

Subject’s
name

Date

# of
# of
involved/ rounds
shooting fired
officers

Officers’
Hit/
weapon(s) nonhit

Fatal/
non-fatal

Subject
weapon?

Subject’s
Race

Mental
health
issues

Officer(s)
disciplined?

Timothy
Bucher
Steven Liffel

5/24/16

2

16

Yes

No

1

White

Yes

No

Quanice
Hayes
Don Perkins

2/9/17

1

3

AR-15

Hit

Fatal

No

2

10

AR-15; 9mm

Hit

Non-fatal

AfricanAmerican
White

No

2/9/17

Yes

No

Terrell
Johnson

5/10/17

1

4

9mm

Hit

Fatal

Assault rifle
and handgun
Rifle and
handgun
Replica
handgun
Replica
handgun
Knife

White

1

Nonhit
Hit

Non-fatal

12/5/16

M4 rifle;
.223 rifle
AR-15

AfricanAmerican

No

No

Fatal

---------Reviewed in OIR Group’s Report Concerning the In-Custody Death of James Chasse, July 2010
---------Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, First Report, May 2012
---------Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, Second Report, July 2013
---------Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, Third Report, November 2014
(no shading) Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, Fourth Report, January 2016
---------Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, Fifth Report, February 2018
---------Reviewed in OIR Group’s Report on Portland Police Bureau Officer-Involved Shootings, Sixth Report, November 2018
a

The Bureau made the decision to terminate the shooting officer. The decision was overturned by the Arbitrator, and he was instead
suspended for 30 days.
b
After being struck by the officer’s gunfire, Mr. Goins raised his gun to his own head and shot himself. The Medical Examiner ruled the
cause of death to be suicide.
d
After both of the officers’ shots missed, Mr. Coady shot himself in the head. The Medical Examiner ruled the cause of death to be suicide.
e
The Bureau made the decision to terminate the shooting officer. The decision was overturned by the Arbitrator, and that decision was
confirmed on appeal.
f
None of three rounds fired were deemed fatal, but Mr. Boehler died of smoke inhalation in the ensuing fire in his house.

 RESPONSE TO THE REPORT