Report of Alan M. Stone
To Deputy Attorney GeneralPhilip Heymann

Report and Recommendations Concerning the Handlingof Incidents Such As theBranch Davidian Standoff in Waco Texas

Panelist Alan A. Stone, M.D.
Touroff-Glueck Professor
of Psychiatry and Law
Faculty of Law and Faculty of Medicine
Harvard University

Submitted November 10, 1993

Table of Contents

I. Preamble

II. Introduction

A. Explanation for the delay in the submission of this report
B. Mandate

III. Account of the Events at Waco

IV. Analysis

A. The FBI's behavioral science capacity
1. FBI expertise in dealing with persons whose motivations and thought processes are unconventional.
2. Evaluating the risks of mass suicide
3. The Waco Tactics in light of the group psychology of the FBI
B. Failure to use behavioral science capacity
1. Failure of coordination between tactical and negotiating arms of the FBI
2. Was tactical strategy appropriate with so many children in the compound?
3. The plan to insert CS Gas

V. Recommendations

A. The Deputy Attorney General's formulation and recommendation
B. Recommendations of this panelist
1. Further investigation is necessary
2. The FBI needs to make better use of past experience and existing behavioral science capacity
3. The FBI needs a clear policy on third-party negotiators/intermediaries
4. The FBI and the Justice Department need a systematic policy for dealing with information overload in a crisis
5. The FBI needs a better knowledge base about the medical consequences of CS gas
6. The FBI needs a specific policy for dealing with unconventional groups

VI. Final Word

I. Preamble

The Justice Department's official investigation published onOctober 8th together with other information made available tothe panelists present convincing evidence that David Koresh orderedhis followers to set the fire in which they perished. However,neither the official investigation nor the Dennis evaluation hasprovided a clear and probing account of the FBI tactics duringthe stand-off and their possible relationship to the tragic outcomeat Waco. This report therefore contains an account based on myown further review and interpretation of the facts.
I have concluded that the FBI command failed to give adequateconsideration to their own behavioral science and negotiationexperts. They also failed to make use of the Agency's own priorsuccessful experience in similar circumstances. They embarkedon a misguided and punishing law enforcement strategy that contributedto the tragic ending at Waco.
As a physician, I have concluded that there are serious unansweredquestions about the basis for the decision to deploy toxic C.S.gas in a closed space where there were 25 children, many of themtoddlers and infants.
This report makes several recommendations, first among them isthat further inquiry will be necessary to resolve the many unansweredquestions. Even with that major caveat, I believe the Deputy AttorneyGeneral's suggestions for forward looking changes are excellentand endorse them. This report makes further specific recommendationsfor change building on his proposal.

II. Introduction

A: Explanation for the delay in the submissionof this report
This past summer, the Justice and Treasury Departments appointeda group of panelists, each of whom was to prepare a forward-lookingreport suggesting possible changes in federal law enforcementin light of Waco. For reasons set forth below, I decided thatbefore submitting a report based on my particular professionalexpertise, it was necessary to have a complete understanding ofthe factual investigation by the Justice Department. Having nowhad the opportunity to read and study that report and the DennisEvaluation, I concluded that I did not yet have the kind of clearand probing view of events that is a necessary prerequisite formaking suggestions for constructive change. Deputy Attorney General(DAG) Philip Heymann therefore made it possible for me to pursueevery further question I had with those directly responsible forthe Justice Department's factual investigation and with the FBIagents whose participation at Waco was relevant to my inquiry.Their cooperation allowed me to obtain the information necessaryfor this report.
The Justice Department has sifted through a mountain of information,some of which, in accordance with Federal Statute, can not bepublicly revealed. This evidence overwhelmingly proves that DavidKoresh and the Branch Davidians set the fire and killed themselvesin the conflagration at Waco, which fulfilled their apocalypticprophecy. This report does not question that conclusion; instead,my concern as a member of the Behavioral Science Panel is whetherthe FBI strategy pursued at Waco in some way contributed to thetragedy which resulted in the death of twenty-five innocent childrenalong with the adults. The Justice Department Investigation andthe Dennis Evaluation seem to agree with the FBI commander onthe ground, who is convinced that nothing the FBI did or couldhave done would have changed the outcome. That is not my impression.
I therefore decided it was necessary to include in this reportmy own account of the events I considered critical. I have attemptedto confirm every factual assertion of this account with the FBIor the Justice Department. Although, in my discussions with theJustice Department, I encountered a certain skepticism about whatI shall report here, I was quite reassured by interviews withthe FBI's behavioral scientists and negotiators, who confirmedsome of my impressions and encouraged my efforts. Because theyshare my belief that mistakes were made, they expressed theirdetermination to have the truth come out, regardless of the consequences.I hope that this report will bolster the FBI and its new Director'sefforts to conduct their forthcoming review of Waco, which hasnot yet begun. I also hope that my report and suggestions forchange will in some measure enable the FBI to work more effectivelywith the Justice Department, the Attorney General, and other lawenforcement agencies.

B. Mandate to the panel as I understood it
The mandate to the panelists was "to assist in addressingissues that Federal Law Enforcement confronts in barricade/hostagesituations such as the stand-off that occurred near Waco, Texas...."Specifically, my sub-group (Ammerman, Cancro, Stone, Sullivan)was directed to explore: "Dealing with persons whose motivationsand thought processes are unconventional. How should law enforcementagencies deal with persons or groups which thought processes ormotivations depart substantially from ordinary familiar behaviorin barricade situations such as Waco? How should the motivationsof the persons affect the law enforcement response? What assistancecan be provided by experts in such fields as psychology, psychiatry,sociology, and theology?"There seemed to be two premises in this request by the DeputyAttorney General (DAG). The first premise was that Waco had beena tragic event, so it was important for the agencies and the peopleinvolved to examine the evidence, evaluate their actions, andinitiate change based on those conclusions. Second, although therewere questions about the psychiatric status of David Koresh, theDAG's use of the term, "unconventional," indicated thatwe were also broadly to consider groups with "belief systems"that might cause them to think and behave differently than ordinarycriminals and therefore to be more difficult for law enforcementto deal with and understand. As I understood it, the Branch Davidians'religious beliefs were considered unconven-tional," whichwas not intended to be a pejorative term, but rather a descriptiveone. The panelists were also told that there was concern amongfederal law enforcement officials that more such "unconventional"groups might, in the near future, pose problems for which lawenforcement's standard operating procedures might not be suitable.

Given this important responsibility and the fact that we wereasked to make recommendations "[c]oncerning the handlingof incidents such as the Branch Davidian Standoff in Waco,Texas" (emphasis added), I felt unprepared to go forwardwithout a thorough grasp of the events and decisions that ledto the tragedy. However, the Justice Department was still in thepreliminary stage of their own fact- gathering investigation atour panel briefings in early July. Hoping to convey the particularissues of concern to me, I prepared a preliminary report basedon the initial briefings. Since the factual information I wantedand needed was still being gathered by the Justice Department,I did not attend the subsequent special briefings arranged forthe panel at Quantico, Virginia. Because of my reticence to furnisha report based on incomplete information, the DAG and I resolvedthat I would submit my report subsequent to the completion ofthe Justice Department's factual inquiry. I have now had the opportunityto review the following documents:

1. Report of the Department of the Treasury on the Bureau of Alcohol,Tobacco, and Firearms. Investigation of Vernon Wayne Howell AlsoKnown As David Koresh, September, 1993;

2. Report to the Deputy Attorney General on the Events at Waco,Texas, February 28 to April 19, 1993 (Redacted Version), October8, 1993;

3. Edward S.G. Dennis, Jr., Evaluation of the Handling of theBranch Davidian Stand-off in Waco, Texas, February 28 to April19, 1993 (Redacted Version), October 8, 1993;

4. Deputy Attorney General Philip B. Heymann, Lessons of Waco:Proposed Changes in Federal Law Enforcement October 8, 1993;

5. Recommendations of Experts for Improvements in Federal LawEnforcement After Waco.

As previously mentioned, the Justice Department and the FBI haveanswered my further questions, supplied me with documents, andhelped me explore issues of greatest relevance to my inquiry.

III. Account of the Events at Waco

The FBI replaced the BATF at the Branch Davidian compound onthe evening of February 28 and the morning of March 1. There hadbeen casualties on both sides during the BATF's attempted dynamicentry. David Koresh, the leader of the Branch Davidians, had beenshot through the hip, and the situation was in flux. It wouldbecome, as we have been told, the longest stand-off in law enforcementhistory. The FBI, with agents in place who were trained for rapidintervention, was locked into a prolonged siege. The perimeterwas difficult to control, the conditions were extreme, and thestress was intense. Furthermore, the FBI's people had inheriteda disaster that was not of their own making. "Under the circumstances,the FBI exhibited extraordinary restraint and handled this crisiswith great professionalism" the Dennis Evaluation concludes.While this may be true from the perspective of experts in lawenforcement, it does not contribute to establishing a clear explanationof what happened at Waco from a psychiatric and behavioral scienceperspective. The commander on the ground believes that the FBI'sactions had no impact on David Koresh. He and others who sharehis opinion will likely disagree with the account that follows,which is the product of my own current understanding of the events.

Phase I

During the first phase of the FBI's engagement at Waco, a periodof a few days, the agents on the ground proceeded with a strategyof conciliatory negotiation, which had the approval and understandingof the entire chain of command. They also took measures to ensuretheir own safety and to secure the perimeter. In the view of thenegotiating team, considerable progress was made - for example,some adults and children came out of the compound; but David Koreshand the Branch Davidians made many promises to the negotiatorsthey did not keep. Pushed by the tactical leader, the commanderon the ground began to allow tactical pressures to be placed onthe compound in addition to negotiation: e.g., turning off theelectricity, so that those in the compound would be as cold asthe agents outside during the twenty- degree night.

Phase II

As documented in the published reports and memoranda, this tacticalpressure began at the operational level over the objections ofthe FBI's own experts in negotiation and behavioral science, whospecifically advised against it. These experts warned the FBIcommand abut the potentially fatal consequences of such measuresin dealing with an "unconventional" group. Their adviceis documented in memoranda. Nonetheless tactical pressure wasadded. Without a clear command decision, what evolved was a carrot-and-stick, "mixed-message" strategy. This happened withoutoutside consultation and without taking into account that theFBI was dealing with an "unconventional" group.
Although this carrot-and-stick approach is presented in the factualinvestigation as though it were standard operating procedure forlaw enforcement and accepted by the entire chain of command, itwas instead, apparently, the result of poor coordination and managementin the field. Negotiators and tactical units were at times operatingindependently in an uncoordinated and counterproductive fashion.

Phase III

During the third phase of the stand-off, the FBI took a moreaggressive approach to negotiation and, when that failed, gaveup on the process of negotiation, except as a means of maintainingcommunication with the compound. By March 21, the FBI was concentratingon tactical pressure alone: first, by using all-out psycho-physiologicalwarfare intended to stress and intimidate the Branch Davidians;and second, by "tightening the noose" with a circleof armored vehicles. The FBI considered these efforts a successbecause no shots were fired at them by the Branch Davidians.

This changing strategy at the compound from (1) conciliatory negotiatingto (2) negotiation and tactical pressure and then to (3) tacticalpressure alone, evolved over the objections of the FBI's own expertsand without clear understanding up the chain of command. Whenthe fourth and ultimate strategy, the insertion of C.S. gas, waspresented to Attorney General Reno, the FBI had abandoned anyserious effort to reach a negotiated solution and was well alongin its strategy of all-out tactical pressure, thereby leavinglittle choice as to how to end the Waco stand-off. It is unclearfrom the reports whether the FBI ever explained to the AG thatthe agency had rejected the advice of their own experts in behavioralscience and negotiation, or whether the AG was told that FBI negotiatorsbelieved they could get more people out of the compound by negotiation.By the time the AG made her decision, the noose was closed and,as one agent told me, the FBI believed they had "three options- gas, gas, and gas."
This account of the FBI's approach at Waco may not be correctin every detail. It is certainly oversimplified, but it has beenconfirmed in its general outline by FBI behavioral scientistsand negotiators who were participants at Waco. This account withtheir assistance brings into focus for me the critical issuesabout law enforcement response to persons and a group whose beliefs,motivations, and behavior are unconventional.

IV. Analysis

A. The FBI's behavioral science capacity

1. FBI expertise in dealing with personswhose motivations and thought processes are unconventional.
The evidence now available to me indicates that, contrary to myprevious understanding and that of the other panelists, the FBI'sInvestigative Support Unit and trained negotiators possessed thepsychological/behavioral science expertise they needed to dealwith David Koresh and an unconventional group like the BranchDavidians. The FBI has excellent in-house behavioral science capacityand also consulted with reputable experts outside the agency.Panelists may have been misled, as I was, by FBI officials atthe original briefings who conveyed the impression that they consideredDavid Koresh a typical criminal mentality and dealt with him assuch. They also conveyed the impression that they believed hisfollowers were dupes and he had "conned" them. Basedon reports and interviews, the FBI's behavioral science expertswho were actually on the scene at Waco had an excellent understandingof Koresh's psychology and appreciated the group's intense religiousconvictions.
My preliminary report of August 3 emphasized at some length thoseaspects of David Koresh's clinical history and psychopathologythat contradicted the simplistic and misleading impression givenat the first briefings. Much more information has been made availableabout his mental condition, his behavioral abnormalities, hissexual activities, and his responses under stress. All of thisevidence is incompatible with the notion that Koresh can be understoodand should have been dealt with as a conventional criminal typewith an antisocial personality disorder. However, the evidenceavailable does not lead directly to some other clear and obviouspsychiatric diagnosis used by contemporary psychiatry. Nonetheless,based on the FBI's in-house behavioral science memoranda and otherinformation from outside consultants, I believe the FBI behavioralscience experts had worked out a good psychological understandingof Koresh's psychopathology. They knew it would be a mistake todeal with him as though he were a con-man pretending to religiousbeliefs so that he could exploit his followers.
This is not to suggest that David Koresh did not dominate andexploit other people. He was able to convince husbands and wivesamong his followers that only he should have sex with the womenand propagate children. He convinced parents on the same religiousgrounds to permit him to have sex with their young teen-age daughters.He studied, memorized, and was preoccupied with Biblical textsand made much better educated people believe that he had an enlightenedunderstanding of scripture and that he was the Lamb of God. Hisfollowers took David Koresh's teachings as their faith. He exactedstrict discipline from adults and children alike while indulginghimself.
Whatever else all this adds up to, it and other information clearlydemonstrate as a psychological matter that Koresh had an absoluteneed for control and domination of his followers that amountedto a mania. He also had the ability to control them. The intensityand depth of his ability and need to control is attested to byeveryone in the FBI who dealt with him, from negotiators and behavioralscientists to tactical agents and the commander on the ground.
Unfortunately, those responsible for ultimate decision-makingat Waco did not listen to those who understood the meaning andpsychological significance of David Koresh's "mania."Instead they tried to show him who was the "boss."
What went wrong at Waco was not that the FBI lacked expertisein behavioral science or in the understanding of unconventionalreligious groups. Rather the commander on the ground and otherscommitted to tactical-aggressive, traditional law enforcementpractices disregarded those experts and tried to assert controland demonstrate to Koresh that they were in charge. There is nothingsurprising or esoteric in this explanation, nor does it ariseonly from the clear wisdom of hindsight. As detailed below, theFBI's own experts recognized and predicted in memoranda that therewas the risk that the active aggressive law enforcement mentalityof the FBI -- the so-called "action imperative" wouldprevail in the face of frustration and delay. They warned that,in these circumstances, there might be tragic consequences fromthe FBI's "action imperative," and they were correct.

2. Evaluating the Risks of Mass Suicide
As I have previously stated, there is, to my mind, unequivocalevidence in the report and briefings that the Branch Davidiansset the compound on fire themselves and ended their lives on DavidKoresh's order. However, I am also now convinced that the FBI'snoose-tightening tactics may well have precipitated Koresh's decisionto commit himself and his followers to this course of mass suicide.
The official reports have shied away from directly confrontingand examining the possible causal relationship between the FBI'spressure tactics and David Koresh's order to the Branch Davidians.I believe that this omission is critical because, if that tacticalstrategy increased the likelihood of the conflagration in whichtwenty-five innocent children died, then that must be a matterof utmost concern for the future management of such stand-offs.
Based on the available evidence and my own professional expertise,I believe that the responsible FBI decision makers did not adequatelyor correctly evaluate the risk of mass suicide. The Dennis Evaluation'sexecutive summary concludes that "the risk of suicide wastaken into account during the negotiations and in the developmentof the gas plan." It is unclear what "taken into account"means. The questions that now need to be explored are: howwas the risk of suicide taken into account, and how did theFBI assess the impact of their show of-force pressure tacticson that risk?

Gambling with death.

There is a criminology, behavioral science, and psychiatric literatureon the subject of murder followed by suicide, which indicatesthat these behaviors and the mental states that motivate themhave very important and complicated links. Family violence oftentakes the form of murder followed by suicide. Multiple killersmotivated by paranoid ideas often provoke law enforcement at thescene to kill them and often commit suicide. Even more importantis what has been called "the gamble with death." Inner-cityyouths often provoke a shoot-out, "gambling" with death(suicide) by provoking police into killing them. The FBI's behavioralscience unit, aware of this literature, realized that Koresh andhis followers were in a desperate kill-or-be-killed mode. Theywere also well aware of the significance and meaning of the BranchDavidians' apocalyptic faith. They understood that David Koreshinterpreted law enforcement attacks as related to the prophesiedapocalyptic ending.
In moving to the show of force tactical strategy, the FBI's criticalassumption, was that David Koresh and the Branch Davidians, likeordinary persons, would respond to pressure in the form of a closingcircle of armed vehicles and conclude that survival was in theirself-interest, and surrender. This ill-fated assumption runs contraryto all of the relevant behavioral science and psychiatric literatureand the understanding it offered of Koresh and the Branch Davidians.
Furthermore, there was direct empirical evidence supporting theassumption that the Branch Davidians, because of their own unconventionalbeliefs, were in the "gamble with death" mode. The directevidence for this was their response to the ATF's misguided assault.They engaged in a desperate shootout with federal law enforcement,which resulted in deaths and casualties on both sides. The ATFclaims gunfire came from forty different locations. If true, thismeans that at least forty Branch Davidians were willing to shootat federal agents and kill or be killed as martyr-suicide victimsdefending their "faith." The idea that people with thosebeliefs expecting the apocalypse would submit to tactical pressureis a conclusion that flies in the face of their past behaviorin the ATF crisis. Past behavior is generally considered the bestpredictor of future behavior.

Willing to kill but not cold-blooded killers

The BATF investigation reports that the so-called "dynamicentry" turned into what is described as being "ambushed".As I tried to get a sense of the state of mind and behavior ofthe people in the compound the idea that the Branch Davidians'actions were considered an "ambush" troubled me. Ifthey were militants determined to ambush and kill as many ATFagents as possible, it seemed to me that given their firepower,the devastation would have been even worse. The agents were ina very vulnerable position from the moment they arrived. Yet,as ordered, they tried to gain entry into the compound in theface of the hail of fire. Although there is disagreement, a seniorFBI tactical person and other experts confirmed my impressionof this matter. The ATF agents brought to the compound in cattlecars could have been cattle going to slaughter if the Branch Davidianshad taken full advantage of their tactical superiority. They apparentlydid not maximize the kill of ATF agents. This comports with allof the state-of-mind evidence and suggests that the Branch Davidianswere not determined, cold-blooded killers; rather, they were desperatereligious fanatics expecting an apocalyptic ending, in which theywere destined to die defending their sacred ground and destinedto achieve salvation.
The tactical arm of federal law enforcement may conventionallythink of the other side as a band of criminals or as a militaryforce or, generically, as the aggressor. But the Branch Davidianswere an unconventional group in an exalted, disturbed, and desperatestate of mind. They were devoted to David Koresh as the Lamb ofGod. They were willing to die defending themselves in an apocalypticending and, in the alternative, to kill themselves and their children.However, these were neither psychiatrically depressed, suicidalpeople nor cold-blooded killers. They were ready to risk deathas a test of their faith. The psychology of such behavior-togetherwith its religious significance for the Branch Davidians - wasmistakenly evaluated if, not simply ignored, by those responsiblefor the FBI strategy of "tightening the noose." Theoverwhelming show of force was not working in the way the tacticianssupposed. It did not provoke the Branch Davidians to surrender,but it may have provoked David Koresh to order the mass-suicide.That, at least, is my considered opinion.
The factual investigation reports in detail the many times negotiatorsasked Koresh and others in the compound whether they planned suicide.Also documented are Koresh's assurances that they would not killthemselves. Such questions and answers are certainly importantfrom a psychiatric perspective in evaluating a patient's suicidaltendency. But the significance of such communication depends onthe context, the relationship established, and the state of mindof the person being interviewed. The FBI had no basis for relyingon David Koresh's answers to these questions. Furthermore, hisresponses provided no guidance to the more pertinent question:- `What will you do if we tighten the noose around the compoundin a show of overwhelming power, and using CS gas, force you tocome out?'

The psychology of control

The most salient feature of David Koresh's psychology was hisneed for control. Every meaningful glimpse of his personalityand of day-to-day life in the compound demonstrates his controland domination. The tactic of tightening-the-noose around thecompound was intended to convey to David Koresh the realizationthat he was losing control of his "territory," and thatthe FBI was taking control. The FBI apparently assumed that thistactic and the war of stress would establish that they were incontrol but would not convey hostile intent. They themselves trulybelieved these tactics were "not an assault," and becausethe Davidians failed to respond with gunfire, the FBI consideredtheir tactics effective and appropriate. The commander on theground now acknowledges that they never really gained controlof David Koresh. But, in fact, my analysis is that they pushedhim to the ultimate act of control -- destruction of himself andhis group.
The FBI's tactics were ill considered in light of David Koresh'spsychology and the group psychology of the people in the compound.The FBI was dealing with a religious group, with shared and reinforcedbeliefs and a charismatic leader. If one takes seriously the psychologicalsyndrome of murder/suicide gamble with death and the group's unconventionalbelief system in the Seven Seals and the apocalypse, then youmay conclude, as I have, that the FBI's control tactics convincedDavid Koresh that, in this situation, he was becoming hopelessand helpless -- that he was losing control. In his desperate stateof mind, he chose death rather than submission. When the FBI thoughtthey were at last taking control, they had in fact totally lostcontrol of the stand-off.

3. The Waco tactics in light of the grouppsychology of the FBI
If this had been a military operation, the Waco conclusion wouldhave been a victory. The enemy was destroyed without a singleloss of life for the FBI. This situation, however, was not a militaryoperation. The question is: did a "military" mentalityovertake the FBI? We were told that the FBI considers a conflictwhich results in any casualties on either side a failure. Thelaw enforcement experts on the panel agreed.
There is little doubt that the FBI inherited a terrible situation.Federal agents had been killed and wounded, and there were killedand wounded Branch Davidians in and around the compound. The FBIknew that they were in a dangerous situation, and that they confronteda group of religious fanatics who were willing to kill or be killed.The FBI's initial decision to mount a stand-off and negotiatewas a remarkable exhibition of restraint under the circumstances.In retrospect, tactical units will wonder whether an immediatefull-scale dynamic entry by an overwhelming force would have producedless loss of life.
The FBI stand-off, we were repeatedly told, was the longest inlaw enforcement history. The costs in money and manpower weremounting and, Waco had the media impact of the Iran Hostage takingas the days mounted. The FBI was under enormous pressure to dosomething. Given what I believe the FBI's group psychology tohave been, the desultory strategy of simultaneous negotiationand tactical pressure was enacted as a compromise between doingnothing (passivity) and a military assault (the action imperative).The appeal of any tactical initiative to an entrenched, stressedFBI must have been overwhelming. It may have better suited theirgroup psychology than the group psychology of the unconventionalpeople in the compound they wanted to affect. Given the escalatingpressure to act, the final tightening- the-noose" and C.S.gas strategy must have seemed to the tacticians a reasonable compromisebetween doing nothing and overreacting.
This analysis of the FBI's group psychology is not intended asa matter of placing blame. If it is accurate, it at least pointsto what might be done differently in the future. The FBI shouldnot be pushed by their group psychology into misguided ad hocdecision making the next time around.

B. Failure to use behavioral science capacity

1. Failure of coordination between tacticalandnegotiating arms of the FBI
Throughout the official factual investigation, there are referencesto the failure of communication between the tactical and negotiationarms of the FBI. The commander on the ground thinks that the officialinvestigation and evaluation exaggerate the extent and significanceof that failure. I disagree. The situation can only be fully appreciatedby a thoroughgoing review of the documents. Consider the Memoof 3/5/93 from Special Agents Peter Smerick and Mark Young onthe subject, "Negotiation Strategy and Considerations."The memorandum not only defines the basic law enforcement prioritiesat Waco in the identical fashion as the after-the-fact panel oflaw enforcement experts, also anticipates most of the panel'sown behavioral science expertise and retrospective wisdom. AgentsSmerick and Young were not Monday morning quarterbacks as we panelistsare; they were members of the F.B.I. team on the field of play.The basic premise of their overall strategy was:

1 Insure safety of children [emphasis in original], whoare truly victims in this situation.

2. Facilitate the peaceful surrender of David Koresh and his followers.

The agents went on to emphasize that the strategy of negotiations,coupled with ever-increasing tactical presence was inapplicable.They wrote, "In this situation, however, it is believed thisstrategy, if carried to excess, could eventually be counter-productiveand could result in loss of life." p. 2, Memo of 3/5/93.The agents also were fully aware that Koresh's followers believedin his teachings and would "die for his cause." Theywere fully aware, therefore, of the religious significance ofthe Branch Davidians' conduct and attitudes and were sensitiveto all of the concerns emphasized by the religious experts onthe panel in their reports. They suggested that the F.B.I. shouldconsider "offering to pull back, only if they releasemore children" (emphasis in original). The agents furtherrecommended that, "since these people fear law enforcement,offer them the opportunity of surrendering to a neutral partyof their choosing accompanied by appropriate law enforcement personnel."
These agents recognized that although some in the F.B.I. mightbelieve the Davidians were "bizarre and cult-like,"the followers of Koresh "will fight back to the death, todefend their property [described elsewhere by the agents as sacredground, the equivalent of a cathedral to Catholics, etc.] andtheir faith" (emphasis added). Memo of Smerick andYoung 3/7/93.
My reading of these memos indicates that these agents had placedthe safety of the children first, exactly as did AG Reno. Theyrecognized that it was not a traditional hostage situation, asthe British law enforcement expert on the panel, C.E. Birt, repeatedlyemphasized during our briefings of July 1 and 2, when he foundit necessary to correct the misrepresentation of the briefer.They warned against the carrot-and-stick approach, which was employedand has been criticized by several of the panelists in their reports.Professor Cancro speaks of it as a "double bind," aterm used by behavioral scientists to describe a mixed messagefor which there is no correct response and which, as a result,creates anxiety and agitation in the recipient of the message.
The factual investigation does not explain how or why these expertopinions of behavioral scientists and negotiations within theFBI were overridden. The Justice Department emphasized that thesesame agents whose views I have described gave quite contradictoryviews the very next day. When I asked whether the Justice Department'sfact- finders had questioned these agents as to why they had changedtheir views, no adequate answer was given. I therefore pursuedthat inquiry with the agent who authored the two reports. He madeit quite clear that the contradictory suggestions were offeredonly in response to an expression of dissatisfaction with theprevious recommendations. Although the commander on the groundand the official investigation disagree with my view, I have concludedthat decision-making at Waco failed to give due regard to theFBI experts who had the proper understanding of how to deal withan unconventional group like the Branch Davidians.

2. Was tactical strategy appropriate withso many children in the compound?
The pressure strategy as we now know it consisted of shuttingoff the compound's electricity, putting search lights on the compoundall night, playing constant loud noise (including Tibetan prayerchants, the screaming sounds of rabbits being slaughtered, etc.),tightening the perimeter into a smaller and smaller circle inan overwhelming show of advancing armored force, and using CSgas. The constant stress overload is intended to lead to sleep-deprivationand psychological disorientation. In predisposed individuals thecombination of physiological disruption and psychological stresscan also lead to mood disturbances, transient hallucinations andparanoid ideation. If the constant noise exceeds 105 decibels,it can produce nerve deafness in children as well as in adults.Presumably, the tactical intent was to cause disruption and emotionalchaos within the compound. The FBI hoped to break Koresh's holdover his followers. However, it may have solidified this unconventionalgroup's unity in their common misery, a phenomenon familiar tovictimology and group psychology.
When asked, the Justice Department was unaware whether the FBIhad even questioned whether these intentional stresses would beparticularly harmful to the many infants and children in the compound.Apparently, no one asked whether such deleterious measures wereappropriate, either as a matter of law enforcement ethics or asa matter of morality, when innocent children were involved. Thisis not to suggest that the FBI decision-makers were cold-bloodedtacticians who took no account of the children; in fact, thereare repeated examples showing the concern of the agents, includingthe commander on the ground. Nevertheless, my opinion is thatregardless of their apparent concern the FBI agents did not adequatelyconsider the effects of these tactical actions on the children.

3. The plan to insert CS gas
During U.S. military training, trainees are required to weara gas mask when entering a tent containing CS gas. They then removethe mask and, after a few seconds in that atmosphere, are allowedto leave. I can testify from personal experience to the powerof C.S. gas to quickly inflame eyes, nose; and throat, to producechoking, chest pain, gagging, and nausea in healthy adult males.It is difficult to believe that the U.S. government would deliberatelyplan to expose twenty-five children, most of them infants andtoddlers, to C.S. gas for forty-eight hours. Although it is notdiscussed in the published reports, I have been told that theFBI believed that the Branch Davidians had gas masks and thatthis was one of the reasons for the plan of prolonged exposure.I have also been told that there was some protection availableto the children, i.e covering places where the seal is incompletewith cold wet towels can adapt gas masks for children and perhapsfor toddlers though not for infants. The official reports aresilent about these issues and do not reveal what the FBI toldthe AG about this matter, and whether she knew there might beunprotected children and infants in the compound.
The written information about the effects of C.S. gas which waspresented to the AG has been shared with the panelists. We donot know whether she had time to read it. Based on my own medicalknowledge and review of the scientific literature, the informationsupplied to the AG seems to minimize the potential harmful consequencesfor infants and children.
Scientific literature on C.S. gas is, however, surprisingly limited.In the sixties, the British Home Office, commissioned the HimsworthReport, after complaints about the use of C.S. gas by Britishtroops in Londonderry, Ireland. The report is said by its criticsto understate the medical consequences. The published animal researchon which the report is based acknowledged that at very high exposure,which the authors deemed unlikely, lethal effects were produced.The researchers assumed (as did the Himsworth report) that C.S.gas would be used primarily in open spaces, to disperse crowds,and not in closed areas.
The AG's information emphasized the British experience and understatedthe potential health consequences in closed spaces. The AG alsohad a consultation with a physician; but the exact content ofthat discussion has not been reported, and the available summaryis uninformative. The FBI commander on the ground assures me thatthe agency has detailed, ongoing expertise on C.S. gas and itsmedical consequences. If so, no such FBI information was suppliedin the written material to the AG or subsequently to this panelist.
Based on my review, the American scientific literature on thetoxic effects of C.S. gas on adults and children is also limited.Of course, there has, been no deliberate experimentation on infants.The Journal of the American Medical Association publishedtwo articles in recent years in which physicians expressed concernabout the use of C.S. gas on civilians, including children inSouth Korea and Israel. Anecdotal reports of the serious consequencesof tear gas, however, approved as early as 1956. Case reportsindicate that prolonged exposure to tear gas in closed quarterscauses chemical pneumonia and lethal pulmonary edema. Gonzalez,T.A., et al, Legal Medicine Pathology and ToxicologyEast Norwalk, Conn: Appleton Century Crofts, 1957). Accordingto a 1978 report, a disturbed adult died after only a half-hourexposure to C.S. gas in closed quarters. Chapman, A.J. and WhiteC. "Case Report: Death Resulting from Lacrimatory Agents,"J. Forensic Sci., 23 (1978): 527-30) The clinical pathologyfound at autopsy in these cases is exactly what common medicalunderstanding and ordinary pulmonary physiology predicts wouldfollow prolonged exposure in closed quarters.
The potential effects of C.S. gas are easily explained. C.S. gascauses among other things, irritation and inflammation of mucusmembrane. The lung is a sack full of membranes. The inhalationof C.S. gas would eventually cause inflammation, and fluid wouldmove across the membranes and collect in the alveoli, the tinyair sacks in the lungs that are necessary for breathing. The resultis like pneumonia and can be lethal. Animal studies are availableto confirm that C.S. gas has this effect on lung tissue. Ballantyne,B. and Callaway, S., "Inhalation toxicology and pathologyof animals exposed to omicron-chlorobenzylidene malonitrile (CS),"Med. Sci. Law, 12 (1972): 43-65. The Special Communicationpublished in J.A.M.A 220 (1993): 616-20 by Physicians forHuman Rights reported that its teams, investigating the use ofC.S. gas in South Korea and Panama, found "skin burns, eyeinjuries and exacerbations of underlying heart and lung disease. . . on civilians at sites far removed from crowd gatherings."Dermatologists have reported blistering rashes on skin exposedto self-defense sprays, which use the same C.S. gas. Parneix-Spake,A. et al, "Severe Cutaneous Reactions to Self-DefenseSprays, Arch. Dermatol 129 (1993): 913.
The medical literature does contain a clinical case history ofa situation that closely approximates the expected Waco conditions.Park, S.and Giammona, S.T., "Toxic Effects of Tear Gas onan Infant Following Prolonged Exposure," Amer. J. Dis.Child 123,3 (1972). A normal four month-old infant male wasin a house into which police officers, in order to subdue a disturbedadult, fired canisters of C.S. gas. The unprotected child's exposurelasted two to three hours. Thereafter, he was immediately takento an emergency room. His symptoms during the first twenty-fourhours were upper respiratory; but, within forty-eight hours hisface showed evidence of first degree burns, and he was in severerespiratory distress typical of chemical pneumonia. The infanthad cyanosis, required urgent positive pressure pulmonary care,and was hospitalized for twenty-eight days. Other signs of toxicityappeared, including an enlarged liver. The infant's delayed onsetof serious, life-threatening symptoms parallels the experienceof animal studies done by Ballantyne and Calloway for the HinsworthReport. The infant's reactions reported in this case history wereof a vastly different dimension than the information given theAG suggested.
Of course, most people without gas masks would be driven by theirinstinct for survival from a C.S. gas- filled structure. But infantscannot run or even walk out of such an environment; and youngchildren (many were toddlers) may be frightened or disorientedby this traumatic experience. The C.S. gas tactics, planned bythe FBI, and approved by the AG, would seem to give parents nochoice. If they wanted to spare their inadequately protected childrenthe intense and immediate suffering expectably caused by the C.S.gas, they would have had to take them out of the compound. Ironically,while the most compelling factor used to justify the Waco planwas the safety of the children, the insertion of the C.S. gas,in my opinion, actually threatened the safety of the children.
The Justice Department has informed me that because of the highwinds at Waco, the C.S. gas was dispersed; they believe it playedno part in the death by suffocation, revealed at autopsy, of mostof the infants, toddlers, and children. The commander on the ground,however, is of the opinion that the C.S. gas did have some effect,because the wind did not begin to blow strongly until two hoursafter he ordered the operation to begin. As yet, there has beenno report as to whether the children whose bodies were found inthe bunker were equipped with gas masks. Whatever the actual effectsmay have been, I find it hard to accept a deliberate plan to insertC.S. gas for forty-eight hours in a building with so many children.It certainly makes it more difficult to believe that the healthand safety of the children was our primary concern.
The commander on the ground has informed me that careful considerationwas given to the safety of the children, and that the initialplan was to direct the gas at an area of the compound not occupiedby them. We will never know whether that plan would have worked:the Branch Davidians began to shoot at the tank like vehiclesinserting the gas canisters, and C.S. gas was then directed atall parts of the compound, as previously decided in a fall backplan recommended by military advisers.

V. Recommendations

A. The Deputy Attorney General's formulationand recommendation

The DAG has, in his overview, outlined the critical elements tobe considered in dealing with a situation like Waco in the future.This is an excellent formulation. Based on what I have learnedand what I have described above, I strongly endorse his formulationand the recommendations which follow. However, unlike the otherpanelists in my group, I am impressed that the FBI has adequatein-house expertise to deal with unconventional groups like theBranch Davidians. Furthermore it seems clear that at Waco, theFBI, was suffering from information overload, if from anything.Thus, I believe that the crisis management capacity (seeDAG recommendations) and what I would describe as informationmanagement have to be the particular focus for future change.

B. Recommendations of this panelist

1. Further investigation is necessary
One might think that the highest priority after a tragedy likeWaco would be for everyone involved to consider what went wrongand what would they now do differently. I must confess that ithas been a frustrating and disappointing experience to discoverthat the Justice Department's investigation has produced so littlein this regard. The investigators have assured me that everyoneinvolved was asked these questions and that few useful responseswere given. An undercurrent of opinion holds that everything dependsand will depend in the future on the commander on the ground.SAC Jamar, the commander on the ground, knows that he is on thespot and that there are those who point to his position as theweak link at Waco. When I asked him what went wrong and what shouldbe done differently, he candidly acknowledged his difficult position;but he emphasized how much was still unknown about what happened,and that he still had not met with the FBI Waco negotiators todiscuss their views of what happened. His basic conclusion inretrospect, however, was that nothing the FBI had done at Wacomade any real impact. His opinion is that Koresh sent people outbecause he didn't want them, and not because of the FBI's consciliatorynegotiation strategy. His opinion is that Koresh ended it allin mass suicide not because of the FBI tactical strategy, butbecause that was always his intention. His deep and serious concernabout his responsibilities was impressive and he made it convincinglyclear how much more I and the other experts needed to know aboutthe facts. On this, he was preaching to the converted. There isno doubt in my mind that much more needs to be known about Waco.In my opinion, it is now time for the FBI itself, with the helpand participation of outside experts, to take on that responsibility.Indeed, that is my first recommendation. I agree with the FBI'scommander on the ground that we still do not know enough aboutwhat happened at Waco. We need to know more, not in the spiritof who is to blame, but in the spirit of what went wrong thatcan be made right. What can we learn from a careful study of DavidKoresh and the Branch Davidians that will help us in learningabout other unconventional groups? What can the FBI learn aboutits own behavior at Waco that will help in the future?
Just as I believe the FBI has more work to do, I believe the JusticeDepartment has work to do as well. No clear picture has emergedof how and on what basis the AG made her decision. Given on mycurrent information about C.S. gas, it is difficult to understandwhy a person whose primary concern was the safety of the childrenwould agree to the FBI's plan. It is critical that in the future,the AG have accurate information, so that she can make an informeddecision. If the only information she was given about C.S. gasis what has been shown to the panelists then, given my currentunderstanding, she was ill advised and made an ill-advised decision.None of these matters have been clarified. Certainly for its owneffective functioning, the Justice Department needs to sort thisout for the future.
The sequence of decision making set out in the earlier accountindicates that the FBI had already moved very far down the branchof the decision tree before consulting the AG. This made it difficultfor her to make any other choice. Presumably, others in the JusticeDepartment had been involved every step of the way. Like the FBI,they need to re-examine their own behavior, the channels of communication,the processing of information, and what went wrong or needs tobe done differently in the future. I assume that the DAG's recommendationof a "senior career official" within the Justice Department,who maintains "a familiarity with the resources availableto the FBI," is a forward looking solution to some of theseproblems.

2. The FBI needs to make better use of pastexperience and existing behavioral science capacity.
As we have been told, the commander on the ground was not selectedbecause of his past experience in standoffs or because of hisknowledge of unconventional groups. He was the special agent incharge of the geographical area in which the action took place.The DAG has recommended a different command structure. Nonetheless,the FBI had a situation room in Washington and a command structurein place at Waco which could have brought the agency's past experienceto bear. At the first briefings, when asked to describe theirmost successful resolution of a standoff with an unconventionalgroup, an FBI official reported the successful use of a thirdparty intermediary (negotiator). When I subsequently inquiredabout the FBI's previous experience with the successful use ofCS gas, the example given was a prison riot.
These examples speak for themselves and suggest to me that inmaking decisions at Waco, the FBI did not make the best use ofits own past experience. The commander on the ground believeshis decision to allow lawyers and the local sheriff to meet withKoresh is an example of using a third-party intermediary. However,in their own highly successful resolution of a stand-off withan armed unconventional group, the FBI used a fellow member ofthe religious faith as the intermediary. This option was apparentlyrejected at Waco for reasons that I find unconvincing.
The DAG has recommended that a computer database of past stand-offsbe developed. The critical importance of this is to insure thatthe FBI makes better use of its own experience. It will be importantfor the FBI to distinguish between unconventional groups and prisonpopulations in deciding which tactical measures are strategicallyand ethically appropriate.

3. The FBI needs a clear policy on thirdparty negotiators/intermediaries
The FBI has well-trained negotiators whose skills are impressive.Nonetheless, there came a time at Waco when the FBI's frustrationled them to introduce a new negotiating approach. They changedfrom a conciliatory, trust-building negotiator to a more demandingand intimidating negotiator. The change had no effect and mayhave been counterproductive. The negotiators also tried, at times,to talk religion with Koresh but concluded that this was not productive.
Some FBI negotiators are convinced that they could have gottenmore people out of the compound if the FBI had stayed the courseof conciliatory negotiation. Whether or not that is true, theFBI reached a point where tactical strategy became the priorityand negotiation under those circumstances became ineffective.
It is my recommendation that this point of change be defined asa red light, a time when the decision makers in futurestandoffs should consider the use of a third party negotiator/intermediary.The red light should go on when the commander on the groundor the chain of command begins to feel that FBI negotiation isat a stand still.
The FBI negotiation and behavioral science experts should, atthe least, develop a policy in consultation with experts on whenthey might consider the use of third party negotiators/intermediaries.The current working policy seems to be that third party negotiatorsare counterproductive. The experience justifying that policy needsto be reviewed in light of Waco. It was a significant omissionat Waco not to involve as a third-party negotiator/intermediarya person of religious stature familiar with the unconventionalbelief system of the Branch Davidians.

4. The FBI and the Justice Department needa systematic policy for dealing with information overload in acrisis
A critical element of crisis management based on my analysisof what happened at Waco is information management. Informationoverload allows decision-makers to discount all of the expertadvice they are given and revert to their own gut instincts. Alternatively- as I believe we learn from Waco - the decision-makers can insiston being given advice compatible with their gut instinct. In myopinion, the gut instinct that prevailed at Waco was the law enforcementmind-set, the action-control imperative.
If, as the DAG recommends, the FBI develops a network of academicexperts in behavioral science, religion, sociology, and psychiatry,the FBI can certainly expect an information overload in the nextcrisis. The problem will be how to manage the expert informationoverload. This is a complex problem that requires careful considerationby appropriate experts. However, one pattern that emerged frommy understanding of Waco needs to be changed. The official investigationlists all kinds of experts who allegedly were consulted or whotook it upon themselves to offer unsolicited advice. It is almostimpossible to determine what all this adds up to. One of my fellowpanelists believes - and I am convinced - that the FBI never actuallyconsulted with a religious expert familiar with the unconventionalbeliefs of Branch Davidians. The investigators at the JusticeDepartment disagree with this conclusion. My concern about thisis not a matter of fault-finding: it is critical to my concernabout information management in a crisis. The question is: whatcounts as a consultation with the FBI? One has the impressionfrom the Waco experience that a variety of agents were talkingto a variety of experts, and that some of these contacts werelisted as consultations. We are not told how those contacts orconsultations were sorted through. Who in the process would decidewhat was relevant and important and what irrelevant and unimportant.
In any event, the prevailing pattern in the information flow duringthe crisis was for each separate expert to offer the FBI an opinion.As a preliminary matter, it seems to me important for the FBIto establish who the relevant experts are and then arrange throughconference calls or more high-tech arrangements for sustaineddialogue among them, to understand and clarify the dimensionsof their disagreements and, when possible, to achieve consensus.Information should be exchanged and differences directly confrontedin the circle of consultants; they should not vanish in the informationoverload.

5. The FBI needs a better knowledge baseabout the medical consequences of C.S. gas.
As discussed above, it is my opinion that the AG was not properlyinformed of the risks to infants and small children posed by CSgas. This is not to imply that the FBI intentionally misled her.Indeed, the FBI may not have had the proper medical information.The use of CS gas is, in any event, a controversial matter, andalthough it is understandable that the Justice Department investigationdid not explore medical considerations, a careful evaluation isclearly indicated. The FBI, the Justice Department, and all oflaw enforcement that uses CS gas ought to have as clear an understandingof its medical consequences as possible. The hasty survey of themedical and scientific literature done for this report is hardlydefinitive. These matters should be sorted out so that the AGclearly understands what the use of CS gas entails.

6. The FBI needs a specific policy for dealingwith unconventional groups.
The basic conclusion of my account and analysis is that the standardlaw enforcement mentality asserted itself at Waco in the tacticalshow of force. The FBI should be aware of its own group psychologyand of the tendency to carry out the action imperative. Doubtless,that imperative is appropriate in dealing with conventional criminals;it may be necessary even in dealing with unconventional groups.However, the lesson of Waco is that once the FBI recognizes thatit is dealing with an unconventional group, those who urge punishingtactical measures should have to meet a heavy burden of persuasion.When children are involved, the burden should be even heavierand ethical considerations, which need to be formulated, wouldcome into play.

VI. Final Word

The events at Waco culminated in a tragic loss of life - on thateveryone involved in law enforcement and in the official inquiryagree. There is a view within the FBI and in the official reportsthat suggests the tragedy was unavoidable. This report is a dissentingopinion from that view. There is obviously no definitive answer;but my account and analysis tries to emphasize what might havebeen done differently at Waco, and what I believe should be donedifferently in the FBI's future dealings with unconventional groups.I endorse the DAG's recommendations for change and offer additionalsuggestions. Although such a determination falls outside my province,it is my considered opinion that the failings of the FBI at Wacoinvolve no intentional misconduct.

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