The report, the result of an outside investigation, documents instances of poor communication, bad planning, failure to meet department policy and disregard for standard safety measures on the day widely described as the darkest in department history.
It describes a chaotic scene, with no command post or clear lines of authority, as 115 police units gathered in East Oakland after two motorcycle officers were fatally shot by 26-year-old parolee Lovelle Mixon.
The report concluded that the decision to send SWAT officers into the apartment where Mixon hid was "problematic from its inception" and suggests that police Lt. Chris Mufarreh, who had assumed control of the situation, did not gather "routine intelligence" before officers entered the apartment at 2755 74th Ave. It also faults Capt. Rick Orozco and Deputy Chief David Kozicki for giving the OK to send in SWAT officers.
"Every alternative to dynamic entry was disregarded," the report said, adding, "The alternatives were dismissed with little or no discussion among the team members and command personnel."
Mufarreh and Orozco were informed Wednesday of the department's intentions to demote each of them two ranks, Bay Area News Group learned.
"I think any discipline of these guys is outrageous," said Michael Rains, attorney for Mufarreh and Orozco. "I don't quarrel with the department's desire to do a thorough and complete investigation, but rather than say we need to learn from what happened, they are saying we need to discipline."
Fatally shot March 21 were motorcycle Officer John Hege, 41, of Concord; Sgt. Mark Dunakin, 40, of Tracy; and SWAT Sgts. Erv Romans, 43, of Danville; and Daniel Sakai, 35, of Castro Valley. Mixon was killed by police after they raided the apartment.
"We will build on what we did well and correct those areas we were flawed in," police Chief Anthony Batts said. "We will grow as a department from this."
The report was commissioned last spring by then acting Chief Howard Jordan. A board that conducted the investigation was made up of five outside law-enforcement experts, and the report was authored by James K. "Chips" Stewart, a police consultant and former Oakland police captain.
The report offers nearly 40 recommendations, from providing training on how to set up a proper command post to re-evaluating how SWAT team leaders and tactical commanders are chosen.
The report highlights some of what went right that day, including Lt. Drennon Lindsey and Lt. Ersie Joyner III's work to identify information about where Mixon was located. Sgt. Pat Gonzales also was highlighted for continuing his pursuit of Mixon even after he had been shot in the shoulder.
Officers in the apartment showed restraint, the report said, when they held fire when Mixon's sister unexpectedly started screaming and burst out of an apartment bathroom.
Among the report's findings on what went wrong:
"The (board) recognizes the stresses officers are under when being attacked and shot at," the report said. "However, bravery and courage under fire cannot ever be an acceptable substitute for sound procedures and officer safety."
The report's release, intentionally delayed until after the holidays, brought back the nightmarish day for the department and for the families of the fallen officers, who were briefed on the report before it was released publicly.
John S. Hege, Officer Hege's father, said he felt the report treated his son fairly and added that he was impressed by its thoroughness and the fact that it was done outside the Police Department.
"I don't feel like there's anything more that I personally need to do," Hege said. "I'm sure the Police Department will respond to the report in a way that will improve the department."
Staff writers Sean Maher and Kristin Bender contributed to this story.
Source: Independent Board of Inquiry, Tribune reporting
Read the complete report on the investigation of the March 21 fatal shootings of four Oakland police officers and listen to dispatch and police radio transmissions from that day.