With no one clearly taking the role of on-scene commander, worsening a cascade of poor decisions, a team of law enforcement officers didn't confront and kill the shooter until 77 minutes into his rampage.
Enough officers were on hand to take out the gunman soon after he entered the school and riddled two classrooms with semiautomatic gunfire, killing 19 students and two teachers and injuring 17 others — but they faltered, DOJ investigators said in their 575-page report, released Thursday.
"Relevant policies and training directs officers to drive toward the threat and engage the subject to stop the killing," the report states. "This did not happen."
The federal report is the fullest accounting yet of what went wrong on May 24, 2022, but it provides little new insight into the flawed response and does not call for any criminal charges against officers who contributed to the delay.
Law enforcement waited for a sniper, SWAT team and heavier firearms, leading to precious time wasted during the response, the report said.
The investigation after the shooter was killed, including crime scene preservation, was also compromised. Officers did not follow proper protocols and didn't document who was coming and going from the crime scenes. There were a total of six crime scenes at Robb Elementary.
The report said at least 380 law enforcement personnel from 24 agencies responded to the tragedy. There were 587 children and many teachers and staff at Robb that day.
The first police agencies to respond were officers from the Uvalde Police Department, Uvalde Consolidated Independent School District, Uvalde County Sheriff's Office and the Texas Department of Public Safety.
"Officers on scene should have recognized the incident as an active shooter scenario and moved and pushed forward immediately and continuously toward the threat until the room was entered, and the threat was eliminated."
"That did not occur," it says.
Officers' sense of urgency eased as they began to consider the gunman a "barricaded suspect" instead of an active shooter, even as more officers arrived and the signals of ongoing danger intensified. Protocols for responding to a barricaded suspect call for a slower-moving, more methodical approach than to an active shooter.
"Leadership from UPD, UCISD, UCSO and TX DPS demonstrated no urgency for establishing a command and control structure, which led to challenges related to information sharing, lack of situational statuses, and limited-to-no direction for personnel in the hallway or on the perimeter," the report said.
Eleven officers arrived within the first few minutes of the rampage, enough to confront the shooter. But only six tried to go to the classroom where the shooter was located. And they retreated once two officers were hit by shrapnel. Only one tried to approach the classroom again, according to the report.
"After three attempts to enter the classrooms, the focus of the responders shifted from entering classrooms 111/112 and stopping the shooting to evacuating other classrooms, attempting to negotiate with the subject and requesting additional responders and equipment," the report said.
Department investigators reviewed more than 14,000 pieces of data and documentation for the review, including body-camera footage, interview transcripts and training policies. The department also independently spent 45 days on the ground in Uvalde and conducted more than 260 interviews, federal officials said.
"Leaders must respect the integrity of the crime scene and only access it with a declared and documented legitimate purpose," the report states. "Crime scenes need to be held without contamination until completed."
The report also said official actions after the shooting worsened the pain and confusion of families.
The review is one of four separate investigations into the shooting.
Only one of those inquiries — conducted in 2022 by a special Texas House committee — had made its findings public before Thursday.
The Robb Elementary shooting is widely regarded as an egregious law enforcement failure. As hundreds of officers from local, state and federal agencies responded to the scene — but failed to formulate a plan to confront the gunman quickly — children called 911 from inside the classroom, pleading to be rescued.
The Justice Department review was conducted by the Office of Community Oriented Policing Services to identify lessons learned and best practices to be applied in future incidents. It is not a criminal investigation.
That responsibility lies with Christina Mitchell, district attorney for Uvalde County. She is examining evidence gathered by the Texas Rangers to determine whether anyone should be criminally charged in relation to the tragedy. It is unclear who or what she is focusing on or when she might present evidence to a grand jury.
The DOJ report mirrors some of the findings in the Texas House committee report. That investigation found that poor communication among police officers and the absence of a clear command structure led to a chaotic, ineffectual response.
"The void of leadership could have contributed to the loss of life as injured victims waited over an hour for help, and the attacker continued to sporadically fire his weapon," the committee said in a 77-page report released in July 2022. "A command post could have transformed chaos into order, including the deliberate assignment of tasks and the flow of the information necessary to inform critical decision making."
'A dark path'
The shooter, Salvador Ramos, grew up in Uvalde and attended Robb Elementary. He struggled in school, suffered from bullying and by age 17 had gone no further than 9th grade, according to the House committee report. In 2021, he dropped out of Uvalde High School and "turned down a dark path," becoming obsessed with fantasies of violence and revenge and with the notoriety achieved by mass murderers, the report said.
In February 2022, he began buying gun accessories online, including dozens of ammunition magazines and a snap-on trigger system, also known as a bump stock, which increases the firing rate of semiautomatic rifles.
On May 16, 2022, his 18th birthday, he bought a Daniel Defense DDM4 V7 rifle and 1,740 hollow-point bullets from an online seller. Two days later, he purchased a Smith & Wesson M&P15 rifle and more ammunition, again online.
With months of preparation behind him, he launched his attack on May 24, one of the last days of school before summer break. He wore black pants and a black long-sleeved shirt.
At 11:28 a.m. that morning, he crashed his grandmother's pickup into a drainage ditch near Robb Elementary. He'd stolen the truck after shooting her in the face at her home several blocks from the school. He got out of the truck, taking with him a backpack full of ammunition and his Daniel Defense rifle, leaving behind the Smith & Wesson.
Two men, employees of a funeral home across the street from the school, approached the pickup to offer assistance. Ramos shot at them but missed. They turned and ran back to the funeral home.
Ramos then climbed over a 5-foot security fence on Robb Elementary's perimeter and walked toward the school, firing shots through classroom windows.
At 11:31 a.m., a Uvalde emergency dispatcher received the first 911 call.
Ramos entered the school through an unlocked door at 11:33 a.m., walked to Rooms 111 and 112 and fired several shots through one of the doors. Over the next two and a half minutes, he fired more than 100 rounds inside the classrooms. Investigators later concluded that he killed most of the 21 victims in that initial barrage.
At 11:36 a.m., three officers — one from the Uvalde school district police and two from the Uvalde Police Department — arrived at the scene. As two of the officers approached Rooms 111 and 122 with pistols drawn, Ramos fired through the classroom wall into the hallway, grazing both officers.
They retreated and called for backup. The DOJ report said 380 officers from local, state and federal agencies responded. Some of them waited in the hallway with guns and rifles but did not enter the classroom until 77 minutes after the first officers arrived.
A team of six officers that included members of a Border Patrol tactical unit eventually confronted and killed Ramos.
Some officers later told investigators they were unsure whether Ramos was an active shooter, which would have required an immediate police response, or a barricaded suspect, in which case police could take a more methodical approach.
The federal review
On June 8, 2022, U.S. Attorney General Merrick Garland announced that he had opened a federal investigation at the request of then- Uvalde Mayor Don McLaughlin Jr.
Since then, the Justice Department has been working with 10 subject-matter experts on a "critical incident review." The department has conducted similar reviews of other mass shootings, most recently the June 12, 2016, massacre at Pulse nightclub in Orlando, Fla., in which 49 people were killed.
In a closed-door two-hour meeting in Uvalde on Wednesday night, Garland and Associate Attorney General Vinjay Gupta, another top Justice Department official, briefed relatives of those killed at Robb Elementary and families of some of the 17 people injured.
Some of those families said they learned very few new things from the report, while some demanded accountability or pressure on the DA.
Gupta said in April that the goal of the review was to provide an independent assessment of the law enforcement response, "identify lessons learned and best practices to help first responders prepare for and respond to active shooter events; and provide a roadmap for community safety before, during and after such incidents."
Gupta emphasized that the review "is not a criminal or civil investigation."
The department said the 10 experts have extensive experience in emergency management and active shooter response, school safety, incident command and management, tactical operations, officer safety and wellness, and victim and family support.
As of April, the review team had visited Uvalde nine times and spent a total of 30 days there.
They conducted, viewed or participated in interviews with more than 200 people, including police, first responders, medical personnel, family members, victim services providers, school personnel, government officials, witnesses and hospital staff.
The team collected and analyzed nearly 13,000 pieces of evidence, including policies, procedures and training materials used by the responding law enforcement agencies and many hours of video, photographs, interview transcripts and other material.
The team did a walk-through of Robb Elementary, which has been permanently closed, and observed active-shooter training sessions.
The 10 experts include John Mina, who was the sheriff of Orange County, Fla., at the time of the Pulse nightclub shooting, and Kristen Ziman, who was police chief of Aurora, Colo., when a former neuroscience graduate student shot and killed 12 people in an Aurora movie theater on July 20, 2012.
'Potential criminal charges'
The department's Uvalde investigation is separate from the Texas Rangers' yearlong criminal probe into what led to the shooting and the police response.
In June, the Rangers turned over the results of their investigation to Mitchell, who serves as DA for Uvalde and Real counties. Mitchell initially said she might convene a grand jury by the end of 2023 to consider the case.
Mitchell said this week that her office is still dissecting the Rangers report, "which is quite voluminous." She did not offer a new timeline for presenting evidence to a grand jury.
Mitchell said in a statement Wednesday that the DOJ informed her it was about to release its own review but did not give her a copy.
"I have been informed that the report is based on policies, procedures and best practices, and does not address any potential criminal culpability," she said. "While I am hopeful that the DOJ report will be informative, my office will continue our independent review for any potential criminal charges."
Berlinda Arreola, the step-grandmother of 10-year-old victim Amerie Jo Garza, said she hopes the Justice Department report will recommend criminal charges against law enforcement officers who did not storm the classroom and confront the shooter.
"Getting the report is one thing, but what comes after is another," Arreola said.
At least five officers have lost their jobs over the Robb Elementary response, including two Texas Department of Public Safety officers and Uvalde's then-school police chief, Pedro "Pete" Arredondo.
The Uvalde school district dismissed its entire police force and hired new officers and a new chief. Superintendent Hal Harrell retired under public pressure in October 2022.
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