The independent report on the Oakland police murder details many of the mistakes that led to the tragedy.

Yesterday the Oakland (Calif.) Police Department released the report of an independent board of inquiry that it commissioned to examine the March 21, 2008 incident that claimed the lives of four Oakland officers.

The report ( read it in its entirety ) details a cascade of mistakes that led to the tragic deaths of Sgt. Mark Dunakin, Officer John Hege, Sgt. Ervin Romans, and Sgt. Daniel Sakai. It faults the Oakland PD for poor communication, weak command and control, and poor planning. In other words, chaos.

Produced by police experts, the report pulls no punches. It gives credit where due and slams officers for bad decisions and commanders for bad leadership and organization (Read POLICE Magazine's analysis of the Oakland SWAT ambush ).

The cascade of mistakes begins with the traffic stop by motor officer Dunakin and backup response by motor officer Hege at 1 p.m. on Saturday, March 21. Dunakin pulled over a car driven by parolee Lovelle Mixon and ran the plate and the driver's license. Hege arrived as cover. Hearing that there was no record on file for the license, Dunakin and Hege approached along the driver's door side of the car together. That's when Mixon opened fire. Neither officer was able to draw his weapon and return fire. The report criticizes the tactics of the officers for not using a good tactical approach or contact and cover techniques.

During a press conference yesterday Oakland PD Assistant Chief Howard Jordan said: "I don't know if they (Dunakin and Hege) had done anything differently if the results wouldn't have been the same. Lovelle Mixon was determined, willing, and capable of doing what he did."

After a citywide Officer Needs Help call was broadcast, 115 police units from a variety of agencies converged on the scene. But there was no command center so their efforts were not appropriately coordinated.

(Listen to the OPD radio calls.)

"No command post was established, and the citywide response overwhelmed the on-scene commanders, with many responders self-assigning their own activities. It would be 90 minutes before senior OPD leaders arrived on the scene," the report says.

Three lieutenants basically ended up vying for incident command but with none of them specifically establishing command and control. But that does not mean that some of them didn't do good work. One noted in the report as Lt. #1 obtained the likely location of the suspect from an eyewitness who saw him enter an apartment building. And another noted as Lt. #2 established a perimeter.

Much of the report's critical comments fall on Lt. #3, an officer identified by local media as Chris Mufarreh. The report explains that Lt. #3 assumed command at the scene but was not fully in command. It also implies that he was determined to find out if Mixon was in the apartment as quickly as possible because he doubted that the suspect was in the building.

During all of this command confusion, a sergeant that the report does not identify pitched the idea of having a canine track Mixon from the point of the traffic stop, which he fled on foot. The sergeant even arranged to have the Alameda County Sheriff's Department supply the tracking dog. Lt. #3 reportedly nixed the idea saying that it was too dangerous.

SWAT had not officially been called in. But some SWAT team members had responded to the citywide call for help. Lt. #3 ordered the SWAT team members to form what the report calls an "ad hoc entry team."

The word "ad hoc" in this case means formed from whatever was immediately available. And unfortunately, an entire tactical team was not available. The report says the available tactical team members did not include snipers, hostage negotiators, or tactical operations support. They didn't even have their equipment van although they did have a Lenco Bearcat armored vehicle.[PAGEBREAK]

One of many questions that SWAT operators have been asking about this incident is: Why were two sergeants killed on the same entry team? The report gives insight into why this happened. Sakai and Roman were thrown together on the ad hoc team, which according to the report had never trained together as a team.

Nevertheless by order of Lt. #3 and an assistant chief, identified by local media as David Kozicki, the ad hoc team made entry into the ground floor apartment at 3:02 p.m. What followed was a fierce close-quarter battle.

One SWAT sergeant was mortally wounded as the team entered the apartment. Another sergeant, the first man through the door, was hit in the shoulder. In the middle of the battle Mixon's sister ran out of the back of the apartment toward the officers. The officers "alerted on her," but they did not open fire. She passed through the room without injury, and the report praises them for their fire discipline.

One of the team members spotted Lovelle Mixon behind a bedroom door. He opened fire and Mixon retreated into the bedroom and closed the door. The first officer in the bedroom door was the sergeant with the shoulder wound. He tripped in the dim light and fell in front of Mixon who was now in the bedroom closet. The wounded sergeant saw Mixon holding an assault rifle and opened fire. Other officers also opened fire and Mixon was killed.

The report is extremely critical of the command decisions that sent this ad hoc entry team into the apartment. It cites the following issues:

• The location was not formally scouted and the residents of the apartment building were not evacuated. Also, commanders did not make an inquiry about previous incidents at the address.

• There was no compelling reason to make a dynamic entry. Mixon was not an active shooter and he was not threatening hostages.

• The reports says that dynamic entry was the only option seriously considered. It argues that the commanders should have used negotiators, chemical agents, or dogs to flush Mixon.

• No effort was made to learn the floorplan of the apartment prior to the entry, and the briefing given to the ad hoc team was inadequate.

• Emergency medical personnel were not on hand during the entry.

The report also criticizes the ad hoc entry team for not retreating from the apartment once an officer was hit. "Serious deficiencies in tactics and safety procedures were noted as soon as the ad hoc entry team crossed the apartment's threshold and encountered unexpected high-powered assault rifle fire. The entry team was completely unprepared for this level of resistance and should have withdrawn to safety where careful assessment could be made regarding the new high-risk resistance presented and unanticipated developments," the report says.

Local media has reported that at least two officers, Lt. Mufarrah and Capt. Orozco, have been demoted two ranks for their performance during the incident. Assistant Chief David Kozicki, who was also slammed by the board of inquiry, retired last month.

Oakland attorney Michael Rains, who represents Mufarrah and Orozco, says the officers will contest their demotions. Rains told TV station KTVU that the department "does not need to discipline these very fine people who stepped into a terrible situation and had to make split-second decisions and did so with the information that was available."

Rains has a point. The board of inquiry that created the report met three days in person and several times in teleconferences. Its members then had ample time to come to their conclusions. In contrast, the commanders on the scene were caught up in the moment.

Unfortunately for the command staff of the Oakland PD that argument only goes so far. The report's conclusions are stark and scathing. They paint a portrait of a department in disarray as it reacted to the murder of two of its officers. The chaos, indecision, and bad decisions that followed clearly placed sergeants Romans and Sakai in harm's way.

But it's important to remember that bad decisions and mistakes did not kill Dunakin, Hege, Romans, and Sakai. Lovelle Mixon did.