To Deputy Attorney General
Report and RecommendationsConcerning the Handling
of Incidents Such As the
Branch Davidian Standoff in Waco Texas
- Panelist Alan A. Stone, M.D.
of Psychiatry and Law
Faculty of Law and Faculty of Medicine
Submitted November 10, 1993
Table of Contents
A. Explanation for the delay in the submission of this report
- B. Mandate
III. Account of the Events at Waco
- 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
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
The Justice Department's official investigation published on
October 8th together with other information made available to
the panelists present convincing evidence that David Koresh ordered
his followers to set the fire in which they perished. However,
neither the official investigation nor the Dennis evaluation has
provided a clear and probing account of the FBI tactics during
the stand-off and their possible relationship to the tragic outcome
at Waco. This report therefore contains an account based on my
own further review and interpretation of the facts.
I have concluded that the FBI command failed to give adequate
consideration to their own behavioral science and negotiation
experts. They also failed to make use of the Agency's own prior
successful experience in similar circumstances. They embarked
on a misguided and punishing law enforcement strategy that contributed
to the tragic ending at Waco.
As a physician, I have concluded that there are serious unanswered
questions about the basis for the decision to deploy toxic C.S.
gas in a closed space where there were 25 children, many of them
toddlers and infants.
This report makes several recommendations, first among them is
that further inquiry will be necessary to resolve the many unanswered
questions. Even with that major caveat, I believe the Deputy Attorney
General's suggestions for forward looking changes are excellent
and endorse them. This report makes further specific recommendations
for change building on his proposal.
A: Explanation for the delay in the submission
of this report
This past summer, the Justice and Treasury Departments appointed
a group of panelists, each of whom was to prepare a forward-looking
report suggesting possible changes in federal law enforcement
in light of Waco. For reasons set forth below, I decided that
before submitting a report based on my particular professional
expertise, it was necessary to have a complete understanding of
the factual investigation by the Justice Department. Having now
had the opportunity to read and study that report and the Dennis
Evaluation, I concluded that I did not yet have the kind of clear
and probing view of events that is a necessary prerequisite for
making suggestions for constructive change. Deputy Attorney General
(DAG) Philip Heymann therefore made it possible for me to pursue
every further question I had with those directly responsible for
the Justice Department's factual investigation and with the FBI
agents whose participation at Waco was relevant to my inquiry.
Their cooperation allowed me to obtain the information necessary
for this report.
The Justice Department has sifted through a mountain of information,
some of which, in accordance with Federal Statute, can not be
publicly revealed. This evidence overwhelmingly proves that David
Koresh and the Branch Davidians set the fire and killed themselves
in the conflagration at Waco, which fulfilled their apocalyptic
prophecy. This report does not question that conclusion; instead,
my concern as a member of the Behavioral Science Panel is whether
the FBI strategy pursued at Waco in some way contributed to the
tragedy which resulted in the death of twenty-five innocent children
along with the adults. The Justice Department Investigation and
the Dennis Evaluation seem to agree with the FBI commander on
the ground, who is convinced that nothing the FBI did or could
have done would have changed the outcome. That is not my impression.
I therefore decided it was necessary to include in this report
my own account of the events I considered critical. I have attempted
to confirm every factual assertion of this account with the FBI
or the Justice Department. Although, in my discussions with the
Justice Department, I encountered a certain skepticism about what
I shall report here, I was quite reassured by interviews with
the FBI's behavioral scientists and negotiators, who confirmed
some of my impressions and encouraged my efforts. Because they
share my belief that mistakes were made, they expressed their
determination to have the truth come out, regardless of the consequences.
I hope that this report will bolster the FBI and its new Director's
efforts to conduct their forthcoming review of Waco, which has
not yet begun. I also hope that my report and suggestions for
change will in some measure enable the FBI to work more effectively
with the Justice Department, the Attorney General, and other law
B. Mandate to the panel as I understood it
The mandate to the panelists was "to assist in addressing
issues that Federal Law Enforcement confronts in barricade/hostage
situations 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 motivations
and thought processes are unconventional. How should law enforcement
agencies deal with persons or groups which thought processes or
motivations depart substantially from ordinary familiar behavior
in barricade situations such as Waco? How should the motivations
of the persons affect the law enforcement response? What assistance
can be provided by experts in such fields as psychology, psychiatry,
sociology, and theology?"
There seemed to be two premises in this request by the Deputy
Attorney General (DAG). The first premise was that Waco had been
a tragic event, so it was important for the agencies and the people
involved to examine the evidence, evaluate their actions, and
initiate change based on those conclusions. Second, although there
were questions about the psychiatric status of David Koresh, the
DAG's use of the term, "unconventional," indicated that
we were also broadly to consider groups with "belief systems"
that might cause them to think and behave differently than ordinary
criminals and therefore to be more difficult for law enforcement
to deal with and understand. As I understood it, the Branch Davidians'
religious beliefs were considered unconven-tional," which
was not intended to be a pejorative term, but rather a descriptive
one. The panelists were also told that there was concern among
federal law enforcement officials that more such "unconventional"
groups might, in the near future, pose problems for which law
enforcement's standard operating procedures might not be suitable.
Given this important responsibility and the fact that we were
asked to make recommendations "[c]oncerning the handling
of incidents such as the Branch Davidian Standoff in Waco,
Texas" (emphasis added), I felt unprepared to go forward
without a thorough grasp of the events and decisions that led
to the tragedy. However, the Justice Department was still in the
preliminary stage of their own fact- gathering investigation at
our panel briefings in early July. Hoping to convey the particular
issues of concern to me, I prepared a preliminary report based
on the initial briefings. Since the factual information I wanted
and needed was still being gathered by the Justice Department,
I did not attend the subsequent special briefings arranged for
the panel at Quantico, Virginia. Because of my reticence to furnish
a report based on incomplete information, the DAG and I resolved
that I would submit my report subsequent to the completion of
the Justice Department's factual inquiry. I have now had the opportunity
to 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 Also
Known 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), October
3. Edward S.G. Dennis, Jr., Evaluation of the Handling of the
Branch Davidian Stand-off in Waco, Texas, February 28 to April
19, 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 Law
Enforcement After Waco.
As previously mentioned, the Justice Department and the FBI have
answered my further questions, supplied me with documents, and
helped 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 on
the evening of February 28 and the morning of March 1. There had
been casualties on both sides during the BATF's attempted dynamic
entry. David Koresh, the leader of the Branch Davidians, had been
shot through the hip, and the situation was in flux. It would
become, as we have been told, the longest stand-off in law enforcement
history. The FBI, with agents in place who were trained for rapid
intervention, was locked into a prolonged siege. The perimeter
was difficult to control, the conditions were extreme, and the
stress was intense. Furthermore, the FBI's people had inherited
a disaster that was not of their own making. "Under the circumstances,
the FBI exhibited extraordinary restraint and handled this crisis
with great professionalism" the Dennis Evaluation concludes.
While this may be true from the perspective of experts in law
enforcement, it does not contribute to establishing a clear explanation
of what happened at Waco from a psychiatric and behavioral science
perspective. The commander on the ground believes that the FBI's
actions had no impact on David Koresh. He and others who share
his opinion will likely disagree with the account that follows,
which is the product of my own current understanding of the events.
During the first phase of the FBI's engagement at Waco, a period
of a few days, the agents on the ground proceeded with a strategy
of conciliatory negotiation, which had the approval and understanding
of the entire chain of command. They also took measures to ensure
their own safety and to secure the perimeter. In the view of the
negotiating team, considerable progress was made - for example,
some adults and children came out of the compound; but David Koresh
and the Branch Davidians made many promises to the negotiators
they did not keep. Pushed by the tactical leader, the commander
on the ground began to allow tactical pressures to be placed on
the compound in addition to negotiation: e.g., turning off the
electricity, so that those in the compound would be as cold as
the agents outside during the twenty- degree night.
As documented in the published reports and memoranda, this tactical
pressure began at the operational level over the objections of
the FBI's own experts in negotiation and behavioral science, who
specifically advised against it. These experts warned the FBI
command abut the potentially fatal consequences of such measures
in dealing with an "unconventional" group. Their advice
is documented in memoranda. Nonetheless tactical pressure was
added. Without a clear command decision, what evolved was a carrot-
and-stick, "mixed-message" strategy. This happened without
outside consultation and without taking into account that the
FBI was dealing with an "unconventional" group.
Although this carrot-and-stick approach is presented in the factual
investigation as though it were standard operating procedure for
law enforcement and accepted by the entire chain of command, it
was instead, apparently, the result of poor coordination and management
in the field. Negotiators and tactical units were at times operating
independently in an uncoordinated and counterproductive fashion.
During the third phase of the stand-off, the FBI took a more
aggressive approach to negotiation and, when that failed, gave
up on the process of negotiation, except as a means of maintaining
communication with the compound. By March 21, the FBI was concentrating
on tactical pressure alone: first, by using all-out psycho-physiological
warfare intended to stress and intimidate the Branch Davidians;
and second, by "tightening the noose" with a circle
of armored vehicles. The FBI considered these efforts a success
because no shots were fired at them by the Branch Davidians.
This changing strategy at the compound from (1) conciliatory negotiating
to (2) negotiation and tactical pressure and then to (3) tactical
pressure alone, evolved over the objections of the FBI's own experts
and without clear understanding up the chain of command. When
the fourth and ultimate strategy, the insertion of C.S. gas, was
presented to Attorney General Reno, the FBI had abandoned any
serious effort to reach a negotiated solution and was well along
in its strategy of all-out tactical pressure, thereby leaving
little choice as to how to end the Waco stand-off. It is unclear
from the reports whether the FBI ever explained to the AG that
the agency had rejected the advice of their own experts in behavioral
science and negotiation, or whether the AG was told that FBI negotiators
believed 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 correct
in every detail. It is certainly oversimplified, but it has been
confirmed in its general outline by FBI behavioral scientists
and negotiators who were participants at Waco. This account with
their assistance brings into focus for me the critical issues
about law enforcement response to persons and a group whose beliefs,
motivations, and behavior are unconventional.
A. The FBI's behavioral science capacity
1. FBI expertise in dealing with persons
whose motivations and thought processes are unconventional.
The evidence now available to me indicates that, contrary to my
previous understanding and that of the other panelists, the FBI's
Investigative Support Unit and trained negotiators possessed the
psychological/behavioral science expertise they needed to deal
with David Koresh and an unconventional group like the Branch
Davidians. The FBI has excellent in-house behavioral science capacity
and also consulted with reputable experts outside the agency.
Panelists may have been misled, as I was, by FBI officials at
the original briefings who conveyed the impression that they considered
David Koresh a typical criminal mentality and dealt with him as
such. They also conveyed the impression that they believed his
followers were dupes and he had "conned" them. Based
on reports and interviews, the FBI's behavioral science experts
who were actually on the scene at Waco had an excellent understanding
of Koresh's psychology and appreciated the group's intense religious
My preliminary report of August 3 emphasized at some length those
aspects of David Koresh's clinical history and psychopathology
that contradicted the simplistic and misleading impression given
at the first briefings. Much more information has been made available
about his mental condition, his behavioral abnormalities, his
sexual activities, and his responses under stress. All of this
evidence is incompatible with the notion that Koresh can be understood
and should have been dealt with as a conventional criminal type
with an antisocial personality disorder. However, the evidence
available does not lead directly to some other clear and obvious
psychiatric diagnosis used by contemporary psychiatry. Nonetheless,
based on the FBI's in-house behavioral science memoranda and other
information from outside consultants, I believe the FBI behavioral
science experts had worked out a good psychological understanding
of Koresh's psychopathology. They knew it would be a mistake to
deal with him as though he were a con-man pretending to religious
beliefs so that he could exploit his followers.
This is not to suggest that David Koresh did not dominate and
exploit other people. He was able to convince husbands and wives
among his followers that only he should have sex with the women
and propagate children. He convinced parents on the same religious
grounds to permit him to have sex with their young teen-age daughters.
He studied, memorized, and was preoccupied with Biblical texts
and made much better educated people believe that he had an enlightened
understanding of scripture and that he was the Lamb of God. His
followers took David Koresh's teachings as their faith. He exacted
strict discipline from adults and children alike while indulging
Whatever else all this adds up to, it and other information clearly
demonstrate as a psychological matter that Koresh had an absolute
need for control and domination of his followers that amounted
to a mania. He also had the ability to control them. The intensity
and depth of his ability and need to control is attested to by
everyone in the FBI who dealt with him, from negotiators and behavioral
scientists to tactical agents and the commander on the ground.
Unfortunately, those responsible for ultimate decision-making
at Waco did not listen to those who understood the meaning and
psychological 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 expertise
in behavioral science or in the understanding of unconventional
religious groups. Rather the commander on the ground and others
committed to tactical-aggressive, traditional law enforcement
practices disregarded those experts and tried to assert control
and demonstrate to Koresh that they were in charge. There is nothing
surprising or esoteric in this explanation, nor does it arise
only from the clear wisdom of hindsight. As detailed below, the
FBI's own experts recognized and predicted in memoranda that there
was the risk that the active aggressive law enforcement mentality
of the FBI -- the so-called "action imperative" would
prevail in the face of frustration and delay. They warned that,
in these circumstances, there might be tragic consequences from
the 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, unequivocal
evidence in the report and briefings that the Branch Davidians
set the compound on fire themselves and ended their lives on David
Koresh's order. However, I am also now convinced that the FBI's
noose-tightening tactics may well have precipitated Koresh's decision
to commit himself and his followers to this course of mass suicide.
The official reports have shied away from directly confronting
and examining the possible causal relationship between the FBI's
pressure tactics and David Koresh's order to the Branch Davidians.
I believe that this omission is critical because, if that tactical
strategy increased the likelihood of the conflagration in which
twenty-five innocent children died, then that must be a matter
of 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 adequately
or correctly evaluate the risk of mass suicide. The Dennis Evaluation's
executive summary concludes that "the risk of suicide was
taken into account during the negotiations and in the development
of the gas plan." It is unclear what "taken into account"
means. The questions that now need to be explored are: how
was the risk of suicide taken into account, and how did the
FBI assess the impact of their show of-force pressure tactics
on that risk?
Gambling with death.
There is a criminology, behavioral science, and psychiatric literature
on the subject of murder followed by suicide, which indicates
that these behaviors and the mental states that motivate them
have very important and complicated links. Family violence often
takes the form of murder followed by suicide. Multiple killers
motivated by paranoid ideas often provoke law enforcement at the
scene to kill them and often commit suicide. Even more important
is what has been called "the gamble with death." Inner-city
youths often provoke a shoot-out, "gambling" with death
(suicide) by provoking police into killing them. The FBI's behavioral
science unit, aware of this literature, realized that Koresh and
his followers were in a desperate kill-or-be-killed mode. They
were also well aware of the significance and meaning of the Branch
Davidians' apocalyptic faith. They understood that David Koresh
interpreted law enforcement attacks as related to the prophesied
In moving to the show of force tactical strategy, the FBI's critical
assumption, was that David Koresh and the Branch Davidians, like
ordinary persons, would respond to pressure in the form of a closing
circle of armed vehicles and conclude that survival was in their
self-interest, and surrender. This ill-fated assumption runs contrary
to all of the relevant behavioral science and psychiatric literature
and the understanding it offered of Koresh and the Branch Davidians.
Furthermore, there was direct empirical evidence supporting the
assumption that the Branch Davidians, because of their own unconventional
beliefs, were in the "gamble with death" mode. The direct
evidence 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 ATF
claims gunfire came from forty different locations. If true, this
means that at least forty Branch Davidians were willing to shoot
at federal agents and kill or be killed as martyr-suicide victims
defending their "faith." The idea that people with those
beliefs expecting the apocalypse would submit to tactical pressure
is a conclusion that flies in the face of their past behavior
in the ATF crisis. Past behavior is generally considered the best
predictor of future behavior.
Willing to kill but not cold-blooded killers
The BATF investigation reports that the so-called "dynamic
entry" turned into what is described as being "ambushed".
As I tried to get a sense of the state of mind and behavior of
the people in the compound the idea that the Branch Davidians'
actions were considered an "ambush" troubled me. If
they were militants determined to ambush and kill as many ATF
agents as possible, it seemed to me that given their firepower,
the devastation would have been even worse. The agents were in
a very vulnerable position from the moment they arrived. Yet,
as ordered, they tried to gain entry into the compound in the
face of the hail of fire. Although there is disagreement, a senior
FBI tactical person and other experts confirmed my impression
of this matter. The ATF agents brought to the compound in cattle
cars could have been cattle going to slaughter if the Branch Davidians
had taken full advantage of their tactical superiority. They apparently
did not maximize the kill of ATF agents. This comports with all
of the state-of-mind evidence and suggests that the Branch Davidians
were not determined, cold-blooded killers; rather, they were desperate
religious fanatics expecting an apocalyptic ending, in which they
were destined to die defending their sacred ground and destined
to achieve salvation.
The tactical arm of federal law enforcement may conventionally
think of the other side as a band of criminals or as a military
force or, generically, as the aggressor. But the Branch Davidians
were an unconventional group in an exalted, disturbed, and desperate
state of mind. They were devoted to David Koresh as the Lamb of
God. They were willing to die defending themselves in an apocalyptic
ending and, in the alternative, to kill themselves and their children.
However, these were neither psychiatrically depressed, suicidal
people nor cold-blooded killers. They were ready to risk death
as a test of their faith. The psychology of such behavior-together
with its religious significance for the Branch Davidians - was
mistakenly evaluated if, not simply ignored, by those responsible
for the FBI strategy of "tightening the noose." The
overwhelming show of force was not working in the way the tacticians
supposed. 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 negotiators
asked Koresh and others in the compound whether they planned suicide.
Also documented are Koresh's assurances that they would not kill
themselves. Such questions and answers are certainly important
from a psychiatric perspective in evaluating a patient's suicidal
tendency. But the significance of such communication depends on
the context, the relationship established, and the state of mind
of the person being interviewed. The FBI had no basis for relying
on David Koresh's answers to these questions. Furthermore, his
responses provided no guidance to the more pertinent question:
- `What will you do if we tighten the noose around the compound
in a show of overwhelming power, and using CS gas, force you to
The psychology of control
The most salient feature of David Koresh's psychology was his
need for control. Every meaningful glimpse of his personality
and of day-to-day life in the compound demonstrates his control
and domination. The tactic of tightening-the-noose around the
compound was intended to convey to David Koresh the realization
that he was losing control of his "territory," and that
the FBI was taking control. The FBI apparently assumed that this
tactic and the war of stress would establish that they were in
control but would not convey hostile intent. They themselves truly
believed these tactics were "not an assault," and because
the Davidians failed to respond with gunfire, the FBI considered
their tactics effective and appropriate. The commander on the
ground now acknowledges that they never really gained control
of David Koresh. But, in fact, my analysis is that they pushed
him to the ultimate act of control -- destruction of himself and
The FBI's tactics were ill considered in light of David Koresh's
psychology and the group psychology of the people in the compound.
The FBI was dealing with a religious group, with shared and reinforced
beliefs and a charismatic leader. If one takes seriously the psychological
syndrome of murder/suicide gamble with death and the group's unconventional
belief system in the Seven Seals and the apocalypse, then you
may conclude, as I have, that the FBI's control tactics convinced
David Koresh that, in this situation, he was becoming hopeless
and helpless -- that he was losing control. In his desperate state
of mind, he chose death rather than submission. When the FBI thought
they were at last taking control, they had in fact totally lost
control of the stand-off.
3. The Waco tactics in light of the group
psychology of the FBI
If this had been a military operation, the Waco conclusion would
have been a victory. The enemy was destroyed without a single
loss of life for the FBI. This situation, however, was not a military
operation. The question is: did a "military" mentality
overtake the FBI? We were told that the FBI considers a conflict
which results in any casualties on either side a failure. The
law 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 killed
and wounded Branch Davidians in and around the compound. The FBI
knew that they were in a dangerous situation, and that they confronted
a group of religious fanatics who were willing to kill or be killed.
The FBI's initial decision to mount a stand-off and negotiate
was a remarkable exhibition of restraint under the circumstances.
In retrospect, tactical units will wonder whether an immediate
full-scale dynamic entry by an overwhelming force would have produced
less loss of life.
The FBI stand-off, we were repeatedly told, was the longest in
law enforcement history. The costs in money and manpower were
mounting and, Waco had the media impact of the Iran Hostage taking
as the days mounted. The FBI was under enormous pressure to do
something. Given what I believe the FBI's group psychology to
have been, the desultory strategy of simultaneous negotiation
and tactical pressure was enacted as a compromise between doing
nothing (passivity) and a military assault (the action imperative).
The appeal of any tactical initiative to an entrenched, stressed
FBI must have been overwhelming. It may have better suited their
group psychology than the group psychology of the unconventional
people in the compound they wanted to affect. Given the escalating
pressure to act, the final tightening- the-noose" and C.S.
gas strategy must have seemed to the tacticians a reasonable compromise
between doing nothing and overreacting.
This analysis of the FBI's group psychology is not intended as
a matter of placing blame. If it is accurate, it at least points
to what might be done differently in the future. The FBI should
not be pushed by their group psychology into misguided ad hoc
decision making the next time around.
B. Failure to use behavioral science capacity
1. Failure of coordination between tactical
andnegotiating arms of the FBI
Throughout the official factual investigation, there are references
to the failure of communication between the tactical and negotiation
arms of the FBI. The commander on the ground thinks that the official
investigation and evaluation exaggerate the extent and significance
of that failure. I disagree. The situation can only be fully appreciated
by a thoroughgoing review of the documents. Consider the Memo
of 3/5/93 from Special Agents Peter Smerick and Mark Young on
the subject, "Negotiation Strategy and Considerations."
The memorandum not only defines the basic law enforcement priorities
at Waco in the identical fashion as the after-the-fact panel of
law enforcement experts, also anticipates most of the panel's
own behavioral science expertise and retrospective wisdom. Agents
Smerick and Young were not Monday morning quarterbacks as we panelists
are; 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], who
are 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 this
strategy, if carried to excess, could eventually be counter-productive
and could result in loss of life." p. 2, Memo of 3/5/93.
The agents also were fully aware that Koresh's followers believed
in his teachings and would "die for his cause." They
were fully aware, therefore, of the religious significance of
the Branch Davidians' conduct and attitudes and were sensitive
to all of the concerns emphasized by the religious experts on
the panel in their reports. They suggested that the F.B.I. should
consider "offering to pull back, only if they release
more children" (emphasis in original). The agents further
recommended that, "since these people fear law enforcement,
offer them the opportunity of surrendering to a neutral party
of their choosing accompanied by appropriate law enforcement personnel."
These agents recognized that although some in the F.B.I. might
believe the Davidians were "bizarre and cult-like,"
the followers of Koresh "will fight back to the death, to
defend their property [described elsewhere by the agents as sacred
ground, the equivalent of a cathedral to Catholics, etc.] and
their faith" (emphasis added). Memo of Smerick and
My reading of these memos indicates that these agents had placed
the safety of the children first, exactly as did AG Reno. They
recognized that it was not a traditional hostage situation, as
the British law enforcement expert on the panel, C.E. Birt, repeatedly
emphasized during our briefings of July 1 and 2, when he found
it necessary to correct the misrepresentation of the briefer.
They warned against the carrot-and-stick approach, which was employed
and has been criticized by several of the panelists in their reports.
Professor Cancro speaks of it as a "double bind," a
term used by behavioral scientists to describe a mixed message
for 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 expert
opinions of behavioral scientists and negotiations within the
FBI were overridden. The Justice Department emphasized that these
same agents whose views I have described gave quite contradictory
views the very next day. When I asked whether the Justice Department's
fact- finders had questioned these agents as to why they had changed
their views, no adequate answer was given. I therefore pursued
that inquiry with the agent who authored the two reports. He made
it quite clear that the contradictory suggestions were offered
only in response to an expression of dissatisfaction with the
previous recommendations. Although the commander on the ground
and the official investigation disagree with my view, I have concluded
that decision-making at Waco failed to give due regard to the
FBI experts who had the proper understanding of how to deal with
an unconventional group like the Branch Davidians.
2. Was tactical strategy appropriate with
so many children in the compound?
The pressure strategy as we now know it consisted of shutting
off the compound's electricity, putting search lights on the compound
all night, playing constant loud noise (including Tibetan prayer
chants, the screaming sounds of rabbits being slaughtered, etc.),
tightening the perimeter into a smaller and smaller circle in
an overwhelming show of advancing armored force, and using CS
gas. The constant stress overload is intended to lead to sleep-deprivation
and psychological disorientation. In predisposed individuals the
combination of physiological disruption and psychological stress
can also lead to mood disturbances, transient hallucinations and
paranoid 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 emotional
chaos within the compound. The FBI hoped to break Koresh's hold
over his followers. However, it may have solidified this unconventional
group's unity in their common misery, a phenomenon familiar to
victimology and group psychology.
When asked, the Justice Department was unaware whether the FBI
had even questioned whether these intentional stresses would be
particularly harmful to the many infants and children in the compound.
Apparently, no one asked whether such deleterious measures were
appropriate, either as a matter of law enforcement ethics or as
a matter of morality, when innocent children were involved. This
is not to suggest that the FBI decision-makers were cold-blooded
tacticians who took no account of the children; in fact, there
are repeated examples showing the concern of the agents, including
the commander on the ground. Nevertheless, my opinion is that
regardless of their apparent concern the FBI agents did not adequately
consider 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 wear
a gas mask when entering a tent containing CS gas. They then remove
the mask and, after a few seconds in that atmosphere, are allowed
to leave. I can testify from personal experience to the power
of C.S. gas to quickly inflame eyes, nose; and throat, to produce
choking, chest pain, gagging, and nausea in healthy adult males.
It is difficult to believe that the U.S. government would deliberately
plan to expose twenty-five children, most of them infants and
toddlers, to C.S. gas for forty-eight hours. Although it is not
discussed in the published reports, I have been told that the
FBI believed that the Branch Davidians had gas masks and that
this was one of the reasons for the plan of prolonged exposure.
I have also been told that there was some protection available
to the children, i.e covering places where the seal is incomplete
with cold wet towels can adapt gas masks for children and perhaps
for toddlers though not for infants. The official reports are
silent about these issues and do not reveal what the FBI told
the AG about this matter, and whether she knew there might be
unprotected children and infants in the compound.
The written information about the effects of C.S. gas which was
presented to the AG has been shared with the panelists. We do
not know whether she had time to read it. Based on my own medical
knowledge and review of the scientific literature, the information
supplied to the AG seems to minimize the potential harmful consequences
for infants and children.
Scientific literature on C.S. gas is, however, surprisingly limited.
In the sixties, the British Home Office, commissioned the Himsworth
Report, after complaints about the use of C.S. gas by British
troops in Londonderry, Ireland. The report is said by its critics
to understate the medical consequences. The published animal research
on 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 understated
the potential health consequences in closed spaces. The AG also
had a consultation with a physician; but the exact content of
that discussion has not been reported, and the available summary
is uninformative. The FBI commander on the ground assures me that
the agency has detailed, ongoing expertise on C.S. gas and its
medical consequences. If so, no such FBI information was supplied
in the written material to the AG or subsequently to this panelist.
Based on my review, the American scientific literature on the
toxic 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 published
two articles in recent years in which physicians expressed concern
about the use of C.S. gas on civilians, including children in
South Korea and Israel. Anecdotal reports of the serious consequences
of tear gas, however, approved as early as 1956. Case reports
indicate that prolonged exposure to tear gas in closed quarters
causes chemical pneumonia and lethal pulmonary edema. Gonzalez,
T.A., et al, Legal Medicine Pathology and Toxicology
East Norwalk, Conn: Appleton Century Crofts, 1957). According
to a 1978 report, a disturbed adult died after only a half-hour
exposure to C.S. gas in closed quarters. Chapman, A.J. and White
C. "Case Report: Death Resulting from Lacrimatory Agents,"
J. Forensic Sci., 23 (1978): 527-30) The clinical pathology
found at autopsy in these cases is exactly what common medical
understanding and ordinary pulmonary physiology predicts would
follow prolonged exposure in closed quarters.
The potential effects of C.S. gas are easily explained. C.S. gas
causes among other things, irritation and inflammation of mucus
membrane. The lung is a sack full of membranes. The inhalation
of C.S. gas would eventually cause inflammation, and fluid would
move across the membranes and collect in the alveoli, the tiny
air sacks in the lungs that are necessary for breathing. The result
is like pneumonia and can be lethal. Animal studies are available
to confirm that C.S. gas has this effect on lung tissue. Ballantyne,
B. and Callaway, S., "Inhalation toxicology and pathology
of animals exposed to omicron-chlorobenzylidene malonitrile (CS),"
Med. Sci. Law, 12 (1972): 43-65. The Special Communication
published in J.A.M.A 220 (1993): 616-20 by Physicians for
Human Rights reported that its teams, investigating the use of
C.S. gas in South Korea and Panama, found "skin burns, eye
injuries and exacerbations of underlying heart and lung disease
. . . on civilians at sites far removed from crowd gatherings."
Dermatologists have reported blistering rashes on skin exposed
to self-defense sprays, which use the same C.S. gas. Parneix-Spake,
A. et al, "Severe Cutaneous Reactions to Self-Defense
Sprays, Arch. Dermatol 129 (1993): 913.
The medical literature does contain a clinical case history of
a situation that closely approximates the expected Waco conditions.
Park, S.and Giammona, S.T., "Toxic Effects of Tear Gas on
an Infant Following Prolonged Exposure," Amer. J. Dis.
Child 123,3 (1972). A normal four month-old infant male was
in a house into which police officers, in order to subdue a disturbed
adult, fired canisters of C.S. gas. The unprotected child's exposure
lasted two to three hours. Thereafter, he was immediately taken
to an emergency room. His symptoms during the first twenty-four
hours were upper respiratory; but, within forty-eight hours his
face showed evidence of first degree burns, and he was in severe
respiratory distress typical of chemical pneumonia. The infant
had cyanosis, required urgent positive pressure pulmonary care,
and was hospitalized for twenty-eight days. Other signs of toxicity
appeared, including an enlarged liver. The infant's delayed onset
of serious, life-threatening symptoms parallels the experience
of animal studies done by Ballantyne and Calloway for the Hinsworth
Report. The infant's reactions reported in this case history were
of a vastly different dimension than the information given the
Of course, most people without gas masks would be driven by their
instinct for survival from a C.S. gas- filled structure. But infants
cannot run or even walk out of such an environment; and young
children (many were toddlers) may be frightened or disoriented
by this traumatic experience. The C.S. gas tactics, planned by
the FBI, and approved by the AG, would seem to give parents no
choice. If they wanted to spare their inadequately protected children
the 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 plan
was 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 high
winds at Waco, the C.S. gas was dispersed; they believe it played
no part in the death by suffocation, revealed at autopsy, of most
of 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 hours
after he ordered the operation to begin. As yet, there has been
no report as to whether the children whose bodies were found in
the bunker were equipped with gas masks. Whatever the actual effects
may have been, I find it hard to accept a deliberate plan to insert
C.S. gas for forty-eight hours in a building with so many children.
It certainly makes it more difficult to believe that the health
and safety of the children was our primary concern.
The commander on the ground has informed me that careful consideration
was given to the safety of the children, and that the initial
plan was to direct the gas at an area of the compound not occupied
by them. We will never know whether that plan would have worked:
the Branch Davidians began to shoot at the tank like vehicles
inserting the gas canisters, and C.S. gas was then directed at
all parts of the compound, as previously decided in a fall back
plan recommended by military advisers.
A. The Deputy Attorney General's formulation
The DAG has, in his overview, outlined the critical elements to
be considered in dealing with a situation like Waco in the future.
This is an excellent formulation. Based on what I have learned
and what I have described above, I strongly endorse his formulation
and the recommendations which follow. However, unlike the other
panelists in my group, I am impressed that the FBI has adequate
in-house expertise to deal with unconventional groups like the
Branch Davidians. Furthermore it seems clear that at Waco, the
FBI, was suffering from information overload, if from anything.
Thus, I believe that the crisis management capacity (see
DAG recommendations) and what I would describe as information
management 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 like
Waco would be for everyone involved to consider what went wrong
and what would they now do differently. I must confess that it
has been a frustrating and disappointing experience to discover
that the Justice Department's investigation has produced so little
in this regard. The investigators have assured me that everyone
involved was asked these questions and that few useful responses
were given. An undercurrent of opinion holds that everything depends
and will depend in the future on the commander on the ground.
SAC Jamar, the commander on the ground, knows that he is on the
spot and that there are those who point to his position as the
weak link at Waco. When I asked him what went wrong and what should
be 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 to
discuss their views of what happened. His basic conclusion in
retrospect, however, was that nothing the FBI had done at Waco
made any real impact. His opinion is that Koresh sent people out
because he didn't want them, and not because of the FBI's consciliatory
negotiation strategy. His opinion is that Koresh ended it all
in mass suicide not because of the FBI tactical strategy, but
because that was always his intention. His deep and serious concern
about his responsibilities was impressive and he made it convincingly
clear how much more I and the other experts needed to know about
the facts. On this, he was preaching to the converted. There is
no 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 help
and participation of outside experts, to take on that responsibility.
Indeed, that is my first recommendation. I agree with the FBI's
commander on the ground that we still do not know enough about
what happened at Waco. We need to know more, not in the spirit
of who is to blame, but in the spirit of what went wrong that
can be made right. What can we learn from a careful study of David
Koresh and the Branch Davidians that will help us in learning
about other unconventional groups? What can the FBI learn about
its own behavior at Waco that will help in the future?
Just as I believe the FBI has more work to do, I believe the Justice
Department has work to do as well. No clear picture has emerged
of how and on what basis the AG made her decision. Given on my
current information about C.S. gas, it is difficult to understand
why a person whose primary concern was the safety of the children
would agree to the FBI's plan. It is critical that in the future,
the AG have accurate information, so that she can make an informed
decision. If the only information she was given about C.S. gas
is what has been shown to the panelists then, given my current
understanding, she was ill advised and made an ill-advised decision.
None of these matters have been clarified. Certainly for its own
effective functioning, the Justice Department needs to sort this
out for the future.
The sequence of decision making set out in the earlier account
indicates that the FBI had already moved very far down the branch
of the decision tree before consulting the AG. This made it difficult
for her to make any other choice. Presumably, others in the Justice
Department 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 to
be done differently in the future. I assume that the DAG's recommendation
of a "senior career official" within the Justice Department,
who maintains "a familiarity with the resources available
to the FBI," is a forward looking solution to some of these
2. The FBI needs to make better use of past
experience and existing behavioral science capacity.
As we have been told, the commander on the ground was not selected
because of his past experience in standoffs or because of his
knowledge of unconventional groups. He was the special agent in
charge 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 structure
in place at Waco which could have brought the agency's past experience
to bear. At the first briefings, when asked to describe their
most successful resolution of a standoff with an unconventional
group, an FBI official reported the successful use of a third
party intermediary (negotiator). When I subsequently inquired
about the FBI's previous experience with the successful use of
CS gas, the example given was a prison riot.
These examples speak for themselves and suggest to me that in
making decisions at Waco, the FBI did not make the best use of
its own past experience. The commander on the ground believes
his decision to allow lawyers and the local sheriff to meet with
Koresh is an example of using a third-party intermediary. However,
in their own highly successful resolution of a stand-off with
an armed unconventional group, the FBI used a fellow member of
the religious faith as the intermediary. This option was apparently
rejected at Waco for reasons that I find unconvincing.
The DAG has recommended that a computer database of past stand-offs
be developed. The critical importance of this is to insure that
the FBI makes better use of its own experience. It will be important
for the FBI to distinguish between unconventional groups and prison
populations in deciding which tactical measures are strategically
and ethically appropriate.
3. The FBI needs a clear policy on third
The FBI has well-trained negotiators whose skills are impressive.
Nonetheless, there came a time at Waco when the FBI's frustration
led them to introduce a new negotiating approach. They changed
from a conciliatory, trust-building negotiator to a more demanding
and intimidating negotiator. The change had no effect and may
have 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 gotten
more people out of the compound if the FBI had stayed the course
of conciliatory negotiation. Whether or not that is true, the
FBI reached a point where tactical strategy became the priority
and negotiation under those circumstances became ineffective.
It is my recommendation that this point of change be defined as
a red light, a time when the decision makers in future
standoffs should consider the use of a third party negotiator/intermediary.
The red light should go on when the commander on the ground
or the chain of command begins to feel that FBI negotiation is
at a stand still.
The FBI negotiation and behavioral science experts should, at
the least, develop a policy in consultation with experts on when
they might consider the use of third party negotiators/intermediaries.
The current working policy seems to be that third party negotiators
are counterproductive. The experience justifying that policy needs
to be reviewed in light of Waco. It was a significant omission
at Waco not to involve as a third-party negotiator/intermediary
a person of religious stature familiar with the unconventional
belief system of the Branch Davidians.
4. The FBI and the Justice Department need
a systematic policy for dealing with information overload in a
A critical element of crisis management based on my analysis
of what happened at Waco is information management. Information
overload allows decision-makers to discount all of the expert
advice they are given and revert to their own gut instincts. Alternatively
- as I believe we learn from Waco - the decision-makers can insist
on being given advice compatible with their gut instinct. In my
opinion, the gut instinct that prevailed at Waco was the law enforcement
mind-set, the action-control imperative.
If, as the DAG recommends, the FBI develops a network of academic
experts in behavioral science, religion, sociology, and psychiatry,
the FBI can certainly expect an information overload in the next
crisis. The problem will be how to manage the expert information
overload. This is a complex problem that requires careful consideration
by appropriate experts. However, one pattern that emerged from
my understanding of Waco needs to be changed. The official investigation
lists all kinds of experts who allegedly were consulted or who
took it upon themselves to offer unsolicited advice. It is almost
impossible to determine what all this adds up to. One of my fellow
panelists believes - and I am convinced - that the FBI never actually
consulted with a religious expert familiar with the unconventional
beliefs of Branch Davidians. The investigators at the Justice
Department disagree with this conclusion. My concern about this
is not a matter of fault-finding: it is critical to my concern
about information management in a crisis. The question is: what
counts as a consultation with the FBI? One has the impression
from the Waco experience that a variety of agents were talking
to a variety of experts, and that some of these contacts were
listed as consultations. We are not told how those contacts or
consultations were sorted through. Who in the process would decide
what was relevant and important and what irrelevant and unimportant.
In any event, the prevailing pattern in the information flow during
the crisis was for each separate expert to offer the FBI an opinion.
As a preliminary matter, it seems to me important for the FBI
to establish who the relevant experts are and then arrange through
conference calls or more high-tech arrangements for sustained
dialogue among them, to understand and clarify the dimensions
of their disagreements and, when possible, to achieve consensus.
Information should be exchanged and differences directly confronted
in the circle of consultants; they should not vanish in the information
5. The FBI needs a better knowledge base
about the medical consequences of C.S. gas.
As discussed above, it is my opinion that the AG was not properly
informed of the risks to infants and small children posed by CS
gas. 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, and
although it is understandable that the Justice Department investigation
did not explore medical considerations, a careful evaluation is
clearly indicated. The FBI, the Justice Department, and all of
law enforcement that uses CS gas ought to have as clear an understanding
of its medical consequences as possible. The hasty survey of the
medical and scientific literature done for this report is hardly
definitive. These matters should be sorted out so that the AG
clearly understands what the use of CS gas entails.
6. The FBI needs a specific policy for dealing
with unconventional groups.
The basic conclusion of my account and analysis is that the standard
law enforcement mentality asserted itself at Waco in the tactical
show of force. The FBI should be aware of its own group psychology
and 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 that
it is dealing with an unconventional group, those who urge punishing
tactical measures should have to meet a heavy burden of persuasion.
When children are involved, the burden should be even heavier
and ethical considerations, which need to be formulated, would
come into play.
VI. Final Word
The events at Waco culminated in a tragic loss of life - on that
everyone involved in law enforcement and in the official inquiry
agree. There is a view within the FBI and in the official reports
that suggests the tragedy was unavoidable. This report is a dissenting
opinion from that view. There is obviously no definitive answer;
but my account and analysis tries to emphasize what might have
been done differently at Waco, and what I believe should be done
differently in the FBI's future dealings with unconventional groups.
I endorse the DAG's recommendations for change and offer additional
suggestions. Although such a determination falls outside my province,
it is my considered opinion that the failings of the FBI at Waco
involve no intentional misconduct.