OAKLAND — A newly released internal investigation from BART of the Oscar Grant shooting 10 years ago reveals a more complete picture of the traumatic night, describing an out-of-control cop whose actions escalated the situation, a history of aggression on the part of Grant’s shooter and a department unprepared to take command of the chaotic scene.

Officer Johannes Mehserle was later convicted of fatally shooting Grant, a 22-year-old Hayward man, as he lay belly-down on the Fruitvale station platform on New Year’s Day, 2009. Grant’s death — one of the first to be caught on cell phone cameras — sparked international outrage over police shootings, especially those involving unarmed black men at the hands of the white police officers, and ushered a new era of citizens demanding police accountability.

The internal investigation, obtained by this news organization under a public records request, was released under the state’s new police transparency law, SB 1421, which makes internal records about officers’ sexual misconduct, dishonesty and shootings available to the public.

The report, though heavily redacted, found BART’s police department mishandled nearly every step of its response, from the initial investigation of a reported fight on a train to the lack of supervision from commanding officers and their failure to interview witnesses immediately after the shooting. BART police had a culture of dismissing or not reporting use of force incidents prior to Grant’s shooting, the report found, and some officers lacked basic training in how and when to apply force.

It also casts doubt on Mehserle’s defense in court, in which he claimed he intended to use his Taser, not his gun. Mehserle resigned shortly after the shooting and declined to be interviewed by the firm BART hired to conduct the investigation.

“(Mehserle) can be seen trying to draw it at least two times and on the final occasion, can be seen looking back at his hand on the gun/holster to watch the gun come out,” the report reads. “Deadly force was not justified under the circumstances.”

Mehserle, a 27-year-old who had been working for BART police for only two years, had used force six times in 2008, more than any other officer on the platform that day, and more than most other BART police officers that year, the report found.

If BART had disciplined Mehserle, had suspended him for bad behavior, or otherwise investigated his actions, Grant may still be alive, said Wanda Johnson, Grant’s mother.

“They failed to do anything about it,” Johnson said. “And because they didn’t do anything, and they continued to not hold officers accountable for their actions, my son is dead.”

The department would go on to implement a series of reforms, including establishing an independent police auditor and a citizen police review board to review citizen complaints and provide a higher degree of accountability over BART’s police force. It’s now a department committed to the 21st Century Policing guidelines President Obama issued in the wake of the Michael Brown shooting in Ferguson, Missouri, which sparked another wave of national protests decrying police violence, said Russell Bloom, BART’s independent police auditor.

When officers use force against someone in their custody or care, they must immediately report the incident to their supervisor, Bloom said. That sparks a chain of review that ultimately leads to Bloom, who checks the investigation into the use of force for accuracy and comprehensiveness, including to ensure appropriate disciplinary action is taken.

“It’s a pretty robust system now,” he said, adding that on Friday, he’ll be participating in an all-day conference looking at best practices for civilian oversight of law enforcement. The public is welcome to attend and register at NACOLE.org.

But, at the time, the report found that BART police officers’ own actions, particularly those of former officer Anthony Pirone, contributed significantly to Grant’s shooting. Though he never faced criminal charges, Pirone was fired for his role in the shooting and for the contradictions in his later account of the event, which ran contrary to video surveillance, other officers’ and witnesses’ accounts and even his own retelling.

He and his partner that night, Officer Marysol Domenici, were the first officers to respond to a report of a fight on a train at Fruitvale station. Pirone disregarded his training by entering the train car without Domenici, putting them both in danger, and rushed through the initial investigation, the report found.

Witnesses described Pirone as a “drill sergeant” and “crazy,” “agitated” and “harsh.” One woman said she hadn’t ever seen anything like his behavior in a police officer before.

“The actions of Officer Pirone started a cascade of events that ultimately led to the shooting of Grant,” the report read.

Pirone continuously used profanity when speaking to Grant and his friends and at one point called Grant the “n-word,” an action the report’s authors found inexcusable. He punched Grant in the face and later kneed him in in the head, an action the authors described as “punitive.” He then applied pressure to Grant’s back, preventing him from getting his hands free.

As soon as Pirone released his weight off Grant’s back, Grant put both of his hands behind his back for handcuffing as ordered.

And then Mehserle shot him.

This story was produced as part of the California Reporting Project, a collaboration of more than 30 newsrooms across the state to obtain and report on police misconduct and serious use-of-force records unsealed in 2019.