Independent Review - Moncton Shooting - June 4, 2014

Note: Throughout the document ***** denotes where content was redacted as per the Access to Information Act (R.S.C., 1985, c. A-1) and Privacy Act (R.S.C., 1985, c. P-21). Some photos have also been removed for copyright reasons. Due to the content redactions and removal of photos, the report was re-formatted and therefore differs from the original version submitted to the RCMP.

Introduction The evening of Wednesday, June 4, 2014 in Moncton, New Brunswick was warm and sunny. Children were playing in their yards and on the streets, families were preparing dinner and people were traveling about in their vehicles. No one could have predicted that this bright summer's evening would quickly darken as the tragic events that unfolded would change the lives of many forever. That evening, within 20 minutes, Constables David Ross, Fabrice Gevaudan, and Douglas Larche were murdered, Constables Eric Dubois and Darlene Goguen were wounded, Cst. Martine Benoit survived multiple rounds fired into her police vehicle and several others were exposed to high powered rifle fire. The unthinkable actions of one individual left three families without their husband, son, father, and brother. The Royal Canadian Mounted Police (RCMP) lost three of their own and the community of Moncton and surrounding areas were stripped of their sense of security. People across New Brunswick and the country were shaken to their core as they tried to make sense of such a senseless tragedy. On June 25, 2014, RCMP Commissioner, Bob Paulson sent a message to all RCMP employees stating, "the death of our three members in the course of duty and the near deaths of many others demand that we seek to fully understand the facts, learn from them and, if required, change our practices promptly." On June 30, 2014, the Commissioner appointed Assistant Commissioner Alphonse MacNeil (ret'd) as the Reviewer to undertake an independent review of the circumstances surrounding the shootings. The Commissioner granted a 90 day timeframe to submit a report and identified 13 areas which he wanted reviewed and applicable recommendations made. As Reviewer, I assembled a team to assist in this fact-finding mission and address the 13 areas highlighted by the Commissioner. The team was comprised of RCMP employees from across Canada who have expertise in a multitude of disciplines. In addition, the team received assistance from a number of contributors who are subject matter experts in their respective areas. Our goal from the beginning was to learn from this tragedy so that members in the future, who perform their duty at enormous personal risk, will have the best training, tools and operating procedures the RCMP can provide. Reviews of this nature involve much more than simply conducting an investigation and writing a report. The team conducted a thorough and detailed review but never once lost sight of the fact that members of the Force were killed and injured and many others were impacted in ways that most of us will never understand. We have met with families of the fallen and have collectively spoken with hundreds of people including the members who were present while shots were being fired and many others who responded in the following days. We have talked with civilian witnesses and walked their neighbourhoods countless times to piece together what took place. For those we spoke with, this process was not easy. Wounds were fresh, healing had just begun and people were only beginning to pick up the pieces and move forward. The willingness of the people of Moncton to speak with us and provide information despite their painful memories was remarkable and something we will not soon forget. With this Review there were anticipated and unforeseen challenges. The duration for the Review (90 days) was driven by a need to identify any shortcomings as soon as possible in an effort to mitigate the risk to other members of the Force, however, the time allotted did limit the depths to which some issues could be explored. Nevertheless, we are confident that we had the time, the resources and the independence required to assess the 13 areas within the Review's mandate to identify key issues and suggest improvements. To conduct the Review, the team had to first establish exactly what occurred on June 4, 2014, and the days that followed. To accomplish this we studied pertinent aspects of the Major Crimes investigation and in addition reviewed OCC transmissions, member-to-member radio and telephone communication, 911 calls, video footage, civilian and member statements as well as forensic evidence. The team also re-interviewed multiple members and civilians and attended the scenes with members who were directly involved to obtain first-hand accounts. The information we relied on to understand what took place was largely dependent upon the memories of those involved, including both citizens and police. Following a traumatic event, memories are affected by the trauma, time, subsequent discussions with others and exposure to media, photographs and video. There is an abundance of psychological literature and scientific research on the fallibility of memory in high-stress situations and this supports what we have seen in our Review. Current literature indicates that perceptions are often not the same for officers involved in the same incident. Distortions can include tunnel vision and memory loss for parts of the event. It is natural for officers involved in a traumatic event to not recall or have inaccurate recollections of what took place. As a result of this, the positions of some individuals at key points during the incident are approximations based on the totality of the information available to the Review Team. It is expected that those who read this report who were involved in this incident may experience further evolution of their recollections as they process the information contained herein. Although we analyzed the statement of Justin Bourque, the fact that he was still engaged in the judicial process precluded me from interviewing him. This limited our ability to ask him key questions that could have provided greater insight into his actions and his background. It would be beneficial to interview Justin Bourque to determine what motivated him and to gain insight into how this tragedy could have been prevented. This report opens with a narrative description of what happened from the first 911 call until the subject of concern is arrested 29 hours later. We then examine the 13 questions in the order presented by the Commissioner: Tactics and Response to the Initial Call, Decision Making and Risk Assessment to the Initial Call, Supervision, Evolving Response, Equipment and Weapons, Member Training and Officer Safety Skills, Operational Communications, Communications and Media, Broader Policy Review, Firearms Possession by Accused, Perpetrator Information/Intelligence, Aftercare of Employees and Implementation of Mayerthorpe Recommendations. I would like to take this opportunity to recognize the exceptional work of the team assembled to conduct this Review. They worked long hours with limited time off to produce a product they are deeply invested in. They were exposed to every detail of this horrific incident and will carry the related impact of that exposure. As RCMP employees, they feel this tragedy in a way that motivated them throughout the Review. It is my hope that the recommendations I put forward in this report will contribute to the safety of the membership and enhance the quality of service that supports all RCMP employees and family members. I want to acknowledge the extreme bravery of those who gave and risked their lives to protect others within the community of Moncton and above all else pass on to the families of those who lost their lives our sincerest sympathy.

Narrative Description

June 4, 19:18 to June 6, 00:20 Initial Response to the 911 Call At 19:18 the Operational Communication Centre (OCC) in Moncton received a 911 call reporting a subject of concern (SOC): a male wearing camouflaged clothing walking down the middle of the road towards the woods on Pioneer Avenue, carrying two long guns and bullets. He proceeded into the woods at the western end of Pioneer. The first caller stated she did not see his face but he appeared to have something on his mind; he appeared to be on a mission. Another caller stated that the SOC's expression made her believe he was a threat. This call was dispatched at 19:20 to Cst. Jay Doiron, with Cst. Mathieu Daigle and Cst. Shelly Mitchell as backup. Cst. Eric Dubois responded as backup as well. As the call was being dispatched Cst. Rob Nickerson, Cst. Fabrice Gevaudan, Cst. Andrew Johnstone, Cst. Eric White and the acting Sgt., Cpl. Jacques Cloutier, were finishing a briefing at the Codiac detachment. Codiac members have subsequently told the Review that a call of a suspicious male with a firearm was common in Moncton. In this case, however, there were multiple calls about this individual, including descriptions of the suspect's demeanour. Cst. Nickerson, Cst. Gevaudan, Cst. Johnstone and Cst. White all responded to assist in setting up a perimeter (Nickerson was initially asked to patrol the area). Cpl. Peter MacLean and Cst. Michel Martel partnered up and also responded, with Cst. Martel signing out a shotgun before departing. Cst. Dave Verret ***** when he heard numerous members being dispatched to this call. He went back on the road and took up a perimeter position as directed by the OCC. The Perimeter Set-up Cst. Doiron went to Pioneer Avenue in search of more information about the SOC and spoke to a complainant who was outside and still on the 911 call. He obtained additional information on the suspect's direction of travel and demeanour. He parked at the west end of Pioneer (a dead end) where the suspect was last seen and, with his pistol drawn, walked through the wooded area to a relatively narrow clearing. This clearing consisted of a dirt path that extends from the barricaded end of Mailhot Avenue. The SOC appeared to have taken a path into the wooded area on the western side of the clearing. After following for a few metres, Doiron reassessed the risk, returned to the clearing and took cover behind a telephone pole. That section of woods is very dense with poor visibility, so much so that a camouflaged person 20m away could easily hide from view. Doiron held his position and requested a perimeter be established on the residential streets around the woods and that additional back up and Police Dog Services (PDS) be dispatched. Initial perimeter positions of all officers responding to the initial complaint. Bourque's path is the red line. Cst. Eric Dubois attended Pioneer Avenue as back up for Cst. Doiron. Cst. Daigle was dispatched to the Rennick Road/Shannon Drive area which is where the SOC would appear if he maintained course. Daigle exited his vehicle and positioned himself at a fence behind an apartment building at 185 Rennick Road. Other officers were responding to the call and approaching from this direction as well. Cst. Mitchell had originally gone to Lonsdale Drive, but then made her way to the Shannon/Rennick area, as did Cst. Gevaudan. Cst. Nickerson was still patrolling the area at this time. Cpl. James MacPherson was working in plain clothes on a major crimes investigation and heard this situation developing on the radio. Knowing the area well, he informed members that the wooded area off Bromfield Court comes out on Willshire Way. Cst. Johnstone drove to the end of Mailhot where he could see Cst. Doiron. Doiron requested an ETA for PDS and was subsequently informed by Cpl. Cloutier, by phone, that PDS would be delayed. Johnstone teamed up with Doiron. Cpl. MacLean directed the OCC to have someone speak to the witness to get the best possible description in an effort to try to identify the suspect. Cst. Dubois took on this task and repositioned to the end of Pioneer. Cst. Dave Verret was directed by the OCC to position on Lonsdale Drive to the north of the wooded area. Cpl. MacLean and Cst. Martel were approaching the area in the same vehicle. Cst. Eric White was en route. As numerous members approached with sirens on, the SOC would have known that police were closing in. Establishing Contact with the Subject of Concern Cst. Daigle heard cracking coming from the woods and observed the SOC, carrying something, come out of the woods on the north side of Bromfield Court and quickly cross to the woods on the south side of the Court. Daigle later stated the suspect was walking in a stealthy manner, as though he was hunting (stopping, listening, etc.). Cst. Daigle broadcast that he saw the suspect walking near a new housing development and he appeared to be carrying something (Daigle did not know the street name but the OCC confirms it is Bromfield Court). He then stated on air that he saw the suspect cross the street and enter a wooded area walking in the direction of Ryan Street. This is the wooded area which borders the backyards of residences on Bromfield, Mailhot, Bellerose Court and Willshire Way. At this point, Cst. Daigle attempted to close the distance with the suspect while maintaining visual contact. It did not appear that the SOC had seen Cst. Daigle. After speaking with witnesses on Pioneer Avenue, Cst. Eric Dubois broadcast a confirmation of the SOC's description: "male, late 20s, camouflaged all over, a brown headband, shoulder long brown hair, he has a bow on his back, maybe two rifles, a knife on one leg, and he was really bizarre to everyone, walking straight, possibly under the influence of something." Some radio static was heard as the SOC's demeanor was being described and this made it difficult to understand what was being said. After Cst. Daigle broadcast his latest sighting of the suspect, members began to adjust the perimeter accordingly. It is important to remember that this incident occurred early on a warm, sunny Wednesday evening and that, after a string of rainy days, many residents were outside taking advantage of the pleasant weather. Cst. Gevaudan, Cst. Mitchell and Cst. Nickerson parked their vehicles in the vicinity of the apartment building at 185 Rennick Road and proceeded on foot to Bromfield to back up Cst. Daigle. They spoke briefly with him near where the suspect had last entered the woods. After observing children playing in the backyards on Willshire, Csts. Nickerson and Mitchell went to direct them to go into their homes. Residents located in their backyard about 45m south of the SOC could hear police shouting for people to get in their homes. Csts. Daigle and Gevaudan continued along the treeline of the wooded area on the south side of Bromfield toward Mailhot, trying to see the suspect. They made their way into the woods beside 15 Bromfield just to the south of the home. At this point, Cst. Nickerson was returning from Willshire through the woods and was the next closest member to Daigle and Gevaudan. They can be heard on the radio communicating each other's relative positions as they closed in on the SOC. At about the same time, Cst. White, Cst. Martel (armed with a shotgun) and Cpl. MacLean were approaching Willshire Way (by car). Cst. Mitchell was also making her way back from the direction of Willshire Way. Cst. Doiron, whose vehicle was still on Pioneer, got in with Cst. Johnstone and they drove to Bromfield, parking in the driveway across the street from 15 Bromfield. In total, there were eight members in or approaching the small wooded area. The members were now within 100m of the SOC, attempting to regain visual contact and awaiting the arrival of Police Dog Services. They repeatedly asked about details on the dog handler's arrival. It is during this approach that they were informed by Cpl. Cloutier that "it is going to be a few minutes" before the dog handler, Cst. Ross is mobile. Contact with Subject of Concern & Shooting of Constable Fabrice Gevaudan Cst. Daigle saw the SOC in the woods behind 15 Bromfield and radioed that the SOC was walking away from him. This meant that the SOC was about to leave the woods and enter a backyard. PHOTO Cst. Gevaudan and Daigle conferred briefly, after which Cst. Gevaudan moved around the back of 15 Bromfield to within 30m of the SOC while Daigle moved around the front of the house towards its far side, based on eyewitnesses and physical evidence. Cst. Gevaudan had his pistol drawn and was pointing in the vicinity of the SOC. Cst. Gevaudan was partially concealed from the SOC by trees, but these trees afforded minimal cover. Cpl. MacLean and Cst. Martel, travelling in the same vehicle, broadcast their arrival at Willshire Way just as Cst. Gevaudan directs members to, "clear the air." In his statement the SOC said he heard someone yell "hey!" He turned, saw a police officer and fired three quick shots; his bullets struck small trees about 5m in front of Gevaudan, before striking the residence behind Gevaudan. The SOC did not appear to notice any police officer but Gevaudan. At this point Cst. Daigle was just reaching the north corner of the house A split view of the backyard where Cst. Gevaudan was shot. The first is Cst. Gevaudan's view of the shooter's position. The second is near the shooter's view of Cst. Gevaudan's position. After the first shots were fired, Cst. Gevaudan ran northeast. Gevaudan radioed, "he's shooting at me, he's shooting at me". The gunman fired two more shots: one had an unimpeded trajectory and the other skimmed along the side of a birch tree. Both bullets hit Cst. Gevaudan in the side of the torso from a distance of about 30m and produced wounds which were almost instantly fatal. Cst. Nickerson who had just joined Daigle at the house saw Cst. Gevaudan run behind the back of 19 Bromfield and drop from sight after the last shot but could not see the shooter. The time was 19:47. Suspect Evades Containment & Shoots Constable Dave Ross Once the first, very loud shots were fired, everyone's focus was on tactically repositioning, most did so around the front and side of 15 Bromfield. It wasn't clear that Cst. Gevaudan had been shot. From the road a member caught a glimpse of the gunman fleeing the scene of the shooting, passing through backyards on Mailhot. The gunman emerged just southeast of McCoy Street. To get a better sense of the neighbourhood and the relative locations of houses, several features are noteworthy. Most of the houses do not have fences so it is easy to cross yards quickly. There are trees, landscaping features and sheds in many backyards, so while there is a sense of openness, many sightlines are interrupted. Some of the key sightlines referenced in this report no longer exist as some fences have since been built and vegetation has grown. The street numbering in much of this area increases by increments of six (e.g. 166 Mailhot is next door to 172 Mailhot) but on Bromfield 15 is next door to 19. At this time, Cst. Dave Ross was rapidly approaching 15 Bromfield *****. His situational awareness may have been limited to his brief telephone conversation with Cpl. Cloutier and the OCC before any shots had been fired. He may have heard the broadcast, "shots fired" and "he is shooting at me," However, he would not have known a member had actually been shot. He turned his vehicle right off McCoy onto Mailhot toward Bromfield. Cst. Johnstone, who had moved to the corner of Mailhot and Bromfield, directed Ross to turn around. Cst. Ross completed a U-turn and stated over the air, "got a visual, will be on takedown in a second." At this point, the suspect was calmly walking away (southeast) down Mailhot moving his rifle from one hand to the other. Ross accelerated quickly towards the gunman who was at this point across the street from two civilians in a vehicle that had come to a stop. The gunman turned around to face Ross' oncoming police vehicle. Cst. Ross turned on his lights and drew his pistol as he rapidly closed in on the gunman. Ross fired two rounds through the windshield towards the shooter. There is a photo widely circulated in the media showing a very close grouping of three rounds in the police vehicle windshield. Two of those rounds were from Cst. Dave Ross's handgun, and only one round was from the weapon of the gunman. Cst. Ross' windshield with Bourque's shots in red and Cst. Ross' in blue. It is possible that Ross was trying to hit the shooter with his vehicle (the throttle control sensor and fuel line in the police car were hit with one of the first rifle shots, causing a loss of propulsion). Six rounds were fired at Ross, beginning while his vehicle was approaching and continuing as the vehicle rolled a short distance past the shooter. Cst. Ross was struck by bullets to the thumb of his gun hand, his head and his left shoulder area. The head wound killed him instantly. The time was 19:49:51. Between the time of the first shots at Cst. Gevaudan and the shooting of Cst. Ross, members took cover at the front of 15 Bromfield. Members moved through the front yard in the direction of Mailhot while others took up positions at the northeastern corner of the house, beside a small basketball court on the property. Cst. Daigle can be heard attempting to communicate with Cst. Gevaudan by radio. Members had yet to see Cst. Gevaudan's body before Cst. Ross was under fire. The time between the murders of Cst. Gevaudan and Cst. Ross was just two minutes. Cpl. MacLean walked across the basketball court until he saw Cst. Gevaudan lying face down behind the backyard of 19 Bromfield. He went to Gevaudan, rolled him over and saw two visible gunshot wounds. He removed Gevaudan's vest, applied pressure to the wounds and checked for vital signs; believing that he detected a faint pulse but no breathing. He was joined by Cst. Nickerson, who quickly recognized the need to take cover. Cst. Daigle arrived and the three moved Gevaudan to a shallow gully beside a wooden fence for some cover. Cst. Johnstone arrived and Cpl. MacLean instructed the members to do what they could for Gevaudan before he took Gevaudan's radio and left to pursue the gunman. The members took Gevaudan to the front of 19 Bromfield and into the garage. Cst. White recalled approaching the intersection of Bromfield and Mailhot and observing Cst. Ross do the U-turn on Mailhot. He heard Cst. Ross's PDS vehicle racing down Mailhot and then heard shots just as he was about to round the corner of the home at Bromfield and Mailhot. He saw the PDS vehicle stopped in front of 166 Mailhot, 240m from his location. White ran towards the PDS vehicle, going from house to house for cover. He approached the driver's side window and noted that it was fractured but not broken out. Ross was slumped over, unresponsive, in the driver's seat with visible injuries to his neck and face. Wanting to better assess the condition of Ross, White smashed the window with his hand to unlock the vehicle. He scanned and saw the gunman step onto the street about 100m to the southeast on Mailhot beginning to take aim at him. White sought cover behind Ross' vehicle and observed the gunman go between 143 and 149 Mailhot. This property line leads to a wooded area beside the Hildegard Fire Station. White advised over the radio where he had seen the gunman. He then returned to retrieve Ross and dragged him to a fenced area in the yard beside 166 Mailhot. He quickly realized that Cst. Ross was dead. In response to Cloutier's asking who was injured, White responded with, "Ross is down, Ross is down." White was joined at this location by Cpl. MacLean and Csts. Mitchell, Martel, and Doiron. Scene of Cst. Ross' shooting on a residential street near a parked SUV and bicycle. Bottom Right inset (redacted photo) – Bourque just before shooting Cst. Ross. The centre bottom inset shows the position of spent casings. At about this point Cpl. MacLean broadcasts, "get ERT…call ERT, we need everything we've got!" Shootings on Hildegard Cst. Martine Benoit and Cst. Nick Gilfillan were in the office after a dayshift and were monitoring the call of a suspicious male on the radio. When it was reported that shots had been fired, Cpl. Cloutier came out of his office and said he needed everyone on the road. Cst. Benoit deployed immediately and Cst. Gilfillan, who had already changed into civilian clothes, went to change back into his uniform before responding. At approximately the same time, Major Crimes Unit members Cpl. MacPherson, Cpl. Jean Belliveau, Cpl. Michel Dupuis and Cst. Doug Larche, who were working in plain clothes on an unrelated investigation, returned to the detachment to obtain shotguns to respond as backup. Cst. Benoit drove to the area with lights and sirens activated and turned onto Hildegard Drive just as the OCC reported the suspect was at Hildegard and Mailhot. Of note, the OCC had taken a call from a witness who had actually been following the gunman on Hildegard. The witness first observed the gunman laying in the grass near the Hildegard Fire Station aiming his rifle northeast up Hildegard in the direction of Mountain Road. The caller then observed the gunman get up and walk southwest on Hildegard toward the intersection at Mailhot. The gunman went into a slow jog at one point, crossed Mailhot with the civilian following at a distance, and entered the treeline at the bend in Hildegard just west of Mailhot. This call lasted almost three minutes and the information as to where the gunman entered into the woods was dispatched to members. The OCC operator informed the witness that a police car should be approaching his location. The caller stated he could see the police vehicle and the call with the OCC ended. The time was 19:54 hours. Cst. Benoit was flagged down by several civilians at Hildegard and Mailhot and they pointed to where the gunman entered the woods. She parked her vehicle at the intersection and started opening her door but did not exit the vehicle. She was assessing the situation when she began to take fire. She ducked down to use the engine block as cover and tried to reverse her vehicle, but it wouldn't move as it had been disabled by the gunfire. Cst. Benoit radioed that she was being shot at and the shots were coming from in front of her vehicle. Cst. Benoit was never able to see the shooter. Witnesses later stated the police officer couldn't see the shooter because he was ducking down and would only pop his head up every few seconds, from a deeply shaded and wooded ditch. Cst. Benoit also advised over the radio that her car was disabled. On several occasions, Cst. Benoit asked via radio if it was safe to get out of her car and requested assistance. Cst. Eric Dubois, who left Bromfield Court to retrieve his vehicle from Pioneer Avenue, was now stationed at Hildegard and Mountain to block traffic. On hearing Cst. Benoit's request for assistance, he drove to her location and positioned his vehicle next to Cst. Benoit's where he felt it would provide additional cover from the shooter. He told Cst. Benoit to reposition behind his vehicle. The gunman fired several more shots at them and Cst. Dubois was injured while trying to spot the shooter's position. Cst. Dubois ran to the fire station after observing the gunman cross Hildegard. Cst. Benoit, not knowing the gunman had left, decided to remain behind cover and called for someone to get her. Cst. Nick Gilfillan, who had just arrived at the fire station, drove to her location. She got into his car and they returned to the fire station. Both Cst. Benoit and Cst. Dubois mention lulls in the shooting. A media photographer took several photos of Benoit and Dubois behind Dubois' vehicle (see below), with civilian traffic in the background. He was unknowingly taking these photos from a location on Hildegard just northeast of and across the street from the shooter. Redacted map and photo depicting shots fired at ***** can be observed behind the police vehicle. Cst. Goguen was working in the Southeast District, which borders on the Codiac detachment area. Southeast District uses a different radio frequency and is dispatched through the OCC at "J" Division Headquarters in Fredericton. Members are able to use ***** which allows them to hear radio broadcasts from other channels but these are overridden by any simultaneous broadcasts on their own channel. Cst. Goguen learned about the situation unfolding in Codiac *****. She subsequently phoned her supervisor, Cst. Donnie Robertson and while speaking to Cst. Robertson, he turned on his radio ***** and heard Cst. Benoit on the radio saying she was under fire. Cst. Goguen then heard Sgt. Andre Pepin requesting backup be provided by Southeast cars close to Hildegard. Cst. Goguen replied she was close and was instructed to go to the Hildegard Fire Station. She encountered several civilian vehicles doing U-turns on Hildegard and then heard gunshots nearby. Cst. Goguen was turning her car around when she heard more shots and the front passenger window was shot out of her vehicle and two rounds hit the passenger door above the door handle. As she drove away, another shot broke her driver's window. Six bullets struck Cst. Goguen's car with at least four of them coming extremely close to or striking her. After the last round was fired at Cst. Goguen, the shot was fired that wounded Cst. Dubois. The Complexity of the Situation – Multiple Events Unfolding As Cst. Goguen was operating on a different channel and the OCC in Codiac was not aware she was attending the scene, there was confusion as to how many members were shot, the location of the shootings, where the suspect was and where ambulances were needed. There were two erroneous reports broadcast about shots fired on Lonsdale and the gunman being at the 'corner of Lonsdale and Mailhot' (this is not an actual civic location) as well as a report of him being on Foxwood Drive moving towards Ryan when he had in fact already crossed Hildegard and was heading towards Mailhot. Cst. Goguen had eventually driven to Penrose Street after being assisted by Cst. Robertson. He and Cst. Ugo Desjardins, also from Southeast District, provided protection for her and requested an ambulance. At this time, the members tending to Cst. Gevaudan were waiting for an ambulance at 15 Bromfield. The location of Bourque as he fired upon Cst. Benoit, Cst. Goguen and Cst. Dubois. Glass is depicted where Cst. Goguen's window was hit. The inset to the bottom right is a redacted photo of Cst. Goguen's vehicle driving off, after shots impacted. The redacted photo to the bottom left is Bourque walking away from this shooting scene. There was also confusion as to the condition of Cst. Ross, and thus it was believed an ambulance was needed at 166 Mailhot. In addition, Cst. Dubois had requested an ambulance at the fire station and now Goguen's colleagues were requesting an ambulance at Penrose. As per their policy, no ambulance can enter the area of an active shooting. Goguen was eventually transported to the hospital by her colleagues who realized the ambulance was not coming. Cst. Dubois was transported to hospital by Cst. Mitchell in a car she had commandeered from a civilian. Hildegard Fire Station The fire station parking lot became a staging area for police just out of the line of fire on Hildegard. Cpl. Lisa Whittington had just started her shift as the night shift supervisor at 19:00, responding from the office after Cpl. Cloutier requested she assist Cpl. MacLean in supervising at the scene. Also at the fire station were Csts. Doiron, Gilfillan, Martel, Benoit, Verret and Johnstone. After transporting Cst. Goguen to the hospital, Csts. Robertson and Desjardins also returned to the fire station. Civilian traffic, both on foot and in vehicles, in the area of the shooting was steady throughout the incident. Due to the fact that the gunman had ample opportunity to shoot multiple civilians, members began to make the assumption that the gunman was targeting only police officers. Due to this, members took cover at the fire hall. Video footage of the fire station scene during this time captures the sound of gunfire from the shootout between Cst. Larche and the gunman. It is broadcast that a civilian is down on Isington (this in fact was Cst. Larche who was not in uniform). Constables Doiron, Gilfillan, Martel and Verret determined that this was a "game-changer" and began moving toward Isington. Gilfillan put on his HBA and instructs other members to do the same. They begin moving as a team down Mailhot toward Isington. Shooting of Constable Doug Larche Cst. Doug Larche, one of the plain clothes MCU members who returned to the detachment to retrieve a shotgun before attending the scene, pulled up to the stop sign at Isington at the corner of Mailhot facing west. He radioed to the OCC that he was going to be out on foot at Isington and Mailhot and got out with a shotgun. Cst. Larche did not mention seeing the gunman. The gunman was seen (by a civilian) walking down Mailhot toward Larche's position and, upon seeing Larche, he stepped into the trees beside 71 Isington (the house on the corner of Isington and Mailhot). When he recognized Larche was a police officer because he was wearing soft body armour (SBA), he fired four rounds at him from the concealed position within the trees at the west side of the house. Larche was wounded by rifle rounds passing through his vehicle and dropped to the ground. The gunman went behind 71 Isington and came out on the opposite side of the house. Larche somehow found the strength to get back up and fire his weapon but was ultimately killed by a shot to the head from gunfire from the east side of 71 Isington. It is known that Larche fired a total of seven shots from his service pistol during this 70 second exchange of gunfire. The time was 20:07. Cst. White heard a call that there was an officer down at 16 Mailhot Avenue. He was already heading in that direction so he kept going on foot from backyard to backyard. He came around a house and saw Cst. Larche's shot-up vehicle and several civilians standing around the scene. One of the civilians pointed down Isington Street and said the gunman had been standing there five minutes ago but had run behind the houses. Cst. White and a civilian moved Cst. Larche's body inside 71 Isington. Cst. White called in his location as well as the status of Cst. Larche. When civilians began to gather around Larche's vehicle again, White went outside and retrieved Larche's pistol, shotgun and radio from the ground. The period of time between the shooting of Csts. Fabrice Gevaudan, Dave Ross and Doug Larche was a total of twenty minutes. Map view of Isington Street and Mailhot Aveue depicting Cst. Larche's position and Bourque's location and path around the residence. Photo insets, bottom left depict the first location where Bourque shot Cst. Larche in the backyard of a residence. Bottom right depicts Cst. Larche's vehicle. The gunman was observed after the final shooting fleeing into the woods behind Isington Avenue, and crossing into the woods south of Ryan Street. This was the last time the shooter was seen for the next several hours. After the gunman entered the woods, members held their positions and did not pursue the suspect further. Post Shooting Manhunt The description of this portion of the manhunt phase of the incident will be less detailed than the account of the shootings. The following provides a broad sense of who was in charge at key points during the manhunt, how command structures were established, what actions were taken as resources were mobilized and the arrest of the suspect. Initially, Cpl. Jacques Cloutier, the acting Sgt. was in command from his office at Codiac detachment, which became the centre of operations. While Cloutier was extremely busy calling-in and deploying resources for containment, members at the scenes were largely left to manage on their own. Within half an hour of the first shots, commissioned officers and senior NCOs began to gather at the Codiac detachment. The command structure became less clear to some staff with the arrival of the Codiac Operations Officer, Insp. David Vautour at 20:20. Both continued managing different aspects of the incident from the same office. Insp. Vautour became the Incident Commander at that point, a scribe was appointed and staff were given specific tasks. First responders on the ground were not made aware of the command structure. Both Cloutier and Vautour were extremely busy and the situation in Codiac detachment was hectic. Information was coming in by telephone, radio, CIIDS, direct reports from members in person, and media reports. *****. Supt. Tom Critchlow, a Critical Incident Commander (CIC) arrived at Codiac detachment, *****. He assisted Insp. Vautour and Cpl. Cloutier, ***** No broadcast was made by a commander regarding the specific threat presented to members although members were becoming aware through word of mouth. Some on scene members did not know the full extent of casualties until many hours later. The last known location of the suspect near Ryan Street and Wheeler Boulevard, was attended by many members who were on foot or sitting in marked police vehicles. Without knowledge of the location of the suspect, they were later determined to have been in a very vulnerable position. The first two "J" Division Emergency Response Team (ERT) members to arrive on scene linked up with a Police Dog Service member who believed his dog had identified a starting point from which to track the suspect into the wooded area between Ryan Street and Highway 15. When two more ERT members arrived, the PDS member began tracking into the woods with the four ERT members in support. When the team leader, who was still driving to Moncton, was informed of this pursuit he ordered them to stop as it was nearly dark and the risk of ambush was too high. At this time, which was still within an hour of the last shots being fired, police from other districts and detachments, municipal agencies and "H" Division members poured into Moncton in response to Codiac's requests for resources. No mechanism to track and coordinate these resources was in place and members began arriving in the Moncton area without direction on where to go or what to do. *****. Throughout the evening, members were responding to unconfirmed sightings of the gunman that were broadcast via radio without sufficient information and tactical awareness. In addition they did not maintain set positions within the semi-established and loosely held perimeter. Many members took positions and responded to broadcasted information without informing anyone in charge or seeking clarity on who was in charge. The OCC and others were assigning members to general perimeter locations, however, members were not told to report their positions. No one at the Codiac detachment was keeping track of these locations, members' identities, additional weaponry on site or the duration of the shifts members were working. Members who were interviewed by the Review Team described this period of time as chaotic and disorganized. Map depicting 'lock-down' area. The red lines depicts Bourque's known movements and the red circle 'B' is his arrest location. Shortly after 21:15, pictures of the gunman walking away from the scene of the shootings on Hildegard appeared in news reports and social media. The photo-journalist who had witnessed the shooting of Cst. Goguen took the pictures with a telephoto lens shortly after that shooting. Family and friends of the gunman quickly called 911 and identified him as Justin Bourque, a 24 year-old Moncton resident who lived at 13 Pioneer Avenue. *****. The Moncton Coliseum (a building with large parking lots about two kilometers from the scene) was initially identified by staff at Codiac detachment as a command post location and arriving members were directed there. Inspector Kevin Leahy, the first accredited Critical Incident Commander (CIC) assigned to the incident decided this was a poor location and it was subsequently moved to the Moncton Garrison Canadian Forces Base Gagetown – Detachment Moncton, formerly known as CFB Moncton. Ultimately, this critical incident command post was not operational until approximately 03:00 on June 5. During the manhunt there was a wide range of concurrent tactical and investigative police activities taking place in what was presumed to be close proximity to a heavily armed police killer. Without knowing Bourque's location it was impossible to have a definitive perimeter and effective containment, thus all policing activities were extremely high- risk. The incident commanders, as well as all deployed responders, were faced with the fact that Bourque had significant tactical advantage, including the ability to fire upon police or anyone else, should he so choose. In addition to actively searching for Bourque, there were multiple crime scenes to examine as part of the ongoing criminal investigation into the murders and attempted murders. As these scenes were all near the last known location of the gunman, protective perimeters were set up around the investigative personnel at these sites. Additionally, there was the massive logistical challenge of effectively equipping and deploying hundreds of RCMP members and police officers from different agencies arriving from across Atlantic and Central Canada so that they were operationally ready. Of the hundreds of police officers arriving in Moncton, there were eventually one hundred Tactical Team members on scene. Three of the four RCMP Atlantic Region Emergency Response Teams, as well as those from "C" and National Divisions, were deployed. The municipal police forces of Bathurst, Miramichi, Fredericton and Saint John also contributed their tactical teams. Providing direct support to these teams were six scribes, four radio technicians, 14 Emergency Medical Response Team (EMRT) members, 11 PDS teams, and EDU & Special "I" personnel. Five RCMP Tactical Armoured Vehicles (TAVs) and aircraft from both RCMP Air Services (including chartered commercial carriers) and Transport Canada provided tactical and logistical support. From the time Bourque fled into the woods, he was always close to large numbers of officers. Over that 29 hour span, members, including ERT, responded to many reported sightings of the suspect all within a couple kilometers of the last crime scene. Only two of the reported sightings appeared to be accurate. By the time ERT responded to the first apparently legitimate report at Isington, shortly after midnight on June 5, Bourque had once again disappeared. The second verified sighting off Mecca Drive resulted in his arrest. The Arrest Late in the evening on June 5, a call was received from the eastern end of Mecca Drive where a resident reported seeing a man crouched outside below the kitchen window, wearing a camouflage jacket and brown pants. The man ran into the wooded area behind the house. ERT members aboard TAV's attended the area and aircraft were deployed *****. *****. *****. *****. He issued an order of, "come out with your hands up!" The suspect replied, "I give up, don't shoot!" He left his firearms behind and came out of his hiding place with his hands up. Members quickly confirmed that they had arrested Justin Bourque. Daylight Aerial photo of arrest location (red dot, 21 Mecca Dr. at 140606 00:10) and the point was last seen (yellow dot, 31 Isington Ct. at 140605 00:36). Police vehicles (blue rectangles) around the arrest location. Two redacted photos show ERT members approaching to arrest. Aerial photo and map identifying these locations: SOC residence. Cst. Doiron's initial position. SOC observed by Cst. Daigle Cst. Daigle first location, follows after SOC. Csts. Daigle Nickerson, Mitchell meet followed by Gevaudan. Cst. Daigle and Cst. Gevaudan see SOC behind 15 Bromfield. SOC escapes, After Cst. Gevaudan shot. Cst. Ross nearing area. Cst. Ross shot by SOC. SOC seen by Cst. White, aiming at him. Witness reporting SOC movement at Fire hall. Cst. Benoits and Dubois under fire. SOC's firing position at location K and M. Cst. Goguen is shot, after Benoit and before Dubois. Cst. Larch position on foot. SOC first shoots Cst. Larche from this position and moves around house shooting again. SOC seen at 00:36 on June 5. SOC arrested at 00:10 on June 6. In the mandate letter to the Reviewing Officer, the Commissioner outlined 13 areas to be examined. Each of the areas will be dealt with separately with the exception of number one, Tactics and Response to the initial call and number two, Decision Making and Risk Assessment to the initial call. These will be combined as one section due to the interrelated nature. Within the report it was necessary to repeat information because of the interrelated nature of the 13 sections. Many of the Sections do not exist in isolation; as such there is overlap and repetition between certain sections.

Section 1: Tactics and Response to the Initial Call Question from the Commissioner: Does the manner in which the members were dispatched and coordinated in their response to this call suggest any improvements can be made in RCMP training, policy or other areas? Are there recommended improvements to the tactics employed given the facts known at the time? The Tactical response will be addressed here, however, Training and Policy improvements will be addressed in their respective areas within the 13 sections.

Section 2: Decision Making and Risk Assessment to the Initial Call Question from the Commissioner: Was there an opportunity to reassess the call and our response as it unfolded in the early moments? The Incident Management Intervention Model (IMIM) The IMIM is a visual aid and guideline which is designed to assist an officer in articulating the decision-making process involved in his/her selection of a particular intervention option. The IMIM is neither policy nor law, nor should it be used on its own to justify any actions on the part of the officer. It is important to understand that it is not a step-by-step approach in the development of an articulation of what the officer did. The intervention option chosen by an officer is based on several variables, which are explained below. The IMIM is designed around 6 basic principles: The primary duty of an officer is to preserve and protect life; The primary objective of any intervention is public safety; Police safety is essential to public safety; The IMIM is consistent with law and policy, in no way does it augment or replace it; The IMIM is consistently intertwined with a risk assessment The risk assessment is continuous and evolves throughout an intervention/situation. The terminology referring to "least intervention", "least amount of force" or "intervention causing the least harm" has been removed from the Criminal Code as the Courts recognized it to be an unrealistic expectation that could put the safety of the officers in jeopardy. This terminology was replaced by "necessary" and/or "reasonable" amount of force to control the subject/situation. There is no step-by-step process to assessing the risk as this is done continuously throughout an intervention. The risk assessment will be influenced by the type of event (planned events vs unfolding events vs spontaneous events). The risk assessment formed is based on the four following categories depicted on the IMIM model. Situational Factors: The situational factors may change throughout an incident and directly impact the officer's risk assessment and include: Environment: weather if outdoor, lighting conditions, location, the availability of cover or concealment, the presence of bio-hazard, etc.

Number of subjects (vs number of officers);

Perceived Abilities of the Subject: diminished by a form of intoxication, increased by a form of intoxication, size/strength/athletic skills, emotional state;

Time and Distance: presence or not of escape routes (both for officer and the subject); does the situation allow officer to create a reactionary gap (increase time/distance);

Threat Cues: verbal and/or non-verbal;

Knowledge of Subject (including, but not limited to personal previous experience with the subject, known to be armed and dangerous, etc.). Subject Behaviour: The key is to understand that an officer's intervention is based on the totality of the situation and that the subject's behaviour alone is not sufficient to dictate the proper intervention option. Tactical Considerations (the model emphasizes tactical repositioning): Striking/deploying and moving (when deploying an intervention option or striking, it is suggested to move away from the original position so that a focused subject can't simply attack the last known position of the officer;

Creating Time and Distance (the longer the officer can acquire and analyse information, the better chance he/she has to use the proper intervention option)

Moving to cover (given that cover is available, this will have the same effect as creating time and distance. Once to safety, an officer should be able to process the information given more effectively)

Complete Disengagement (To a position of containment while awaiting back up for example). The officer must understand and accept that, at times, a complete disengagement is impossible (for example, in the case of an active shooter) because it is responsibility of the police to protect and preserve life. Officer's Perception: The totality of the situation is processed by an individual who brings his/her own set of skills, knowledge, gender, experience, fears/confidence, fatigue/fitness, etc. The officer will continuously assess the risk and formulate an intervention option based on the totality of the situation as processed through his/her perceptions. These perceptions must be reasonable. Two officers facing a seemingly identical situation will likely intervene differently. The intervention should be measured against the actions of a reasonable, trained and prudent officer faced with the same set of circumstances. *****. The initial multiple member response on June 4 was robust and appropriate, based on the original complaint, the IMIM and RCMP backup policy. A sufficient number of members were dispatched, directed and responded. At the time of the first report, the end of a dayshift and the beginning of a nightshift were overlapping. Several members who had finished their shift were still in the office and returned to duty as the incident escalated. *****. The OCC obtained adequate detail during the two initial complaints from Pioneer. This information was broadcast and responding members identified. This was the beginning of the risk assessment process. Codiac detachment has policy on containment and perimeters wherein *****. Members were effectively directed to appropriate locations by the OCC in order to set up an initial perimeter and they were doing so with emergency equipment engaged. Without knowing the SOC's intent, setting up a perimeter to acquire visual contact was the correct police response. The members who knew the neighbourhood were assisting in making the perimeter as effective as possible. The recommendations relating to the function of the OCC are found in section 7: Operational Communications. Cst. Doiron was the first member to arrive at Pioneer Avenue, and he was able to gather additional information which he then relayed to the rest of the responders. This included that the SOC appeared irritated. This detail should have heightened the responders' risk assessment. The road supervisor for the incident, told Doiron to stay out of the woods and wait for PDS. Cpl. Cloutier immediately recognized the need for PDS to track the SOC and contacted the on-call PDS member. Cst. Johnstone was the first member to arrive on Mailhot and he asked about getting civilians into their houses and Cpl. Maclean responded that this would be a good idea. Residents who were told to return to their homes report that members were clearly taking the threat as significant. All of these actions were tactically sound. Throughout the incident some residents ignored the orders of police to clear the area and became a distraction. There are two specific actions which cause concern, that were not taken by responding members, despite the risk assessment and situational factors known at the time. Even though it had been clearly communicated that the SOC was carrying firearms, none of the responding members put on their HBA, and only one member who departed Codiac detachment to attend took the initiative to bring a shotgun. *****. A comprehensive discussion of the weapon and HBA choices will be held below. The recommendations relating to Hard Body Armour and firearms are found in section 5: Equipment and Weapons. As the perimeter was set, responding members were utilizing appropriate radio communication. Their vehicles and locations were confirmed through the OCC. Cst. Dubois was asked to speak with more witnesses to potentially identify the SOC. The situation began to change rapidly when Cst. Daigle saw the SOC. At first visual, Cst. Daigle asked for all members to "clear the air" (stop using the radio), so he could provide everyone with updated information. Cst. Daigle reported he had seen the SOC and where he was walking. At this point, because he could see the suspect, he took on the lead role in response to this incident. The other responders began to reposition based on his information. Verbal intervention was an option for Daigle at this point, but Daigle's perception was the SOC was beyond pistol range. Giving away his location may have put him at a significant tactical disadvantage should a gunfight ensue, given that the SOC was in possession of a rifle. Daigle's decision to try and maintain visual contact with the SOC was also appropriate, given that the dog handler had not yet arrived and the SOC was entering a residential area. Shortly thereafter, Cst. Daigle lost direct visual contact with the SOC, but believed he knew the general area where he was headed as being behind the residences on the south side of Bromfield. Other members quickly converged on foot from various perimeter positions to Cst.Daigle's location, in order to provide him with assistance and attempt to reacquire visual contact with the SOC. By closing in on the area where the SOC was believed to have last been seen on foot, members left their vehicles. Unfortunately, they also left behind their HBA *****. Any location information for individual members would now have to be transmitted via radio. This fact hampered both OCC and watch supervisors in determining where members were at any given time. At this point the members had to reacquire visual contact with the SOC in order to initiate any form of verbal intervention and coordinate effective containment. Situational factors affecting the collective risk assessment of the responding members included: Layout of this particular neighbourhood;

Presence of numerous civilian bystanders;

Members' lack of appropriate long guns;

Unknown time delay before PDS arrival;

Behaviour and unknown intentions of the SOC. Each of these considerations contributed to their decision to close in quickly. Members' perceptions of the danger to the public impacted their risk assessments and created an understandable sense of urgency in trying to locate the SOC. Obtaining sight of him again would eliminate the need to wait for PDS to commence a tracking operation, enable containment plans to be implemented, and provide crucial intelligence as to his actions and behaviours. Cst. Daigle met up briefly with Cst. Gevaudan at some point after visual contact with the suspect had been lost. Subsequently, as a team, they used the concealment of the wooded area behind the residences on 15 and 19 Bromfield as best they could to hide their approach towards where they believed the SOC was located. Cst. Gevaudan advised other members over the radio where he and Cst. Daigle were positioned. Radio communication between Cpl. Cloutier and Cst. Doiron clearly indicated that the PDS member (Cst. Ross) was a few minutes from being mobile. At the same time Csts. Mitchell, Johnstone and Doiron were yelling for people to go into their houses on Willshire, which was a prudent measure. The specific communications between Cst. Daigle and Cst. Gevaudan as it related to the tactical plan they devised is unknown. Their discussion was not broadcast over the radio, and as such no other members were aware of the details of their strategy for continuing to search for the suspect, or what to do once he was located. It has already been noted in this report that the reliability of the individual and collective recollections of members has been inconsistent. This is understandable given the traumatic incidents that followed, and is perfectly normal. Based on this reality, the Review Team is required to make an assessment of what took place during those critical seconds where shots were first fired by incorporating information which is known to be reliable with potentially less-reliable eyewitness accounts. From a radio transmission, it is established that Csts. Gevaudan and Daigle were together in the wooded area beside 15 Bromfield. Cst Daigle is seen on surveillance video from the front northwest corner of this same residence and Cst. Gevaudan is not with him. Cst. Daigle is seen on the video to make a radio transmission via his portable, which has been matched to a recording where he asks Cst. Gevaudan to provide his (Gevaudan's) location. No shots had been fired up to this point. Several other members subsequently appear on the video footage. Several head out towards Bromfield while others (including Cst. Daigle) move along the front of the house towards the garages on the northeast side of the house. Cst. Gevaudan is not among either group. Cst. Gevaudan apparently decided to move behind the residence at 15 Bromfield. We cannot know the specific reason(s) for this decision; if he saw Bourque he did not communicate this fact on the radio. If he decided to reposition himself based on an individual assessment of the situation, this was not communicated to Cst. Daigle. He did radio for members to clear the air. Subsequently, while members were moving across the front of the house, shots rang out from behind it. Cst. Gevaudan is almost immediately heard on the radio yelling "He's shooting at me!" He is alone at this point, armed with only his pistol, and the suspect is armed with a high-powered, semi-automatic rifle. The suspect is in a static firing position, which affords both cover from pistol fire (in the form of trees and possibly a depression in the ground) as well as concealment (trees, foliage, and his camouflage clothing). Cst. Gevaudan, in contrast, is more visible in his uniform, which is in stark contrast to his surroundings. The fact that witnesses in neighbouring houses were able to see member uniforms through the foliage supports this. The tactical advantages are overwhelmingly in favour of Bourque. What Cst. Gevaudan saw, and why he decided to remain behind the house when Cst. Daigle circled around to the front of it, is not known. What is known is that his life was in immediate danger, and his overwhelming consideration would have been to seek cover. His actions were consistent with this thought process. He showed remarkable awareness by calling on the radio that he was under fire. Without the benefit of a full understanding of these critical few seconds, these are the only definitive conclusions we can prudently draw. Several shots are fired in close succession. Members are seen reacting to the gunfire on the surveillance footage. Bullet entry and exit holes in several trees, recovered empty rifle casings, and rifle fire damage to property located behind 15 Bromfield and to the back of the house itself, provide information as to where Bourque was positioned at the time he opened fire. They also provide information as to the movements of Cst. Gevaudan in response to being fired upon. We do not know exactly where he was positioned when he first drew fire, but he ran towards an open area behind the adjacent residence (19 Bromfield). Why he chose to run in this direction is something we will never know with any certainty. He was reacting to being fired upon unexpectedly, and was forced to make a split-second decision to try and save his life. What we do know is where he ultimately fell to the ground as a result of incurring two gunshot wounds, and as such can track his movements based on the firing pattern of the suspect. As per the IMIM, if the SOC was aware of the police presence and believed they were there because of him, they would have ascertained that at a minimum he was displaying active resistant behaviour. This behavior, combined with the fact that he was known to be armed, wearing camouflage, and hiding among the trees, raised the risk assessment of the responding members significantly. Tactically, Csts. Gevaudan and Daigle had very little time to discuss options in view of the circumstances. They were also at a tactical disadvantage in terms of firepower (considering the description of the SOC's guns). Subsection 25(1) of the Criminal Code authorizes a police officer who is acting in the administration or enforcement of the law to use as much force as necessary. Given the situational factors, all members approaching the SOC should have been ready to respond immediately with lethal force should it become necessary. Once they sighted the SOC again, the appropriate intervention option given the totality of the situation was verbal intervention with *****. *****. The Review Team spoke with many members who indicated that a call of a suspicious person with a firearm was not unusual for Codiac. While the initial response and approach to the subject displayed appropriate risk assessment and decision making (pistols drawn and pointed toward subject), the perception that this may be another routine call may have been a factor in that no member was in a position to return fire. 1.1 It is recommended that additional training on lethal force over-watch be provided to members. Cst. Gevaudan was forced to tactically reposition because he was under fire with limited concealment. Without intimate knowledge of these surroundings, he could not have known that his chosen path would result in him being more exposed to additional rounds from the SOC. Cst. Daigle was the first to reach the corner of the garage at 15 Bromfield, followed by Cst. Nickerson, seconds later. Csts. White, Mitchell, Martel and Cpl. Maclean were moving around 15 Bromfield as shots were being fired. Cst. Nickerson saw a portion of Gevaudan's run but did not see the shooter. Csts. Johnstone and Doiron were near the corner of Mailhot and Bromfield. Cst. Gevaudan broadcast he was being shot at and was now unaccounted for and not responding to radio calls. Members quickly ascertained the shooter was using a high powered firearm capable of firing multiple rounds in rapid sequence (they had just heard multiple gun shots). Tactically, armed with service pistols and one shotgun, they were at a disadvantage due to the superior fire power and range of the shooter's weapon. At this point, it would have been appropriate for the members to seek cover, conduct a risk assessment and establish a rescue plan for Cst. Gevaudan and a plan to neutralize the threat. The time between the shooting of Cst. Gevaudan and Cst. Ross is just under two minutes. After the initial shots the shooter heads towards Mailhot. The members who went to the front of 15 Bromfield were now fully occupied with seeking cover and locating Gevaudan. Ross, who had just arrived in his PDS vehicle, was quickly able to engage the shooter. Upon reaching Bromfield, Ross was immediately directed down Mailhot by a member near the corner of Bromfield and Mailhot. Cst. Ross saw the shooter and attempted to stop him. There were still people on Mailhot near the SOC and this may have affected how Cst. Ross chose to approach the shooter. The Ops NCO began to dispatch more members based on shots being fired at Cst. Gevaudan. A broadcast in plain language stating that the suspect had just shot a member with a high powered rifle was not made, even after the road supervisor reached Gevaudan. This critical information could have changed the response and risk assessment of other members arriving at the scene as back up. None of this second wave of members utilized HBA even though a member had been shot. It is clear from the Ops NCOs question on the radio, "who's injured?" that he was unaware a member had been killed (members were still performing first aid on Gevaudan). This led to confusion around how many ambulances were required and where. The road supervisor, having lost his radio, did not hear Cst. Ross' broadcast. This combined with applying first aid to Cst. Gevaudan, left him unable to assess the overall tactical situation. The Ops NCO had less information, knowing only what was broadcast on the radio. Without situational awareness the ability of any supervisor to effectively intervene at this point was minimal. There was a tendency for members to avoid using plain language on the radio due to a lack of encryption and a desire to avoid broadcasting details to the public. Moncton has avid monitors of police transmissions and unfolding calls were routinely posted to a news chasing group on social media. RCMP training instructs members to use 10 codes (despite their being widely available in the public domain) for this purpose. Members should be encouraged to use plain language in crisis situations. The recommendation relating to the use of plain language is found in section 7: Operational Communications. After the shooting of Cst. Ross, the term "active shooter" started to be used by members and the telecoms operators who were calling in additional resources and informing senior managers of an "active shooter". Active shooter is associated to RCMP IARD training ***** IARD training. ***** and moving from cover to cover. Even after seeing or learning that Cst. Gevaudan had been shot, members continued to track the shooter in an effort to stop him, despite the danger he clearly posed to police. One member who did not feel IARD was the appropriate tactical response was Cst. White, a Basic Firearms Instructor (BFI) and IARD instructor. Immediately after leaving Bromfield Court he moved on his own down Mailhot, from cover to cover opting for speed. After closing the 260m distance to Cst. Ross' vehicle in a couple of minutes, he saw the shooter further down the street. Cst. White's decision not to attempt lethal force with his pistol when he observed Bourque on Mailhot was tactically sound. Given the distance involved (about 90m) and only being armed with his pistol, Cst. White would have been at a severe disadvantage in an engagement with the SOC. He effectively took cover behind the PDS vehicle and radioed his situation, thus giving other responding members the current location of the shooter. Once the road supervisor arrived, he requested ERT in recognition of the shooter's firepower and the tactical limitations of general duty first responders. The recommendation relating to the ***** Member Training and Officer Safety Skills. Cst. Martine Benoit drove to the area with lights and sirens activated via Mountain Road. She turned onto Hildegard Drive just as the OCC reported the suspect was at Hildegard and Mailhot. The tactics and risk assessment of both she and Cst. Nick Gilfillan were based on this information. Cpl. Cloutier directed them to attend the scene of the shooting; however, there was no discussion of specific roles for them. A witness pointed out where the SOC had entered bushes down the road. She parked her vehicle at the intersection and assessed the situation. She had just decided it was best to stay in her car when she began to take fire. At this point she employed the best reactionary tactics possible *****. Benoit calmly radioed that she was being fired upon at and the shots were coming from in front of her vehicle, giving other responders a good indication of the shooter's location. Once her vehicle was disabled she clearly transmitted this fact and asked if it was safe to get out of her car. She then requested assistance. She was concise in her request and conveyed pertinent information to inform her own risk assessment and that of her colleagues. Cst. Eric Dubois answered Cst. Benoit's call for assistance. He drove to her location and stopped his vehicle next to hers where he felt it would provide additional cover from the shooter. He then made a sound tactical decision by getting himself and Cst. Benoit to the back of the police car thereby placing the entire vehicle between them and the shooter. While attempting to spot the shooter's location by raising his head periodically from behind cover, Dubois was injured by bullet fragments or secondary projectiles. He subsequently attributed his being hit to having popped up from the same location too consistently. Dubois ran to the fire station after seeing the gunman cross Hildegard and assuming he had left the scene. Cst. Benoit made the decision to stay behind cover and called for someone to get her. Both members' assessments were reasonable at the time. Cst. Benoit had not seen the suspect leave and was not convinced he had finished shooting at them. Cst. Gilfillan recognized that Cst. Benoit needed assistance in order to move to cover at the fire station. He drove his police vehicle alongside the vehicle where Cst. Benoit was taking cover. Once she was inside his vehicle, he was able to safely return to the fire station. While the shooting occurred at Hildegard and Mailhot the initial responders continued to follow the broadcast sightings of the shooter. Csts. Mitchell, Doiron and Martel traveled as a team down Mailhot to Kenview Drive, then up toward the back of the fire station, which was the reported location of the shooter shortly after they began their pursuit. Cst. Mitchell commandeered a civilian vehicle with the intent of camouflaging herself, moving more quickly, and potentially running down the gunman. Her decision to commandeer the vehicle was a sound tactical decision and it shows that she had realized that police were the gunman's sole targets. Cst. Mitchell at no time came in contact with the gunman and she transported Cst. Dubois to the hospital. Cst. Goguen, from Southeast District, unknowingly drove directly to the shooter's location as Bourque was in the process of firing multiple rounds at police vehicles parked at the intersection of Hildegard and Mailhot. Southeast District uses a different radio frequency and is dispatched through the OCC at "J" Division HQ in Fredericton. Members are able to use a scan feature which allows them to hear radio broadcasts from other channels which are overridden by any simultaneous broadcasts on their own channel. Cst. Goguen believed her scan button was not functioning properly and had insufficient information to make an informed risk assessment. She heard gunshots, started to turn her car around and was hit by the gunfire. After being shot she drove to safety a few blocks away on Penrose Street, where members transported her to hospital. Cst. Goguen's quick reaction to reposition her vehicle was a factor in saving her life. The shooting of Cst. Goguen added to the chaos of the situation. As she was dispatched on a different channel, no one on Codiac's radio channel was aware Cst. Goguen had been shot. Codiac's OCC only learned she had been under fire when someone found her bullet riddled car. They mistakenly believed and shared that she had been shot on Penrose Street where her car was parked, adding to the confusion regarding the gunman's movements. During the period of 19:51 to 20:05, overall tactical awareness was poor. The OCC was overwhelmed by calls about SOC sightings, positioning of incoming back-up and dispatching medical care for wounded members. Members on the scene continued to move toward the sound of gunfire and no individual member took charge over the radio leaving OCC dispatchers to do their best to continue to coordinate operations from their vantage point. Accurate risk assessments were difficult as members were calling for ambulances to multiple locations. Sightings were being reported based on caller location (as opposed to suspect location), then broadcast out of order. There were wounded members in need of medical attention. There were two erroneous reports broadcast about shots fired on Lonsdale and the SOC being seen at the (non-existent) corner of Lonsdale and Mailhot as well as a report of him being on Foxwood moving towards Ryan when he had, in fact, already crossed Hildegard and was moving towards Mailhot. Based on the radio traffic, it would have been nearly impossible to form an accurate tactical view of the situation. The current locations being broadcast by members were interspersed with stale or inaccurate information from 911 callers being relayed by the OCC. It is around this time that the Hildegard Fire Station became a staging area. Members dispatched from Codiac and Southeast District after the first shooting were told to go there. Cpl. Whittington, Cst. Gilfillan, Cst. Verret and others arrived there after the shooter had left and traveled beyond the intersection of Mailhot and Hildegard. By this point, members had established that the shooter was only targeting police officers. Those gathered at the fire station made sound *****, donning their HBA and positioning themselves to engage the shooter whose whereabouts were unknown. Given they were already inside the "shooting area", this was the most appropriate action. Some members went to fire station as it was the last known location of the suspect. As they gathered there other members joined and others were dispatched to the fire hall believing this was a location to stage. Since the shooters' whereabouts were unknown it was not a safe location and some members were not aware of their role once they arrived at the fire hall, or who would be directing them once they got there. Upon hearing shots being fired further down Mailhot and hearing the erroneous broadcast that a civilian was down in the same area, members' risk assessments and subsequent response should have changed drastically. This was the case for several members who began tracking toward that location, including Cst. Gilfillan who suggests others don HBA. He was the first member to recognize this critical officer safety component. Video of the fire station from the period after Cst. Benoit was retrieved from her vehicle until Cst. Larche was shot shows a lack of coordination and supervision. At least six members were present. Many vehicles and pedestrians can be observed passing by. No direction was given by any member to block either end of Hildegard. It is not until Forensic Identification Section (FIS) Cpl. Denis Leblanc heard about the situation that he responded and offered to block westbound traffic on Hildegard Drive. Unfortunately, no one decided to block the other end of Hildegard at Ryan Street. The recommendations relating to supervision are found in section 3: Supervision During the Entire Incident. The response of the four Major Crimes Unit (MCU) members began immediately after the first shots. They returned to the office to get shotguns and made their way toward Hildegard in four cars. The Codiac detachment members and supervisors were not previously aware MCU was working and the Ops NCO did not hear the radio broadcasts indicating they were responding to assist. The OCC broadcast confirmation they were on the way, but no one at the scene or supervising gave them a duty. During the drive toward Hildegard, Cst. Larche broke off from the two cars ahead of him and went to Mailhot and Isington. There was no discussion on the radio about this action, and the other members of the Major Crime Unit do not know why Larche made this decision. Cst. Larche told the OCC where he was and that he would be out of the vehicle. He got out with a shotgun and immediately began scanning the area for the SOC. The gunman was concealed by the trees in close proximity to where Larche was standing by his vehicle. The gunman identified Larche as a police officer because he was wearing SBA and began shooting at him. All shots were fired from less than 20m. It must be noted that Doug Larche was very seriously wounded before he could fire his shotgun. After being knocked down by the first bullet(s) he did not give up; he struggled back to his feet and drew his pistol to engage the gunman. Cst. Larche fought until the end, firing seven rounds, the last after being hit by what proved to be the fatal shot. Cst. Larche was shot at 20:05. At that time, the only members south of Hildegard were Cst. Larche and possibly Cst. White who was tracking on his own. All the other members deployed to the scene were occupied in various capacities. Tactically the situation was not under control. The shooter proceeded into the woods on the south side of Ryan Street as the members tracked down Mailhot, eventually reaching Cst. Larche. Cst. White reached Cst. Larche after civilians had already covered him. White then moved Cst. Larche into a nearby residence and remained with him. Once at the end of Mailhot, members began to radio their positions in to the OCC and take the best cover they could facing the woods. Members did not advance further into the woods in pursuit of the SOC. This was a tactically sound decision.

Section 3: Supervision During the Entire Incident Question from the Commissioner: Does the manner in which this incident was supervised suggest any areas for improvement? On June 4, 2014, supervisors in Codiac were confronted with a situation that in many ways exceeded what supervisors are trained to deal with. They were faced with a crisis situation that evolved quickly, was operationally challenging and highly emotional. The level of supervision required to manage an incident is directly proportional to its scope. As a paramilitary organization the RCMP works within a rank structure where increases in rank come with corresponding levels of responsibility. Supervisory Structure of Codiac Detachment Codiac detachment has an Officer in Charge (OIC) at the Superintendent level, and an Inspector who is the Operations Officer. The Codiac system of general duty supervision involves uniform officers assigned to two watches who work 11.20 hour shifts. The two watches have Staff Sergeants in charge who work during day time hours that jointly cover the full seven days. The S/Sgts. manage two Sgt. Operations (Ops) NCOs who cover the core working hours, 06:00 to 04:00. The Ops NCO manages Corporals whose job is to supervise two groups of Constables. One group, the responders, answers calls for service and cover the shifts 24/7. This group does not carry investigations past their assigned shift. Matters requiring follow-up investigation are assigned to the other group of Constables, the Further Investigation Team (FIT) who manage lower level investigations involving persons and property related offences. These Constables do not work 24/7, however, are in uniform and expected to complement the responder group for serious matters. Supervisory Structure in Codiac During the Incident On the evening of June 4, supervision in Codiac consisted of the following: Operations NCO, Cpl. Jacques Cloutier was the acting Sergeant. He was scheduled to work until 04:00 hrs. The Ops NCO is the manager of operations and is accountable for providing overall operational direction. The Ops NCO is responsible to keep a strategic view of events during the course of the shift whereas Team Leader Corporals are more tactically focused. The Ops NCO is tasked with making decisions on the activation of support sections and seeking additional resources as required (GIS, MCU, Air Services, Ground Search and Rescue, etc.). The Ops NCO monitors all calls for service through CIIDS and has the final authority on the management of member deployment. The Ops NCO supports the Team Leaders by providing direction and uses their expertise at the scenes of major incidents to ensure overall direction is being followed at the tactical level. In Codiac, the Ops NCO primarily works from the office and does not normally attend calls for service. Team Leaders, Cpl. Peter MacLean and Cpl. Lisa Whittington were the first line of supervision. Cpl. MacLean was the evening supervisor, working until 21:00 and Cpl. Whittington was the night supervisor working until 06:00. Both Team Leaders were on shift and in the office at the time of the initial call. The Codiac Operational Communications Centre does not have a formal supervisory function, but they play a critical role in the management of police response. During the incident, OCC dispatchers provided direction based on incoming information. The Codiac OCC consists of two dedicated 911 call takers, one dedicated fire dispatcher and an assistant dispatcher. There is also one dedicated RCMP dispatcher along with an assistant dispatcher for a total of six staff working any given shift. The main RCMP dispatcher communicates with RCMP members via the single live monitored radio channel. The assistant dispatcher picks up the overflow from the main dispatcher. Resources available in addition to the uniform presence included a four person Major Crimes team who were working on an unrelated matter in plain clothes and unmarked vehicles. This team, which included Cst. Doug Larche, was led by a Cpl. who did not take on a substantive supervisory role. This is standard practice as support resources fall under the established command structure for general duty calls. The neighbouring Southeast District had four members working with an acting Cpl. in charge. He did not take on a substantive supervisory role either as he too fell under the established command structure. Initial Call The initial call was well managed and coordinated by the OCC, Cpl. Cloutier, Cpl. MacLean and Cst. Doiron and lasted approximately 20 minutes, until the suspect was located near Bromfield. Cpl. Cloutier ensured all available resources were dispatched and that Cpl. MacLean was assigned to attend in person as the road supervisor. Cst. Doiron was the first officer to arrive on scene and made a sound tactical decision in requesting additional resources, assisting with the establishment of a perimeter and providing situational awareness. Cpl. MacLean provided direct supervisory oversight, he ensured the perimeter was held, requested PDS, obtained a more accurate assessment of the suspect, advised members against venturing deep into the woods until PDS arrived and instructed civilians to leave the area. Cpl. MacLean's supervisory actions were a very good example of how this type of call is initially managed. It must be noted however, that not a single member responded wearing available HBA and only one deployed with a long gun. Codiac detachment has a policy on containment and perimeters wherein *****. The OCC did a commendable job having members contain the suspect and isolate him in the wooded area. Cpl. Cloutier was at the office monitoring the radio, telephone, and the CIIDS terminal. He was also coordinating PDS and ensuring members had left the office to assist in the response. Cpl. Cloutier relied on information from the scene and did a very good job of assembling resources. He was also responsible for monitoring all other calls for service in the detachment area. Cpl. Cloutier's ability to effectively manage this incident was impacted by a lack of adequate mapping *****. A recommendation in relation to this can be found in the section on the OCC. Locating and Following the Suspect The amount of frontline supervision during this phase was minimal as the road supervisor was still enroute to the scene. As the perimeter was being established and members were positioning, the suspect was located by Cst. Daigle. He radioed the position of the suspect and, knowing backup was on the way, decided to follow him on foot in an effort to keep him in sight. At this point the road supervisor was aware that PDS would be delayed, thus he did not direct Daigle to hold his position as he had done earlier. The road supervisor was making his way to the scene to provide direct supervision and was allowing Cst. Daigle to direct the approach of members. This was appropriate given Cst. Daigle could see the SOC. Engaging the Accused The members' approach to the SOC evolved rapidly and unexpectedly. It was a challenge for the road supervisor to provide direct supervision given he was just transitioning from his vehicle to go to the scene on foot. He had broadcast that he was enroute over the radio to ensure members were aware of his location. Unfortunately his portable radio had accidentally detached from his belt as he exited his vehicle and he was not in possession of a cell phone. During this critical time he had no communication with the other members. 3.1 It is recommended that members be in possession of a cellular phone and police radio while on duty, as a required part of Service order #1. Shots Fired The road supervisor was moving into position to meet with Cst. Daigle and Cst. Gevaudan when shots were fired. This was a rapidly evolving and dynamic situation where the SOC was moving toward a busy neighbourhood leaving little opportunity for discussion between members and supervisors as to how they would tactically handle the situation. *****. This would have been valuable information for providing tactical advice. Once the shooting of Cst. Gevaudan occurred, radio communication intensified. Poor situational awareness during the moments that followed can be attributed, in part, to poor radio protocol. Members were not using plain language, which caused confusion as to the severity of the situation. This made it made it difficult for supervisors to give direction. Supervisors indicated a reluctance to talk over the radio because they did not want to tie up vital airtime, potentially preventing a member in direct danger from being able to communicate. The Ops NCO was over-tasked monitoring radio traffic, making calls and other logistics with nobody to delegate to. Had he been in a position to delegate some of these duties it may have offered him the opportunity to better manage the incident. The level of supervision during this phase should have transitioned to one of command and control. Urgency of action took precedence. As Cst. Dave Ross approached the scene his situational awareness may have been limited to his brief telephone conversation with the Ops NCO and the OCC before any shots were fired. He likely heard the broadcast location of the SOC and "shots fired" and "he is shooting at me". Cst. Ross radioed "I have a visual and will be on takedown in a second." Disrupted radio chatter immediately followed this transmission and another member stated more shots were fired. Cst. Ross was killed as he drove toward the suspect in his police vehicle. The road supervisor would not have heard Cst. Ross' broadcast because he did not have a radio and was the first member to find Cst. Gevaudan after he was shot and killed. He immediately began providing first aid to Gevaudan therefore he was not in a position to assess the overall tactical situation at that point. The Ops NCO had less information, knowing only what was broadcast on the radio. Without situational awareness, the ability of any supervisor to effectively intervene at this point was minimal. However, as time passed no supervisor obtained a clear understanding of what was occurring therefore could not provide direction. ***** it could be understood given the emotional gravity of the situation and lack of training and experience in dealing with this type of tragedy. A radio broadcast that explained Cst. Gevaudan had been shot by the suspect in plain language, thus providing critical situational awareness to the other members, did not occur. This could be explained by virtue of the fact that members including the road supervisor were putting their lives at risk in a highly emotional effort to provide first aid to Cst. Gevaudan in what was a tactically dangerous location. 3.2 It is recommended the RCMP examine how it trains frontline supervisors to exercise command and control during critical incidents. For a recommendation related to plain language, refer to section 7. There were eight members assembled near the scene of the shooting either performing first aid on Cst. Gevaudan or providing cover. Cst. White and the road supervisor decided to leave the group and pursue the accused. Although the actions of both members were very brave, at this point the road supervisor transitioned from his role of supervisor to first responder without discussing a tactical plan with the six Constables before he left. Nobody established a command presence during this period. Members were acting on their own accord without a unified tactical plan. Order could have been established if a supervisor had obtained a situational update and requested members report their positions. Most members at this time were on foot. Nobody at a supervisory level had an overall view of where resources were positioned and this remained the case for the next hour or more. Members were taking heroic and commendable action as individuals and in small teams, however, they were not coordinated with a common plan and direction. As the situation evolved and additional resources became available to the Ops NCO, a scribe should have been assigned to record decisions, resource allocations, member positions and other important information. This would have facilitated a smoother transfer of command to the CIC and an accurate record of events. At this point two members were shot and killed but many members involved were unaware their colleagues were dead. This impacted their risk assessments. Once the Fire Department arrived and they took over CPR on Cst. Gevaudan, the remaining six Constables assembled in two teams of three and advanced in search of the accused using IARD contact formations. No supervision was sought or provided to these teams and they were not coordinated as a whole. The Ops NCO was still unaware that two members were dead. An uncoordinated situation persisted. At 19:51 the road supervisor asked over the radio for "ERT, we are going to need everything we got". Hildegard Drive Shootings Although the shootings of Csts. Gevaudan and Ross occurred only two minutes apart, the time between the shooting of Csts. Ross and Larche was 18 minutes. During this period, Csts. Dubois and Goguen were wounded and Cst. Benoit was fired upon on Hildegard Dr. There was an opportunity for supervisory direction to the members present during this time. The road supervisor says in his interview with the Review Team that he was leaving it to the OCC to direct members because they had the mapping system and the vehicle location data. *****. Although the OCC was doing an exceptional job in coordinating the members on scene, a senior NCO with tactical experience posted to the OCC during this critical incident would have been in the best position to coordinate resources with real time, accurate information. Recommendation 7.9 in the Operational Communications section addresses the need to post a Senior NCO to the OCC. The road supervisor was the supervisor with the best situational awareness and may have been able to provide tactical direction from the scene. The Ops NCO, who was alone in the office for the hectic half hour after shots were fired, was flooded with radio, telephone and other concurrent activity that was necessary to bring in additional resources. He did not have adequate situational awareness to provide proper tactical direction. The night supervisor was assigned by the Ops NCO to attend at approximately 19:47. She was dealing with a prisoner at the time and had to secure him before responding. She was heard on the radio responding at 19:55 with her siren activated, asking to be sent a copy of the dispatched file. She drove up Mountain Road and onto Hildegard; because she was aware Hildegard was where the members were. Once there, she parked at the fire station. Several significant developments occurred on Hildegard Drive, where the opportunity to take some supervisory action would have been possible. However, the road supervisor was not fully aware of the planning and action taking place as members were taking it upon themselves to act. The road supervisor did not play an active role in the supervision of the incident. Video of the fire station area from the period after Cst. Benoit was retrieved from her vehicle until Cst. Larche was shot shows a lack of coordination and supervision, while at least six members were present. Many vehicles and pedestrians are observed passing by. No direction is given to block either end of Hildegard. It was not until FIS Cpl. Denis Leblanc hears about the situation that he responds and offers to block westbound traffic on Hildegard Drive. Unfortunately, no one decided to block the other end of Hildegard at Ryan Street. Supervisors at this point should reasonably be expected to direct perimeter control and teams. Members were not provided guidance and took it upon themselves to act. Many members participated in courageous and selfless acts and placed themselves in danger. Advance to Isington and the Shooting of Cst. Larche The response of the four Major Crime members began immediately after the first shots. The Codiac detachment members and supervisors were not aware MCU was working and the Ops NCO did not hear the radio broadcast that they were responding to assist. The OCC did note they were on the way, but no uniformed supervisor was aware. Cst. Larche broke off from the two cars ahead of him on Hildegard and drove to Mailhot and Isington where he left his vehicle and was killed after encountering the suspect. The accused was observed after the shooting fleeing into the woods behind Isington Avenue toward Ryan Street This would have been the point last seen for the next several hours. Post Shooting Manhunt and Later Sightings This phase of the incident should have brought stabilisation and enhanced coordination to this crisis, as the intensity of the observable threat diminished. Although no additional shots were fired, resources remained in a state of disarray, with members responding in an uncoordinated manner to reported sightings of the accused and not holding their perimeter positions. Many members were not briefed and took it upon themselves to locate and respond to evolving situations without any person in charge being aware. The OCC and others were assigning members to general and non-specific perimeter locations, however, no direction was provided over the radio for members to report positions, nor was anybody keeping track of these locations, their identities, additional firepower on site, or the duration of the shifts. Some members worked in excess of 24 hours without a replacement. The fatalities were not known to some of the members or supervisors who responded to the initial call until approximately 21:00, others did not know the full extent until many hours after this. A roll call or situation update was not conducted to establish if all resources were accounted for. Members on duty did not receive a detailed update from a supervisor about the threat they were facing. The awareness members had was circulated by word of mouth. At the point last seen, adjacent to Ryan Street and Wheeler Boulevard, there were members with marked police vehicles who were exposed without knowing the shooter was last seen nearby. Members from other Districts, Detachments, Municipal agencies and "H" Division were starting to arrive and there was no mechanism to track and coordinate these resources. Challenges with tracking police vehicles from outside Codiac Detachment will be dealt with in Section 7 of the Review. Command evolved from the initial Ops NCO, with the arrival of the Codiac Operations Officer at 20:20 and both managed different aspects of the situation from the same office. The Ops Officer became the Incident Commander at that point, a scribe was appointed and people were given specific tasks. The execution of those tasks was not monitored and various people were continuing to conduct unassigned tasks without direction. The command structure was not clear to those on the ground. Both the Ops NCO and Ops Officer were extremely busy and the situation in Codiac detachment was intense and emotionally draining. Both men must be recognized for their dedication and the effort they put forth under extreme circumstances. Supt. Tom Critchlow, a trained Critical Incident Commander and former Operations Officer at Codiac detachment, was not working but heard about the situation and went to Codiac to lend assistance and he stayed to provide advice to the Ops NCO and Ops Officer, *****. Even though Command transferred from the Ops NCO to the Ops Officer, an official briefing and transfer of Command did not take place and the Ops NCO believed he was in charge until he went home at 06:00 on June 5. The Ops NCO's actions and decisions were not recorded. Insp. Leahy was the assigned Critical Incident Commander (CIC) who had to travel to Moncton from the Fredericton area. The actual time command was transferred to the CIC is somewhere between 00:30 and 03:00 on June 5. A more precise time could not be established. The CIC indicated he permitted the Ops NCO and Ops Officer and Supt. Critchlow to continue commanding the incident from Codiac detachment while he worked on getting his Command Post (CP) up and running at the Moncton Garrison. He did not feel that he was in a position to take over until such time as his CP was established. He feels that his CP was not ready to assume overall command until about 03:00, at which point things began to normalize. As outlined above with regards to the lack of recorded information, it was difficult for the CIC to obtain information he required on what had occurred. An example of the confusion that was taking place related to a credible sighting that came in at 00:39 near the point where Bourque was last seen. An ERT response ensued but was not well communicated, as some of those in command were unaware of the ERT response and did not have a record of it. Although it is indicated there was an absence of clear direction from commanders who were performing various functions, some members took it upon themselves to take a leadership role. Members interviewed by the Review Team commented on two specific examples involving a coordinated effort to establishment a perimeter as well as a staging area for ambulances. The morning of June 5, members were provided with relief. In many cases, members were sent home without a debriefing. Proper debriefings would have provided valuable information to the Commanders who took over. Dealing with the Influx of Responders At least two supervisors made the call for additional resources from other police agencies and districts. A large number of members were eventually on site in Moncton and the command structure was not in place to deal with the influx of resources. This could have proven very dangerous; given the accused was in close proximity to the perimeter members who were positioned near the most recent sightings. Several members described not receiving or seeking direction and just "drove around", many of whom were not tracked by the Moncton OCC. Requesting additional resources with no plan t