Activities of Federal Law Enforcement Agencies Toward the Branch Davidians/Section 7

a. overview of the plan to end the standoff
On April 12, 1993, the FBI presented Attorney General Janet Reno with a plan to end the standoff with the Branch Davidians. On April 17, 1993, the Attorney General gave her approval for the plan to be implemented on April 19. The stated mission of the plan was to "secure the surrender/arrest of all adult occupants of the residence while providing the maximum possible security for the children within the compound." A key component of the plan was the decision to use CS, a chemical riot control agent, which would be sprayed into the Branch Davidian residence in an attempt to induce the Davidians to leave. The plan was implemented on April 19, but the Davidians did not leave their residence as government officials suggested. Instead, 6 hours after the beginning of the operations, a fire erupted inside the structure, ultimately consuming it and the more than 70 persons inside.

1. Overview of the written operation plan to end the standoff
As early as March 22, 1993 the FBI began formulating an operation plan to end the standoff with the Davidians. On April 12, 1993, the FBI presented its plan to the Attorney General for her approval. According to the Justice Department Report, "Over the next several days the Attorney General and Senior Justice Department and FBI officials discussed, debated and dissected every aspect of the plan."

The operations plan provided that its mission was to "secure the surrender/arrest of all adult occupants of the residence while providing the maximum possible security for the children within the compound." The key component of the plan was the delivery of a chemical riot control agent, known as CS, into the Branch Davidian residence in order to induce the Davidians to leave. While the CS agent was being inserted, FBI officials planned to use a loud speaker system and the telephone to advise the Davidians that tear gas was being inserted into the residence to force them to leave, but that an attack was not underway. The plan also provided for a demand that all subjects leave the building and surrender to authorities.

The plan provided for the operation to last up to 48 hours or until all subjects had exited the residence and surrendered. The plan provided for the first insertion of CS agent to be made into the front/left portion of the residence. After a period of time, which was to be dependent on the Davidians' response to the initial delivery of the CS agent and any subsequent negotiations that were possible, an additional tear gas delivery was to be made into the back/right portion of the residence. After a third delivery of CS, into an area not specified in the plan, all subsequent deliveries of CS agent were to be made into the upper and lower windows of the residence.

During the first three insertions, the CS agent was to be delivered into the residence by two combat engineering vehicles (CEV's), an armored vehicle similar to the Bradley Fighting Vehicle (Bradley), but which is unarmed. The CEV's at Waco were mounted with boom-like arms which were capable of penetrating the walls of the structure. Mounted on the arms of the CEV's were mechanical devices designed to spray a stream of CS agent into the holes made by the booms. After the third insertions of CS agent, the operations plan called for agents located in unarmed Bradley Fighting Vehicles to maneuver close enough to the residence so that they could fire Ferret round projectiles through the windows of the structure. These small non-explosive grenade-like projectiles contained CS agent which would rise into the air when the projectile broke open upon impact. The use of Ferret rounds was to be in addition to continuing insertions of CS by agents in the CEV's.

The plan also provided for specific assignments for the different HRT and SWAT teams involved in the operation. It specified the maneuvers to be made by the two CEV's, the nine Bradley Fighting Vehicles, and the M-88 tank retrieval vehicle, and provided for miscellaneous administrative and logistical issues such as types of uniforms to be used and the appropriate manner for handling prisoners.

Additionally, the plan provided to the Attorney General on April 12, 1993 included details concerning where the FBI's snipers were to be positioned and the positioning and capabilities of SWAT team members. The plan contained a "medical annex" providing for a means to treat "the potentially large number of casualties which could exceed the current medical capabilities of any single agency present" as well as procedures to be followed to arrest persons who had been exposed to CS. The annex also provided for locations where the injured were to be treated, provided a list of local and secondary hospitals (including address, latitude/longitude location, and estimated air travel time). And the medical annex provided instructions to the agents on the procedure to handle a mass surrender by the Davidians.

Finally, the plan provided for the possibility that the Davidians might not surrender. The final contingency provision in the plan stated that "if all subjects failed to surrender after 48 hours of tear gas, then a CEV with a modified blade will commence a systematic opening up/ disassembly of the structure until all subjects are located."

2. Acceleration provisions of the operations plan
While the operations plan called for the government's actions to end the standoff to unfold over a period of 2 days, the plan also contained contingency provisions that allowed for a departure from the concept of a methodical insertion of CS. One of these provisions was implemented on April 19 and resulted in a rapid acceleration of the insertion of CS agent.

The first of the two contingency provisions in the plan provided that if the Davidians were observed in the tower during the operations, after having been informed not to be there, agents were permitted to insert CS gas into the tower by firing Ferret round projectiles into the tower. More importantly, however, the second contingency provision in the plan provided:


 * If during any tear gas delivery operations, subjects open fire with a weapon, then the FBI rules of engagement will apply and appropriate deadly force will be used. Additionally, tear gas will immediately be inserted into all windows of the compound utilizing the four Bradley Vehicles as well as the CEV's.

c. the way the plan actually unfolded
At approximately 5:55 a.m., Dick Rogers, commander of the FBI's Hostage Rescue Team, ordered the two CEV's, which were to insert the CS riot control agent, deployed to the compound. At 5:56 a.m., the FBI's chief day-to-day negotiator, Byron Sage, telephoned the residence and asked to speak with Davidian Steve Schneider. It took approximately 3 minutes for someone to come to the phone. At 5:59 a.m., Sage informed the person answering the telephone that "We are in the process of putting tear gas into the building. This is not an assault. We will not enter the building." The person on the other end of the telephone responded "You are going to spray tear gas into the building?" whereupon Sage replied, "In the building . . . no, we are not entering the building." While the Justice Department Report is ambiguous on the person to whom Sage was speaking, Sage testified at the hearings before the subcommittees that the person he talked with was Schneider. At the conclusion of this conversation, someone threw the telephone outside of the building.

From 6 a.m. to approximately noon on April 19, 1993, FBI agents implemented the operations plan and injected a large quantity of CS riot control agent into the Branch Davidian residence in four distinct phases. The agents moved close to the Davidian residence in CEV's equipped with devices which could shoot a horizontal stream of CS agent in short bursts or continuously for up to 15 seconds. The device uses carbon dioxide as a disbursant to propel a stream of CS agent, suspended in methylene chloride, horizontally into the air. Once the CS stream is fired, the carbon dioxide quickly evaporates and the methylene chloride gas disperses the CS evenly through a room, until the methylene chloride itself evaporates. The CS agent, which is a fine powder, then slowly falls to the floor, where it remains. The capacity of each delivery system on the CEV's was 30 grams of CS agent.

The insertion of CS agent into the Branch Davidian residence was performed in four phases. The first two phases employed two CEV's. On one CEV was mounted two CS delivery systems, while four systems were mounted on the second CEV. The CEV's were operated in tandem, each inserting the entire contents of the six CS agent delivery systems during the first two phases of the operation, at 6 a.m. and again at approximately 8 a.m. In each of the first two phases, a total of 180 grams of CS was delivered. The third and fourth phases, also 2 hours apart, involved only one CEV, as the second CEV had experienced mechanical difficulties and no longer operated. Four cylinders of CS were delivered in each of these two phases, for a total 120 grams of CS inserted into the residence. Thus, over the entire 6 hours of the operation, a total of 600 grams of CS agent was inserted into the Branch Davidian residence.

During the standoff with the Davidians, FBI agents used unarmed Bradley Fighting Vehicles as a means of transportation while guarding the perimeter of the residence. The FBI's overall operational plan for April 19 provided for the Bradleys to be used in a contingency plan to be implemented in the event the Davidians began to fire on the CEV's. If that occurred, agents in Bradleys who had maneuvered close to the building and were standing ready were to insert additional quantities of CS agent into all parts of the building. Agents in the Bradleys were to fire Ferret round projectiles into the residence. Ferret rounds resemble large plastic bullets, and are fired from hand-held grenade launchers. Each projectile carries 3.7 grams of CS agent, mixed in a suspension of methylene chloride.

Once the Davidians began firing on the CEV's Rogers gave the order to implement the contingency plan. The agents in the Bradleys then maneuvered close to the Branch Davidian residence and began to fire the Ferret round projectiles through the windows of the building. During the 6-hour operation, 400 Ferret round projectiles were fired at the Branch Davidian residence, a number of projectiles struck the side of the building and did not enter the building. Estimates of the number of projectiles that actually entered the residence range from 300 to 380. Had all 400 projectiles fired at the residence actually entered the residence, however, the total quantity of CS agent delivered by the Ferret round projectiles would have been 1,480 grams.

1. Introduction
Chlorobenzylidene malononitrile, commonly called CS, is one of a family of approximately 15 chemical compounds used to control civilian populations during periods of disturbance and unrest. These "riot- control agents" cause acute irritation to the eyes, mouth, nose, and upper respiratory tract, that is relatively brief and not usually accompanied by permanent toxic effects. Exposure to riot-control agents renders the victim temporarily incapacitated, but the symptoms typically persist for only a few minutes after cessation of exposure.

The first riot control agent was developed in the early 1900's. In 1928, two chemists, Corson and Stoughton, developed 2- chlorobenzylidene malononitrile, code named CS. However, CS was not developed as riot-control agent until the 1950's, when the British War Office began to search for a chemical that was more potent than either CA or CN. By the 1960's, CS had replaced CN as the preferred tear gas among police authorities around the world. Its popularity stemmed from the fact that it was shown to be a more potent irritant than CN, and appeared to cause less long-term injury, particularly to the eye. Military forces also saw CS as a potent weapon for particular operations. Large quantities of CS were used by the United States during the Vietnam War. CN is no longer used by the U.S. military operations, but it is still used by some civil authorities, and by individuals for self-defense. Among civilian law enforcement agencies CS is, by far, the most widely-used riot control agent.

2. Concerns over use of CS
CS has gained wide acceptance as a means of controlling and subduing riotous crowds. However, its widespread use has raised questions about its safety. Most published studies have concluded that, if used correctly, the irritant effects of exposure are short-lived and do not cause permanent damage. However, there have been isolated reports of fatalities from the use of riot control agents. The most common reports involve deaths attributed to the use of riot control agents by American miltary personnel in Vietnam. The United States used large amounts of CS during the Vietnam War in both offensive and defensive military operations. The basic doctrine for the use of CS weapons by U.S. sources is summarized in the following passage taken from a 1969 Army training circular: The employment of riot-control agents (CS, CN) in Counter guerilla operations is most feasible in tactical situations characterized by close combat in which rapidly responding systems are essential and permanent effects are undesirable. Riot-control munitions can be used tactically to temporarily disable hostile troops, to suppress their fire, or to cause them to abandon their position. Offensively, riot-control agents can be used to "flush out" unprotected enemy troops from concealed positions or to reduce their ability to maneuver or use their weapons. Defensively, riot-control munitions can be integrated into defensive perimeters to provide rapid CS delivery in case of enemy attack. CS was employed for defensive purposes such as in the event of a surprise attack from superior enemy forces, and to help secure helicopter extractions of combat units or downed airman. It was used extensively in area-denial operations to render terrain uninhabitable by the enemy. CS was also used routinely in direct engagement of the enemy during offensive combat operations. U.S. forces were issued gas masks to protect themselves against use of CS and other tear gases by the enemy. According to one U.S. evaluation, the North Vietnamese had only a limited supply of tear gas, but they used it to good effect. During the conflict, the general service respirator was replaced by a lighter mask, which went through a number of further modifications. The protection which it conferred was adequate but not complete, because dense CS aerosols can have a strong irritant effect on bare skin, especially in hot and humid conditions when the skin is moist. Additionally, other reports involve injury and death from the use of CS in Chile, Panama, South Korea, and the Gaza Strip and West Bank of Israel. It has been unclear from these reports, however, whether the riot control agent used was CS or another, more toxic, agent. Of particular concern, however, has been the indiscriminate use of riot control agents in enclosed and indoor spaces where it is feared that resulting high concentrations may have resulted in harmful levels of exposure. Severe injuries from exploding tear gas grenades as well as deaths from the toxicity of riot control agents used in confined, indoor spaces have been reported.

Critics of the use of these agents argue that the available toxicological data is insufficient to describe with any confidence the potential for long-term pulmonary, carcinogenic, and reproductive effects. One recently published review of the toxicological data on riot control agents concluded that relatively little has been published in the mainstream medical literature and that epidemiologic studies following tear gas use under actual field conditions are almost nonexistent. The author of this review wrote:


 * There is clearly a great need for openly conducted research illuminating the full health consequences of exposure to riot-control agents including outcomes such as tumor formation, reproductive effects, and pulmonary disease. Consideration must be given to the possible effects of these agents on the young, the elderly, and other persons who might have increased susceptibility.

1. Common effects of exposure to CS
All riot control agents, including CS, produce intense sensory irritation even in the most minute concentrations. For most of these agents, the eye is the most sensitive organ, with pain arising rapidly, accompanied by conjunctivitis, excessive tearing, and uncontrolled blinking. The inside of the mouth and nose experience a stinging or burning sensation, and there is usually excessive discharge of nasal mucus. Chest tightness and burning are accompanied by coughing, sneezing, and increased secretions from the respiratory passageways. A burning sensation is felt on the skin, often followed by inflammation and redness, and in some cases, actual burning of the skin occurs. Tear gas exposure may also irritate the stomach, leading to vomiting and possibly diarrhea. In addition to the physical symptoms, panic and severe agitation are common among those individuals with no prior experience of exposure to tear gas.

Most of the symptoms are felt within 10 to 30 seconds after exposure to the agent. After cessation of exposure, however, most symptoms continue to persist for a period of minutes before subsiding and disappearing. The effects of expose vary among individuals. Additionally, weather conditions, such as temperature and humidity, can heighten the potency of these agents.

2. Toxicity of CS
A review of the scientific literature concerning the use of CS indicates that limited conclusions as to the toxicity and lethality of CS are known. It seems generally accepted by the scientific community that the concentration of CS agent which is noticeable by humans and which will provoke physical responses in humans is 4 milligrams per cubic meter (4 mg/m^3). While no studies on humans have been conducted concerning the lethality of CS, several studies have projected the concentrations at which CS is lethal to humans from the effects of studies performed on animals. Those studies estimate that the concentration of CS agent which would prove lethal to 50 percent of any given human population ranges from as low as 25,000 to as high as 150,000 mg-min/m^3. Recent estimates by the U.S. military, however, estimate that the lethal concentration for humans is 61,000 mg- min/m .\522\ That study projects that the concentrations which would be injurious to the health of approximately 50 percent of any human population range from between 10-20 mg-min/m^3.

It is important to note, however, that there are no published studies which find that any human death has been caused by exposure to CS agent. While a number of unverified reports of human deaths can be found in the literature, in all of these reports it is unclear precisely whether CS or some other, more toxic, riot control agent was used or whether some other circumstance could have caused the deaths. The most extensive study of the use of CS agent on humans, by United Kingdom forces in Northern Ireland in the late 1960's, found that no deaths (and no long-term injuries) resulted from the widespread use of CS agent there. The only other documented study of the effects of CS used on a large number of humans confirms this finding.

Some people may find curious the fact that all of these studies (and similar studies on the effects of chemical agents) uniformly give estimates of the level at which CS is lethal or injurious to 50 percent of a given population of humans. It appears from the literature that the effect of CS on humans (and on other animals) is not "linear," i.e., that proportionately greater concentrations do not have equally proportionate increases in effect. While scientists can estimate the levels which would prove lethal to 50 percent of a given population, it would be incorrect to presume that half of that quantity would kill 25 percent of that population. In fact, the most well-known study of the effects of CS on humans estimates that the likelihood of death after exposure to a dose of CS that is one-tenth the estimated lethal does is less than 1 in 100,000. Accordingly, any analysis of the lethality of the CS agent used in the concentrations that resulted on April 19 can only be performed in light of the 50 percent lethality estimates.

Even when the quantities of CS riot control agent used do not reach lethal toxic levels, there are, nevertheless, significant physical consequences that occur from exposure to CS, and often severe emotional reactions caused by the symptoms brought on from exposure to CS. As discussed above, one recent study of the use of large quantities of CS against a population unable to leave the area in which the CS was used indicated that first, second, and even third degree burns are possible when skin is exposed to CS. Additionally, some studies have shown that exposure to CS can cause allergic contact dermatitis. Other studies have shown that when CS can cause severe gastroenteritis when ingested, whether directly or as a result of ingesting mucus secretions containing CS from oral inhalation.

Additionally, some studies on animals have suggested that exposure to CS might cause cancer and genetic abnormalities. Some studies have stated that exposure to high concentrations of CS for prolong periods could result in inflammatory changes in the respiratory tract that might be conducive to secondary respiratory infection. And it is believed that CS may exacerbate existing medical conditions of persons with bronchitis or asthma, although no reports of death from these conditions exist.

1. Lethality of CS as used at Waco
Testimony before the subcommittees presented contradictory evidence on the effects of CS riot control agent. The published literature described above, however, is more consistent in the conclusions drawn. While it cannot be concluded with certainty, it is unlikely that the CS riot control agent, in the quantities used by the FBI, reached lethal toxic levels. The evidence presented to the subcommittees does indicate, however, that CS insertion into the enclosed bunker at a time when women and children were assembled inside that enclosed space could have been a proximate cause of or directly resulted in some or all of the deaths attributed to asphyxiation in the autopsy reports.

In order to answer the question of whether the quantities of CS agent inserted into the residence might have reached lethal levels, the subcommittees attempted to determine the concentrations that were present in the residence under the "worst-case" circumstances. To make this determination, a number of assumptions must be made. Many of these assumptions were overstated solely for the purpose of calculation in order to place the greatest scrutiny on the government's actions.

In each of the first two phases of insertion into the Branch Davidian residence, a total of 180 grams (180,000 mgs) of CS was delivered. For the purposes of analysis, the subcommittees assumed an "extreme case" scenario, where all 180 grams were delivered into the building by the two CEV's at the same instant, and that one-quarter of the Ferret rounds fired at the residence were fired at the precise moment that the CS delivered by the CEV's entered the residence. If so, then during the first and second phases of the CS operation, 550 grams (550,000 mgs) of CS were delivered to the residence. During the first and second phases, therefore, the total concentration of CS delivered into the compound was 108.92 mgs/m^3. During the third and fourth phases, due to the mechanical failure of the second CEV, only 490 grams (490,000 mgs) of CS agent was delivered into the residence. During each of the third and fourth phases the total concentration at the (assumed) moment of insertion was 97.04 mgs/ m^3.

Assuming the Branch Davidian residence been air-tight, so that none of the CS agent escaped the building (which was not the case), the total amount of CS agent delivered present in the building would have been 411.92 mgs/m^3. This concentration is far below the 61,000 mgs/ m amount projected to be lethal to 50 percent of a given population of humans. Stated in another way, it would take a concentration of CS 148 times greater than the greatest amount that could have been present at the Branch Davidian residence on April 19 to reach that lethal level.

In reality, the concentrations of CS inside the Branch Davidian residence did not reach even these levels. The Branch Davidian residence was a poorly constructed structure which allowed for air to move in and out of the residence continuously. The air circulation carried some of the CS agent out of the building. Adding to the air circulation inside the Davidians residence that day was the fact that the FBI began to use the CEV's to ram openings into the building, ostensibly to create a means of escape for the Davidians and, later, to "deconstruct" portions of the structure in an effort to prevent the Davidians from occupying those areas of the residence. These actions greatly enhanced the circulation into the residence and further depleted the concentration of CS agent inside the residence. Additionally, on April 19th, the winds were gusting up to 25 mph. This fact greatly enhanced the air circulation inside the residence, adding to the dissipation of the concentration of CS agent in the residence. Thus, the actual levels of CS inside the Davidian residence were less than those calculated above.

Some who have contacted the subcommittees have suggested that the above analysis is flawed because it does not allow for the possibility that some CS agent was concentrated in certain areas of the residence rather than being evenly distributed throughout the entire structure. The subcommittees believe that it is important to address that possibility.

Because the largest group of bodies recovered after the fire was found in the area of the residence commonly known as the gun room or bunker consideration was given to the concentrations of CS in that area. The bunker was a solid concrete room inside the Davidian residence. It had no windows or other access to the outside of the building, but did open into a hallway inside the residence. It appears that there was little opportunity for CS to have been directly sprayed into the bunker and that any CS that was present in the bunker likely drifted into that room after it was sprayed into one or more of the rooms along the outside of the structure. The subcommittees note, however, that the videotape of the insertion of CS on April 19 indicates that one of the CEV's drove into the structure near the bunker during the fourth phase of the CS insertion. If the door to the bunker had been open at that time, it is possible that CS might have been injected directly into the bunker.

Based on this possibility the subcommittees attempted to determine, as a worst case scenario, the concentration of CS that would have been present in that room had the CEV emptied the entire contents of one of its CS containers into the bunker. It appears, however, that even in that event the concentration of CS would not have reached lethal levels.

The volume of the bunker room was approximately 44.40 cubic meters. Assuming that an entire cylinder (30 grams) of CS was injected into the room, the concentration at that moment would have been 675.67 mgs/ m^3. As discussed above, the concentration level estimated to be lethal to humans is 61,000 mgs-min/m^3. Even had the CEV which was mounted with four containers of CS inserted the contents of all four containers into the bunker, the resulting concentration would have been 2,702.70 mgs/m^3. Again, this figure is well below the concentration level estimated to be lethal to humans.

Another worse case scenario considered by the subcommittees was the possibility that one of the CEV's might have delivered the entire contents of one of its cylinders of CS agent into one of the smallest rooms of the residence, and that that room was inhabited at the time. It still appears that the concentration of CS would not have reached lethal levels. The smallest rooms in the structure were the women's quarters located on the second floor of the residence. The smallest of these had a total volume of 16.17 cubic meters. Assuming that an entire cylinder of CS had been injected into this room, the concentration at that moment would have been 1855.29 mgs/m^3. Assuming further that a number of Ferret rounds also happened to be fired into the room at the exact moment that the CS was injected by the CEV (assume an impossible event such as 20 rounds entering the room at the same instant), the concentration at that instant would have been 6,431.66 mgs/m^3. Again, these figures fall far below the concentrations estimated to be lethal to humans.

While concluding that it is unlikely that the CS reached toxic levels, the subcommittees note the level of exposure to CS experienced by an individual Davidian cannot be determined. It is possible that a person near one of the CEV's injecting the CS may have been subject to a level of CS that was high enough to cause death. Additionally, 10 of the autopsies indicate asphyxiation as the cause of death, but do not indicate whether CS or other factors may have lead to this. The subcommittees are unable to conclude that CS did not play a part in the deaths of these persons.

2. Lethality of methylene chloride used with CS at Waco
During the gassing operation, each cylinder of the CS riot control agent introduced into the Branch Davidian residence by the CEV's was mixed with approximately 1,070 grams of methylene chloride. This suspension was then dispersed into the structure by carbon dioxide, which almost immediately evaporated, leaving the suspension of CS and methylene chloride. Additionally, each of the Ferret round projectiles contained 33 grams of methylene chloride as the dispersant medium for the CS agent.

The four phases of insertion of CS agent into the Branch Davidian residence were conducted approximately 2 hours apart. During the first and second phases six cylinders of CS agent were inserted into the residence, delivering approximately 6,420 grams of methylene chloride in each phase. During the third and fourth insertions only four cylinders of CS agent were inserted, accounting for approximately 4,280 grams of methylene chloride during each insertion. Assuming a worse case scenario of all of the CS insertions in one phase occurring at the same moment and approximately \1/4\ of the Ferret round projectiles entering the building at that same time, thus adding an additional 3,300 grams of methylene chloride in each phase, the total concentration of methylene chloride delivered into the building during the first and second insertions was 1,924.87 mgs/m^3.

A review of the scientific literature concerning CS agent has located no estimates of the concentration of methylene chloride which would prove harmful or lethal to humans. The only estimates which do exist are with respect to mice and rats. For example, the concentration that would prove lethal to 50 percent of a rat population is estimated to be 2,640,000 mgs-min/m^3. As can be seen from the above figures, therefore, the total concentrations of methylene chloride at the Davidian residence on that day were less than the concentrations that would prove lethal to even rats. It appears, therefore, that the methylene chloride used with the CS agent could not have caused the death of any of the Davidians.

As in the case with CS, the subcommittees considered the possibility that some methylene chloride was concentrated in certain areas of the residence rather than being evenly distributed throughout the entire structure. Because the largest group of bodies recovered after the fire was found in the area of the residence commonly known as the gun room or bunker, consideration was given to the concentrations of methylene chloride in that area. As discussed above, the bunker was a solid concrete room with no windows or other access to the outside of the building, but did open into a hallway inside the residence. Again, it appears that there was little opportunity for the methylene chloride carrying the CS agent to have been directly sprayed into the bunker and that any methylene chloride that was present in the bunker likely drifted into that room after it was sprayed into one or more of the rooms along the outside of the structure. But the subcommittees again note that the videotape of the insertion of CS on April 19 indicates that one of the CEV's drove into the structure near the bunker during the fourth phase of the CS insertion. If the door to the bunker had been open at that time, it is possible that methylene chloride carrying the CS agent might have been injected directly into the bunker.

Based on this possibility the subcommittees attempted to determine, as a worst case scenario, the concentration of methylene chloride that would have been present in that room had the CEV emptied the entire contents of one of its CS containers into the bunker. It appears, however, that even in that event the concentration of CS would not have reached lethal levels.

The volume of the bunker room was approximately 44.40 cubic meters. Assuming that an entire cylinder of CS (with 1,070 grams of methylene chloride as a disbursant) was injected into the room, the concentration at that moment would have been 24,099 mgs/m^3. Even if the CEV that was mounted with four cylinders of CS inserted the contents of all four containers into the bunker, the resulting concentration would have been 96,396 mgs/m^3. Both of these figures are well below the concentrations estimated to be lethal to rats.

Another worse case scenario considered by the subcommittees was the possibility that one of the CEV's might have delivered the entire contents of one of its cylinders of CS agent into one of the smallest rooms of the residence, and that that room was inhabited at the time. It still appears that the concentration of methylene chloride would not have reached lethal levels. The smallest rooms in the structure were the women's quarters located on the second floor of the residence. The smallest of these had a total volume of 16.17 cubic meters. Assuming that an entire cylinder of CS had been injected into this room, the concentration of methylene chloride at that moment would have been 66,171.93 mgs/m^3. Assuming further that a number of Ferret rounds also happened to be fired into the room at the exact moment that the CS was injected by the CEV (assume, for example, an event as unlikely as 20 rounds entering the room at the same instant), the concentration at that instant would have been 106,988 mgs/m^3. Again, these figures fall far below the concentrations estimated to be lethal to rats.

3. Other possible effects of methylene chloride used with CS at Waco
While the subcommittees conclude that the levels of methylene chloride did not reach lethal toxic levels, the subcommittees also considered whether the levels of methylene chloride may have affected the Davidians in other ways. At levels over 1,000 parts per million (ppm) anaesthetic effects begin to occur in humans. At levels above 2,300 ppm, exposure to methylene chloride may cause dizziness.

Because methylene chloride evaporates rapidly when released into the air, the subcommittees considered separately the concentrations of methylene chloride during each of the four phases of the CS agent insertion. The levels of methylene chloride were greatest during the first two phases (because one of the CEV's was unable to inject the CS agent/methylene chloride mixture during the third and fourth phase).

During the first and second phases, six cylinders of CS agent were inserted into the residence, delivering approximately 6,420 grams of methylene chloride in each phase. Assuming that all of the CS inserted by the CEV's during one phase was inserted at a single moment, and that approximately \1/4\ of the Ferret round projectiles used during the entire operation also entering the building at that same time (thus adding an additional 3,300 grams of methylene chloride in each phase ), and that the Davidian residence was airtight, the concentration of methylene chloride during each of the first two phases would have been 548 ppm. At this concentration, studies have shown no observable effects in humans.

In considering the possibility that some methylene chloride was concentrated in certain areas of the residence, rather than being evenly distributed throughout the entire structure, the subcommittees found that it was possible that the levels of methylene chloride reached concentrations that might have caused levels that produced an anaesthetic effects in humans.

Again, the subcommittees considered the possible concentration in the bunker, as the largest group of bodies recovered after the fire was found there. The volume of the bunker room was approximately 44.40 cubic meters. Assuming that an entire cylinder of CS (with 1,070 grams of methylene chloride as a disbursant) was injected into the room, the concentration at that moment would have been 6,861 ppm. This concentration was sufficient to induce dizziness and other anaesthetic effects in humans.

As stated, however, the evidence is not determinative as to whether one of the CEV's did, in fact, insert CS directly into the bunker. Additionally, it is unknown if the bunker door was open or closed, a factor that would have significantly affected the concentration levels inside the room. Finally, the air circulation inside the building would have affected the levels of methylene chloride present at any one time. The subcommittees conclude, however, that it is possible that the levels of methylene chloride in the bunker were such that the chemical impaired the Davidians' ability to escape the room. Additionally, the possibility cannot be dismissed that other Davidians, in other areas of the residence, might have been similarly adversely affected if they were directly exposed to an insertion of an entire cylinder of the CS agent/ methylene chloride mixture. Thus, the levels of methylene chloride that were present in the Davidian residence as a result of the use of the CS riot control agent might have impaired the ability of some of the Davidians to be able to leave the residence had they otherwise wished to do so.

1. The decision not to storm the residence
The subcommittees received testimony concerning the FBI's decision not to storm the residence in order to end the standoff. Additionally, the Justice Department Report on these events also discusses the factors that went into this decision. According to that report, FBI tactical experts believed that there was a substantial likelihood of significant casualties to FBI agents if a frontal assault on the residence was attempted. The FBI believed that the Davidians had fortified the residence and were ready to offer resistance equal to or perhaps even greater than that they had showed during the failed February 28 assault on the residence by the ATF. The FBI was also concerned about the possibility of suicide by the Davidians in the event of such an assault.

Experts on tactics testified before the subcommittees that a frontal assault is one of the riskiest types of tactical operations. That risk was even greater in this situation given the large size of the structure and the wide-open areas around the structure with the resulting lack of cover for any approach to the residence.

The FBI's decision to pursue options other than a frontal assault in order to end the standoff was a wise one. It seems clear that a raid, even one better planned than that of the ATF of February 28, was of unacceptably high risk. It is likely that FBI agents would have sustained casualties in such an assault. Any assault on the Branch Davidian residence also risked the lives of the Davidians. Additionally, the FBI appropriately considered the possibility of suicide by the Davidians in the event of an assault.

a. The situation would not soon be resolved
One of the key factors influencing the FBI's decision to recommend to the Attorney General that the standoff be ended on day 51 was the belief by FBI officials that continuing to negotiate with the Davidians would not lead to their peaceful surrender. At the hearings held by the subcommittees, FBI chief negotiator Byron Sage testified that he believed that further negotiations would not be fruitful. Tactical commander Jeffrey Jamar testified that he was skeptical that negotiations would end the stand-off, and that he became even more skeptical after Koresh reneged on a promise to come out on March 2. Documentary evidence reviewed by the subcommittees indicated, however, that some of the FBI's behavioral experts believed that there were further steps that could be taken through negotiations. Additionally, at the subcommittees' hearings, testimony was received from the attorneys for the Davidians that they believed further negotiations could have led to the Davidians' peaceful surrender.

Sage's view was that Koresh had broken many of the promises he had made throughout the standoff. After a experiencing a number of these broken promises, Sage and the other FBI commanders believed that they could not rely on Koresh's assurances.

Another factor that may have affected the FBI commanders' view of the situation, but which was given little emphasis in the Justice Department Report, is mental and emotional fatigue affecting the FBI decisionmakers. Sage was one of the first FBI agents on the scene on February 28. He worked every day, all day, of the 51 day standoff, and only returned to his home in Austin for a short period of time on 1 day to gather more clothes. Jamar and the other senior FBI commanders were also on site for almost the entire time of the standoff. It seems only natural then, that physical and mental fatigue would begin to set in and that dealing with Koresh's rhetoric and disingenuousness would lead to emotional fatigue as well. Indeed, the Justice Department Report indicates that the law enforcement personnel present were tired and that their "tempers were fraying."

Nevertheless, FBI commanders to become firmly convinced that nothing more would come from further negotiations with Koresh. That belief was communicated by Sage to Associate Attorney General Webster Hubbell during a 2-hour telephone conversation on April 15. This belief played a crucial role in influencing Attorney General Reno's decision to end the standoff on April 19.

During the hearings, however, the subcommittees received testimony from the Davidians' attorneys that Koresh was hard at work writing his interpretation of the Seven Seals discussed in the Book of Revelation in the Bible. They believe that Koresh was willing to surrender when he finished his writing.

The FBI's commanders knew of Koresh's desire to write this manuscript but did not believe he was actually working on it. It appears that fatigue and frustration at the lack of achieving success in obtaining the release of additional Davidians may have led the negotiators to be less than receptive to this information. That the negotiators were not open to this new information, and did not pass it on to their superiors, played a part in the Attorney General's decision to end the standoff on April 19 and in the manner chosen to end it.

b. ???? the children as shields
Another factor that went into the FBI's recommendation to the Attorney General to end the standoff on day 51 was the fear that the Davidians might attempt to breakout of the residence using the children as human shields. According to the Justice Department Report, "some [unnamed] experts" had suggested this possibility and that to combat this possibility, the FBI had to be certain that its best trained troops (the Hostage Rescue Team members) would be on the scene. There was some doubt as to how much longer the HRT could remain at the residence.

There was little evidence to support this fear. At no time did Koresh or Schneider threaten that the Davidians might attempt to break out of the residence or take any other offensive action. In fact, from February 28 to April 19 all of the Davidians' actions could be viewed as defensive in nature--defending what they believed to be sacred ground, their residence. Given the Davidians' professed devotion to their residence, it is difficult to understand why the FBI thought the Davidians would try to leave. Given that the FBI also knew that the Davidians were very much aware of the perimeter security around the residence it is difficult to understand why the FBI thought the Davidians believed they could escape. In short, there appears to have been little support for the FBI's concern that the Davidians would try to break out of the residence. To the extent it played a part in the FBI's decision to recommend that the standoff be ended on April 19, this unfounded fear contributed to the tragic results of that day. The Attorney General knew or should have known that the fear of breakout argument was unfounded.

c. The FBI Hostage Rescue Team needed rest and retraining
According to the Justice Department Report, another important factor that played a part in the Attorney General's decision to end the standoff on April 19 was concern over the continuing readiness of the Hostage Rescue Team. It is unquestioned that the HRT possesses more skills and skills that are more highly developed that any other civilian tactical unit within the Federal Government. These skills need constant use in order to be retained, much as a superior athlete must train each day to maintain his or her level of athletic skill. Without that training, these skills begin to deteriorate.

According to the Justice Department Report and testimony presented to the subcommittees, the concern about the possible deterioration in HRT skills was raised at a meeting of Justice Department and FBI officials with the Attorney General on April 14, 1993. By that date, the HRT members had been present at the Branch Davidian center for almost 7 weeks without the opportunity for the type of training that they otherwise would be pursuing every day. Also present at that meeting were several military officers. As a Defense Department witness testified before the subcommittees, the officers explained that they were present at the April 14, 1993 meeting at the invitation of FBI officials in order to answer any questions that the Attorney General might pose to them about ending the standoff. The officers had been selected because of their special tactical training and experience. During the meeting, one of the officers advised the Attorney General that if the HRT were military troops under his command he would recommend pulling them away from the Branch Davidian center for rest and retraining.

According to the Justice Department report, HRT commander Dick Rogers informed the Attorney General that the HRT members "were not too fatigued to perform in top capacity in any tactical operation at that time" but that if the standoff continued for any extended period of time he would recommend that they "stand down" for rest and retraining. At the subcommittees' hearings Mr. Rogers and Floyd Clarke, Deputy Director of the FBI in early 1993, each testified that they believed the HRT could have remained on site for at least 2 additional weeks before he would have recommended that they "stand down."

The point at which the deterioration of HRT members skills becomes unacceptable is not a fact which appears to be readily quantifiable, but rather is a matter of informed judgment. Nothing in the evidence presented to the subcommittees leads to the conclusion that the HRT members' skills were not deteriorating or that the recommendation of the military officers and the HRT commander to remove the HRT members for rest and retraining was not well-informed. But this observation does not answer the questions of what weight this fact should have played in the Attorney General's decision to end the standoff on day 51.

The Justice Department Report states that the Attorney General discussed with the FBI the possibility of using FBI SWAT teams to relieve the HRT for a time so that the HRT could be pulled from the scene, rested, and retrained but that the FBI discouraged that option and took the position that it should be used only as a last resort. At the hearings before the subcommittees, however, Floyd Clarke, Deputy Director of the FBI in early 1993, testified that the FBI was formulating plans to use FBI SWAT teams in place of the HRT teams if the Attorney General did not approve the plan to end the standoff in mid- April.

The FBI testified that the qualification of its several SWAT teams do not equal that of the HRT. What must be considered, however, is the actual task for which the SWAT teams would have been used. It would not have been an attempt to enter and take control of the residence. As the Justice Department Report and hearing testimony made clear, during the 51 day standoff the HRT was used only for perimeter security--keeping the Davidians in and outsiders out of the residence. Had the HRT had been relieved by SWAT teams, they would have been assigned to the same task. In short, while HRT capabilities exceed SWAT capabilities, the HRT's additional capabilities are not those essential to the task of securing the perimeter of a crime scene.

Given that the threat of a Branch Davidian breakout was minimal at most, it appears that the FBI was overcautious in informing the Attorney General that its own SWAT teams were not capable of securing the residence perimeter. While the HRT might best have done the job of securing the residence, nothing in the record suggests that the SWAT teams could not have done that job adequately for a short time. Indeed, had the Attorney General not approved the plan to end the standoff in mid-April, the FBI was planning to use its SWAT teams to relieve the HRT. It does not appear that the FBI informed the Attorney General of this fact, however.

Representatives of the Texas Rangers testified before the subcommittees that they believed that State police SWAT teams could have relieved the FBI HRT and maintained the perimeter while the HRT was rested. Representatives of the Texas Rangers interviewed by subcommittees' staff stated that the Texas State police did offer to assist the FBI in maintaining the perimeter during the standoff but that this offer was rejected.

The FBI's decision to reject outside assistance is consistent with the prevailing FBI attitude of resisting any involvement from other agencies, whether Federal, State, or local. This attitude is counterproductive. While the subcommittees cannot evaluate the capabilities of the Texas State police, and are mindful of the command and control problems that may be encountered when bringing together members for organizations that have had no previous experience together, it appears short-sighted for the FBI to have rejected out of hand the offer of assistance from the State police and, specifically for not considering using State police SWAT teams to help maintain the perimeter around the Branch Davidian residence. Given FBI concerns with the size of the perimeter to be maintained, it would seem that these additional personnel could have been of some assistance to the FBI, even if they were used in a merely supporting role, such as at a secondary perimeter established beyond that maintained by the FBI.

While using FBI SWAT teams to relieve the HRT might not have been the optimal approach to the problem, using them (perhaps augmented by State police teams) would have enabled the FBI to rest and retrain the HRT so that it could have been redeployed to the scene after an appropriate time. The FBI's failure to recommend to the Attorney General that SWAT teams be used to relieve the HRT, or to inform her that the FBI planned to use them for this very purpose had she not approved the plan to end the standoff, limited the options and created an unnecessary sense of urgency about ending the standoff. The Attorney General knew or should have known that the HRT did not need to stand down to rest or retrain for at least 2 more weeks after April 19, and if and when it did stand down, FBI and local law enforcement SWAT teams could have been brought in to maintain the perimeter. If she did not know the true facts it is because she did not ask the questions of the FBI that a reasonably prudent person faced with the decision would have asked. If the Attorney General did ask these questions, someone in the FBI lied to her or was grossly negligent in reporting the facts. If the latter was the case, the responsible party should have been disciplined long ago. The absence of such action leads the subcommittees to conclude that the Attorney General was herself negligent.

d. Conditions inside the residence were deteriorating
Another factor that the Attorney General says played a part in her decision to end the standoff on April 19 was a concern about deteriorating conditions inside the residence. There is little support for this concern and it should not have played any significant part of the decision to end the standoff.

The concern about deteriorating conditions is mentioned in only two places in the Justice Department Report. The report also States, however, that the FBI became convinced that while Koresh was rationing water to ensure discipline he was continuing to replenish the water supply. The report further States that the FBI believed that the Davidians had food to last up to 1 year.

In short, if the concern about conditions inside the residence was a factor in the Attorney General's decision, it could only have been about lack of electricity or the lack of sanitation inside the residence. While electricity to the residence was cut off for the final time on March 12, the Davidians had kerosene lamps inside the residence which they used to illumine the interior. And while the Davidians had no way to cook food, they had ample stores of food that did not need to be cooked. In short, there is no evidence that the lack of electricity resulted in any real harm to the Davidians.

The purported concern over sanitary conditions inside the residence is also exaggerated. Even before the February 28 raid, the Davidians had never had running water or other sanitation inside the residence. Human waste was collected in buckets and other containers each day and taken outside to an designated dumping site for the waste. During the standoff, waste was dumped into the half-finished swimming pool next to the residence. Apart from the odor from the swimming pool, however, there is no evidence that the materials in the pool was leaking or leeching into the residence. At the hearings before the subcommittees, one of the surviving Davidians testified that sanitation "was no worse on the last day than it was throughout the fifty-one days." The assertion in the Justice Department Report that "sanitary conditions had deteriorated significantly" is simply incorrect.

In summary, the conditions inside the residence had changed only slightly from those in which the Davidians lived before February 28. The conditions appear to not have presented any immediate health risk to the adults or children inside the residence. If concerns about these conditions played a role in the Attorney General's decision to end the standoff on April 19, they were unfounded and she knew or should have known this.

e. There was the possibility of on-going physical and sexual child abuse
The Justice Department Report states that during the week of April 12, an (unnamed) individual informed the Attorney General that the FBI had learned that the Davidians were physically abusing the children in the residence and that this abuse had occurred after February 28. The report states, "[T]he Attorney General had no doubt that the children were living in intolerable conditions." The report goes on to State that the Attorney General had been told that Koresh had sexually abused minors in the past and "continued to have sex while recovering from his wounds." The report does not State on what intelligence these assertions were based.

In another part of the report, however, the Justice Department admits that the FBI had no direct evidence of physical or sexual abuse. As the reports states,


 * [T]here was no direct evidence establishing that any children were being either sexually abused of physically abused the February 28 through April 19 time period. There were circumstantial indications, however, that the children were living in a deteriorating environment, and that the prospect of living in a deteriorating environment, and that the prospect of sexual or physical abuse was likely as the standoff continued.

There is little circumstantial evidence revealed in the report as well.

It is clear that Koresh sexually abused minor females at the residence, in addition to having consensual sexual relations with a several of the adult females who lived there. A number of former Davidians provided affidavits detailing these sexual relations, including the sexual abuse involving minors females. Joyce Sparks, an employee of the Texas Children's Protective Services agency provided the FBI with a report of an interview she conducted with a child who lived at the residence detailing an incident of sexual abuse. This child testified about her experience before the subcommittees at the July hearings. Also, during conversation between the FBI and Steve Schneider during the week of April 14, Schneider admitted that he knew of Koresh's sexual abuse of a minor female. While all of these incidents occurred prior to February 28, FBI behavioral expert Dr. Park Dietz, in an April 17 memoranda to the FBI, opined that "Koresh may continue to make sexual use of any minor female children who remain inside."

It also appears certain that Koresh employed severe physical punishments as a means of disciplining the children. A March 26 report of Dr. Bruce Perry, a child psychiatrist who interviewed the children who had been released during the standoff, confirmed that Koresh physically abused children who had misbehaved.

On April 19, the Attorney General made several television statements during which she stated that her concern of on-going child abuse was factor that led her to decide to end the standoff. While the Attorney General's concerns for the children's welfare were real, there was no reliable evidence that conditions inside the compound had worsened substantially from those existing prior to the February raid or that the Davidian children were suffering greater harms than they had in the past. Additionally, as the Justice Department report makes clear, the Attorney General was aware of the potential for extreme danger to the children in pursuing the FBI's assault plan.

Given the lack of evidence that the children inside the compound faced immediate life-threatening harm from the ongoing standoff and the Attorney General's awareness of the extreme risks of an assault, including the potential for serious or even life-threatening injury to the children, the Attorney General's decision to approve the raid based on concerns for the children's welfare was flawed.

While the Justice Department Report tries to downplay this factor by asserting that the Attorney General was more influenced by other factors, the Attorney General's public statements on and after April 19 indicate otherwise. Particularly troublesome is the statement in the Justice Department report that "[u]ltimately, it made no difference whether the children were undergoing contemporaneous abuse, because the environment inside the residence was intolerable in any event." This statement is an attempt to mask the fact that the Attorney General either was misinformed or misunderstood what was happening inside the residence as of the third week of April or intentionally exaggerated the conditions to provide an excuse for approving the plan she knew could likely end in violence and put the children at greater risk.

a. The FBI's mindset--"This is not an assault"
At 5:59 a.m. on April 19, FBI chief negotiator Byron Sage spoke with Steve Schneider by telephone and told him, "[W]e're in the process of putting tear gas into the building. This is not an assault. We will not enter the building." Schneider responded by throwing the telephone out of the residence. Sage then began to broadcast the following message over loudspeakers pointed toward the residence:


 * We are in the process of placing tear gas into the building. This is not an assault. We are not entering the building. This is not an assault. Do not fire your weapons. If you fire, fire will be returned. Do not shoot. This is not an assault. The gas you smell is a non-lethal tear gas. This gas will temporarily render the building uninhabitable. Exit the residence now and follow instructions.


 * You are not to have anyone in the tower. The tower is off limits. No one is to be in the tower. Anyone observed to be in the tower will be considered to be an act of aggression and will be dealt with accordingly.


 * If you come out now, you will not be harmed. Follow all instructions. Come out with your hands up. Carry nothing. Come out of the building and walk up the driveway toward the Double-E Ranch Road. Walk toward the large Red Cross flag.


 * Follow all instructions of the FBI agents in the Bradleys. Follow all instructions.


 * You are under arrest. This standoff is over.


 * We do not want to hurt anyone. Follow all instructions. This is not an assault. Do not fire any weapons. We do not want anyone hurt.


 * Gas will continue to be delivered until everyone is out of the building.

Immediately after Sage spoke with Schneider, two CEV's approached the residence. Both CEV's were fitted with a long triangular boom-like arm on which was fitted a device that would spray CS agent mixed with carbon dioxide. The CEV's were maneuvered close enough to the residence so that the boom could be rammed into and through the wall of the building. The operator then inserted CS agent into the building using the device affixed to the boom of the CEV. Insertions of CS agent by the CEV's occurred in four distinct phases throughout the morning of the April 19.

During this phase of the plan, FBI agents in the Bradleys also maneuvered close to the residence. The agents used hand-held grenade launchers to fire CS agent in projectiles knows as Ferret rounds thorough a firing port in the Bradleys and into the windows of the residence. This activity also went on throughout the morning of the 19th.

As Sage testified at the subcommittees' hearings, the FBI did not consider these actions to be an assault against the residence. To Sage, the fact that the FBI did not plan to enter the residence at any time, and did not enter the residence, was determinative as to whether the operation was an assault. While this distinction may have made complete sense to the FBI, it made sense only because FBI agents, and especially HRT members, deal with these concepts each day as part of their duties.

The FBI assessed the situation only on their terms. They failed to consider how their actions would be perceived by those who were the targets of their actions--the Davidians inside the residence. This failure was a significant error.

b. The FBI's failure to consider the "Reasonable Branch Davidian"
As the FBI implemented its plan to end the stand-off the Branch Davidians were confronted with the sound of military vehicles approaching their home, the vibrations from holes being rammed into the sides of their home, and by the effects of a gas-like substance being sprayed into their home. Most people would consider this to be an attack on them--an "assault" in the simplest terms. If they then saw other military vehicles approaching, from which projectiles were fired through the windows of their home, most people are even more likely to believe that they were under an assault. If those vehicles then began to tear down their home there would be little doubt that they were being attacked. These events are what the Davidians inside the residence experienced on April 19, yet the FBI did not consider their actions an assault.

Compounding this situation is the fact that the Davidians were not "most people." They were a close-knit group with ties to their home stronger than those of most people. The Davidians considered their residence to be sacred ground. Their religious leader led them to believe that one day a group of outsiders, non-believers, most likely in the form of government agents, would come for them. Indeed, they believed that this destiny had been predicted 2,000 years before in Biblical prophecy. Given this mindset, it can hardly be disputed that the Davidians thought they were under assault at 6 a.m. on April 19.

The FBI's failure to consider how the Davidians might respond to their actions was important. The FBI's operations plan called for a systematic insertion of the CS riot control agent at different intervals throughout the day. But the plan also called for a back-up operation if the armored vehicles used in the operation came under fire. This contingency plan involved rapid insertion of CS agent and the eventual "deconstruction" or tearing down of the residence itself. The vehicles came under fire almost immediately after the gas insertion began. The FBI resorted to their fall-back plan as of 6:07 a.m.

As the Justice Department Report makes clear, the majority of the FBI's briefing to the Attorney General involved the main FBI plan involving the deliberate, slow insertion of CS agent. Little discussion apparently took place about the contingency provision in the plan calling for the rapid insertion of CS agent and the deconstruction of the residence.

Curiously, the FBI seemed to know that their principal plan would not govern the way that events would actually unfold on April 19. The FBI's overall commander, Jeffrey Jamar, testified at the subcommittees' hearings that he had a belief to a 99 percent certainty that the contingency plan would be implemented, as he believed the Davidians would open fire on the CEV's. As he testified before the subcommittees, "I believed it was 99 percent when we approached with the tank they would fire. I believe that. Not all people agree with me on that, but I believed that at the time, yes." Although the Justice Department Report does not mention that Jamar informed his superiors of his belief, it is clear the Attorney General also believed the Davidians would open fire on the FBI. In referenced to firing on the FBI, the Attorney General testified that she "knew what these men would do."

It cannot be known whether the Attorney General would have decided differently had she known that the FBI expected the contingency provisions of the operations plan to be implemented. What is clear is that she never had the opportunity to consider this fact because the FBI believed that their actions did not constitute an attack, based on an incomplete understanding of the Davidians. Had the FBI considered how the Davidians would perceive their actions they might have been able to predict that the fall back plan would be used. If this fact had been communicated to the Attorney General she might have decided things differently.

h. presidential involvement in the events at waco, tx
The involvement of the White House occurred in several ways. According to White House Chief of Staff Mack McLarty, two parallel lines of communication existed--one from Acting Assistant Attorney General Stuart Gerson to McLarty, and the other from Gerson to White House Counsel Bernard Nussbaum. Senior advisor Bruce Lindsey also kept informed on developments in Waco.

No White House officials objected to the plan to end the standoff at an April 13, 1993 meeting between White House and Justice Department officials, including Hubbell, Nussbaum, Lindsey and Deputy White House Counsel Vince Foster. On Sunday, April 18, 1993, Reno called the President to inform him that she had decided to approve the FBI's request to use CS as part of a plan to end the standoff. The President told Reno "it is your decision." Clinton later told the American people, "I was aware [of the plan to insert CS into the residence.] I think the Attorney General made the decision. I knew it was going to be done, but the decisions were entirely theirs."

i. findings concerning the plan to end the standoff
evident the Attorney General knew or should have known that the contingency provision of the plan would be implemented once the operation began on April 19, that the Davidians would not react by leaving the residence as suggested by the FBI, and that there was a possibility that a violent and perhaps suicidal reaction would occur within the residence. At no time has the Attorney General indicated that she reflected on the consequences of the possibility. At the very least this demonstrates gross negligence on the part of the Attorney General in authorizing the plan to proceed. deaths the President should have accepted it.
 * 1) The Attorney General's decision to end the standoff on day 51 was premature, wrong, and highly irresponsible. The decision by Attorney General Janet Reno to approve the FBI's plan to end the standoff on April 19 was premature, wrong, and highly irresponsible. In authorizing the CS assault to proceed Attorney General Reno was seriously negligent. The Attorney General knew or should have known that the plan to end the stand-off would endanger the lives of the Davidians inside the residence, including the children. The Attorney General knew or should have known that there was little risk to the FBI agents, society as a whole, or to the Davidians from continuing this standoff and that the possibility of a peaceful resolution continued to exist.
 * 2) The "benefits" of avoiding problems were not properly evaluated. The FBI's belief that the standoff was likely to continue indefinitely was too pessimistic given the advice of behaviorist Dr. Murray Myron and the Davidians' attorneys that Koresh was turning his attention to what he considered to be his principal theological work, his interpretation of the meaning of the Seven Seals. As they believed that no resolution was possible through further negotiations, the FBI wrongly concluded and convinced the Attorney General that there was no alternative to going forward with the plan to end the standoff. The only issue was timing. There was also no need to rush into action on April 19, but having lost patience with the negotiating process and facing an initially reluctant Attorney General, FBI officials manufactured or grossly exaggerated arguments for urgency. There was never any overt act or even a statement made by Koresh to support the FBI's asserted fear that the Davidians might try a breakout. Using the threat of a breakout as a reason to go forward with the CS assault plan sooner rather than continue the negotiations was wrong. The FBI and the Attorney General knew or should have known there was no remotely imminent threat of such a breakout. Also, there was no reason to go forward on April 19 out of concern that the HRT was exhausted and needed to step down for retraining. According to the HRT's own commander, the HRT could have remained on duty at the residence for at least 2 more weeks. In addition, FBI and local law enforcement SWAT teams could have been brought in to maintain the perimeter if the HRT had to step down for a short time. The FBI and the Attorney General knew or should have known this. The Attorney General wrongly based her decision to act in part on concerns that the conditions inside the residence were deteriorating and that children were being abused. There was no evidence that sanitary and other living conditions inside the residence, stark at the beginning of the standoff, had deteriorated appreciably during the standoff. Further, while there is no question that physical and sexual abuse of minors occurred prior to February 28 and may have continued thereafter, there is no evidence that minors were being subjected to any greater risk of physical or sexual abuse during the stand-off than prior to February 28. The Attorney General knew or should have known this. In light of the risk to the children from a forced end to the stand-off, and the remaining possibility of a peaceful resolution, it was inappropriate for the Attorney General to have been occupied with apprehending Koresh for violations of State law which were outside her jurisdiction to enforce.
 * 3) The risks of ending the standoff were not fully appreciated. In deciding to end the standoff on April 19, the FBI and the Attorney General failed to properly evaluate the risks to the Davidians of the FBI's operational plan. The FBI's plan was based on an assumption that most reasonable people would flee the residence when CS agent was introduced. The FBI failed to fully appreciate the fact that the Davidians could not be relied upon to act as other reasonable people might. The FBI failed to properly account for the Davidians' resolve, group cohesiveness, and loyalty to what they believed to be sacred ground.
 * 4) More troubling is the fact that the FBI commanders either knew or should have known that the contingency provisions of the plan presented to the Attorney General would likely be implemented. While the plan as described to the Attorney General called for a slow and deliberate insertion of CS agent in an effort to deny the Davidians access to some areas of the residence and encourage them to exit the residence in specific locations, the contingency provision in the plan called for much larger quantities of CS to be inserted all at once, and in all areas of the residence, if the Davidians opened fire on the agents inside the CEV's. The result of the contingency provision would be much larger quantities of CS being present inside the residence with the attendant greater likelihood that harmful concentrations might be reached, and also the strong likelihood that the all-out assault would cause panic in the people inside the residence. Jeffrey Jamar, the FBI's overall commander at the residence testified before the subcommittees that he believed there was 99 percent chance that the contingency provision would be implemented because the Davidians would open fire on the FBI against. Clearly, given the Davidians' actions in response to the ATF raid on February 28, it was almost certain that the Davidians would respond to the FBI's actions with gunfire. Yet, Jamar never communicated his opinion to the Attorney General, or apparently to anyone else for that matter. Other senior FBI officials, however, should have realized that the Davidians would respond with gunfire and that the contingency provision of the plan would be quickly implemented. Given this, they should have more fully briefed the Attorney General on this aspect of the plan. More importantly, however, the Attorney General herself admitted during her testimony before the subcommittees that she expected the Davidians to fire on the tanks, and that she understood that if they did the rapid acceleration of contingency plan would be implemented. It is
 * 1) FBI commanders in Waco prematurely ruled-out the possibility of a negotiated end to the stand-off. After Koresh and the Davidians broke a promise to come out on March 2, FBI tactical commander Jeffrey Jamar viewed all statements of Koresh with extreme skepticism and thought the chances for a negotiated surrender remote. While chief negotiator Byron Sage may have held out hope longer, FBI officials on the ground had effectively ruled out a negotiated end long before April 19 and had closed minds when presented with evidence of a possible negotiated end involving Koresh's work on interpreting the Seven Seals described in the Bible's Book of Revelation.
 * 2) FBI tactical commander Jeffrey Jamar and senior FBI and Justice Department officials acted irresponsibly in advising the Attorney General to go forward with the plan to end the stand-off on April 19. Jamar and senior FBI and Justice Department officials advising the Attorney General knew or should have known that of the reasons given to end negotiations and go forward with the plan to end the stand-off on April 19 lacked merit. To urge these as an excuse to act at the time the Attorney General made the decision to do so was wrong and highly irresponsible.
 * 3) The FBI's refusal to ask for or accept the assistance of other law enforcement agencies during the stand-off demonstrated an institutional bias at the FBI against accepting and utilizing such assistance. Throughout the 51 day stand-off the FBI refused to ask for the assistance of other law enforcement agencies and even refused offers of such assistance. The subcommittees find that there is an institutional bias inside the FBI against allowing other agencies to participate in FBI operations. Such bias is short-sighted and, in this case, proved to be counter-productive in that the failure to seek or accept assistance added to the pressure to end the stand-off on April 19.
 * 4) It is unlikely that the CS riot control agents used by the FBI reached toxic levels, however, in the manner in which the CS was used the FBI failed to demonstrate sufficient concern for the presence of young children, pregnant women, the elderly, and those with respiratory conditions. CS riot control agent is capable of causing immediate, acute and severe physical distress to exposed individuals, especially young children, pregnant women, the elderly, and those with respiratory conditions. In some cases, severe or extended exposure can lead to incapacitation. Evidence presented to the subcommittees show that in enclosed spaces, such as the bunker, the use of CS riot control agent significantly increases the possibility that lethal levels will be reached, and the possibility of harm significantly increases. In view of the risks posed by insertion of CS into enclosed spaces, particularly the bunker, the FBI failed to demonstrate sufficient concern for the presence of young children, pregnant women, the elderly, and those with respiratory conditions. While it cannot be concluded with certainty, it is unlikely that the CS riot control agent, in the quantities used by the FBI, reached lethal toxic levels. The presented evidence does indicate that CS insertion into the enclosed bunker, at a time when women and children were assembled inside that enclosed space (i.e., during the fourth CS riot control agent insertion), could have been a proximate cause of or directly resulted in some or all of the deaths attributed to asphyxiation in the autopsy reports. It is clear from the testimony at the hearings that the FBI expected the adult members of the community to care for the children by removing them from exposure to the CS agent by coming out of the residence with them. This presumption was flawed. As the Defense Department's witness testified before the subcommittees, one of the two senior military officers who attended the meeting with the Attorney General on April 14, told the Attorney General that during the use of CS mothers might "run off and leave their children." Yet the Attorney General failed to appreciate the fact that this possibility was in direct contravention to a key assumption of the plan's provision for the use of the CS agent--that the adult members of the community would care for the children. The FBI failed to properly inform the Attorney General of the risks of using CS agent on children by not appreciating the military officer's warning that parents might abandon their children and by not fully apprising the Attorney General that there was little scientific information on the effects of CS on children. While the Attorney General cannot be faulted for relying on the advice given her by persons whose job it was to be fully informed about the use of CS, it appears that the Attorney General failed to fully consider the flawed assumption in the FBI's plan once it should have become obvious to her.
 * 5) There is no evidence that the FBI discharged firearms on April 19.
 * 6) Following the FBI's April 19 assault on the Branch Davidian compound, Attorney General Reno offered her resignation. In light of her ultimate responsibility for the disastrous assault and its resulting

j. recommendations

 * 1) Federal law enforcement agencies should take steps to foster greater understanding of the target under investigation. The subcommittees feel strongly that government officials failed to fully appreciate the philosophy or mindset of the Davidians. If they had, those officials might have been better able to predict how the Davidians would react to the plans to raid the residence on February 28 and the plan to end the standoff on April 19. If so, perhaps many of the errors made on February 28 and during the standoff could have been avoided. The subcommittees found troublesome the fact that many of the ATF and FBI officials involved in this matter seemed uninterested in understanding the Davidians' goals and belief system. The views of these officials ranged from assumptions that the Branch Davidian were rational people likely to respond to authorities as would most citizens to a belief that the Davidians were a "cult" which could not be dealt with in any way other than by force. Seldom did these officials seem interested in actually trying to understand this group of people and their motivations. This attitude was shortsighted and contributed to several of the mistakes that the government officials made at different points from February 28 through April 19. This change in organizational culture can only result if senior officials in the Federal law enforcement agencies implement changes in training and operational procedures. The benefits of these changes will not only protect the targets of government action but, by making it more likely that Federal law enforcement officials will carry out their mission in the manner most likely to succeed, will help to protect the safety of the law enforcement officers as well.
 * 2) Federal law enforcement agencies should revise policies and training to encourage the acceptance of assistance from other law enforcement agencies, where possible. The subcommittees recommend that FBI officials take steps to change the prevailing FBI culture that leads agents to believe that only the FBI knows best how to handle a situation. While agency pride is appropriate, and deserving in the case of the FBI, this pride appears to have caused the agents to have been foreclosed to other possibilities of dealing with the situation at hand, such as by allowing other persons whom the Davidians trusted to become more involved in negotiations or using other law enforcement agency forces to maintain the Branch Davidian center perimeter and thus relieve pressure on the HRT. The FBI could have been open to these possibilities while maintaining its ultimate control of the situation. The FBI needs to take steps now to ensure that this close-mindedness does not occur in the future.
 * 3) The government should further study and analyze the effects of CS riot control agent on children, persons with respiratory conditions, pregnant women, and the elderly. The subcommittees recommend that the FBI and Department of Defense investigate further the effects of exposure to CS on children, pregnant women, the elderly, and persons with respiratory problems. Until such time as more is learned about the actual effects of exposure to this agent, the subcommittees recommend that CS not be used when children, persons with respiratory conditions, pregnant women, and the elderly are present.
 * 4) The FBI should expand the size of the Hostage Rescue Team. One of the pressures that led the FBI to recommend to the Attorney General that the standoff be ended on April 19 was the need to rest and retrain the HRT. There were not sufficient numbers of HRT members to both guard the perimeter of the residence and to relieve members on the line periodically. Given this limitation, the subcommittees also note that if another hostage or barricade situation had developed involving a Federal law enforcement agency while the standoff with the Davidians was continuing, the FBI would have been faced with the choice of not responding to that situation or pulling the HRT out of Waco and moving them to the new location. Both of these scenarios suggest the need to enlarge the size of the HRT. While the subcommittees are aware that the FBI has increased the size of the HRT from the 48 "operator" agents on the team as of early 1993 to 78 operators as of July 1996, the subcommittees recommend that further consideration be given to this issue. As the subcommittees have concluded that the government should have waited beyond April 19 and continued to negotiate with the Davidians, inherent in that recommendation was that the HRT or some other tactical force should have remained at the residence. The FBI should ensure that the HRT is large enough to maintain a long standoff in the future, should the need arise, while also having the capacity to respond to another hostage or barricade situation elsewhere in the country during the standoff.