IIRC First Report - Critical incidents


Posted at Sep 20 2010 06:00 PM | Updated as of Sep 21 2010 05:56 AM


There were Critical Incidents in the chain of events as reconstructed. These Critical Incidents are those points in the chain of events where the action taken, or the inaction, the evaluations and decisions made or omitted, the lapses, that occurred during or resulting from the Critical Incident affected the final outcome of the incident under review.

The First Critical Incident

First Critical Incident was that the Crisis Management Committee was not activated in accordance with the Manual on the activation of a Crisis Management Committee (CMC). Mayor Alfredo Lim of the City of Manila was the person in authority charged with the duty of activating the CMC.

While there was a semblance of a CMC organized by General Magtibay as the Ground Commander, the sub-groups required under the Manual were not activated. As borne by the events as they transpired, this lapse or omission resulted in the inefficiency of, and lack of critical information to make an informed judgment by, the components of the teams assigned to handle the crisis situation most especially the Chief Hostage Negotiator.

There was no intelligence gathering sub-group that would have systematically gathered relevant information to aid the Hostage Negotiating Team and ultimately the assault team. The testimonies given by Amensec and the released hostages were clear that no one took the effort of debriefing or interviewing them to gather relevant information. Right from the very start, the nationality of the hostages was reported as Koreans when the correct information could have been easily obtained from Amensec who reported the incident to the police authorities. Technical information related to the bus such as the emergency exit door, the release button of the main door from the outside, and the make and material of the window panels, were readily available from Amansec and which could have aided decisions related to the assault on the bus. The hostages were also not debriefed as they were released. The basic and important information of seating arrangements or position of the hostages on board the bus was not even obtained. Family members and friends who showed up were not interviewed by the authorities. All these rich intelligence data were not gathered because CMC sub-group for this purpose was not activated.

The sub-group for psychologist(s) to aid the CMC or the Hostage Negotiator in evaluating the Hostage Taker’s behavior and/or actuations did not exist. There were various instances where inputs from a psychologist would have been helpful and in fact critical. Examples of these are: (1) the implications of the Hostage Taker releasing hostages even before his demands (including for food and media) were not yet met; (2) the attempt to fire his gun but where his gun misfired; (3) the potential implications or repercussions of presenting the letter from the Ombudsman in the tenor it was written and its deviation from the demand of the Hostage Taker; (4) the firing of his gun after the letter or the Ombudsman was presented to him and where Gregorio Mendoza told the Hostage Taker that his (Gregorio’s) gun was not returned; (4) the implications or repercussions of even involving Gregorio Mendoza;(5) the potential repercussions of arresting Gregorio, to name just a few. (As an aside, allowing the Hostage Taker to directly communicate with civilian authorities is a breach of protocol on hostage negotiations).

There was notably the absence of a point person to handle media relations, another sub-group of the CMC. This omission later proved to be a major contributory factor to the tragic result of the crisis incident.

The authorities resolving the crisis situation, which included the Hostage Negotiating Team, were clearly not properly guided with relevant inputs or assessment from a psychologist required by the circumstances or nature of the crisis situation.

The Second Critical Incident

The improper appreciation of the nature of the demand of the hostage taker was the Second Critical Incident. How or when the demand for “an order for reinstatement to the service” was convoluted to “a letter promising to review Mendoza’s case” by the Ombudsman could not be satisfactorily explained by the authorities concerned. If it was intentional, then a proper assessment of its implications should have been made. The tenor of the letter was simply, a promise for further delay of the already delayed resolution of Mendoza’s Motion for Reconsideration. It should be noted that at this point the expectations of Mendoza has been raised with the promise of the delivery of the demanded Order. He talked to Vice Mayor Moreno and was even allowed to directly talk to the Ombudsman and was given assurances. It should have been assessed that having raised his expectations, the frustration level could potentially be high if his demand was not met. As borne by testimony, the only action taken related to the tenor of the letter was to read the letter aloud and to ask Gregorio, if it would be acceptable to the Hostage Taker. Gregorio was obviously unqualified to make such assessment!

Related to this was the non-delivery of Mendoza’s case file to Sec. De Lima of the Department of Justice as demanded by Mendoza on two occasions. The first time, to Maj. Salvador, and again reiterated to Col. Yebra. Also twice, PO2 Rivera proceeded to deliver the documents but on both occasions, he was recalled to the Advance Command Post. The only explanation was that the file was going to be reviewed.

The non-delivery of the documents to the Department of Justice in compliance with the request or demand of Mendoza was an omission that excluded the possibility of setting into motion the involvement of the Department of Justice in giving its inputs on the legal viability of complying with the demand for an Order for Reinstatement and in aiding in the resolution of the crisis situation.

The Third Critical Incident

The presentation to Mendoza of the letter from the Ombudsman and the resulting breakdown of negotiations constituted the third Critical Incident. As earlier discussed, at this point the expectations of Mendoza that his demand for and Order for reinstatement was high because this was reinforced by the assurances from the Ombudsman and the Vice Mayor.

There also appears to be a lack of judgment in including Gregorio Mendoza with the Negotiating Team. The point in time when the demand of the hostage taker is “complied with” should have been handled with more sensitivity especially as there was the possibility that the letter would be rejected since it was a deviation from the actual demand of Mendoza. With proper evaluation, elements that could potentially compromise success could have been eliminated.

When the letter from the Ombudsman was read by Mendoza his reaction was almost instantaneous, as born by the transcript of the recording on air from DZXL. Mendoza said: “Basura ito!” (This is garbage!). The rejection was obviously a breakdown in the negotiation. While Col. Yebra attempted to salvage the situation by offering an alternative (the conditional reinstatement pending appeal), several factors converged that affected the appreciation by Mendoza of the offered alternative. Mendoza’s attention was being distracted by his simultaneous engagement in an “interview” by Michael Rogas and his brother, Gegorio, was reporting that his gun was not yet returned. This latter report from Gregorio further infuriated Mendoza because he felt betrayed, claiming that Yebra had earlier told him that the gun was returned.

The criticality of the incident was underscored by Mendoza aiming and firing his rifle at the Negotiating Team (by Maj. Salvador’s account). The implications of the above incident was not also properly evaluated.

The Fourth Critical Incident

The acts, omissions and reaction, of the authorities concerned with resolving the crisis situation, to the initial breakdown (the third Critical Incident) is the Fourth Critical Incident.

Immediately upon return of the Negotiating Team, with Gregorio, to the Advance Command Post, Col. Yebra accused Gregorio of being a conspirator and an accessory. Whether he was shouting or not is not really material. The fact is Col. Yebra displayed his loss of focus on the task at hand. He was distracted by a peripheral matter. More important to addressing the actuations of Gregorio was re-building the confidence of Mendoza, re-establishing contact with him, and salvaging the negotiations that clearly broke down, by working on the offered alternative solution. Instead, Col. Yebra, Mayor Lim, Gen. Magtibay, and other police officers present focused on handling the peripheral matter involving Gregorio resulting to Mayor Lim’s order for Gregorio’s arrest, looking for handcuffs, and conferring on how to handle Gregorio. By attending to the peripheral matter, precious time to salvage the negotiations, already critical at this late hour of the crisis situation, was lost. The windows of opportunity were closing.

This incident led to a chain of events that became the tipping point that pushed Mendoza to become fatally hostile.

The Fifth Critical Incident

The arrest of Gregorio Mendoza upon orders of Mayor Lim was the Fifth Critical Incident. Viewed in perspective, this was the proximate cause of the chain of events that led to Mendoza’s shooting at the Hostages. The potential adverse reaction of Mendoza to an arrest of Gregorio was not lost to Mayor Lim. This is borne by his instruction to the escorting officers to use the back door of the Advance Command Post to avoid media. That Mendoza was viewing television at this time was already known at this point. The instruction to avoid media should be taken in this context.

Given the tenuous situation, i.e., negotiations having broken down, adding a potential irritant to Mendoza with the arrest of his brother, was a lack or absence of sound judgment. Again, the absence of a properly constituted CMC (the First Critical Incident) affected decisions made as there was no one properly evaluating implications of actions and advising decision makers.

The Sixth Critical Incident

The departure of Mayor Lim and General Magtibay from the Advance Command Post at a crucial time was the Sixth Critical Incident.

Immediately preceding events aggravated by lack of evaluation of their implications, compounded by error in judgment, resulted in the Sixth Critical Event. The absence of Mayor Lim and General Magtibay in the Advance Command Post created a vacuum in command or decision makers. This resulted in the inability of those present to handle crisis events as they unfolded. Everything that Mayor Lim and General Magtibay hoped to accomplish at Emerald Restaurant, including taking a meal, could have been accomplished at the Advance Command Post and even better because they would have been in a position to react to events promptly.

The most significant of events that transpired after Mayor Lim and General Magtibay left the Advance Command Post were the coverage of Gregorio being arrested, the deadlines being given by Mendoza before he starts shooting the hostages and the actual shooting of hostages.

The Seventh Critical Incident

The inefficient, disorganized and stalled assault brought about the Seventh Critical Incident. The manner by which the assault on the bus, to rescue the hostages and take down Mendoza, was carried out was the convergence of efficiencies omitted, and inefficiencies committed, through-out the day.

There was an absence of relevant intelligence information that could have aided the formulation and execution of a proper assault plan, including the choice of equipment needed to efficiently carry out the same. The information about the emergency exit door, the emergency button to open the main door and the strength of material of the window panels were vital information. Unfortunately, from the very start, there was no intelligence gathering sub-group activated.

The choice of the SWAT to carry out the assault is by itself a judgment call that requires scrutiny. The IIRC is not in doubt that an order directly from General Santiago and also through Major Medina, to utilize the SAF was given to General Magtibay. Considering that an order to assault entails danger to lives, extra-ordinary diligence in making the decision should be the measure of determining the correctness of the decision.

The SAF is reputably a better trained and equipped unit for the type of assault to be carried out under the circumstances, a matter known to General Magtibay as a high ranking officer in the PNP. This alone demonstrates the error in judgment in General Magtibay’s choice of the SWAT to carry out the assault. Assuming that the proper judgment call was made in the choice of the SWAT, the order for the SAF to support the assault should have been immediately given when the assault faltered and the SWAT was confronted with difficulty in breaching the bus. Precious minutes ran out before the SAF was ordered to assist or support the SWAT assault. There was omission of immediate judgment called by the circumstances.

The Eight Critical Incident

The absence of an organized Post Assault Plan constituted the Eighth Critical Incident. This is significant because an efficient post assault plan is an integral part of managing a crisis situation. Among others, it has for its purpose providing timely and efficient medical attention to hostages that are injured or whose lives could still be saved, securing the area to avoid further harm or injury (the reason for an Explosive Ordinance Unit), and the preservation of the scene for evidence gathering to aid in the investigation that would necessarily follow.

What transpired immediately after the neutralization of Mendoza clearly demonstrated the absence of a Post Assault Plan or the inefficient manner such a plan was carried out, if indeed there was a plan. There was no crowd control that resulted in by standers rushing to the immediate vicinity of the bus thereby hampering evacuation of hostages. Media reporters were even allowed to board ambulances. There was also no clear coordination with medical facilities as shown by the testimony that victims were rejected by one hospital because they could no longer be accommodated. Time was lost in traveling to the next nearest hospital.

Another critical result of the absence of, or lack of proper implementation of a post assault plan was that the scene of the incident, in and around the immediate vicinity, was not preserved. Potential forensic evidence were either lost or contaminated so as to render them practically useless for the purpose of investigation and evidence gathering. The IIRC is witness to the difficulty in reconstructing the events relative to the assault and what transpired inside the bus, even while Mendoza was alive, due to the contamination of forensic evidence.

Again, this Critical Incident is a result of the CMC not being properly convened and the obvious lack of foresight and planning by the Ground Commander and all other authorities charged with the function of ensuring the proper and efficient handling of the crisis situation from its inception to the post assault events.

Return to main page of IIRC First report


Basis of authority and mandate of the IIRC

Summary of proceedings

Limitations of the report

Facts and sequence of events

Forensic findings

Critical incidents

Evaluation of CMC and police actions

Evaluation of media coverage


Conclusions on accountability



These parts of the report have not yet been made public by Malacañang, pending further review by the President's legal team (see statement above).


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