Learning from Tragedies: Police Risk Mitigation Through Root Cause Analysis

by | December 4, 2019

Former Minneapolis police officer Mohamed Noor was recently convicted of third-degree murder in the 2017 shooting of Justine Ruszczyk Damond. Officer Noor and his partner, Matthew Harrity, were investigating a 911 complaint by Damond of a possible sexual assault in progress near her home. The officers arrived in the area and drove up an alley with their lights off. By some accounts, Noor had drawn his service weapon out in his lap as they proceeded up the alley.

The officers approached the end of the alley and were in the process of returning to service when they heard a loud bang on the driver’s side of the car. Damond then appeared at the driver’s window wearing a pink shirt.

Harrity gave a statement to investigators after the incident, but Noor never gave his account until he testified at trial. During Noor’s testimony, he indicated he feared for his partner’s life because Harrity yelled and was struggling to pull out his weapon. Noor saw the woman raise her right arm and then fired one shot, killing Damond. He further explained he made a split-second decision to stop the threat and save his partner’s life. Noor had two years on the job and Harrity had one, but the two had been working together for months.

I had been following this case and was interested in hearing Noor’s account of the incident; it reminded me of the incident in New York City in which Akai Gurley was accidentally shot in the dark stairwell of an apartment building. Officers were doing a sweep of the dark stairwell with their guns drawn, which is a common practice. Gurley and his companion came through a doorway and Officer Peter Liang unintentionally discharged his weapon. The bullet ricocheted and struck Gurley, killing him.

A police agency can have excellent written policy content, but if the agency does not “live” that content, then it is worthless.

Liang was also prosecuted and convicted of manslaughter by a jury, but a judge downgraded the conviction to criminally negligent homicide. Noor was sentenced to 12 ½ years in prison while Liang received probation and 800 hours of community service. Why the stark difference? I believe it may have come down to Noor’s own account of the incident. Prior to the trial, it had been my presumption, based upon the information available and my training and study of human performance factors, that Noor was startled by the noise and/or sudden appearance of Damond at the window, leading to an unintentional discharge. This would have been similar to the shooting by Liang.

Upon reading Noor’s testimony, however, I immediately thought about my June 2019 Counsel’s Corner article about how a use of force explanation founded upon the Graham factors can be misleading. Noor’s testimony implies a reasoned, cognitive decision and perception of a threat as compared to an automatic and reflexive response. Given how he laid out his perceptions and the steps he followed prior to shooting, I am not surprised he was convicted. But I think it’s far more likely that what Noor experienced was an automatic, reflexive and heuristic-based response.

Determining the Root Cause of an Incident

Both incidents were tragedies. Two lives were lost. Two careers are over. An officer who wanted to serve his community is facing more than a decade in jail. The families of everyone involved are changed forever.

Contemporary police administrators and trainers owe it to their officers to learn as much as they can from such tragedies to try to prevent similar occurrences. This article is not intended to be critical of the departments or officers involved in these incidents or to judge them with the benefit of hindsight. After decades in law enforcement, I am confident neither officer came to work that day expecting or wanting to kill or injure another human being. However, it would be equally inappropriate not to study these incidents and learn as much as we can from them. All law enforcement leaders have an obligation to ask if something similar could happen in their jurisdiction.

Learning organizations are those that can perform true self-reflection of their policies and practices and modify them as necessary. Groupthink is the cancer of this process and those involved must be open-minded and willing to candidly share their opinions.

When a tragedy occurs, it is easy to blame the individual officers and take no further action. But this ignores the process followed that led to the tragic result. To be a true learning organization, administrators must be willing to ask these questions: Did we in some way contribute to this result? Could another officer in a similar situation have done the same thing? The answer to these questions can come from an analysis based on the five pillars of risk identified by Lexipol co-founder Gordon Graham: People, Policy, Training, Supervision and Discipline. If one or more of these pillars contributed to the result, then it is not just an individual failure. It is also an organizational failure.

A police agency can have excellent written policy content, but if the agency does not “live” that content, then it is worthless. Training should reflect and reinforce policy and provide realistic and practical training. Supervision should do the same while officers are doing their jobs. Discipline should be used for those who will not comply with policy and procedure, while recognizing the adage, “Train ‘don’t know’ and punish ‘don’t care.’” The goal of all five pillars is to prepare officers as much as they possibly can for situations they may predictably encounter. Training should, whenever possible, be evidence-based and include an assessment and balancing of the risks involved.

Application to the Shootings

Using these incidents as an example of root cause analysis, a first point of focus would be on the appropriateness of officers having their weapons drawn in such situations. (For the purposes of this article I will assume Officer Noor did have his gun out and in his lap while driving up the alley.) I learned a long time ago that having your weapon out in a situation that does not warrant it can be more of a liability than an asset. In a time-compressed situation, you now have limited your options. Attempting to holster your weapon and then transition to another tool can take valuable time and expose you to additional risk.

In addition to the issue related to drawing a weapon, it needs to be determined whether the officers (and officers in general) inappropriately and inadvertently placed their finger on the trigger. A recent study of 171 unintentional discharges found that a “startle response”—a sudden sight, sound or contact that caused an officer to pull a trigger if his/her finger was in the trigger guard—was an established factor in six of the cases. These occurred under higher risk situations, but numerous other unintentional discharges occurred under low-stress situations, including when officers were clearing a call. Unintentional discharges are a known risk and occur even with professionals who receive significant firearms training.

I have identified two possible risks so far—having a firearm out when it is not appropriate and unintentional discharges. The next step is to balance those risks against the reasons officers feel it is necessary to take them. Noor testified that he feared they would be ambushed. The question that must be asked is whether it is a good idea to drive down a narrow alley while contained within the vehicle if you fear you could be ambushed while doing so. Are there alternatives, such as parking the car, getting out and listening and observing from a position of cover? Officers could at least be trained to assess the location of such calls and consider alternative approaches prior to simply doing the same thing every time.

In both situations the real question comes down to this: If someone wants to ambush you in your car or a stairwell, will having your firearm out really prevent that from happening?

Similarly, vertical patrols of New York City buildings take place all the time. They have a purpose because of the crime that can occur within them. But if a stairwell is dark, is moving up the stairwell the only option available? If lights appear to be intentionally damaged, could the protocol be changed to bring more officers in with lights before proceeding? Are announcements and warnings possible prior to moving up in an exposed manner? Would the installation of cameras in the stairwells help reduce the inherent risk to officers involved in such patrols, along with improving the quality of life for the residents? It would certainly be less expensive than the $4 million civil settlement in the case.

In both situations the real question comes down to this: If someone wants to ambush you in your car or a stairwell, will having your firearm out really prevent that from happening? Action is almost always faster than reaction. A person with felonious intent has an advantage that may only be overcome by an officer being unpredictable or unwilling to place him or herself in that vulnerable situation.

Policy and Training

Policy and training need to be consistent and, whenever possible, evidence-based. New York City policy gives officers the discretion as to when to draw their weapons. This is a good policy. But in their training, they are informally told to have their weapons out when doing vertical patrols. It is also my understanding that officers in Minneapolis are informally trained to have their weapons out when checking alleyways.

Training and supervision must be consistent with policy and reinforce it. What is the basis for this training? If these are widespread practices, then how many times did they save officers? How many incidents occurred when an officer did not have their weapon out and was killed or injured as a direct result of that? And in those cases, would the officers having their weapons out have prevented it from happening? Around the time of the Liang trial, two New York City officers were shot and injured while conducting a vertical patrol. Did those officers have their weapons out and, if so, why did it not prevent them from being shot (if that is what their training implies)? Perhaps their training should focus more on the assessment of each individually encountered situation and determining if there are risk-reducing alternatives.

Another important training component is stress-based training, which can help officers learn to manage the startle response. During such training cycles trainers should be focused on the trainee’s finger placement on their weapon as well while they are under stress.

This article was not intended to be a comprehensive overview of these two incidents in the absence of all the facts surrounding them. My intention is to demonstrate the analysis all administrators should follow in the wake of tragic incidents, asking themselves whether the incident could happen in their own agencies. Trainers should be challenged to show the “officer safety” components of their training to be both legal and truly safe. Asking the questions is the key. The worst outcome of such questions is that you determine your practices are sound. The best is that you change the way you do business and continue to improve as a learning organization.


  1. Remsberg C. (8/17/17) Update on Force Science Research about Unintentional Discharges. Force Science Institute. Retrieved 10/29/19 from https://www.forcescience.org/2017/08/update-on-force-science-research-about-unintentional-discharges/.

MIKE RANALLI, ESQ., is a Program Manager II for Lexipol. He retired in 2016 after 10 years as chief of the Glenville (N.Y.) Police Department. He began his career in 1984 with the Colonie (N.Y.) Police Department and held the ranks of patrol officer, sergeant, detective sergeant and lieutenant. Mike is also an attorney and is a frequent presenter on various legal issues including search and seizure, use of force, legal aspects of interrogations and confessions, wrongful convictions, and civil liability. He is a consultant and instructor on police legal issues to the New York State Division of Criminal Justice Services, and has taught officers around New York State for the last 15 years in that capacity. Mike is also a past president of the New York State Association of Chiefs of Police, a member of the IACP Professional Standards, Image & Ethics Committee, and the former Chairman of the New York State Police Law Enforcement Accreditation Council. He is a graduate of the 2009 F.B.I.-Mid-Atlantic Law Enforcement Executive Development Seminar and is a Certified Force Science Analyst.

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