'No one took leadership': A detailed look at the failings in Uvalde school shooting

In the Hill Country of South Texas, where Highways 90 and 83 intersect in a community named Uvalde, the pain is inescapable.

All over town, 60 miles north of the Mexican border, are reminders of what happened on May 24 -- the day a gunman stormed Robb Elementary and killed 19 fourth graders and two of their teachers. Tributes to the dead dot the landscape; murals with the victims' faces, signs that say, "Pray for Uvalde," and "Uvalde Strong."

What has remained largely obscured, however, is the story of why it took 77 minutes for any of the nearly 400 law enforcement officers assembled that day to confront the killer and bring the massacre to an end.

"We failed," said Col. Steve McCraw, director of the Texas Department of Public Safety, leading the investigation. "And I say 'failed,' and I said 'we' ... because collectively we did."

But what has now come into focus during the last eight months is the sheer depth of the failures, the scope of the missteps and how they cascaded one on top of the other to create a chaotic and botched response that may well stand in the future as Exhibit A of how law enforcement should not operate when dealing with an "active shooter" incident.

Over the last three months, ABC News has pieced together never-before-seen investigative files -- including 911 and police-dispatch audio, along with real-time video recordings -- and coupled that with new interviews as well as public accounts and previous work by a special legislative committee. The picture of May 24 that emerges is one that leaves little doubt about law enforcement's lapses. One of the questions that remains is whether any of them could lead to criminal charges.

"Certainly there was malfeasance committed that particular day," McCraw said in his first interview since investigators submitted their initial report to prosecutors in Uvalde. "My belief is there's possible criminal culpability."

"There were a lot of failures that day," said Eva Guzman, a former state supreme court justice who served on a special committee of the Texas Legislature that investigated the Robb shooting. "We expect our police officers to run toward the danger ... and we now know that's not what happened."

Others seem oblivious to their own missteps, including Pete Arredondo, the embattled former police chief of the Uvalde School District.

"As we approached, of course there was some gunfire coming out, and I know it was coming out through the walls some in our direction," Arredondo told investigators in the aftermath of the shooting. "And obviously I backed off and started taking cover."

The 77-minute siege ended with a counterassault led by a SWAT team from the US Border Patrol. In the process, lone gunman Salvador Ramos was shot and killed, the records show. Now, District Attorney Christina Mitchell is weighing whether to press charges against any of the police leaders.

"We have one chance to get this right," said Scott Durfee, a special assistant DA assigned to the Uvalde case. "And it is very important for the decision to prosecute to be based on all of the evidence."

A siege

The end-of-school-year buzz was in full swing on May 24 when Gloria and Javier Cazares blew a kiss to their 9-year-old daughter, Jackie, after an awards ceremony at Robb, where she attended third grade.

"It was going to be a good day," said Arnulfo Reyes, a fourth-grade teacher at the school.

Parents trickled out of the ceremony and students settled back into their classrooms. That's when Amy Marin, a school speech specialist, witnessed something strange outside -- a car had crashed into a ditch. She scrambled to assist the driver.

"I was running to him to help him," Marin said. "I thought somebody had a heart attack."

Within seconds, however, she realized this single car crash was something far more sinister. Security footage confirms what Marin said she witnessed: a gunman emerged from the car and began approaching the school. Standing in an exterior doorway, Marin dialed 911.

"Oh my god, he has a gun," she told the dispatcher, according to audio. "He's jumping into the schoolyard, ma'am! He just jumped over the fence. He's running towards the school."

Inside the classrooms, gunshots can be heard, and confusion sets in -- but not yet panic.

"My students were asking me, 'what's going on? What's that noise?'" Reyes recalled. "And I kind of, like, froze to think about it. Like, 'It couldn't be.'"

Reyes told his students to hide beneath tables and pretend to sleep.

Marin, becoming increasingly alarmed, conveys every development to the 911 operator. Then, as the gunman opens fire on the school, surveillance footage shows her kicking away a rock used to prop open the door and retreating back into the building, believing the door would lock. It doesn't -- a reality that still haunts Marin.

"You see me kick the rock and pull the door," she told ABC News' John Quinones.

"You did not leave it open?" Quinones asked.

"No," she replied.

What Marin didn't know, which investigators would later uncover, is that the lock on the outside of the door was not engaged, and the door wasn't locked. There was no way for Marin to lock it from the inside.

At 11:33 a.m., surveillance video shows the gunman opening the exterior door and disappearing inside. A 911 dispatcher delivers the news over police airwaves.

"He made it into the school, guys."

'A cloud of smoke'

Surveillance video from inside the school shows a man dressed in black menacing the hallways. He is Salvador Ramos, an 18-year-old local resident and former Robb student. As Ramos surveys the corridor, a boy is spotted on surveillance exiting a bathroom down the hall when he sees the attacker and narrowly escapes.

The shooter turns to his left and enters two adjoining classrooms, 111 and 112. A barrage of gunfire ensues -- the gunman fires more than 100 rounds in the first three minutes.

"That's when he shot my arm," said Reyes. "I just remember just falling to the ground … and then he came up to the front and shot my kids after that." Reyes would be shot a second time.

Within minutes, investigators would later say, the gunman unleashes more than a hundred rounds inside the classroom. Marin, at this point barricaded across the hall, remains on the phone with police dispatchers.

"I'm asking the operator, 'Where are the cops?' Where are the cops?'" she said.

By 11:36 a.m., officers arrive in two groups from different directions: On the north side, three Uvalde police officers make entry through the same door as the shooter. On the south side, two Uvalde police officers enter followed by Uvalde School District Police Chief Pete Arredondo and one of his officers.

"It was a cloud of smoke," Arredondo, a career police officer who co-authored the district's active-shooter response plan, later told investigators. "As we approached, of course there was some gunfire coming out, and I know it was coming out through the walls -- some in our direction."

Surveillance footage shows officers approaching the classroom. The gunman turns his fire towards the door, shooting 16 additional rounds and causing the officers to retreat.

Arredondo, who would later explain he dropped his radios before entering the building because he thought they would slow him down, calls a police landline from his cell phone, relaying that the gunman "shot a whole bunch of times" and requesting backup: "I need a lot of firepower, so I need this building surrounded."

Experts and investigators told ABC News these initial moments were especially crucial.

"Initially, it was reported that this was a barricaded subject," said McCraw. "But this wasn't a hostage situation. This was not a barricaded subject. It was in fact an active shooter."

"He was wrong. He made a wrong call," McCraw said of Arredondo's judgment. "Their job was to get their ass into that classroom and kill the subject, plain and simple."

Arredondo later explained he thought the attacker was "cornered." Investigators say he failed to understand that, even as Ramos holed up in a classroom, the episode was still an "active shooter" attack that mandates the most aggressive police response.

"It's a place where you have to step up, put your own life on the line," Guzman added. "And that starts at the top."

Another source of confusion that day was the chain of command as, investigators say, a leadership vacuum crippled the response. Arredondo would later say that he didn't see himself as on-scene commander despite what the active shooter plan made clear: that he, as chief of the school police, would assume leadership and command in the event of an active shooter.

"This event took place in a school," said John Cohen, an ABC News contributor and veteran law enforcement official with expertise in active-shooter and mass-casualty incidents. "It fell under the jurisdictional authority of the school police, the chief of the school police was on scene."

Soon, other local law enforcement leaders arrived on the scene, including Uvalde County Sheriff Ruben Nolasco and acting Uvalde Police Department Chief Lt. Mariano Pargas. Neither assumed the role of command.

"I have never seen a response to a mass casualty attack that was this problematic as the one in Uvalde," Cohen added.

Crisis of command

By 11:45 a.m., 18 law enforcement officers from various agencies had congregated in the building, investigators determined. But confusion among them is visible on police body-worn cameras as officers hunt for keys to the classroom. Meanwhile, anxious parents gather outside the school -- already frustrated by the lack of information.

"Police, of course, trying to hold people back," Javier Cazares recalled of the scene.

"What did they tell you?" Quinones asked.

"'Nobody can answer you, we don't know what's going on,'" he said. "Confused -- they were all confused themselves, you know? A lot of them were [confused]."

Inside, Arredondo makes the decision to evacuate children from neighboring classrooms.

"I know this is horrible and I know this is what our training tells us to do, but we have him contained," Arredondo told investigators in a recorded interview obtained by ABC News. "There's probably going to be some deceased in there, but we don't need any more from out here. So I called out and I said get these kids out."

McCraw characterized this decision as "the wrong call," and said it conflicts with longstanding active shooter protocols.

"We've learned that lesson from Columbine," McCraw said. "And the doctrine since then has been that in an active shooter situation, it's to immediately locate the subject, isolate him, and neutralize him."

Instead, Arredondo attempts to negotiate with the attacker, who never engages despite repeated efforts to make contact. At 12:03 p.m., however, another voice from inside the room makes contact with police: Khloie Torres, a 10-year-old student, calls 911. Over a series of phone calls during the next 46 minutes, she repeatedly pleads for help.

"Please hurry," Torres tells the operator. "There's a lot of dead bodies. Please, I'm going to die."

The 911 operator attempted to relay information from Torres to officers in the building. But spotty wireless connections and radio operations hobbled those efforts.

"That information should've been taken in by the call-taker, should've been immediately relayed to the incident commander, who should have used that information to understand that this was still an active shooter event," said Cohen.

But there was no command post set up to centralize information -- and no one collecting and effectively disseminating crucial details in real time. Without a command post, Cohen said, there was no way to ensure that police stacked up inside the hallway had the information they needed to make the right decisions. In dynamic situations, Cohen said, information is critical as police try to save as many lives as possible.

In Uvalde, there was plenty of police firepower, equipment and know-how, Cohen said. However, said Cohen, "No one took leadership. No one performed the basic function that's needed in an incident such as this to take command and control over the situation."

At one point during the siege Arredondo urges officers not to rush, captured on body-worn cameras telling others that "time is on our side" and ordering them to "calm the [expletive] down for a minute." He would later say he was trying to get the rest of the building cleared before they breached the classroom.

'What are we waiting on?'

Inside the classroom, however, the circumstances remain dire. Twelve minutes since her initial call, Torres remains on the line, telling the operator, "Please help, my teacher is about to die." Torres' father, a former marine, said his daughter at one point wiped blood on herself to make it look as though she'd been shot.

Other responding officers appear to share the younger Torres' urgency. The entire time, officers are just feet away with guns drawn.

"So how many are still alive?" Uvalde's then-acting police chief, Lt. Mariano Pargas, is overheard on a body-worn camera asking dispatchers about the information Torres had relayed.

"Eight to nine are still alive," the dispatcher can be heard telling Pargas in a recording of the call. "She's not too sure ... she's not too sure how many are actually [dead on arrival] or possibly injured."

In an interview with investigators weeks after the shooting, Pargas said he could not remember having that conversation.

By 12:20 p.m., nearly 40 officers are inside Robb when another burst of gunfire is heard from inside the classroom. Officers retreat away from the door. Arredondo is overheard on body-worn camera discussing next steps -- and already considering how the law enforcement response might be perceived.

"People are going to ask why we're taking so long," he said, according to body-worn camera footage. "We're trying to preserve the rest of life."

Other officers appear to grow restless. At 12:35 p.m., 49 officers are in the school. One is overheard on body-worn camera asking a simple question: "What are we waiting on?"

Help arrives

"Please help," Torres begs the 911 operator, 35 minutes after she first called. "Can you tell the police to come to my room?"

Finally, at 12:50 p.m., 77 minutes after the rampage began, a tactical unit led by U.S. Border Patrol agents breaches the doorway and kills the gunman.

Officers rush into the two adjoining classrooms. The scene is gruesome: one officer is overheard on body-worn camera vomiting as he absorbs the carnage. Torres survives, along with nine classmates. Teacher Arnolfo Reyes, who was shot twice, is bleeding profusely.

"They don't know how they're going to take me to the hospital," he said. "They don't know, because everything is blocked. Everything is a mess out there. But I hear them talking and saying, like, 'Do we put him in back of a car in the trunk?'"

In addition to the law enforcement response, investigators probing the shooting have also homed in on the chaotic medical response. Some victims were dragged outside, others were triaged inside the school's hallway or classrooms. In a communication vacuum, parents tried frantically to locate their kids, first at a designated reunification center, then, for some, at the hospital.

"We waited hours," Gloria Cazares recalled. "And one time where it got really angry, and I was yelling in the hallway, and I said, 'I need to know something now.' And, sure, a few minutes later, there was a chaplain and two [Texas] Rangers that came looking for us ... and so I asked, 'Is she alive?' And one of the Rangers just looked at me and said, 'No, she's not.' And that's all I remember."

Communication breakdown

The tragedy of 21 lives lost on May 24 was almost immediately compounded by a series of embarrassing communication blunders -- statements that mischaracterized the police response and required public corrections. In one glaring example, McCraw said that Marin -- referring to her not by name, but as the teacher who first called 911 -- had left the exterior door propped open.

"I'm standing in front of the TV and McCraw starts speaking," Marin recalled. "And he said a teacher left the door propped open … I looked at my daughter and I said, 'He's lying. That's a lie' … I was sick to my stomach, I was shaking."

McCraw corrected the record within days and later apologized publicly. A demonstration by the Department of Public Safety later revealed though that it was impossible for Marin or anyone else to lock the door from the inside.

But the misinformation didn't end there. After top officials, including Texas Gov. Greg Abbott, initially lauded the bravery of first responders, it soon became clear that they sorely mismanaged the response. Day by day, the facts started to change, and information was walked back.

Abbott and McCraw eventually said they were misled by local officials, and only realized the truth once they were able to lay eyes on the bodycam and surveillance footage.

"The idea that this was an heroic and well-done and effective and efficient operation was not the case," McCraw said. "And when we determined that it was not the case, we reported otherwise."

The reframed narrative did little to satisfy an upset public who felt that they were being lied to -- and those shifting stories became a key focus of the probe by the special committee of the Texas legislature.

"The stories were different. They were different varying by network, by speaker. One leader said one thing, another leader said another," said Guzman. "And it was time to deliver answers to the people of Uvalde."

For the families of victims, those public acknowledgments of wrongdoing have brought little solace. Those who lost children continue to suffer, and even those who made it out alive carry a heavy burden: "She does have survivor's guilt," said Ruben Torres, Khloie Torres' father.

And the frustration lingers.

"I was very proud of her during that [911] call," Torres said. "And when I heard her voice, you know, again, the shedding the tears already happened for me ... and I was like, '46 [expletive] minutes, and you guys did nothing."

Missed opportunities

Some investigative records have raised questions about crucial missed opportunities to potentially thwart the attack -- including the shooter's interactions on social media and, perhaps most notably, the shooting he perpetrated before descending on Robb.

Around 11:21 a.m., Ramos shot his grandmother at her home on Diaz Street -- located just blocks from the school. His grandmother survived the shooting and police were eventually called to the scene, but not until 11:35 a.m. -- after Ramos had already entered the school.

"Those seven to nine minutes could've made a difference," Guzman said. "We'll never know. It'll always be a 'what if.'"

Uvalde's acting sheriff, Ruben Nolasco, responded to the shooting on Diaz Street. He told investigators he had been on his way to the scene of the initial car accident when he rerouted. On his way to the Diaz Street scene, Nolasco radioed in, and three of his deputies hear the call and respond. After the grandmother is in the care of EMTs, Nolasco made his way to Robb.

"Diaz Street is shrouded in mystery," Guzman said. "What time did the sheriff get there? How long did it take him to get there? Did he, or anyone else on that scene, make an immediate effort to locate the shooter?"

Later, inside the school, investigative records suggest other opportunities to breach the classroom were missed. Arredondo told investigators that he "heard [Ramos] reload" his weapon at least once -- a golden opportunity "to immediately breach and engage," Cohen said.

Officers also spent precious minutes searching for keys, it turns out, they did not need: the door was "locked but it was not secured," McCraw said -- a maintenance issue that had been reported but not addressed.

"In terms of crystallizing the events of the day, it's hard to say that there was one moment, and yet it's all about moments," Guzman said. "We know that if there had not been these systemic failures, that if one person had responded differently at any moment, maybe the outcome could have been different."

Criminal culpability?

In sum, 376 law enforcement officials -- including many who helped evacuate children and secure the perimeter -- responded to the attack. Accountability has taken time. But some have already faced consequences.

In the months since, school district police chief Pete Arredondo was fired, and the entire school district police force was disbanded. Then-acting Uvalde police chief Mariano Pargas stepped down after officials said they would move to fire him (he was reelected in November to his position as county commissioner). Additionally, one responding state trooper has been fired for his actions on that day, another has resigned, and a third is appealing dismissal.

Arredondo did not respond to ABC News' requests for an interview, but he has repeatedly defended his actions and told investigators he did not believe the gunman was an active shooter when he arrived. He also has insisted he was not in command of the police response.

The day Arredondo was fired, his lawyer released a statement saying, "Incident Command obligations … fell upon several law enforcement agencies before and during the horrific events inside the hallway, which had nothing to do with the district of Chief Arredondo."

Pargas declined to comment. In January, he addressed a county commissioner meeting, saying, "All I ask is that you give me the opportunity until after the investigation is done. A lot out there is not correct."

Nolasco declined to comment for this story.

Meanwhile, as repercussions for law enforcement officials continue to trickle out, prosecutors have laid out their plans, explaining that the investigative findings will be brought to a grand jury, which will then decide whether to indict anyone. The Texas Department of Public Safety has completed an initial investigation and is now focusing on whether any of the failures at Robb constitute crimes. A final version of the DPS report is expected to be submitted to the district attorney in March.

"From our standpoint, [we're] looking at every officer and looking internally at our own officers," McCraw said. "What did they know? When did they hear? When did they arrive? What did they do at that point in time? What information they received while they were there, and how did they act upon that particular information?"

The investigation is examining the actions of every law enforcement officer who responded that day, and sources tell ABC News the focus is on the law enforcement leadership who were there that day and the decisions made in the critical first moments.

"The consequences of police inaction at the scene -- that is really the whole point of the investigation," said Durfee, the special ADA working on the case. "And that would be a part of what's presented to the grand jury."

Still, the families of the victims continue to struggle. Many have channeled their grief into action -- including advocacy for stricter gun control legislation at the state and federal levels.

The Cazareses are leading that charge, even as they learn troubling new details about their daughter's final moments. The family says they were recently briefed on the autopsy report for their daughter. They say it suggests that she was not shot in the first barrage of bullets, but later in the siege.

"Because of her injuries, she would have bled out quickly," Gloria Cazares said. "And if she was shot at the very beginning, then she wouldn't have had a pulse at the end of the 77 minutes. And she did. She was still alive."

"What does that tell you?" Quinones asked Cazares.

"So that, for sure, tells me that, if the cops would have gone in when they should have, then my daughter would still be here with me today," she said.

Cazares said it's "justice for my daughter" that keeps her going.

"We don't want them ever to be forgotten," she said. "And definitely, we're not going to let that happen."

ABC News' Alexandra Myers, Ali Dukakis, Charlotte Greer, Cho Park, Evan Simon, Gerry Wagshal, Jared Kofsky, Kaitlyn Morris, Kate Holland, Laura Romero, Mike Levine, Pete Madden, Sara Avery, Soorin Kim, Victor Ordonez, Will Kim, Christopher Looft, Ismael Estrada, Nicco Quinones and Tomas Navia contributed to this report.