CNN)On an August morning at Wright-Patterson Air Force Base, the medical treatment facility was holding a mass casualty drill. Personnel acting as the injured streamed in. Across the base, unbeknownst to the medical staff, a second active shooter drill was taking place, with a second set of people pretending to be injured. Then a real injured person came on the scene: someone who worked at the medical facility hurt their ankle jogging on base, and called another employee screaming and crying. There was an "incredible convergence of stimuli," Col. Thomas Sherman, commander of the 88th Air Base Wing, told reporters Wednesday. "Sounds, yells, sights. All of those things that are really testing the senses."

In the confusion, someone in the emergency room called the Base Defense Operations Center reporting a real active shooter. Events spiraled from there.

"A breakdown of communication led to a completely uncoordinated and ineffective combined response that could have resulted in serious injury or property damage," the Air Force said in a report summarizing the findings of its investigation into the incident.


In the confusion, someone in the emergency room called the base's defense operations center reporting a real active shooter, the report said. The hospital broadcasted a "Code Silver" alert over its intercom system alerting hospital staff to an active shooter situation, and the hospital went into lockdown. When one employee heard the "Code Silver" alert, they called 911 on their cell phone -- and civilian law enforcement rushed to respond -- what's known as a Code 99 response.


Units from the Dayton area and the state of Ohio responded en masse. At the same time, authorities on base requested a SWAT team. They didn't know about the Code 99 response. Soon there were officers all over the hospital grounds. "We had a sincere effort from the local community to come provide support. ... They rapidly responded to an event that was unfolding that they believed to be true," Sherman said.

Some of them had problems communicating with the incident commander -- Sherman said that would be the base fire chief on duty -- because the Air Force and local police systems didn't work together. Some never checked in with the incident commander, the Air Force said. Some who did had trouble identifying the chief on the radio. Air Force security went into the hospital. And when one airman encountered a locked door, five shots were fired.

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