[Text from scanned pages via optical character recognition (OCR). Full document via: http://secure.wikileaks.org/wiki/UNMIT_investigation_into_the_shooting_of_East_Timor_President_Ramos_Horta_2008. We recommend checking original before quoting. Notes are in brackets in their original position at bottom of pages. Most Annexes were not OCRed. – John Miller/ETAN.]
UNMIT - United Nations Integrated Mission in Timor-Leste
Report - UNMIT Internal Review Panel
Conducted from 1 April to 24 April 2008
Upon the request of Mr. Atul Khare, Special Representative of the Secretary-General for Timor-Leste on 1 April 2008
On the UN Actions in Response to the Attacks on the President and the Prime Minister on 11 February 2008
Chairperson: Ms. Claudia BANZ, 1-288666
Chief Joint Operations Centre
Member: Ms. Kelly Smith, 1-287631
Senior Administrative Officer
Member: Ms. Anjet Lanting, 1-114605
Human Rights Officer
Member: UNPOL David Carr, CP-7609
National Vulnerable Persons Unit
The Panel received support from Mr. Alexander Rose 1-586799, Chief Planning and Best Practices Unit and Ms. Ancy Price 1-296456, Administrative Assistant.
Table of Contents
I. Constitution, Terms of Reference and Methodology
II. UNPOL's Response to the Attacks on the President and Prime Minister on 11 February 2008
A. Institutional Security RolesIII. Mission-Wide Response to the 11 February Incidentsi. UNMIT's MandateB. Attack at the President's Compound
ii. Other Security Forces
iii. Trilateral Coordination Forum
iv. The State's Approach to the Alfredo Reinado Issuei. Sequence of EventsC. Attack on the Prime Minister's Motorcade
ii. UNPOL Response Analysis
a) Police and Ambulance Response Times
b) Safe Arrival Pointi. Sequence of EventsD. Observations on Security Arrangements
ii. Role of the Prime Minister's UNPOL Close Protection Team
iii. UNPOL Response Analysis
a) Escort of the Prime Minister's Fam11 y
b) Timeliness of Escort Arrival
c) Response to the Crime Scene
E. Capturing Reinado's Insurgents
F. Prevention of the 11 February Incidents
G. Compliance with UNPOL Proceduresi. National Operations Centre (NOC)
a) NOC Operations
b) NOC as Command Centre
ii. Formed Police Units (FPU)
iii. The National Investigations Department (NID)
iv. Command and Control
a) Crime Scene
b) Command Delegation of Response Units
v. UNPOL Interaction with the Media
vi. Areas Lacking Guidelines
a) Emergency Duty Rostering
A. Strategic Actions of the Mission LeadershipIV. Best Practices
B. Crisis Management Activities
i. Substantive Components
(i) Security Operations Centre (SOC)
(ii) Security Response Team
b) Public Information
c) Mission Support
V. Lessons Learned
a) United Nations PoliceVI. Conclusions
b) National Operations Centre (NOC)
c) Security Operations Centre (SOC)
d) Standard Operating Procedures (SOPS)
a) GeneralVII. Recommendations
b) Medical Response
e) Police Response to the Attack on the President
d) Police Response to the Attack on the Prime Minister
e) Protection Arrangements
f) Airedo Reinado Issues
h) Mission-wide Response
I. Constitution, Terms of Reference and Methodology
1. In accordance with the 1 Apr11 2008 instruction by the Special Representative of the Secretary-General (SRSG), an internal Review Panel, hereafter referred to as "The Panel" was established to review the UNMIT's (United Nations Integrated Mission in Timor-Leste) response to the events of 11 February 2008. The terms of reference  for the Panel were to:
- review the immediate and short term UNMIT responses to the 11 February attacks, including the United Nations Police (LTNPOL) response, particularly in the first hours, and the crisis management response, including UN Security and Public Information, with a view to assessing whether proper procedures and good practices were followed, and identifying best practices and lessons learned.
- make recommendations on ways to improve UNMIT's capacity to respond to a future crisis.
2. The Panel received an initial briefing from the Acting Chief of Staff and the Legal Advisor during the morning of 1 Apr11 2008.
3. The amount of time allotted to the Panel to bring its work to fruition was a key factor in determining the methodology it adopted. The Panel commenced its work after the completion of the initial briefing and the Panel gathered pertinent documents, identified key parties to be consulted and decided on a plan of action. The Panel requested meetings with relevant UN staff and written requests were sent, as necessary, to pertinent non-UN personnel. Other less formal meetings were conducted at the discretion of the Panel members.
4. Before interviews were conducted, the Panel made clear its terms of reference, underlining the fact that it was conducting a fact-finding or lessons !earned exercise, not an investigation. Interviews were recorded with the prior consent of the interviewee. The Panel considered the accounts of some 80 people who had direct knowledge of the events of 11 February 2008. Before coming to a considered and unanimous view, the Panel deliberated upon the information collected from primary and secondary sources and verified to the extent possible within the time frame.
 Annex 1 – Terms of Reference
II. UNPOL'S Response to the Attacks on the President and Prime Minister on 11 February 2008
A. Institutional Security Roles
5. The Panel reviewed UNMIT's response to the events of 11 February 2008, with a view to ascertaining whether the Mission's response was timely and in compliance with procedures and good practices. The Panel resolved not only to look the internal actions of UNMIT, but also to assess the validity of any perceived shortfalls of UNMIT's response.
6. In accordance with the Constitution, the Government of Timor-Leste has primary responsibility for the maintenance of security and stabilityin Timor-Leste. At the request of the Government of Timor-Leste, the Security Council mandated UNMIT in Resolution 1704 (2006) to support the Government and relevant institutions with a view to consolidating stabilityand to ensure the restoration and maintenance of public security in Timor-Leste, through the provision of support to the Timor-Leste National Police (PNTL). This includes interim law enforcement and public security unt11 the PNTL is reconstituted, as well as liaison with the Government on security tasks.
7. UNMIT's executive police authority is deta11 ed in the Supplemental Agreement. In accordance with section 5.1 of the Agreement,  the Police Commissioner is considered as the interim PNTL General Commander and is accordingly vested with all powers and authority which are conferred on and enjoyed by the PNTL General Commander by the national laws with regard to the conduct of operations. The Police Commissioner reports directly to the SRSG and receives and accepts instructions solely from the SRSG. Hence, the PNTL has been placed under the command of UNPOL, and the Police Commissioner is standing in for the PNTL General Commander unt11 such time as the PNTL is reconstituted. For UNPOL, this implies both authority and responsibility for the operational and executive policing area.
8. On 11 February, some 640 UNPOL were on duty in Dili, including 201 in Dili District, some 180 at Headquarters and 259 Formed Police Units (FPU) members (141 from Portugal and 118 from Malaysia). During the absence of the Police Commander, the Deputy Police Commissioner for Administration Juan Carlos Arevalo Linares was the Acting Police Commissioner unt11 13:30 hrs. when he handed over the command to the then Deputy Police Commissioner for Operations Hermanprit Singh, who returned to Dili from abroad. As SRSG Atul Khare was in New York to brief the Security Council, the Acting Police Commissioner reported to the Acting SRSG Finn Reske-Nielsen that day.
 Arrangement on the restoration and maintenance of public security in Timor-Leste and on assistance on reform, restructuring and rebu11 ding of the PNTL and the Ministry of Interior Supplemental to the Agreement between the United Nations and the Democratic Republic of Timor-Leste and the Status of the United Nations Integrated Mission in Timor-Leste (UNMIT) dated 1 December 2006.
9. The UNPOL Close Security Protection Unit (CSP) provides some 20 high ranking State officials and important political figures  with bodyguards, although the Mission was never designed to provide this service. On 11 February, 58 CSP Officers were on duty, including two UNPOLs and five PNTL CSP officers to ensure the security of Prime Minister Xanana Gusmão, and 2 UNPOL and 2 PNTL members to protect his wife. Following a request by President Ramos-Horta that his close protection be staffed by PNTL, UNPOL replaced the President's close protection deta11 with exclusively PNTL on the instruction of the then Deputy Police Commissioner for Operations on 6 January 2008. 
Other Security Forces
10. The Falint11 -Forca de Defesa de Timor-Leste (F-FDTL) has the responsibility of providing military defense for Timor-Leste. In accordance with the Constitution, it shall guarantee national independence, territorial integrity, and freedom and security of the populations against any aggression or external threat. Following a Government decision in March 2007, the F-FDTL provides static security at a number of key installations, including the President's residence. 
11. The International Stabilization Force (ISF) is an Australian-led and Security Council endorsed armed force which was deployed at the behest of the Government of Timor-Leste in May 2006.  In its Resolution 1704, the Security Council called upon the ISF to fully cooperate with and provide assistance to UNMET for the implementation of UNMIT's mandate. ISF assistance can be requested to control law and order situations, prevent loss of life and property and reinforce UNPOL and FPUs to defuse public disturbances in all 13 districts, and for specific tasks such as during a high risk police raid or when ISF prevents police operations from being disrupted from external elements (outer cordon).
 On 11 February, the Prime Minister, supported by the National Parliament, requested Australia to deploy additional ISF troops to Timor-Leste. One hundred and twenty additional troops and '70 Australian Federal Police Officers arrived on 12 February 2008.
Trilateral Coordination Forum
12. While the primary responsibility for the maintenance of security and stability is with the Government, UNMET and ISF have important roles to support the Government in this regard. On 26 January 2007, the Government of Timor-Leste, the United Nations and the Government of Australia signed a Memorandum of Understanding ("Trilateral Agreement") establishing a
 Government officials and political figures include the Prime Minister, his wife, President of the National Parliament, Minister of Foreign Affairs, Minister of Tourism and Commerce, Secretary of State for Security, Minister of Justice, General Prosecutor, President of the Appeal Court, Minister of Agriculture, STAE Director, the President of the Fret11 in party, the Fret11 in Secretary General, President of PSD party, President of ASDT party and the President of the CNRT party.
 Code Cable CTX-006 of 7 January 2008 refers.
 F-FDTL provides static security at the Ministry of the Airport, Power Station, Comoro Market, Water Pump, Ministry of Education, Ministry of Development, Ministry of Labour, Ministry of Transport, GPA and President's residence.
 As per the exchange of letters between the Governments of Timor-Leste and Australia of 25 May 2006 and the Status of Forces Arrangement between Timor-Leste and Australia of 26 May 2006, both Governments determined that the ISF would at all times remain under Australian operational control.
 NOC's (National Operations Centre) "Standard Operating Procedures for Requesting ISF Assistance to UNPOL in Police Operations",
Trilateral Coordination Forum as the principal coordination body to discuss security issues relevant to the management and stab11 isation of the security environment in Timor-Leste. In accordance with the Trilateral Agreement, the F-FDTL, ISF and UNMIT also cooperate with regard to security operations. On 11 February. at UNMIT's initiative, the Trilateral Coordination Forum held an Emergency Meeting at09:00 hrs. at the Office of the Prime Minister to set priorities and coordinate the security response.
The State's Approach to the Alfredo Reinado Issue
13. After its inauguration in August 2007 the Government decided to engage in a dialogue process with Alfredo Reinado. On 12 October 2007, President Ramos-Horta issued an order which provided Alfredo Reinado  and his men with freedom of movement and the guarantee that neither he nor his men would be arrested While the dialogue process was ongoing. The President further requested that all national and international institutions in Timor-Leste "fully respect, comply with and implement the present order".  The President reiterated that the Government's ultimate goal continued to be Reinado's voluntary surrender and submission to judicial proceedings. According to the President, dialogue was the only way to finally resolve the 2006 crisis and to uphold justice. T. supported the Government's position that dialogue was the preferable means of bringing fugitive Reinado to justice). 
B. Attacks at the President's Compound
14. The narrative below is based on a timeline produced after having consulted the accounts of some 80 persons with knowledge about the II February events and a review of relevant documentation. The Panel has made efforts to be as precise as possible, in particular as to the timing of the different events and actions. However, it should be noted that people utilised different timepieces that are not synchronised. Therefore, times varied slightly from one source to the other. 
Sequence of Events
15. On 11 February 2008 at about06:00 hrs., President Jose Ramos-Horta left his residence to go for his regular morning walk accompanied by two F-FDTL soldiers, as he did not want to wake up his PNTL close protection so early "just" to escort him on his walk  Only one of the two FFDTL guards was armed and had a.45 calibre pistol.
 Note on the Emergency Trilateral Coordination Forum Meeting by O/DSRSG. The meeting was chaired by the Prime Minister and attended by the Vice Prime Minister, F-FDTL Commander, the Prosecutor General, Acting SRSG, Acting Chief of Staff, Acting Police Commissioner and ISF Commander, among others.
 Alfredo Reinado, who was an F-FDTL Military Police Commander, left his base in Dili on 3 May 2006 with a number of subordinates and policemen with their weapons and moved to the western part of the country unt11 his arrest in Dili in July 2006. He and his men escaped from prison on 30 August 2006 and retreated to mountains in the western part of the country. Reinado was the leader of this group of armed men unt11 his death on 11 February 2008.
 Order "Freedom of movement for Major Alfredo Reinado and his group" attached to Code Cable CTX-436 of 19 October 2007.
 Report of the Secretary-General, S/2008/26, para 6.
 The watch of the Operations Commander (Becora 3) seems to consistently differ from Mr. Dos Remedios' timepiece by two to three minutes. Becora 3's timings differ four to five minutes from those of the NOC. The NOC timings seem to be consistently some five minutes ahead of the timings provided by other witnesses, including the timings on the Timor Telecom b11 ls. The NGO Security Adviser and NOC have a five minute difference.
 Interview of President Ramos-Horta with ABC on 28 March 2008.
16. Shortly after 06:00 hrs., fugitive Alfredo Reinado and some of his men armed with automatic weapons arrived at the President's Compound. At the main gate, the group disarmed the F-FDTL security guard standing in for a colleague who had gone to the to11 et. No shots were fired when Reinado's group entered the Compound. Sixteen F-FDTL soldiers are b11 leted at the President's Compound, 13 were present on this day. By their own admission, with the exception of four  of the 13, all F-FDTL guards abandoned their posts for the period of Reinado's occupation of the Compound. 
17. The shooting started around 06:50 hrs. when an F-FDTL jeep coming from Metinaro was shot at from inside the Compound. The driver, an F-FDTL member on his way to Dili, was seriously wounded and his vehicle crashed in the ditch alongside the road. MeanWhile, the President walking on his way back home was seen at the Caz Bar. The Senior Legal Advisor to the President, Paulo Dos Remedios who lives in the area, noticed that he had two missed calls on his mob11 e telephone one from the President at 06:55 hrs. and one from the President's brother, Arsenio Horta, at 06:58 hrs. Arsenio Horta later stated that he tried to reach Mr. Dos Remedios after he had heard shots While he was st11 l in his room at the President's Compound. Just before 07:00 hrs., the President received a phone call from his sister who had been told by a friend that shots had been fired near his Compound. He told her that he was aware, and that he would try to find out what was happening.
18. At 07:04 hrs., Mr. Dos Remedios called the President who answered and told him that he had just been shot and needed help. Mr. Dos Remedios then called two other Presidential Advisers and F-FDTL Commander Taur Matan Ruak. At 07:10 hrs. he left his house to go to the President's Compound. Neither Mr. Dos Remedios nor Arsenio Horta informed the police or called for an ambulance. However, at some time around07:00 hrs., the Dispatch Centre of the Ministry of Health received a phone call from an unidentified person requesting an ambulance for the President. 
19. The police received its first report of shots fired from the Presidential Compound at06:59 hrs. through the National Operations Centre (NOC) when an international NGO Security Adviser reported it. The NOC immediately dispatched two UNPOL teams from the Becora Police Station to the area to verify the report. According to the CARLOG  record, both UNPOL teams (call signs Becora 1.0 and 1.1) left Becora base at06:59 hrs.
20. At 07:03 hrs., the Portuguese UNPOL Formed Police Unit (GNR ) was informed by a Timorese neighbour of the President that shots were being fired in the area of the President's Compound. The GNR Special Weapons and Tactics (SWAT) Team was about to leave their compound to attend a shooting exercise, when the GNR Captain who is the Contingent
 Two F-FDTL soldiers accompanied the President on his walk, the third was forcefully disarmed by Reinado and his men and kept at the entrance, and number four, who would later shoot Reinado, was st11 l asleep.
 They only returned to the residence after the evacuation of the President by ambulance and once GNR and UNPOL had secured the area.
 While the Ministry of Health did not log this call, it confirmed that the first person who called for an ambulance noted that the President had been injured.
 All UNMIT vehicles, with the exception of FPU vehicles, are connected to the CARLOG system an electronic device designed to log data about a vehicle's movements, including its driver, the time of starting and switching off the engine and the speed driven.
 Guarda Nacional Republicana Portuguese (GNR).
Commander (hereafter referred to as the GNR Commander) directed them to immediately attend the scene and to take their civilian nurse with them. Five to ten minutes later, the SWAT Team left its compound in Caicoli in two Armoured Personnel Carriers (APCs) accompanied by the nurse. Some time around07:10 hrs., F-FDTL Commander Taur Matan Ruak arrived at the GNR Headquarters to request help at the President's Compound. He was informed that the SWAT Team had already been dispatched. 
21. At 07:05 hrs., the NOC received another phone call from a distressed woman reporting gunfire in the area of the President's Compound. The NOC immediately dispatched an ambulance and requested the GNR who were already on their way to attend the scene. At07:15 hrs., the NOC requested the ISF to assist UNPOL at the scene through an ISF Officer who is co- located in the NOC.
22. At around 07:10 hrs., Becora 1.0 stopped 370 metres from the President's Compound to report automatic gunfire to the NOC. Mr. Dos Remedios, who was on his way to the President, encountered Becora 1.0. According to their CARLOG, Becora 1.1 arrived at07:14 hrs.
23. The Becora Chief of Operations (call sign Becora 3) received a telephone call from the NGO Security Advisor reporting shots fired from the President's Compound. He departed his accommodation at07:09 hrs.  and joined Becora 1.0 and 1.1 at07:18 hrs. Becora 3 chose the location of the Safe Arrival Point in the two minutes before the two GNR APCs arrived. After having briefly conferred, Becora 3 and the GNR began the approach to the Compound of the President followed almost immediately by the ambulance of the Ministry of Health.
24. At 07:23 hrs. they located the President lying wounded on the ground in front of his Compound. His brother Arsenio, his niece and Mr. Dos Remedios were with him. The nurse accompanying the GNR provided critical trauma aid to stab11 ize the President. He applied measures to stop bleeding, an IV drip and oxygen and accompanied the President when the ambulance left at07:25 hrs.  for the Aspen Medical Clinic. The President was also accompanied by his relatives and Mr. Dos Remedios and escorted by the PNTL Task Force and the GNR.
25. When the ambulance left, Becora 3 and the GNR Commander decided to withdraw down the road as they did not have enough men to secure the area. While withdrawing, they noticed a seriously injured person in the F-FDTL jeep that had crashed into a ditch on the side of the road. Becora 3 applied advanced first aid, after which a second ambulance immediately arrived. The ambulance left the scene at 07:30 hrs. for Dili Hospital.
26. At around 07:30 hrs., about 15 F-FDTL soldiers with long barrelled weapons arrived at the scene by truck. At 07:35 hrs., a group of ISF soldiers of the New Zealand M11 itary followed on foot, and they were later reinforced. At the request of Becora 3, the F-FDTL soldiers took a position in the ditch along the main road to secure the parameter. At 07:40 hrs., an additional GNR APC arrived at the scene, as well as ISF reinforcements. The GNR, assisted by the ISF, then started to clear the area, including a number of bu11 dings and shelters surrounding the President's Compound.
 At 07:20 hrs., he reportedly entered Camp Phoenix and then went to the Aspen Clinic where the President was being treated.
 Per CARLOG record.
 According to Becora 3's watch, by Mr. Dos Remedios' timepiece, it was 07:20 hrs. when the ambulance left for the Aspen Clinic.
27. While clearing the area, UNPOL were told that Alfredo Reinado and his men had attacked the President and that Reinado had been shot. MeanWhile, a team of the National Investigations Department (NID), including forensic experts arrived at07:45 hrs. at the Safe Arrival Point.
28. At around08:00 hrs., the GNR entered the President's Compound and located two bodies. FFDTL security guards confirmed that the deceased were Alfredo Reinado and one of his associates. According to witness accounts, a boy from an IDP fam11 y living in the Compound, who had seen the group enter, woke up one of the F-FDTL security guards who later shot Reinado and one of his men from the cover of the bu11 ding in the kitchen area. Reinado was shot after the attack on the passing F-FDTL jeep, some time between06:54 and07:02 hrs . Immediately after Reinado was shot, his men fled the Compound. It appears that on their way out they encountered the President and shot him.
29. At no point after the arrival of UNPOL at the scene were credible sightings of the perpetrators reported to UNPOL. At08:42 hrs., the officers of the NID arrived at the Presidential Compound from the Safe Arrival Point after the area had been cleared by the GNR and started examining the crime scene and interviewing key witnesses, which took all day.
30. Shortly after09:10 hrs., the Strategic Intelligence Department (SID) arrived at the scene and confirmed that the deceased were Alfredo Reinado and one of his men. This information was then communicated to the NOC and UNPOL on the scene called for the bodies to be removed by ambulance. Although the Prime Minister only officially confirmed Reinado's death at 15:00 hrs., the news was spreading rapidly resulting in numerous people without an official function appearing at the scene to find out what had happened. In the meantime, steps which are deta11 ed in other sections of the report were initiated to prevent an outbreak of unrest in the wake of this attack. 
UNPOL Response Analysis
Police and Ambulance Response Times
31. According to witness accounts, Alfredo Reinado and his men were inside the President's Compound for at least 50 minutes before the F-FDTL soldier shot Reinado and one of his men. None of those present during that time, some 20 people including the eleven F-FDTL soldiers, relatives, IDPs and staff, notified the police or alerted the President of the armed intrusion into the Presidential Compound. The Panel notes they chose to inform their personal contacts of the shootings, rather than the police. A number of people outside the Compound reportedly heard gun shots between06:47 hrs. and06:59 hrs., when the NOC was first made aware of gunfire at the President's Compound.
 No witness reported the exact time.
 On UNMIT's initiative, an Emergency Trilateral Coordination Forum meeting was held at09:00 hrs. to coordinate the security response and to set priorities. In line with the joint security plan – developed in a subsequent working level meeting and approved by the Prime Minister UNMIT together with ISF implemented a robust security blanket throughout Dili and a reinforced presence in Covalima and Ermera districts.
32. The Panel also learned that two calls made by UN staff members to the Security Operations Centre (SOC) at06:53 hrs. and some time before07:00 hrs., informing that gunshots had been heard at and near the President's Compound were not followed by action.  As a result, it is only six minutes later, at06:59 hrs., that the NOC was notified by an international NGO Security Advisor of "shots from the President's Residence" . The Night Shift Supervisor, who took the call, did not seem to understand the gravity of the report as coming from the Presidential Compound rather than from the vicinity. Therefore, she only dispatched two Becora Patrol Teams to attend the scene. However, when the Day Shift Supervisor recognized the caller's name as a dependable source and the second call reporting shots came in, he requested an ambulance and dispatched the GNR.
33. According to UNMIT procedures, an 'FPU Tactics Team' is to be dispatched when gunfire is reported.  The Panel notes that the decision to dispatch two patrol units to verify the report before dispatching the FPU SWAT Team was made by the NOC officer because in the preceding two weeks, the NOC had received a number of false reports of shots in this area, and reports of gunfire in Dili are too frequently unsubstantiated to dispatch an FPU to each report. However, since gunfire was reported "from the President's Residence" the NOC should have immediately activated the FPU SWAT Team as stipulated in the SOP. Nevertheless, the GNR had already dispatched themselves at07:03 hrs. rather than at07:15 hrs. when the NOC called to dispatch the GNR.
34. The UNPOL response could have been up to four minutes faster if the GNR had been called earlier by the NOC. This would have made a difference, provided only if the GNR Commander had taken the same decision, as he did four minutes later, to send the GNR nurse with the SWAT Team. In the Panel's view, the nurse's care of the President was instrumental in stab11 izing his condition to prevent further blood loss. Moreover, an earlier dispatching of the GNR by the NOC would not have speeded the arrival of the ambulance.
35. Several sources made calls to activate an ambulance. At around07:00 hrs., the ambulance driver on duty in the Dispatch Centre of the Ministry of Health received a phone call from an unidentified person requesting an ambulance for the President. While the Ministry of Health did not log this call, it confirmed that the first person who called for an ambulance noted that the President had been injured. The NOC also called for an ambulance after the second call reporting shots at07:05 hrs. without knowing that casualties were involved. Regarding repeated allegations that the ambulance was delayed at a "roadblock," the Ministry of Health informed the Panel that the ambulance driver drove unobstructed all the way to the President's Compound. 
36. Given the timeframe established by the Panel in which the President had been shot, he had been lying wounded for a maximum of 19 minutes before the GNR and the ambulance arrived at the scene.
 The exact time of the second phone call is unknown as neither of the two calls were logged by the SOC although the first call was verified from Timor Telecom records.
 NOC Log 11 February 2008.
 As per the NOC SOP "Formed Police Units (FPUs)".
 The fact that the ambulance was not stopped at the Safe Arrival Point was corroborated by the NGO Security Adviser who witnessed the scene.
Safe Arrival Point
37. The Becora units who responded to the incident report travelled at speeds of up to 98km/h  to reach the scene. The first Patrol Team (Becora 1.0) stopped 370 metres from the Presidential Compound when they saw a number of Timorese people running and crying. A Timorese woman told them that gunshots were fired from the President's Compound.  Only one of two UNPOLs was armed with a pistol. Becora 1.0 immediately reported back to the NOC, with automatic weapons fire being overheard during the call by the NOC operator. The NOC Shift Supervisor subsequently instructed them to wait for reinforcement of the appropriate force level before entering the firing zone.
38. The NGO Security Advisor, who was present at the Safe Arrival Point, recalls that a Timorese man arrived at around07:13 hrs. The man was very agitated urging the UNPOL Team "to go there immediately." After interviewing the NGO Security Advisor, Mr. Dos Remedios, and after reviewing the incident reports of the Becora units, the Panel found no indication that Mr. Dos Remedios ever identified himself by name or title. The Pane! assumes that this individual telling the Becora unit "to go there immediately" was probably Mr. Dos Remedios. Mr. Dos Remedios claims that he told the UNPOLs at the scene that the President was injured and needed help, which was confirmed by the NGO Security Advisor. However, it remains unclear if the UNPOL heard or understood what the individual actually said. In Becora 1.0's incident report of 11 February, there is no mention of a civilian man at the scene and they did not mention casualties when they briefed the Operations Commander and the GNR who arrived a few moments later at the scene. 
39. At the time that Mr. Dos Remedios was present at the Safe Arrival Point, he was not aware that the GNR SWAT Team had already been activated. The Panel notes that the UNPOL Patrol Team even if it had moved in would not have affected the arrival time of the GNR, its nurse and the ambulance, as they were already on their way. Furthermore, UNPOL Patrol Teams are neither equipped nor trained to provide critical medical trauma aid to victims nor armed to suppress insurgent activity.
40. At07:18 hrs., Becora 3 arrived and established a Safe Arrival Point.  The establishment of the Safe Arrival Point was in compliance with UNPOL Standard Operating Procedures. As per the NOC's "Dealing With Disorder Standard Operating Procedure," tactics have been developed in order to "ensure the safety of members by providing a measured response to incidents under command and control arrangements," as follows:
* "The UNPOL units should be advised to approach the scene cautiously and try to ascertain what is happening from a distance."
* "Ensure there are sufficient staff ava11 able to safely and effectively deal with the incident."
 Per CARLOG records.
 Incident report of 11 February of Patrol Team Leader Becora 1.0.
 It was impossible to interview the UNPOLs, as they had already left the Mission at the time of the writing of this report.
 Also referred as Staging Area or Form-up Point.
* "If serious civil disorder is found to be occurring the UNPOL units are to withdraw to a safe spot and await further support."
* "A safe Form Up Point should be selected. This may be the point the units have to withdraw to."
* "Provide a Form Up Point (FUP) for patrols to assemble prior to attending disorder and civ11 unrest incidents to enable the PFC to better coordinate the incident and his or her staff."
* "If UNPOL units are present when group violence breaks out they should be directed to tactically withdraw immediately to a safe location (FUP) and await support."
41. The Safe Arrival Point selected by Becora 3 satisfied the conditions of proximity, being outside the direct view of the scene to avoid potential snipers and observation by attackers, containing an area for passers-by to be turned around, and space to park emergency and first response vehicles unt11 the attack zone is cleared. The SOP also underlines that sufficient staff should be ava11 able to safely and effectively deal with the incident and deter patrols from arriving alone or in a haphazard manner which could leave them vulnerable to attack.
42. The GNR arrived two minutes after Becora 3 at the Safe Arrival Point, they conferred briefly and moved in convoy towards the Presidential Compound followed by the ambulance. At07:23 hrs.  they located a person lying wounded on the ground in front of the Presidents Compound. Three civ11 ians were with him. All first responders at the scene (Becora 3, the GNR Commander and the nurse) emphasized when questioned that they had no idea when they were dispatched and when they found the first casualty that it was the President. All confirmed that they treat all the requests for aid in the same manner with the highest priority being the safety of the victims and staff.
43. The Panel concludes that the establishment of a Safe Arrival Point was a standard safety action and that it did not impede any emergency services or personnel from reaching the scene as substantiated by all witnesses and participants at the scene. The decision of the first UNPOL teams to wait for reinforcement and to establish a Safe Arrival Point is justified as moving into the scene at that stage would have risked further injury or death and it would not have expedited the arrival of the GNR with its nurse or the ambulance. 
C. Attack on the Prime Minister's Motorcade
Sequence of Events
44. At about07:30 hrs. on 11 February, an UNPOL Close Security Protection Officer informed the Prime Minister that the President had been shot after he had received the information from his PNTL colleague. The Prime Minister then told his Close Security Protection (CSP) team to prepare the motorcade, which left the house at07:37 hrs.34 A PNTL vehicle headed the motorcade, followed by the vehicle of the Prime Minister. The third vehicle was that of two UNPOL CSP Officers. The Prime Minister's wife and ch11 dren stayed behind,
 According to Becora 3's watch, which seems to consistently differ from Mr. Dos Remedios's timepiece by 2-3 minutes.
 "A dead hero helps nobody," Becora 3 told the Panel when asked why he decided to establish a Safe Arrival Point.
 According to CARLOG records.
waiting for her CSP Team, who would only arrive on shift at08:00 hrs. However, three PNTL officers provided static security at the house, although it appears only one had a long barrelled weapon.
45. At about07:40 hrs., about 800 meters from the Prime Minister's Residence, the motorcade came under automatic weapons fire from both sides of the road. To draw gunfire away from the Prime Minister's vehicle, the UNPOL vehicle stopped, and one of the UNPOL CSP Officers stepped out on the road and opened fire on the closest gunman using a PNTL Styer machine gun. The Prime Minister managed to escape unharmed. Shortly thereafter, the driver of the PNTL vehicle lost control of his vehicle, which crashed into a ravine. Due to a flat tyre, the Prime Minister's vehicle was forced to stop about two k11 ometres down the road. The Prime Minister, the driver and a PNTL CSP Officer continued on foot.
46. MeanWhile, the two UNPOL returned to the Residence to protect the Prime Minister's fam11 y. The PNTL CSP driver of the Prime Minister's wife, who was himself on the way to the Residence, said to go to the Residence. From the Residence at about07:45 hrs., the Prime Minister's UNPOL CSP Officer called the Prime Minister's driver who passed the phone on to the Prime Minister. The latter informed that he was safe and directed the UNPOL CSP Team to protect his fam11 y. Armed men in camouflage uniforms were spotted by the UNPOL CSP Officers at several points overlooking the Residence. According to the PNTL CSP Officers who went out to talk to the armed men, they were from Reinado's group and Salsinha was among them. During their conversation, they reportedly asked the PNTL members to surrender their weapons and inquired how many weapons were with the UNPOL CSP Officers. They also asked the PNTL members to leave the Residence so they could attack the UNPOL. The PNTL members did not agree to any of their requests.
47. At08:00 hrs., the UNPOL CSP Team Leader reported to the NOC that the Prime Minister's motorcade had been ambushed and subsequently split and that he and his colleague were back at the Prime Minister's Residence. He also asked for a helicopter to rescue the Prime Minister's fam11 y. He told the Panel that he also requested backup. At about the same time, FFDTL Commander Taur Matan Ruak called the GNR Commander who was at the President's Compound to inform him about the attack on the Prime Minister's motorcade. Without reporting to NOC, the GNR Commander immediately directed two GNR APCs to proceed to the scene. At08:22 hrs., the NOC requested the Dili Sub-District to send two patrol units to attend the situation at the Prime Minister's residence." At08:25 hrs., the NOC activated the GNR, who were already on their way, informing them that the Prime Minister's motorcade had been ambushed and that the UNPOL CSP Team was at the Prime Minister's Residence. At08:40 hrs., the NOC requested ISF to send troops to the Prime Minister's Residence. The ISF arrived shortly after the GNR, but took no action. At09:30 hrs., the UNPOL CSP Team Leader notified the NOC that the GNR had arrived and they were about to evacuate the Prime Minister's fam11 y and bring them to the Government Palace.
Role of the Prime Minister's UNPOL Close Protection Team
48. The only UNMIT involvement in any protective capacity for the President and the Prime Minister on 11 February was the Prime Minister's UNPOL Close Security Protection. When the Prime Minister was informed by his CSP elements that the President had been shot at his residence and taken to hospital, the Prime Minister decided to immediately leave his home.
Neither the PNTL nor the UNPOL, despite being aware of the possible risks, advised him to limit his movements for security reasons. When the Prime Minister's motorcade came under fire, one of the UNPOL CSP Officers mounted a counterattack on the assa11 ant using a PNTL Styer machine gun. Although UNPOL  are only allowed to carry pistols, the Panel considers that the UNPOL CSP officer used the best means ava11 able in view of the imminent threat and used proportionate force that may have saved the life of the Prime Minister. The Styre machine gun belonged to the PNTL CSP team that did not show up for work that day. The UNPOL CSP officers' decision to return to the Prime Minister's Residence was a judgment call based on their knowledge that the Prime Minister had already left the scene. It was made at the request of the PNTL CSP Driver of the Prime Minister's wife, and the knowledge that the latter and her ch11 dren were without close protection and were only protected at their home by three PNTL static guards without sufficient firepower. In hindsight, the Panel, knowing that Salsinha and his armed rebels had surrounded the Residence, believes that the decision by the UNPOL CSP Officers to return to the Residence to protect the fam11 y, was the correct decision.
UNPOL Response Analysis
Escort of the Prime Minister's Fam11 y
49. After the ambush on the Prime Minister's motorcade, approximately 90 minutes elapsed from the time the Prime Minister's CSP Team requested through the NOC at08:00 hrs., a helicopter evacuation for the Prime Minister's fam11 y at the Residence, unt11 the actual evacuation by the two GNR APCs at about09:30 hrs. took place. The Panel looked into some of the issues and documentation surrounding this delayed response, including the escorting of the Prime Minister's fam11 y to a safe place and securing of the three crime scenes resulting from the ambush on the Prime Minister's motorcade.
50. The08:00 hrs. telephone call from the Prime Minister's UNPOL CSP Team Leader (call sign PZ1.2) was answered by a NOC PNTL officer who handed the phone to an UNPOL Radio Operator. The Radio Operator recorded the following on his job sheet, "PZ1.2 informed NOC that the convoy of the PM heading to Dili was ambush. PZ1.2 was cut of from the convoy and returned to PM residence to guard the wife and ch11 dren of the PM Requested Hell evacuation of PM's fam11 y" The NOC requested the ISF to send a helicopter but no helicopter was ever sent. The CSP Team Leader told the Panel that he had also requested backup. However, it appears that the NOC Operator did not hear nor understand this request, if it was made as the Team Leader said, and no units were dispatched to rescue the fam11 y.
51. It appears that for the 22 minutes following this telephone call various NOC personnel were attempting to locate the Prime Minister's whereabouts he was at that time unaccounted for as a priority. The Telephone and Radio Operators were repeatedly trying to call the CSP Team Leader who did not respond. 
52. The Prime Minister's Residence lies within the area of responsibility of Dili Sub-District. At08:22 hrs., the NOC called the Dili Sub-District Patrol Supervisor (call sign Dili 1.0), and
 Except members of the FPU.
 The telephone reception at the Prime Minister's residence is reported not to be good and requires going outside the house which was not advisable at this time because of the gunmen surrounding the house recorded the following, "Notified Dili 1.0 that there is a situation in the PM's residents and send two (2) Dili units ASAP in the location." No unit ever responded to the scene.
53. The NOC also dispatched the GNR to the location at08:25 hrs. although the GNR Commander had been notified of the ambush on the Prime Minister's motorcade between07:45 and08:00 hrs. by F-FDTL Commander Taur Matan Ruak and was already on its way. At08:45 hrs., the NOC was informed by the OIC Security that the Prime Minister had arrived safely at his office. At09:24 hrs., the ISF reportedly arrived in the area of the Prime Minister's Residence but could not locate the CSP Team Leader and since the GNR had arrived, the ISF left without performing any significant actions. Six minutes later at09:30 hrs., the CSP Team Leader reported that the GNR had arrived and that they were moving out together with the Prime Minister's fam11 y. At09:36 hrs., he reported to the NOC that they had arrived at the Government Palace.
Timeliness of Escort Arrival
54. The Panel was unable to find any evidence suggesting that the GNR were told by the NOC that they had to extract the Prime Minister's fam11 y from harms way when they were instructed to attend the scene. The fact that it took them over an hour to arrive on site at the Residence can be attributed to several factors. The GNR did not know exactly where the Residence was located as they had only been in country for two weeks. The GNR also stopped twice on the way. Firstly, to disarm a group of armed men they encountered, who turned out to be PNTL CSP Officers. Secondly, to inspect the PNTL vehicle that was abandoned in the ravine.
55. The NOC, although calling ISF for a helicopter rescue of the Prime Minister's fam11 y, did not seem to have tracked the result of their ISF request nor had made any additional moves to ensure that the fam11 y was actually rescued in a timely manner. Although there are opposing views on whether the message of the Prime Minister's Close Protection Team Leader to send backup units was actually sent or understood, the Panel questions why the NOC which exercises a command and control role during crisis situations did not track whether a helicopter evacuation occurred since the request is clearly noted on the job sheet. 
56. After attempting to dispatch both the Dili Sub-District units and the GNR, the NOC neither ensured that an extraction team was sent by road nor did it track its timely arrival as per the NOC SOP "Roles and Duties of Shift Supervisor," that states that the NOC "Takes an active command and control role in the event of any serious or emergency situations." This is of particular concern since the NOC seems to have been aware of the gravity of the request. 
57. Even more problematic is the absence of any concrete response from Dili Sub-District and the ambiguous responses the Panel received in this regard. However, the Panel notes that when the NOC called Dili Sub-District on 11 February 2008 at08:22 hrs. stating "there is a situation in the Prime Minister's house and needed two Dili units as soon as possible at the location," no action was forthcoming that morning.
 NOC logged at08:00 hrs.: "Requested for helicopter to evacuate the fam11 y of the PM".
 The Panel noted one of the NOC job sheets reviewed was entitled "Gunshots by unknown people at the location" and on another the title was "The Prime Minister's residence probably surrounded by gun men" where the Operators logged the events.
58. However, according to the Patrol Supervisor of Dili Sub-District, Dili 1.0, he directed his patrol units to rally at the station to ensure that they were issued and wearing their protective gear. The Panel noted that the NOC had already sent out the message to all UNPOL units to don their protective gear at07:15 hrs. Patrol Supervisor Dili 1.0 claims that the Station Commander instructed them to remain at the Station to await further instruction, and also that after the NOC's call to go to the Prime Minister's Residence, the Station Commander would not let them go as there had been "reports of armed men up there" and he did not want his patrols to attend the scene without ISF or GNR escort.
59. The Panel also interviewed the UNPOL Chief of Operations with regard to NOC's dispatching role. He confirmed that the NOC has the abilityto connect with any unit in the country in its area of responsibility and to task them to carry out necessary action. When questioned whether it is compulsory to implement dispatch tasking from the NOC, the Chief of Operations stated that this was an order and not a request for the police. Thus, the police receiving the call "must give feedback in real time" (immediately respond by acknowledging their response to the order) when the NOC dispatches, as well as that the unit must respond and that the NOC log its response. The Panel could not determine whether or not this had been done from the various log sheets it reviewed.
60. Dili Sub-District did not at any time directly acknowledge nor report that they declined to send units to attend the Prime Minister's Residence as ordered. Instead, at08:40 hrs., Dili Sub- District Operations Commander (Dili 3.0) requested ISF assistance to escort the patrols to the Prime Minister's Residence. The NOC immediately relayed the request and at08:55 hrs., ISF left their base to go to the Prime Minister's Residence.
61. A NOC Operator told the Panel that he had problems raising the Dili patrols on the radio at first. One patrol unit said it could not respond to the call because he was alone in the vehicle and another patrol unit wanted to wait for the FPU to attend the scene. Both GNR and ISF went directly to the scene without passing by the police station to escort patrol units. Dili Sub-District units never responded to the Prime Minister's Residence that morning and at 11:20 hrs., the NOC activated the PNTL Task Force from A11 eu to guard the Prime Minister's Residence.
62. During that morning the only action logged as taken by Dili Sub-District was the dispatching of two Dili Sub-District units at09:37 hrs., to assist in escorting the President's brother to his Residence and back. This was requested by the NOC after the ISF Commander had advised the NOC that the President's brother needed assistance at09:34 hrs to collect passports. The Dili Sub-Districts units completed the task at 10:46 hrs. From interviewing three more Dili Sub-District patrol officers, the Panel only encountered one other Patrol Officer who accompanied his Contingent Commander to guard the front gate at the Dili UNPOL Headquarters and one who was "static for quite some time." 
63. If the NOC believed that the Dili Sub-District did not correctly respond to its order, the NOC may have contacted the chain of command (through the Dili District Commander) according to what the UN'POL Chief of Operations told the Panel. The Panel could not speak with the Dili Sub-District Commander or the Dili District Commander as they had already left
 Response of a Dili Patrol Officer on the question what he was doing in the morning of 11 February 2008 after they were called into the Station to check they had their protective gear.
the Mission at the time of writing this report, although an e-mail query was sent to the former Dili Sub-District Commander for which no reply has yet been received.
Response to the Crime Scene
64. The Panel also observed there was a significant time lag in the UNPOL response to securing the crime scenes related to the ambush on the Prime Minister's motorcade. The crime scenes went unattended by UNPOL for over four hours, including the ambush site as well as the site where the Prime Minister abandoned his vehicle because of the flat tyre and the location where the PNTL lead vehicle went off the road into the ravine.
65. A NID investigator was requested to analyze the evidence surrounding the ambush on the Prime Minister. He departed the President's Compound at around 11:30 hrs. with one Language Assistant as there were no other NID personnel to accompany him because no PNTL NID Officers came to the crime scenes at the President's Compound. The NID investigator found the bullet-holed and abandoned Prime Minister's vehicle, determined this was not the ambush site, and contacted the NOC for assistance in order to continue and to search for the actual ambush site. At 12:10 hrs., the NOC dispatched Dili units to assist the NID investigator to secure the Prime Minister's vehicle. The NID Investigator left his Language Assistant to guard the site and continued in the direction of the Prime Minister's Residence unt11 he found the PNTL lead motorcade vehicle in the ravine about three k11 ometres from the Prime Minister's vehicle. He informed the NOC of this and requested back up and Dili 1.1 was sent. The Investigator then identified the site of the ambush. At this point, he secured the site and waited for Forensics to arrive which did not happen unt11 17:00 hrs. as they were at the President's Compound. No forensic PNTL staff reported to work at the crime scenes on 11 February leaving the Forensic Unit short staffed.
66. The NOC/PNTL activated the Bombeiros (Dili fire brigade) and the Prime Minister's vehicle was towed to the PNTL Headquarters for safekeeping. The vehicle in the ravine remained there unguarded overnight; in the mass redeployment of UNPOL on the evening of 11 February, no static guard was assigned to guard it. This was also due to the fact that the UNMIT crane operator was no longer ava11 able because of safety considerations for UN staff in view of the lateness of the hour when the crane was requested. In addition, it was deemed to be a traffic accident as the vehicle was not fired upon in the ambush.
67. The Panel's initial review of the UNPOL response times to the issues involved in the different facets of the ambush on the Prime Minister reveal a need for deeper query on the part. of UNPOL to ensure that an appropriate level of attention was given by UNPOL to handle each aspect of the response to the attack, including ensuring that information flowed and was acted upon appropriately and that command and control issues were properly exercised. This could be accomplished as a part of an UNPOL's After Action Review of the events of 11 February 2008, or it might already have been done within some section of UNPOL. However, the Panel was unable to verify this.
D. Observations on Security Arrangements
68. With regard to static security arrangements at the residence of both the President and the Prime Minister, the Panel notes that UNMIT has no responsibility for these areas. Nonetheless, the Panel observed that some basic safety precautions were not in place to better protect the President and Prime Minister from harm. Both residences lack high walls or other structural barriers to prevent attackers from entering the premises. In addition, the Prime Minister's Residence is surrounded by h11 ls where reconnaissance can be done or an attack launched, and assa11 ants can enter the compound on foot paths without the gate guard's knowledge. A risk assessment might be undertaken to strengthen security arrangements of both these or future residences.
69. The Panel also suggests that a review is conducted regarding the number, type and shift schedules of personnel deta11 ed to guard the President and Prime Minister, so that, given the new circumstances, the protection they receive in a static manner at their residences and While they are carrying out their duties are optimised. Training on the necessity to be appropriately armed at all times and to prevent close protection officers allowing their Principal (VIP) to enter an active firing zone or danger zone and using overlapping shift schedules could also be contemplated.
D. Capturing Reinado's Insurgents
70. The Panel notes that the international forces have been criticized for not immediately pursuing those responsible for the attacks of 11 February. President Ramos-Horta said in an ABC interview on 28 March 2008 that critics felt that the perpetrators could have been captured "within hours" if a cordon and search operation had immediately been initiated. Legally speaking, any police officer, or in their absence, any person witnessing an offence can carry out an arrest in flagrante delicto.  However, when the GNR SWAT team and UNPOL arrived at the scene, it was immediately made known to them by F-FDTL soldiers that the attacks had been perpetrated by the fugitive Alfredo Reinado and his men, who were armed with automatic weapons. Therefore, the attack on the President was clearly of a military nature.  The DPKO Policy "Authority, Command and Control in United Nations Multidimensional Peacekeeping Operation" dated Apr11 2007, gives the circumstances where the FPUs have primacy in addressing the situation in support of or ih cooperation with national law enforcement. This occurs in a situation of disorder of a non-military nature which "refers to the situations of public disorder where there is no sustained use of firearms or military weaponry," which was clearly not the case of the attackers of the Presidential Compound.
71. At a strategic level, the Panel notes that the Emergency Trilateral Coordination Forum meeting held on 11 February at09:00 hrs. did not prioritize capture of the perpetrators nor ask UNPOL to participate in any such capture, other than by setting up roadblocks. Stakeholders
 Any police authority or any person witnessing an offence may carry out an arrest in flagrante delicto. Flagrante delicto refers to any crime that is in the process of being committed or that has just been committed. Flagrante delicto also applies to any case in which the perpetrator is, as soon as the crime has been committed, tracked down by any person or found with items or indications that clearly show that he or she has just committed or taken part in the crime." (article 218-219 Decree Law 13/2005 Timor-Leste Criminal Procedure Code).
"With the exception of flagrante delicto, an arrest may only be carried out without a warrant if
1. Pre-trial detention is admissible, AND
2. There are strong indications that the defendant is preparing to escape legal action, AND
3. The situation is too urgent or dangerous to wait for a Judge's intervention." (article 220, Timor-Leste Criminal Procedure Code)."
 This is defined in DPKO Policy as situations "where there is sustained use of firearms or military weaponry. In such circumstances units of the M11 itary Component should have primacy in addressing such situations in support of or in cooperation with relevant national agencies".
agreed that the coordination of the security response to the 11 February events between UNPOL, PNTL, F-FDTL and ISF was critical. The Forum prioritized the strengthening of security in and around a number of key national institutions in Dili, enhancing the close protection of government representatives, and establishing checkpoints around the city. The Government only requested ISF's assistance, with UNMIT's support, for the capture of Reinado's men on 13 February after an exchange of letters.
72. Neither UNPOL nor FPUs have the mandate or the capacity to apprehend insurgents armed with automatic weapons, camouflaged in military fatigues in a terrain they are fam11 iar with and who had the added advantage of being on higher ground. The insurgents could only have been pursued through a military operation which would have required prior coordination between the Government and the ISF if international forces were to have initiated pursuit rather the F-FDTL who saw the attackers in fiagrante delicto. Had the capture of the perpetrators been deemed a priority by the F-FDTL or the Trilateral Coordination Forum, for UNMIT this would have been a clear case of a Tier 3 situation as per the "Standard Operating Procedure for Requesting ISF Assistance to UNPOL in Police Operations" that states, "Immediate ISF assistance sought at a situation where UArPOLIFPU resources are unable to adequately respond to that situation" which also outlines situations where ISF support is appropriate. 
73. Any action by the UNPOL or indeed the ISF without proper consultation with the Government may not only have put lives in jeopardy, but may have also not achieved the desired results. Indeed, on 4 March 2007 for instance, actions undertaken by ISF fa11 ed to apprehend Reinado and his men. Five of Reinado's men were k11 led in a lethal exchange of fire. A short but severe spike in violence ensued in Dili and tensions in the western part of the country, causing instability and the overstretching of UNMIT's resources.
74. It is difficult to ascertain whether requests made at the operational level to ISF to pursue the perpetrators and to dispatch helicopters  ever reached the appropriate level in the ISF chain of command. No one had the time to authorize and f11 l out the cumbersome ISF Request Form although support was requested through the alternate methods as per the SOP.  During its review, the Panel ascertained that a UN staff member on site at the President's Compound heard from the ISF that the ISF were going after the attackers. The GNR Commander informed an ISF soldier that an F-FDTL soldier had advised that the perpetrators were hiding in the h11 ls and that ISF leadership should be requested to authorise a pursuit. The NOC Shift Supervisor requested,
 ISF assistance can be requested to control law and order situations, prevent loss of life and property and reinforce UNPOL and FPUs to defuse public disturbances in all the 13 districts and for specific tasks such as during a high risk police raid or when ISF prevents police operations from being disrupted from external elements (outer cordon).
 ISF helicopters were requested to rescue the Prime Minister's fam11 y from the Residence during the time his fam11 y was there surrounded by Salsinha's men after the ambush. Requests were made by the UNPOL CSP Team Leader to the ISF Liaison Officer, the Prime Minister's wife through her Secretary, and the NOC. None were ever sent although one was sighted passing over the vicinity of the Presidential Compound later in the morning of 11 February around 10:00 hrs.
 The SOP states in section 6 Tier 3 Assistance:
"6.2. In the situation where it is assessed that Tier 3 assistance is required the following procedure is to be adhered to:
a. "If an UNPOL or PNTL call sign has responded to a situation that requires further assistance, the call sign is to inform the NOC through normal means of communications. The next step in the escalation of force is to deploy a FPU element at the discretion of the NOC supervisor." This did occur.
e. "If the UNPOL LO (ISF POC) cannot be contacted, the FPU Commander or FPU Operations Office should request ISF support through the NOC Supervisor to the ISF staff in the NOC." This did occur.
but did not log, the ISF staff assigned to the NOC to contact their hierarchy to have ISF pursue the perpetrators. All these requests were made at a tactical or operational level, not at the strategic level as far as the Panel could ascertain.
F. Prevention of the 11 February Incidents
75. The international forces have also been criticised after the 11 February incidents for fa11 ing to anticipate the attacks, including fa11 ure to track the movements of Alfredo Reinado and his men into Dili.
76. The Panel notes that UNMIT had reported on rising tensions in the weeks leading up to 11 February attacks, including potential security implications related to the Government's engagement with the Petitioners as well as Reinado's attempts to link the Petitioners and those who decided to join Petitioners' spokesperson Salsinha and Reinado's group.  In its reports, the Mission also highlighted three incidents which occurred in the week prior to the 11 February attacks.  All these issues were discussed with the President, the Prime Minister and Fret11 in Secretary-General Alkatiri.  From the intelligence shared by all the partners, including the Trilateral Coordination Forum, none of these developments suggested the possib11 ity of attacks on the President and the Prime Minister. On 11 February, the Prime Minister told the Acting SRSG after the Emergency Trilateral Coordination Forum meeting that he had at no point envisaged that such attacks could take place.
77. As for UNMIT's and ISF's fa11 ure to monitor the movements of Reinado and his men, it need only be reminded that, on 12 October 2007, President Ramos-Horta issued an order which provided Alfredo Reinado and his men with freedom of movement and the guarantee that neither he nor his men would be arrested While the dialogue process was ongoing. As such, it was not the responsibility of UNMIT to monitor and report on movements by Reinado and his men.
G. Compliance with UNPOL Procedures
78. This section outlines the relevant DPKO and Mission SOPs applicable to the various UNPOL officers responding to the events of 11 February. The actions carried out and processes followed by the different branches of UNPOL active in responding to the events of 11 February were assessed with a view to ascertaining the existence and relevance of their standard operating procedures as well as the knowledge and training of the officers of the SOPs as a guide to weigh the appropriateness of UNPOL's response. In aeneral, the NOC and the NID have a good procedural base with their officers frequently quoting procedure when questioned by the Panel as to why they executed various actions that day. By contrast, the CSP and the GNR FPU have no standard operating procedures and do not see this as an area to correct.
 UNMIT Weekly Situation Report, Code Cable CTX-059 of 5 February 2008.
 Incidents include the firing of gunshots in Ermera District by Reinado and his men on 6 February 2008, when they came across an ISF patrol, as well as explosive devises detonated in the vicinity of the Petitioners Compound in Aitarak Laran, and at the ISF Camp Phoenix in Dili on 6 and 7 February 2008 respectively. UNMIT Da11 y Situation Report, of 7 February 2008 and 8 February 2008. There was no indication that the three incidents were linked.
 See Code Cables CTX-004 of 7 January 2008, CTX-014 of 11 January 2008, CTX-054 of 2 February 2008, CTX055 of 2 February 2008, CTX-057 of 4 February 2008, CTX-063 of February 2008.
National Operations Centre (NOC)
79. As per its SOP entitled "Dealing with Disorder," the National Operations Centre (NOC) serves as a communications hub and dispatches police units to respond to reported incidents. For major incidents or emergencies, the NOC is to provide command and control support and advises the higher echelons of the police and prepares situation reports.
80. While the NOC logged information to the extent possible, there were problems with the accuracy and thoroughness of logging on that day. This can in part be explained by the sheer volume of calls and the inexperience of some of the Radio Operators. In addition, the NOC log did not provide a fa11 -proof chronology of events as NOC staff members were logging times based on a variety of personal time pieces which were not synchronized rather than on one central clock.
81. Interpretation of a provision of the NOC SOP may have delayed the moment when the NOC notified the UNPOL leadership of the attack on the President. The SOP states that "The night shift supervisor will text-message the Police Commissioner prior to0630 hrs. each morning of any significant incidents overnight. Even if nothing to report a message to that effect should be sent." The Shift Supervisor sent a text message to the Acting Police Commissioner and other relevant parties at07:30 hrs., which in his own words "was very labour intensive" and took him no less than 20 minutes to send because of constant operational interruptions. He could have contacted the Acting Police Commissioner, who was already aware of the incident through informal communications means at that time, by telephone as this was a critical incident. Other minor procedural issues include the need to update the Aeromedical Evacuation (AME) Procedure to the January 2008 version, updating the "Dealing with F-FDTL" SOP and the Senior Command to be Advised of Serious Incidents section of the "Roles and Duties of Shift Supervisor" SOP.
82. Its staffing limitations notwithstanding, the NOC complied with UN procedures and contributed to ensuring that operations were conducted as fluidly as possible. However, the NOC's task of dispatching was in some instances complicated by the fact that not all units were fully equipped to proceed immediately to the "hot scene." For example, at07:15 hrs., the NOC informed all police officers to don their protective gear given the serious incidents taking place. This forward thinking safety move exposed the issue that some UNPOLs did not carry their protective gear with them at all times. Valuable time was spent returning to their accommodations or other locations to get their gear.
The NOC as Command Centre
83. The NOC attempted to take a command role in the immediate aftermath of the attack on the President, but was insufficiently resourced at that time. It is only at09:00 hrs. that additional staff arrived as part of their usual shift. These staff took on routine duties such as traffic accidents and crimes unrelated to the crisis events of 11 February. The team of Radio and Telephone Operators who responded to the attack incident calls reportedly consisted of junior officers with varying degrees of language proficiency and professionalism. Furthermore, given the overwhelming number of calls, Language Assistants were requested to take calls, although they are not qualified police officers and not trained to log, analyze and respond to emergency calls. The Panel does not believe the NOC has the dedicated resources or skilled staff in sufficient numbers, including experienced Radio and Telephone Operators, to handle a multi- layered crisis with far reaching security implications and to function as a Command Centre in these circumstances, and that this may have affected the UNPOL response.
84. In order to function as a true national Command Centre  in a crisis situation, more experienced and higher ranking staff should be designated in the SOP and automatically activated by the Shift Supervisor or other designated officers as necessary to operate the Command Centre. This command team should be based in a room adjacent to the NOC, which is modelled on the concept  of the Crisis Management Room for the Crisis Management Team and fully equipped with communications gear. The Command Centre staff with a higher level of expertise and authority, including Operators, would immediately analyze incoming data, task ava11 able assets and have immediate access to senior leadership of the Mission, Government and International Forces.
Formed Police Units (FPU)
85. As per the DPKO Policy of 9 November 2006 "Functions and Organization of Formed Police Units in United Nations Peacekeeping Operations," the FPU are used for crowd and riot control tasks and may conduct joint patrols with national law enforcement patrols. Command and Control arrangements for FPUs are defined by the tactical requirements although they report through the Deputy Police Commissioner to the Police Commissioner who controls their operations.
86. While the GNR FPU was instrumental in the initial UNPOL response on 11 February, the Panel observed that their Commander was not aware of UN or Mission-specific SOPs related to operations of UNPOL or FPUs or requirements to report their whereabouts to the NOC. The GNR operated in line with tactical SOPs for operations in Portugal and 'Rules of Engagement' which actually apply to the military component and not UNPOL. UNPOL uses the `Directive for the use of Force and Firearms' as per the DPKO Policy "Authority command and Control in United Nations Multidimensional Peacekeeping Operations." The GNR Commander's lack of knowledge of relevant UN SOPs contravenes DPKO's "Guidelines for FPUs on Assignment with Peace Operations", which states that it is required to "Ensure and monitor that all members of the FPU [need to be] aware of their responsib11 ities, including through induction, to adhere, both in and off duty, to these guidelines, standard operating procedures and all other United Nations rules, regulations and other issuances."
The National Investigations Department (NID)
87. The "UNMIT National Investigation Department Standard Operating Procedures," which is based on the Timor-Leste Code of Criminal Procedure, states that although the main powers of investigation rest with the Public Prosecutor, UNPOL is a procedural participant with an important role in criminal investigation, especially in the initial stages. The SOP further states that, "The first contact with the crime scene, the preservation and seizing of evidence, and initial
 On 11 February, the Dili District Commander and Chief of Operations attempted to restructure the operations in an ad hoc manner for a short period of time.
 Similar to DPKO policy on Crisis Management.
inquiries with witnesses and suspects are the responsibility of the investigators and are crucial to the success of the investigation." And further, "the investigating officer should undertake the following initial activities:
* Secure and process the crime scene, coordinating with the Forensic Unit for technical requirements if necessary;
* Locate and identify as many witnesses as possible and take relevant sworn statements;
* Obtain any physical and/or material evidence;"
The SOP also underlines that "All investigators must bear in mind that only the initial inquiries are those that are considered urgent in order to establish the particulars of a case or to prevent the concealment, loss or destruction of evidence (such as processing the crime scene and obtaining witness details) or to preserve the safety of an individual."
88. The on-scene investigators attempted to comply with all the above mentioned steps. However, some could not be complied with as the site became closed to the investigators and witnesses unava11 able for questioning despite the legal requirement that "Unlike a suspect, a witness is obliged to provide information about the facts they witnessed" The investigators did interview as many people on the scene as possible at the moment and were able to obtain statements from many later, but certain Government employees or fam11 y members and close associates of the President were no longer ava11 able once they left the incident scenes. Negative comments made by officials carried in the press did not facilitate openness on the part of witnesses working with the Government. However, the investigators' proactive approach allowed the gathering of evidence that would have been lost later when access to the witnesses was closed.
89. The above mentioned NID SOP also states that investigators are to:
* "Preserve the scene of the crime unt11 it has been thoroughly examined.
Where possible fingerprint and photograph the scene;"
The scene was photographed. However, the F-FDTL restricted the investigators access to the President's Compound to continue their examinations on the days subsequent to 11 February.
* "The search of the crime scene must be thorough; the investigator must be satisfied he/she has found all the available evidence;"
According to those interviewed, the police felt that a thorough examination
was lacking because of access restrictions.
* "The first responsibility at a crime scene is to make sure: medical assistance is given (if required); "
Both the President and the injured F-FDTL soldier were given immediate medical attention by UN staff.
* "prevent contamination of the scene".
90. At the President's Compound, the NID officers encountered an extremely difficult crime scene to manage which was beyond their staffing resources at the scene. As they were processing the scene, F-FDTL soldiers were wandering about the scene in an agitated state. Controlling their movement within the Compound in order to preserve evidence became nearly impossible. At one point, the soldiers actually levelled their guns at the UNPOL officers and told them to leave. The presence of so many people living in the President's Compound also complicated the situation. Ch11 dren reportedly walked up to UNPOL officers to give them shell casings. The scene also attracted visits from numerous people with no official function at the scene, including all ranks of Timorese, ISF and UN officials. Forensics' abilityto appropriately handle and store exhibits  was compromised by the lack of control over the people at the crime scene. Key pieces of information were stolen such as Reinado's cell phone and SIM cards (the Prosecutor later used his good offices to arrange a return of portions of the evidence to the investigators, but full access to Timor Telecom records was refused) and other evidence was contaminated such as shell cases flattened by passing road traffic.
91. Two other problems were encountered by the NID. No PNTL member of the Forensics Unit attended the scene at the President's Compound or the scene of the attack on the Prime Minister as they were not present at Headquarters when the original teams left the office and did not follow them later to the scene. Thus, a valuable opportunity for mentoring on a complex and high prof11 e investigation was lost as was a hands-on knowledge of the layout and circumstances of the scene to aid in further analysis leading to the prosecution of the perpetrators. It also !eft the Forensics Unit short of officers when additional Forensic Officers were needed to attend the multiple crime scenes of the ambush on the Prime Minister and may have contributed to the lack of a timely response.
92. Additional issues such as PNTL officers being absent from their duty station at police stations and crime scenes was brought to the attention of the Panel during its review of the 11 February events. Systemic problems with the night time on-call procedures and the shift change practices at police stations were highlighted. Reportedly, because the PNTL lack Government issued transportation and means of communication, it is essentially not possible to contact a PNTL Officer nor are they able to reach a crime scene outside office hours. During shift change, police stations do not have the full complement of staff as UNPOL is picking up incoming shift personnel and driving home those who completed their shifts.
93. The investigators at the President's Compound were accompanied by a Language Assistant, who was not provided with any protective gear. At certain times, when immediate danger was perceived at the scene, the UNPOLs in their own ballistic gear moved to shield the Language Assistant. However, as a Language Assistant faces identical dangers as UNPOL at any time during their presence at an operational scene,  s/he should be provided with the same protective equipment as the UNPOL they are accompanying. UNPOL lacks an SOP regarding the use of Language Assistants containing provisions such as those in the UNIVIISET SOP prohibiting a Language Assistant from assuming a police officer's duty or placing a Language Assistant in danger at any time.
94. The Panel concludes that the investigators were able to reconstruct the crime scene and gather a number of exhibits. Because the crime scene was not controlled tightly by roadblocks or the cordons operated by a variety of police and military participants no guard was placed at the gate of the Presidential Compound and there was no viable method to control the movements of
 The Panel did not look into the issue of handling and storage of exhibits and seizures as this is beyond the scope of reviewing the police response in the first few hours. The evidence at the scene could not be handled properly as noted above because the scene could not be cleared of the F-FDTL and others, and this was beyond the control of the NID Officers given the circumstances.
 NOC "Standard Operating Procedure for Dealing with Medical Emergencies involving UN Staff and UNPOL" that states, "UNPOL staffs attending the scene of violent incidents are at risk of suffering injury from rocks, darts and even firearms. Whilst UNPOL have not been specifically targeted this can not be discounted in the future. UN staff may also inadvertently become involved in violent disturbances with the associated risks to their safety."
the F-FDTL at the Presidential Compound scene the investigators acted appropriately to gather and secure as much evidence and testimony as possible.
95. Since 11 February, the NID has faced a number of obstacles in the criminal investigation into the incidents, including lack of cooperation, as well as military and political interference. However, examining these issues would go beyond the scope of the Panel's Terms of Reference.
Command and Control
96. At the President's Compound, the most senior officer, Becora 3, took command initially, followed by a 'joint' command with the GNR Commander and they worked together unt11 the site was declared safe from attackers and the investigators were called in. Becora 3 and the GNR Commander then began working separately, both believing they were in command unt11 the NID Director arrived and took command. However, these changes of command required a telephone call to the Acting Police Commissioner to clarify who was in command. The fact that coordination and command and control worked can be attributed to the fortuitous fact that all people concerned were very experienced and had sound knowledge of operational tactics.
97. The NOC SOP entitled "Dealing With Disorder" underlines the need for the early appointment of a Police Forward Commander (PFC) that allows the Police to act more cohesively and with clear lines of command and control to control a crime scene. This NOC procedure does not cover situations in which UNPOL and FPU are working at the same scene in an unplanned operation. The DPKO FPU Policy only states that "command and control arrangements for each FPU are defined by their tactical requirements". None of these provisions were instituted. In pre-planned operations between FPUs and non-FPU UNPOLs, an Operations Order (OpO is developed determining the command relationship.
98. When the scene at the President's Compound transitioned from one of immediate danger into a crime scene, coordination was less effective. This may have aggravated the problem of crowd control at the site as no overall area commander commanded and delegated any UNPOL present to stop entry to the scene by persons with no relevant role to play, nor halt the passing of road traffic, nor post a guard at the gate to the Compound and stop parking on the different crime scenes. As such, the absence of an SOP or a standing Operational Order (0p0) covering command and control in critical incidents impeded, but did not jeopardize, smooth operations.
Command Delegation of Response Units
99. In two instances, the response to the incidents at the President's Compound was self-initiated. The GNR Commander left for the scene after receiving a phone call through the informal network. The NOC requested the GNR attendance after they had already departed from their base. After another informal contact (NGO Security Adviser) reported to Becora 3 that gunshots had been fired, he immediately left his accommodation to attend the scene. He kept the NOC informed at all times. The GNR commander, upon learning about the attack on the Prime Minister from F-FDTL Commander Taur Matan Ruak, again self-dispatched to the scene without informing the NOC, although the NOC log includes contacting the GNR afterwards at08:25 hrs. Although on 11 February the informal network informing the GNR and their taking the initiative to go to crime scenes proved beneficial, in effect, the GNR was tasking themselves without anyone in a command position aware of their actions.
100. The Panel is of the opinion that command and control was relatively well-executed during the initial response to the incident at the President's compound. Once the attack on the Prime Minister took place, command and control faltered to the point that the response to the Prime Minister's Residence was handicapped. The Panel also believes that had a true Command Centre at the NOC been activated, it would have been able to better track ava11 able assets and deploy them appropriately. It would also have allowed them to immediately activate more officers from non-essential units to assist. It is questionable whether the current arrangements at the NOC are adequate to deal with multiple critical incidents.
101. The DPKO FPU Policy states that these "arrangements should not result in any operational delays to address such situations of public disorder. in this regard standard operating procedures should be adopted by the mission and regular training, rehearsals and exercises, including simulations, should take place on a regular basis" and that the arrangement must be applied in letter and spirit. This has not been done in UNMIT with Mission-specific actions. Therefore, the Mission should adopt an SOP as a guideline for initial operations in different serious incident scenarios, such as those listed in the second page of the NOC "Roll and Duties of Shift Supervisor" SOP, in the absence of a direct command from the Police Commissioner in order that there is neither confusion nor operational delay.
UNPOL Interaction with the Media
102. There is neither record nor mention of direct police interaction with the media at the scene on 11 February. UNPOL did not dispatch its spokesperson to the scene at the President's Compound to interact with the media. Journalists were escorted from the area by ISF and UNPOL on at least two occasions. UNPOL and the Communications and Public Information Office (hereafter referred to as PIO) did not delegate any staff member to provide basic information at the scene. While the UNMISET UNPOL SOP outlines the guidelines for release of information to the media stipulating that the media should not be prevented from going to the scene of an incident on the grounds that it is dangerous, the UNMIT SOP does not mention interaction with the media.  In 11 February, the only interaction UNPOL appeared to have had with media personnel was when the Acting Police Commissioner attended the Government and UNMIT press conferences. The Panel recommends that the UNPOL SOP include a section on UNPOL Officer's obligations with regard to the media as per the "Handbook on Policing in United Nations Peacekeeping Missions."
 "United Nations Department of Peacekeeping Operations Standard Operating Procedures for Civilian Police Officers on Assignment with United Nations Mission Support in East Timor", March 2004.
"18.1.6 Members of the media should not be prevented from going to the scene of an incident on the grounds that it is dangerous: The danger should be explained to them, but the decision to go or not is the prerogative of the individual journalist.
18.1.7 In exceptional cases where the presence of the media may endanger Civilian Police personnel, the respective chain of command should be notified immediately
18.1.8 Should the situation arise whereby a Civilian Police officer must speak to the media personnel at the scene of an incident, he/she should give only the facts, never opinion or judgements. "
Areas Lacking Guidelines
103. While reviewing actions of 11 February the Panel found that some SOPs were lacking in areas where the Panel believes a set of guidelines would help coordinate a timely and effective response. These include Mission-specific SOPs on Command and Control, UNPOL Close Security Protection, UNPOL's interaction with the Media, Debriefing, Road Blocks, Working with Language Assistants and a Rapid Redeployment Roster.
Emergency Duty Rostering
104. The mass redeployment of UNPOLs on 11 February  to implement the preventative security measures for key installations, Timorese Officials and potential trouble spots was conducted in an ad hoc manner as there was no rostering mechanism in place. Therefore, because of the press of time, UNPOLs on CTO were put on guard duty, some units were closed down, and Officers who played a crucial part in analysing the attacks of the President and Prime Minister were reassigned to guard duty.
105. It is important that UNPOL establishes a manageable system aimed at enabling UNPOL to quickly identify and redeploy a large number of staff along functional lines for short-term special emergency/humanitarian operations as occurred on 11 February as well as in the past.  Similar to the Emergency Staff List utilised by the civilian component against eventualities such as relocation and Avian Influenza outbreak, UNPOL should develop a system rostering of noncritical UNPOL to be utilized for surge operations.
106. While there are scattered references  to debriefing personnel at critical incident scenes, there is no SOP concerning debriefing as an integral part to the wrap-up and reporting phase of incident processing. From the information gathered by the Panel, it appears that the GNR Commander, the Head of the Becora team, the Commander of Dili District or the Acting Police Commissioner did not debrief their subordinates during or after the events of 11 February. Officers interviewed cited the lack of operational debriefs aimed at consolidating and acting upon the information gathered from different team members as well as the lack of stress debriefs as an issue. The Panel found no instance of UNPOL's having knowledge or availing themselves of the services of the Staff Counselling Unit.
 UNPOL were tasked to assume static guard duty at important facilities throughout Dili and to enhance the protection of key Government figures.
 Other examples include the shooting incident at the Airport IDP camp in February 2007, the rice riots in Dili, the unrest following ISF's attempt to capture Alfredo Reinado in March 2007, the announcement of the new Government in August 2007 and during the high level UN visits in November and December 2007.
 According to the NOC SOP on "Dealing with Disorder," "When the incident is finalised, the PFC should "consider a 'hot' debrief of staff at scene." Regarding the broader issue of 'stress debriefing,' the 7 September 2006 DPKO/PD/2006/00108 "Directive on Detention, Searches, and Use of Force for UNPOL on Assignment with UNMI7'," signed by Police Commissioner Tor and effective 27 December 2006 states that one of the "primary responsibilities of the Contingent Commander in the mission" is to "care for the mental and physical health and welfare of the personnel of their contingent." This is echoed in the DPKO "Guidelines for FPUs on assignment with peace operations" dated 8 May 2006: Formed Police Units Contingent Commander duties and responsibilities include to "Monitor the welfare and medical condition of all members of the FPU from their contingent whilst in mission and to ensure that necessary action is taken to ensure the well-being of staff".
III. MISSION-WIDE RESPONSE TO THE 11 FEBRUARY INCIDENTS
A. Strategic Actions of the Mission Leadership
107. This part of the report examines UNMIT's preparedness to handle crisis situations. A timeline of critical actions undertaken at the strategic level by UNMIT senior management between 11and 13 February 2008 to support the Government in ensuring stability is attached. 
108. Shortly after07:00 hrs. on 11 February, the Acting SRSG was informed by a UN staff member, who lives next to the President's Compound, that there was gunfire at the Compound. The Acting SRSG contacted ISF Commander James Baker and informed UNMIT senior management of the situation by telephone. The SRSG, who was on mission in New York to brief the Security Council, was called at around07:30.hrs. and in turn informed the Secretary-General and the Under Secretary-General for Peacekeeping Operations.
109. On 11 February, the first crisis management meeting was held at08:00 hrs., chaired by the Acting SRSG. It was agreed that UNMIT would be placed on high alert, that the Acting SRSG would request the Prime Minister to convoke an Emergency Trilateral Coordination Forum meeting and that close protection arrangements for Timorese VIPs be enhanced. The Trilateral Coordination Forum meeting took place at09:00 hrs. and was attended by the Government, UNMIT, ISF and F-FDTL. As agreed by all parties during this meeting, a working group including all security forces was established to prepare a security plan to be approved at 15:00 hrs. the same day by the Prime Minister. The second UNMIT crisis management meeting was held at 14:00 hrs. It discussed priority actions and also agreed to refer a discussion on a possible change in the UN Security Phase to the Extraordinary Security Management Team scheduled for 15:00 hrs. During that meeting, it was agreed that the Acting SRSG would request the Secretary-General to change the UN Security Phase from II to III. In parallel, UNMIT Mission Support activated UNMIT's contingency operations plan. Shortly after the return of the SRSG from New York on 12 February, a third crisis management meeting was held in which updates were provided including on the security arrangements and the status of the criminal investigation into the attacks.
110. The Mission regularly updated DPKO Headquarters. On 11 February, three flash reports on the latest developments and two more analytical Code Cables, including a draft briefing for the Security Council  were sent to New York. In addition, the Joint Operations Centre (JOC) provided the DPKO Situation Centre with regular oral updates. On 13 February, an additional four Code Cables were relayed to New York with updates on the situation.
111. The UNMIT senior management issued security directives from 11-13 February to all staff to restrict movement and comply with the state of siege, which was declared in the evening of 11 February. Two Town Hall meetings were held to brief staff on the latest developments and security measures taken on 11 February. An additional Town Hall meeting was held by the SRSG on 13 February.
 Annex 2 Crisis Management Timeline.
 DPKO briefed the Security Council during its consultations on the events in Timor-Leste on 11 February 2008. and the Core Group for Timor-Leste on 12 February 2008.
112. The first press release was issued by the Communications and Public Information Office (hereafter referred to as PIO) in the late morning of 11 February. PIO also answered questions from the national and international media on the events. UNMIT held a press conference once every day from 11-13 February.  The Acting Police Commissioner also attended the first press conference of the Government at 10:55 hrs. on 11 February, in which the Prime Minister appealed for calm.
113. As demonstrated above, UNMIT senior management ensured appropriate and timely information flow through both formal and informal channels, with a view to expediting UNMIT's response both internally and externally. The Mission was proactive in ensuring that all stakeholders were consulted through the appropriate fora and that a consensual strategy was adopted with a view to minimizing the potential for instability.
B. Crisis Management Activities
114. The crisis management arrangements worked extremely well and showed UNMIT's preparedness to manage a crisis situation. However, UNMIT does not have Mission-specific Crisis Management SOPs along the lines of the 2006 DPKO SOP "Crisis Management in DPKO-Led Missions," nor does it have a Crisis Management Team SOP to clarify the role of critical components in consolidating information flow and accelerating decision making. However, the Mission has a designated Senior Management Group responsible for overall decision making and coordination of effort which is led by the Head of Mission. The Senior Management Group includes those members that are listed in the DPKO SOP to deal with the special operational requirements in times of crisis. As a result, although UNMIT does not have the Crisis Management SOPs on paper, the Mission actually works in exactly the manner prescribed by the DPKO SOP.  An After Action Review is to be initiated by the Head of Mission as per the indicated SOP.
115. Many Mission procedures were activated to best ensure both preparedness and action during the 11 February events by both the Substantive and Mission Support components. In terms of interaction with DPKO, the SRSG personally alerted the Secretary-General and USG Guehenno in the initial early moments of the crisis and subsequent written and oral reports were transmitted to DPKO on a regular basis. The Security Management Team ensured the UN Country Team was updated on all developments and UN Agency staff received UNMIT security and other broadcasts. The UNMIT security directives also applied for the UN Country Team members. Information was also shared with the international community. The Joint Mission Analysis Cell (JMAC) continued to conduct threat assessments which were complemented by security risk assessments. Redeployments of UNPOLs, in Dili and the Districts, including FPU members commenced.
116. UNMIT staff were regularly informed about the situation and on safety measures. The first radio message went out at07:25 hrs. The first SMS message to staff to avoid the affected
 During these press conferences, updates were provided on the incidents and on UNPOL's response, including timelines. Clarifications were also made regarding close protection arrangements for both the President and Prime Minister.
 With the exception of the physical meeting point of the Crisis Management Team.
area was sent at07:43 hrs. Lotus Notes broadcasts were sent throughout the day and the following days with multiple security advisories and directives, press releases, extracts from international media reports, a statement by the SRSG, and two Town Hall meetings were held also providing for updates on the situation and measures for the staff to take regarding work and personal activities. The Mission stemmed a potential leak of information by stopping the circulation of photos of the deceased fugitive Reinado by UN e-mail. Essential staff required to travel at night or into areas of security concern were given armed escorts as necessary. In the Regions, security meetings were held and preparations made by the Regional Support Centres as well in the locations where the only UN presence is deployed UNPOLs.
117. During the first days of the State of Siege, the Security Warden system was activated and worked very well with Wardens contacting staff and verifying their whereabouts. However, the Security Operations Centre (SOC), when questioned by the Panel, indicated that it did not have access to the Warden database to locate staff. After the events of 11 February, the Security Section proactively conducted a Lessons Learned Exercise.
Security Operations Centre (SOC)
118. The Security Operations Centre (SOC) acts as a focal point for security issues related to mission personnel and property and for coordinating all emergency situations including liaising with the NOC for UNPOL action. It is also to alert relevant Sections for arranging MEDEVAC and other emergency assistance and to provide security updates advising staff members to avoid affected areas through broadcasts as per its SOPs.
119. The SOC SOPs underline the following procedures that were not fully complied with:
The Radio Operator will "notify the Duty Officer immediately of any incident and accident reported via the communication network" and the SOC will "receive, process, record and forward all security related information to the appropriate departments."
120. A UN staff member contacted the SOC by radio at06:53 hrs. to advise that shooting had been heard in the President's Compound. According to the staff member, he was told that the SOC would revert as soon as possible. However, the UN staff member was never called back by the SOC and the call was not noted in the log book. A few minutes after the first call, the SOC received a second call, from a different UN staff member.6° providing similar information to the first and the staff member was told that the SOC would send someone to check but this also did not occur. The Panel noted upon review of the SOC log that this call was not logged or acted upon either. It took 28 minutes after the first call for the Radio Operator who took the phone call from the NOC at07:21 hrs. (reporting to the SOC that there was gunfire at the President's Compound) to inform the Duty Officer about the incident. The Operator explained to the Panel that he did not want to be disrespectful and interrupt the Duty Officer who was on the phone during handover procedure. The Panel notes that the Duty Officer's office is separate from that
 The staff member does not remember the exact time of the call but is certain that it was before07:00 hrs.
of the radio and telephone operators. As such, Duty Officers cannot directly monitor incoming telephone calls to ensure they are being properly handled and logged.
121. The Panel notes that, had the SOC immediately reported these two calls to the NOC, the Mission's response could have started earlier for both UNPOL to attend the scene at the President's Compound and the Security Section to extract the UN staff members from their residence. As such, the Panel concludes that one of the SOC's main objectives, which is "to receive, evaluate, disseminate, and respond to emergencies within the shortest possible time by maximizing utilization of resources in order to solve the problem and prevent or prevent/minimize the extent of damage, loss, or injuries," was not met on 11 February.
* "SOC will ensure that all security emergency channels are properly and effectively monitored and utilised by users in compliance with laid down principles."
Neither of the SOC Duty Officers  were monitoring their radios when the initial calls by UN civilian staff and UNPOL reporting shots fired on the UNMIT and UNPOL radios were made. The fact that the Duty Officers are not co-located with the Operators makes effective monitoring of calls and operations impossible.
* The Security Operations Centre (SOC) is tasked to provide the Security Advisor through the Head of SIOC  with a 24 hour full situational awareness through timely and accurate monitoring and reporting." The SOC played no part in relaying information from the Security Response Team (SRT) to the OIC Security during the events of 11 February. The OIC Security received his information from informal channels and completed all required actions, including notifying the Security Advisor.
* SOC will "Keep record of events and all follow-ups with timings and all contacts."
122. The Panel reviewed the occurrence and call logs of 11 February and found a surprising lack of calls and activities listed for the day and subsequently identified calls and activities that were neither logged nor acted upon. In addition, the SOC does not log calls by one central clock, but rather by different time pieces. Thus, times in the logs cannot be verified for accuracy.
123. With regard to the SOC's role in facilitating MEDEVAC, there is no notation in the SOC log book. At07:40 hrs., the NOC called the SOC to arrange a standby MEDEVAC in the event the President had to be evacuated to Darwin. The Duty Officer told the Panel that when she called the OIC Security to inform him, he instructed her to inform the NOC to direct the request to the Dili National Hospital rather than to have the UNMIT aircraft readied. She says she contacted the NOC and passed the information. However, UNMIT's plane was readied when Mission Support was made aware of the request through informal channels.
124. Staff members were kept advised of security related developments as mentioned above through multiple security advisories and directives issued by Security on 11 February and the
 On the morning of II February 2008, the SOC was operated by two Radio Operators, who were completing their night shift at08:00 hrs., and a Duty Officer, who completed his shift at07:00 hrs. The incoming Duty Officer arrived for work at06:50 hrs.
 Security Information and Operations Centre (SIOC)
following days by radio, SMS and Lotus Notes broadcasts. See the Crisis Management Timeline for further details at Annex 2 on alerts to staff.
125. During the Lessons Learned exercise conducted by the Security Section, it identified some of the issues highlighted above. The Panel was informed, but did not verify, that a number of training sessions were being arranged for relevant Security personnel.
* Security Response Team (SRT)
126. After having informed the SOC at06:53 hrs., the UN staff member who lives near the President's Compound also telephoned the OIC Security to inform him of the situation. At07:50 hrs., the OIC Security instructed the SOC supervisor to extract the UN staff member from his home. A Security Response Team (SRT) consisting of three Security Officers  in two soft-skin vehicles left Obrigado Barracks at approximately08:10 hours. They delivered the staff member to his office at09:15 hrs. 
127. According to the SRT SOP, the SOC Duty Officer is to be aware of the whereabouts of the SRT at all times. In addition, the SOC should be kept informed of SRT activities at all times prior to and during the operation. The SOC Duty Officer told the Panel she was unaware of the SRT activities. However, the OIC Security was in regular contact with the SRT.
128. The Panel notes that the PIO prepared and released UNMIT's first media statement at 10:47 hrs. with the salient message that was agreed upon in the crisis management meeting confirming attacks of the President and Prime Minister, informing of UNPOL and ISF's high state of alert and announcing a press conference later in the day. The Panel did not have sufficient time to conduct a media content analysis. It appears that most calls from the media were handled by the UNMIT Spokesperson and PIO staff.
129. The Panel noted that the PIO has no Mission-specific SOP. While the Spokesperson and PIO had direct access to, and close collaboration with, the Acting Police Commissioner who also attends the press conferences, the UNPOL Spokesperson does not appear to have been involved in dealing with the media or liaising with the press, as stipulated in the DPKO Operational Policy "Policy and Guidance for Public Information in United Nations Peacekeeping Operations." According to the Policy:
"The Police Spokesperson or focal point would, in cooperation with the Chief of Public Information and in coordination with the Spokesperson, ensure release of timely and accurate information on police aspects of the mission and security matters and facilitate coverage of the mission by journalists on matters related to the police and security. The Chief of Information and Spokesperson should have direct access to the Police Commissioner as required, although this task would normally be assigned to the Police Spokesperson or focal point."
 The team included the SOC Supervisor.
The evacuation was slightly delayed because the armoured car refused to start. The vehicle has since been replaced.
130. The UNMIT Aviation Section began a search of ava11 able aircraft to evacuate the President when his condition would become stable, including the UNMIT and other aircraft in the area. It was decided to take the President out on a jet aircraft of a private company in order to get him to Australia in the shortest possible time period. In order to speed up the SRSG's return to the Mission from UN Headquarters in New York, the UNMIT Aviation Section arranged flight clearances and ground handling permits to fly to Bali, Indonesia and extended opening hours at Dili airport.
131. The contingency plan for the establishment of a Concentration Point prior to staff relocation and evacuation was activated. Arrangements were made both in Timor-Leste and at the designated safe haven. On 11 February, the Personnel Section immediately began an exceptional update on the Essential Staff List, which is the foundation for determining staff needed for essential operations, ava11 able for relocation or who are out of country.
132. The contingency stock  was updated on a daily basis as from 12 February in case staff were to be supported in Concentration Points. In addition, the Camp Management Team met to ready the designated UNMIT compounds for accommodation. In line with the Fuel Contingency SOP, all fuel tanks in Obrigado were topped up, and the Fuel Contractor was instructed to fill to full capacity all fuel tanks at UNMIT facilities throughout Timor-Leste. 
133. The Fly Away Team, an advance team tasked to prepare for relocation to Darwin, was alerted and made necessary preparations for departure. The UNMIT Darwin Office canvassed the local accommodation situation and prepared to support possible relocation of UN staff.
 The emergency stocks consist of water, combat ration packs, camp cots, helmets & flack jackets, fuel, etc.
 An additional two 5,000 litre fuel tanker trucks were positioned at the Obrigado Barracks and a 5,000 litre tanker at the Balide Compound.
IV. BEST PRACTICES
1. The National Operations Centre's instruction, at07:15 hrs., for all UNPOL to wear their protective gear unt11 further notice, was a proactive safety precaution.
2. The National Operations Centre's decision to dispatch an ambulance prior to confirming casualties was prudent and forward-thinking. This likely contributed to the prompt evacuation of the injured F-FDTL soldier.
3. The senior management, many of whom were Officers-in-Charge, were promptly informed by formal and informal channels and immediately instituted crisis management measures and practices, including invoking the contingency plans and notifying staff of operational guidelines for their safety. Senior management also promptly ensured the political dimension of the crisis was addressed through coordination of the major political, security and diplomatic actors in Timor-Leste.
4. UNPOL continue to prioritize assigning Officers to Mission duties based on the type of experience and skill set they bring with them.
5. UNMIT Security undertook a lessons learned review on their actions on 11 February. All pivotal components, including UNPOL and the Communications and Public Information Office should undertake an After Action Review, which should include actionable recommendations and lessons learned with a timeline for their implementation.
6. The Security Response Team was able to extract a UN staff member perceived to be under threat during in the morning of 11 February. This initiative would be further improved if the Security Operations Centre had access to an armoured car during times of crisis.
V. LESSONS LEARNED
United Nations Police
1. At the President's Compound, the UNPOL National Investigation Department investigators carried out their duties in a tense and crowded environment While doing everything within their means to secure the crime scene and interview as many witnesses as possible. With a view to best preserving a crime scene, no UN staff, including UNPOL and military, should be permitted into a crime scene, unless they have a direct role to play and/or are specifically called to the scene by National Investigation Department. This directive should be included in the National Operations Centre "Dealing with Disorder" Standard Operating Procedure.
2. The informal network used by several people throughout the day had a positive effect in terms of information dispersal and official action. However, action taken based on information from the informal network complicated UNPOL command and control as it makes it difficult to track assets. The Portuguese Formed Police Unit did not keep the National Operations Centre informed about their movements, operations and intelligence gained.
3. The Portuguese Formed Police Unit should be given a follow-up induction training on UN and UNMIT procedures and requirements, including the need to maintain contact at all times with the National Operations Centre, and on the appropriate command and control requirements regarding tasking during joint operations with non-Formed Police Units and UNPOL as per the DPKO "Guidelines for FPUs on assignment with Peace Operations."
4. Mission-specific Standard Operating Procedures on 'Command and Control' should be developed to clarify roles and responsibilities during joint operations, as well as updating the one on interaction with the F-FDTL, interacting with the media and guidelines for working with Language Assistants and Interpreters.
5. UNPOL should examine its current shift change system at all police stations with a view to ensuring that there is no gap time between shifts; this should also UNPOL rosters. This recommendation also applies to support staff such as Language Assistants as well as to Timor-Leste National Police (PNTL) colleagues who are being mentored.
6. There was no formal operation debriefings with UNPOL involved in the incidents with a view to exchanging critical information about the incident and to identifying best practices and lessons learned. Operational debriefings should be instituted at all levels of UNPOL after a critical incident.
7. Stress debriefings should also be held for the participants in critical incidents. If the unit commanders do not arrange stress debriefings, special efforts should be made to inform the UNPOLs of the availability of the Staff Counselling Unit. UNMIT's Staff
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to ensure they can monitor incoming calls and facilitate an appropriate response. They must also be required to carry and monitor their hand-held radios at all times while they are on duty.
14. Additional measures to standardise and improve Security Operations Centre operations would be to ensure radio and telephone operators have the necessary language skills to comprehend and be understood by callers and personnel monitoring the radios. Standardising the terminology used between them and the National Operations Centre to minimize the potential for miscommunication should also be undertaken. The Security Operations Centre must have one time piece used for logging purposes in order to ensure more accurate timing. The Security Operations Centre should have an armoured car ava11 able at all times for the use of the Security Response Team or to perform escort duties during potentially insecure situations.
15. The Security Operations Centre Duty Officer should have access to the Warden database in order to be able to immediately locate staff. During crisis periods, the Chief Warden should operate from the Security Operations Centre to facilitate the Security Response Team's extraction efforts.
Standard Operating Procedures
16. NMIT does not have a Mission-specific Standard Operating Procedure for both Crisis Management and a Crisis Management Team. Therefore, UNMIT should prepare Mission-specific Standard Operating Procedures based upon the Department of Peacekeeping Operations policies and the Mission's own practices on these issues.
17. The Communications and Public Information Office should develop a Mission-specific Standard Operating Procedure and involve the UNPOL spokesperson in events with significant police content. It is also recommended that in the future a designated staff member interacts directly with the press at a scene to properly direct their queries to ensure a cooperative relationship and negation of speculative rumours.
18. A set of guidelines for the use of Language Assistants and Interpreters in both normal and operational environments should be developed, in which it is explicitly stated that Language Assistants going into operational situations need to have provided the same protective gear as UNPOL.
19. UNMIT should send broadcasts to remind staff of the importance of informing the NOC when law and order situations they witness require a police response. The staff were also kept apprised of the unfolding political situation through Town Hall briefings, press releases and articles from the commercial media and a statement by the SRSG and diminish any perception of being 11 l-informed or neglected.
1. UNMIT's quick response to the attack on the President benefited from a number of fortuitous circumstances and the information flow was augmented by informal channels that expedited the response. The Portuguese Formed Police Unit Special Weapons and Tactics Team was already in the process of going out for a shooting exercise. They were almost fully assembled with all required equipment when they received an informal call that there was shooting at the President's Compound.
2. The two seriously injured victims encountered on the scene the President and the F FDTL member received emergency medical treatment by the UN prior to receiving hospital care and both survived. Ambulances were immediately ava11 able and standing by, as multiple sources called for ambulances to go to the scene.
3. However, the UNPOL response could have been even quicker if one of the people inside the Presidential Compound had called the police during the 50 minute period that Reinado's men were inside the Compound. A few minutes could have been saved had the UNMIT Security Operations Centre informed the National Operations Centre after it had first been notified that there was gunfire at the President's Residence at06:53 hrs and also if the Portuguese Formed Police Unit had been called earlier by the National Operations Centre when it received its first report at06:59 hrs.
4. The swift decision-making of trained and experienced officers in some operational key positions significantly contributed to a timely UNPOL response to the attack on the President on 11 February 2008. The Panel recommends UNPOL to continue to prioritize assigning UNPOL Officers to functions based on the experience they bring into the Mission.
5. Given the timeframe established by the Panel for the shooting of the President, he had been lying wounded for a maximum of 19 minutes before the Portuguese Formed Police Unit and the ambulance arrived at the scene. It should be noted that the President's Compound lies outside of Dili and it takes 15 minutes to drive from the Ambulance Dispatch Centre at the Ministry of Health to the Presidential Compound. The ambulance driver confirmed that he had not been stopped on his way. This, coupled with the fact that the Portuguese Formed Police Unit without knowing that there were casualties decided to send its nurse along with the Special Weapons and Tactics Team, shows an extraordinar11 y quick response. The nurse provided critical trauma care and stabilized the President before and during the time he was evacuated by ambulance which would have been a factor in stemming his loss of blood.
Police Response to the Attack on the President
6. Alfredo Reinado spent at least 50 minutes in the President's Compound before he was shot. None of the at least 20 people present, including relatives, guards on duty or people living and working in the Compound notified the police or warned the President who was on his morning walk. Additionally, most of the people who heard the gunshots in the first ten minutes of the attacks called friends or colleagues rather than the police or ambulance services. Immediate calls to the police by these witnesses could have reduced the response time of both the police and the ambulance.
7. UNPOL established a Safe Arrival Point 370 metres from the President's Compound. This standard safety action did not impede any emergency services or personnel from reaching the scene, as substantiated by all witnesses and participants at the scene. Therefore, the instruction to wait for reinforcement of an appropriate force level before entering the firing zone and to establish a Safe Arrival Point was advisable. Moving into the scene at that stage would only have risked further injury or death. Furthermore, it would not have expedited the arrival of the Portuguese Formed Police Unit or the ambulance that were already on their way.
8. During the initial response to the scene at the President's Compound, F-FDTL, ISF and UNPOL cooperated effectively to secure and clear the area. Throughout the rest of the day, the responses to specific tasks were less effective as tasks were not assigned through central command centre with the ability to track all assets in Dili.
Police Response to the Attack on the Prime Minister
9. The only UNMIT involvement in any protective capacity for the President or the Prime Minister was the Prime Minister's UNPOL Close Security Protection (CSP) team whose quick reaction of mounting a counterattack on the nearest assa11 ant may have saved the Prime Minister's life. While two of the Prime Minister's PNTL CSP team members had not come to work that day, the Timor-Leste National Police (PNTL) static guards remained at the house with the fam11 y when it was circled by armed insurgents, as well as the Prime Minister's wife's CSP team who arrived on shift after the ambush. The Timor-Leste National Police (PNTL) Officers initiated a dialogue with the gunmen, identified Salsinha as being present, refused to surrender their weapons or provide information on UNPOL weaponry and refused the request to desert the premises so the gunmen could attack UNPOL.
10. The Panel's initial consideration of the UNPOL response times to rescue the Prime Minister's family after the ambush and to secure the crime scenes indicate an area for LTNPOL review. This would also include ensuring an appropriate level of attention was brought to bear on the different aspects of the response to the ambush, whether information flowed and was acted upon appropriately and that command and control issues were properly exercised.
11. UNMIT has no responsibility for the President's close protection arrangements or static security at his Compound. The Panel concludes that the measures taken for the President's security on 11 February were insufficient and ineffective. For the Prime Minister's protection, the sole UN responsibility was providing a team of two UNPOL Close Security Protection Officers to mentor the Timor-Leste National Police (PNTL) Close Security Protection Officers. However, in this case the UNPOLs took an active role in the protection of the Prime Minister by opening fire on the gunman which drew the firing away from the Prime Minister's vehicle and to the UNPOL himself as he stood on the roadside.
Alfredo Reinado Issues
12. Given President Ramos-Horta's written guarantee of movement for Alfredo Reinado and his men of 12 October 2007. UNMIT had no responsibility to track their movements. There were no indications to predict that Alfredo Reinado and his men were planning an attack on the President and the Prime Minister.
13. When UNPOL arrived at the Presidential Compound, it was known that Alfredo Reinado was dead. The decision on the timing of the official confirmation of Reinado's death was made by the Government and this timing also allowed coordinated security precautions related to public safety concerns to be set up through the coordinated good offices of the Trilateral Coordination Forum.
14. In its Emergency Meeting, the Trilateral Coordination Forum did not prioritize the capture of the perpetrators of the 11 February 2008 attacks, nor did it ask UNPOL to participate other than by setting up road blocks. According to the law, any police officer, or in his absence, any person witnessing the incidents could have pursued those responsible for the attacks. No UNPOL at the President's Compound saw any suspects fleeing. F-FDTL who had the advantage of being armed, witnessing the attack, having knowledge of the terrain and language did not institute a search. Furthermore, it was known when UNPOL arrived at the scene that the attackers were Reinado and his men who were armed with automatic weapons. The Panel concludes that UNPOL has neither the mandate nor the capacity to apprehend armed insurgents.
15. No one person or entity had overall command at the crime scene at the President's Compound which made it difficult to control the area. The Panel also concluded that there was no practicable way to restrain the F-FDTL behaviour on site at the President's Compound without risking a confrontation.
16. No PNTL officer was involved in the initial investigation of the scenes of attack on both the President or the Prime Minister as they had not reported to their duty stations when the National Investigation Department left for the scene and did not follow their colleagues later that day. Valuable opportunities to mentor the Timor-Leste National Police (PNTL) on how to process a major crime scene were lost.
17. UNMIT senior managers held a crisis management meeting an hour after the attack on the President. The Mission leadership was proactive in initiating an Emergency Meeting of the Trilateral Coordination Forum on 11 February 2008 to bring together the major security actors in Timor-Leste. The meeting set priorities and delegated individual responsibilities in order to coordinate the security response and the Mission immediately implemented its decisions. To this end, UNPOL also carried out major redeployments to implement a robust security blanket throughout Dili and reinforced their presence in Covalima and Ermera districts.
18. The staff of UNMIT and the UN Country Team continued to work throughout the day of 11 February 2008. Senior Managers ensured that staff were kept informed by holding two Town Hall meetings to brief staff on the latest developments, security measures were taken and contingency plans activated.
1. UNPOL, in consultation with the Timor-Leste National Police (PNTL), conduct an After Action Review on its preparedness and response to the events of 11 February 2008, as they did after the electoral period, with a particular focus on the response to the attack on the Prime Minister, response times and methodology to critical incidents as well as command and control issues.
2 Through its good offices, UN-MIT could advise the Government on strengthening security arrangements for both the President's and Prime Minister's Residences and their close protection.
3. UNPOL should develop its own specific Standard Operating Procedures for each section or unit in order to pass them on to the Timor-Leste National Police (PNTL) as part of its mentoring role.
4. UNPOL Close Security Protection should formulate specific Standard Operating Procedures and share them with their Timor-Leste National Police (PNTL) counterparts to ensure standardization of action between the various teams providing protection to State Officials, Mission and visiting VIPs.
5. The Security Operations Centre could benefit from altering its physical arrangement to require the Duty Officers to be co-located with the Radio and Telephone Operators in order to facilitate monitoring. It would also be well advised to initiate a refresher theoretical and practical training on the Security Operations Centre's Standard Operating Procedures to ensure compliance in everyday and surge operations as well as regular practice dr11 ls for crisis scenarios.
6. A review should be conducted to examine the minimum requirements necessary for the National Operations Centre to become a National Command Centre that handles high level or multiple emergency events. While maintaining its daily operations. Areas of focus would include whether the current staffing numbers and experience levels are optimal as well as the space and equipment allocation. It is recommended that a training regime by unit and by scenario with periodic practice drills for crisis operations is developed and implemented.
Annex 1 Panel's Appointment and Terms of Reference
Annex 2 Crisis Management Timeline
Annex 3 Abbreviation List
Annex 4 List of Selected Documents Consulted
Annex 5 Site Maps [not with original received – JMM]
IX. Signatures [See original document]
UNMIT Internal Review Panel into the response to the events of 11 February 2008
On the instructions of the SRSG, an UNMIT Internal Review Panel, to look into UNMIT's response to the events of 11 February 2008, is hereby convened. This formal body, under the authority of the SRSG, will interview key witnesses, both inside and outside of UNMIT, and review all relevant documentation, to produce a report that will be officially submitted to UNHQ and to the government of Timor-Leste.
Terms of Reference
1. Review the immediate and short term UNMIT responses to the 11 February attack, including:
a) UN police response on 11 February, particularly in the first hours
b) Crisis management response, including UN Security and Public information response with a view to
- assessing whether proper procedures and good practices were followed; - identifying best practices (what worked well)
- identifying lessons learned (what could have been done better)
2. Make recommendations on any ways to improve UNMIT' s capacity to respond to a future crisis in each of the above areas.
Chair Claudia Banz
UNPo1 David Can
Admin Kelly Smith
Human Rights Anjet Lanting
Guidance and Support:
PBPU Alexander Rose, Chief PBPU
Secretarial Ancy Price
Focus on procedures: The objective is to make an honest assessment of the actions that were taken in response to the events on the morning of 11 February, and identify any shortcomings or lessons that could be learned from that response.
Consensus: The final report of the Panel must be a consensus report.
Deadlines: A preliminary draft, covering at least 1 a), should be submitted by COB 9 Apr11. The complete report is to be submitted by COB 13 Apr11.
Timeline of the Crisis Management Response, Including UN Security and Public Information
[see original document]
List of Abbreviations
[see original ]
List of Documents Consulted