The San Ysidro McDonald’s Shooting was the largest mass shooting in U.S. history at the time and really the first of its kind. While hindsight is always 20/20, taking a look at what is now the 8th largest mass shooting is necessary to review what we have changed, what we have improved upon, and what has stayed the same in the lessons learned since the massacre. This is an analysis of information presented.

On July 18th, 1984, James Huberty walked into a McDonald’s restaurant in San Ysidro, CA and opened fire with a 9mm pistol, a 9mm Uzi carbine, and a 12 gauge shotgun. Huberty shot and killed 21 patrons, staff, and passersby while wounding 19 others before being shot by a San Diego Police Department SWAT team sniper’s bullet from atop the U.S. Post Office next door 77 minutes after the shooting began.

The first SDPD officer to arrive on scene found himself easily outgunned as he only carried a standard-issue .38 revolver. Needless to say, the SDPD no longer uses the .38 revolver.

As the San Diego Police Department has implemented changes to its protocols and equipment in response to this tragedy, what has changed in terms of what actually failed to allow the shooting to occur and to continue as it did?

One area that seems to be troubling is that of communication. There were two major communication failures that could have possibly prevented the shooting, mitigated it, and/or decreased police response time.

The first incident that may have changed the situation was that Huberty called a mental health clinic on July 17, the day before the shooting, to request an appointment. He left his contact information with the receptionist and awaited a return call for several hours, before leaving his house on his motorcycle. The receptionist misspelled Huberty’s name and did not feel his situation merited “crisis” status, thus it was to be handled within 48 hours. The issue here is that it is apparent that the receptionist didn’t ask any direct questions of Huberty’s mental health status which may have opened Huberty to share his issues with her. Phone screenings tend to be “yes or no” and “fill-in-the-blank” questionnaires with fields designated for contact information, not open-ended questions which the receptionist may not be trained to ask.

I am not suggesting the receptionist’s knowledge of mental health was the issue, rather the communication techniques she used both within the triage system she was given and her own verbal skills were what could have made the biggest difference. She stated Huberty’s calm demeanor did not indicate a crisis. Assessing demeanor has its merits, yet this could have been cleared up with a simple question: “What mental health issues have you had?” A brief explanation and description would have given the receptionist everything she needed to know. If she didn’t ask a direct question such as that, then what could be the reason for the call? What could be the reason for the clinic’s mental health line?

Other questions remain regarding the mental health clinic and its response in terms of staffing, protocols, etc. However, it cannot be speculated whether or not the receptionist used direct questioning with Huberty. It is an apparent and glaring weakness that led to a missed opportunity to possibly prevent a disaster. I say “possibly” because it is not known whether a return call would have changed Huberty’s intentions. The day after the call, Huberty told his wife “Well, society had their chance” before carrying out the shooting later that day. Between waiting for several hours by the phone on July 17th and carrying out a mass shooting at the McDonald’s a day later, one may say this was a half-hearted attempt to further justify his actions rather than authentically seek help.

Misspelling a name can be seen by many as a common, honest error. However, it is completely preventable. There are ironclad ways of ensuring correct spelling over the phone.

Allow me to analyze how direct questioning could assist in this situation:

Receptionist: “What is your last name?”

Caller: “Huberty.”

Receptionist: “Spell ‘Huberty’.”

Caller: “H-U-B-E-R-T-Y.”

Receptionist: “Ok, you said ‘H-U-B-E-R-T-Y’, is that correct?”

Caller: “Yes.”

Receptionist: “Thank you Mr. Huberty, what is the reason for your call today?”

It’s that easy and 100% full-proof. But for those untrained in questioning, small errors become catastrophes. Therefore, direct questioning is key.

There were conflicting reports regarding the police response to the shooting. One report indicates that as the first 911 calls were placed, dispatch directed police to the wrong McDonald’s location two miles away at the U.S./Mexico border while another report states that two police officers nearby heard the gunfire and immediately responded.

Let’s assume the first scenario did occur:

This mistake allowed for several more minutes of undeterred shooting from Huberty. It’s possible that the initial calls placed at 4:00pm were describing the location as “The McDonald’s at the border” which is better known because of its location at the end of the trolley line and immediately outside the exit of the pedestrian border into the United States. Had they described it as “The San Ysidro Mcdonald’s” the dispatcher would have been making an assumption that either there was only one McDonald’s in San Ysidro or that if there was a shooting at a McDonald’s in San Ysidro it would have been taking place at the international border. Clarity is key and using direct questioning is how best to address assumptions which may present themselves.

That is not to say the dispatcher didn’t do an excellent job of coordinating the response and relaying information. (Reference this audio of the SDPD radio traffic that begins at 4:03pm, approximately 7 minutes after the shooting begins:

As you can hear in the audio, she has a detailed description of a single shooter from 9-1-1 callers, yet the police at the scene did not accept this information as they believed there were multiple shooters inside the restaurant.

The San Diego Police Department changed its tactics and procedures to better prepare themselves for SWAT to respond to such a scenario. SDPD also observed the need for increased firepower for each officer and even moreso for their SWAT team. That being said, while each officer on today’s force is grateful to not be carrying a .38 revolver, no public trace of direct action to change dispatcher questioning procedures can be found. Had the 911 dispatcher gathered the correct information during the first call, SDPD officers could have been on scene much quicker. Again, this is one scenario that conflicts with other reports. If police dispatchers are not trained in direct questioning, information will be inaccurate at times.

These are examples of how aspects of communication such as questioning are indeed a “hard” skill.

All of the new tactics, weapons, and procedures of the San Diego Police Department’s SWAT unit mean absolutely nothing if they are directed to the wrong location. Assumptions and errors in how questions are asked may have been the biggest detriment in police response to this horrific circumstance. I am confident that this error was identified and action was taken, even though no reports suggest it. However, when an incident occurs, more funding is naturally the most common solution. Better equipment and a larger staff are almost customarily added in response to events that occur that there is no precedent for. That is completely acceptable if the problems are addressed.

Say what you will about “staging” and its relevance to active shooter scenarios in today’s world, procedures will continue to evolve as the latest mass shooting is dissected and analyzed. It’s the regard for communication as a skill that also needs to change in order to take the biggest leap forward in public safety.

The scars of this shooting are still apparent. The McDonald’s was torn down and a Southwestern College extension was built at the site. Bullet holes can still be found in the Post Office building’s west side. The deeper wounds within those affected directly by the shooting that live with the memories of lost loved ones and physical scars of their own, the community is forever changed. Even after 35 years, we still have a lot to learn from this event.