The review by Halifax Regional Police blames communication gaps, false assumptions and misunderstood roles for Crockwell's embarrassing and potentially deadly escape after a weeklong siege in Bay Bulls, N.L.
Crockwell, considered armed and dangerous, slipped undetected out a side window with two guns the night of Dec. 10, 2010. He was arrested the next day without incident about 18 kilometres away after the Royal Newfoundland Constabulary was tipped by a couple who'd given him a ride.
Right up to Crockwell's arrest, the RCMP incident commander was so convinced Crockwell was still in the house that plainclothes Mounties who ultimately arrested him weren't given additional backup, says the report.
On the night Crockwell bolted, RCMP officers with reinforcements from New Brunswick, Nova Scotia and P.E.I. had been working in shifts for six days as he refused to negotiate and at times fired at them.
Officers wrestled with a high-pressure water hose just before Crockwell's escape as they pumped thousands of litres into the house in an effort to flush him out. The tactic had left the house only partially surrounded.
Incident commanders took no apparent action when officers radioed that night that they heard "stuff breaking on the green side of the building," says the report obtained under Access to Information laws.
"Approximately eight minutes after the 'movement' communication, (officers) reported ... that civilians located behind their position were yelling out: 'Go Leo, go Leo.' The (incident commanders) acknowledged this communication and a patrol unit was dispatched to investigate the matter. They later reported that the civilians had moved on."
At least one officer on duty that night told the review team that sounds of glass smashing were reported to Incident Command "but the review team could find no record of this communication."
Sounds of falling debris inside the house were apparently mistaken for Crockwell's presence, says the report.
An otherwise "textbook" handling of an extraordinarily long standoff could have ended differently if not for such communication gaps, the report concludes.
"The primary concern that arises from this situation was the failure of Incident Command to recognize the potential implications of the previously mentioned communications given the fact that the very purpose (of the operation) ... was to eject the subject from the residence."
Moreover, a fundamental best practice of incident response wasn't followed, says the report. Ideally, the police emergency response team leader, the head negotiator and incident commanders are in constant communication at a single command post as events unfold, it says.
"One area of concern identified during the review was that this practise was not regularly adhered to."
Instead, incident commanders alternated between the Bay Bulls Town Hall command post and a mobile command post used during tactical operations. At various times during the week, officers used tear gas, pepper spray, noise grenades, a battering ram and ultimately the water hose as they tried to force Crockwell out.
The review team in particular found that the absence from the central command post of the emergency response team leader — who was often out helping short-staffed officers — "may have inadvertently impacted the outcome of this incident" as communications the night Crockwell fled weren't given proper weight.
The Mounties declined to release the full report when its findings were first made public in July 2011, citing security concerns.
"It's really quite boring," Sgt. Boyd Merrill said at the time.
Merrill highlighted the review team's praise for how officers handled themselves under intensely stressful conditions. He also focused on how the RCMP emergency response team had just eight members at the time of the standoff when its full strength is 12, and on the use of two command posts that "negatively impacted this incident."
RCMP spokesman Sgt. Marc Coulombe said Thursday that the force asked Halifax police to review its actions and accepted the entire review report. The RCMP has since expanded the capacity of its emergency response team, he said in an email.
It has also trained more incident commanders and is working on a new agreement with the Royal Newfoundland Constabulary that would see its separate emergency response teams co-operate, Coulombe said.
The Crockwell standoff cost more than $444,000, according to documents released under Access to Information. It started when a neighbour phoned police after Crockwell's sister said he had held a gun to her neck.
Crockwell, now 58, was convicted last June on five of six charges including assault with a weapon and careless use of a firearm. He was sentenced to four years in prison.