The Good, The Sad, and The Ugly.


Human Being Extraordinaire: Dee Berry. You’ll just have to watch last night’s council meeting….there are no words. Mr. Zack was a “gentle giant” who would never be violent or dangerous and moreover, would—because of his extremely strong Catholic faith—never consider suicide.  He was doing exactly what he was reported to say he was doing on Memorial Day: praying. And he’d done something similar before: APD had previously brought him home one morning from Crown Beach when he’d sat on the beach overnight praying….

Humble Pie: APD Chief Noonan as evidenced about 2/3rds the way into KTVU Channel 2 News coverage of last night’s meeting. Thank you, Chief, for your humility and your apologies.

Effective: City Manager Russo acknowledging the evidence in the Grijalva Report that points to a hostile and dysfunctional relationship between the city’s sister first responder agencies: the AFD and the APD. Both agencies must have been chastised and been given an ultimatum by CM Russo to fix this as both Chief Noonan and Acting Interim Chief D’Orazi went to great lengths to mention interdepartmental programs and training. Also effective: CM Russo correctly took notes listing the questions posed by residents speaking at the podium and returned to those questions later, having Chief Grijalva answer them.

Overall: Despite the almost missing—it is so minimal—emphasis in the Grijalva report on improved procedures and protocols, it appears that the AFD and the APD have been and will be focusing on bringing their P&Ps up to date and improving Incident Command System familiarity and capabilities particularly where mutual aid and multiple agency responses are required. (OTOH, the AFD’s emphasis on being self-sufficient seemed to contradict this last night.)

Doing his job: Council Member DeHaan asking good questions. God know, no other council member was! Thank You to Mr. DeHaan for this, for taking his job sincerely and truly representing we-the-people’s interests and concerns. Why is every other other council members failing us in this regard?

Teamwork: CM Russo coined a new term, Team Alameda. I hope that term becomes common parlance and the meaning fully integrated into our political and social culture.


Hall of Shame: Mayor Marie Gilmore sounding like she has no clue how to lead the discussion last night.  She is a kissing-babies mayor, not a thought and critical-discussion leader. When the meeting got to the point where Grijalva would answer the questions posed by residents, Mayor Gilmore had no clue what to do: she hadn’t taken a single note about the important questions that concerned residents took their time to bring to her attention during this meeting! CM Russo stepped in & saved that day. But then, OMG, the one thing Dee Berry requested last night of Mayor Gilmore—to please remove the term ‘suicidal’ and ‘suicide’ from any descriptions of Raymond Zack—went completely ignored. For shame. How hard would it have been to tell this woman that these terms would be removed from the Grijalva Report and to instruct CM Russo and Chief Grijalva to do so? After what Ms. Berry has been through at our hands and how extremely gracious she was last night, why on earth would Mayor Gilmore not respond to her one simple request?!  This incomprehensible incompetence and insensitivity displayed by our mayor, her single most embarrassing act to date, absolutely breaks my heart. Given the gracious and heart breaking and wrenching talks that Ms. Berry and her friend gave last night, there is no excuse for this omission. Mayor Gilmore’s lip service about caring has been fully negated by this single unbelievably insensitive and unnecessary act of omission last night. Mayor Gilmore should be ashamed, and she should today instruct any reference of Mr. Zack as suicidal be removed from every city record and report, and make a press release stating she has done so and why it’s important to properly characterizing Mr. Zack. The problem for the city is this: the first responders’ performance that day looks even worse if Mr. Zack was not suicidal (that has been the key to the oft proferred excuse for failing to do their job: the man was dangerous to the first responders and he was suicidal; the first responders couldn’t be put at risk [pure bullshit!]). So sorry this makes you look bad; the city needs to man up! Final, but petty, note: Mayor Gilmore doesn’t understand the word ‘proactive’….the work done by both the AFD and APD to fix what’s broke is reactive to an extreme failure and a full-scale CYA.

Telling me that I make the firefighters look bad: Dom Weaver, IAFF Local 689 President (fire union).  The FF’s have done this all on their own. Every firefighter knows what needs to be done with a toxic fire. Every firefighter knows how important the incident command system is. Every firefighter knows how to walk out into calm, warm water and talk to a potential victim. As APD Chief Noonan said last night, one of the primary things that first responders do is talk to people; this is not news nor is it a skill or experience they do not have, firefighters included.


Wrong headed: that the AFD still doesn’t get that using the Alameda County Sitstat report is important.  The AFD knew about the County SitStat report (list of all rescue equipment available in the region for rescues via mutual aid) but never used the information it contained on Memorial Day. Missing last night was any mention of the AFD valuing and using this critical document on a daily basis; rather, Acting Chief D’Orazi talked about how the AFD has enough equipment to be self-sufficient now; Council Member Tam reiterated this prideful self-sufficiency line that is contradicted by every other part of the discussions last night and by the Grijalva Report itself. Wasn’t that this the big issue in the first place? That we cannot be self-sufficient for every emergency response and our firefighters need to know how to engage and rely on other agencies when need be?  The APD, OTOH, stated quite clearly that it now integrates the daily updated County SitState report into working knowledge every day.

Spin: CM Russo’s questions posed to Chief Grijalva. Mr. Russo asks why Grijalva characterizes Mr. Zack as suicidal. Grijalva says that’s how the call came into county dispatch. Mr. Russo fails to take this to the logical next step: why did the first responder mischaracterize Mr. Zack as suicidal? What information did he use to arrive at this conclusion? With Ms. Berry right there in the audience, and after her gracious single request to strike ‘suicidal’ from the characterizations of her son, why would Mr. Russo reinforce a conclusion that Mr. Zack was suicidal? Hasn’t the woman been through enough? Why not get at the heart of the matter, man up, and find a way to suggest that the first responder may have misconstrued the facts? For everything indicates that this may be true. Why not throw Ms. Berry that bone? And Grijalva’s Report gets facts other wrong too. Russo asks about the effect of water being quite a bit warmer than Chief Grijalva reported it to be: wouldn’t that increase the survivability window for Mr. Zack? Well, yes it would. Then Mr. Russo moves on to the next question. HUH?  The corollary to the corrected fact, that the water was in the 60s and not in the 50s, is this: warmer water makes it even less of a risk to our first responders; they had even more reason to simply wade out there. Mr. Russo goes on to ignore the evidence presented last night by Rosemary McNally that the water was lapping the shores and not the 1 to 3 foot waves that Chief Grijalva reports. This is further evidence that the environmental conditions that day posed no threat to first responders. Why did Chief Grijalva get these facts so wrong? Why was it important to use facts to indicate significant risk factors existed for the first responders when in fact the environment posed very little risk at all? CM Russo fails us miserably here; that he has an agenda, is self-evident.

Black Out: still no answer to the single most significant cause of the failure that contributed to Zack’s death. What we still do not know after last night—and apparently Gilmore, Grijalva, Russo, D’Orazi and Weaver are in collusion on this because the omission is so glaring and consistently ignored by each of them—-is why the firefighters never conducted their funded, scheduled rescue-swimmer training in 2009. And what happened to the $27,000 allocated for that training?  We should know these things. Why don’t we? Grijalva says he was able to discover nothing about this. Why not?  Why did Mr. Russo accept Grijalva’s report as complete and thorough?

Mortal Sin: I know for a fact that the Alameda Fire Department paramedic on scene at the negligent homicide of Raymond Zack failed, and failed miserably (it’s in the docs the city published): he failed to keep the equipment on his ambulance in working order. That’s right: the equipment that is used to resuscitate victims had dead batteries. It is interesting, is it not?, that the Grijalva report ignores any AFD EMS activity. It wasn’t in the purview of his tasks, he said. Why not? We’re talking about a wrongful death at the hands of our first responders! Worse: when Council Member DeHaan asked him point blank if the EMS staff onsite that day had all the equipment they needed to resuscitate Mr. Zack, Chief Grijalva answered YES.

Summary: systems, organizations, and groups of people naturally evolve towards optimization. That’s a fact. The only time we do not is when there is ignorance or corruption that skews the outcome, veers us away from optimization. Mayor Gilmore, CM Russo, Chief Grijalva, Acting Fire Chief D’Orazi, and IAFF Local 689 President Weaver are not ignorant nor are they ignorant of the facts and which questions should be posed and answered.

I’m not making anyone look bad here (don’t Shoot the Messenger); people make themselves look bad. Res ipsa loquitur (the thing speaks for itself).

If you’re not outraged, you’re not paying attention. If you’ve read this far, there are no excuses.

Caveat to those who want to throw me under the bus for saying what I see: I’ve never said that calling a thing or an act bad is the same thing as calling the person bad. For instance, in CM Russo’s case, he clearly has an agenda to conceal facts here in order to protect the firefighters. This is a disservice to the public and to himself. At the same time his throw down to AFD and APD to fix what’s wrong with the interdepartmental culture is excellent. CM Russo’s powerful personality clearly got action from D’Orazi and Noonan here, action that will make a clear difference in the future IF all of the intents alluded to become reality. Lena Tam, OTOH, seemed focused on throwing the police under the bus and praising the fire services no matter what. Note to Dom Weaver: anything you can do to better represent the Alameda firefighters to the public would be effective towards a better dialog. We know the firefighters are well-trained, that they have the skills and tools to do their job. We know they are heartbroken when they don’t get to do their job well and someone suffers and/or dies (FISC firefighter death, Raymond Zack death). What we don’t know is why they did not protect themselves and us from toxic asbestos and crude oil?  Or why they didn’t follow through with the rescue swimmer training. And mostly why one of yours and one of ours had to die? Without the facts, we cannot trust you which means the firefighters are poorly represented (I doubt very seriously they wish to hide behind the smoke & mirrors that conceal the facts) and the public cannot work with you to optimize public safety services.


About Denise Lai

Alive. Swim (fly is the best). Walking with my dog (weims are the best). Life is good. Would prefer people understood negative externalities and prevented themselves from creating them. Feeling the love anyway. View all posts by Denise Lai

4 responses to “The Good, The Sad, and The Ugly.

  • blanche knott

    Altho its good Noonan @ least apologized, nagging questions remain: Since Mr. Zack had previously been 5150’d by APD, they had to know he had a history of NON-violent contact. They had no reason to assume “possibly violent” in fact they had a duty to assume the opposite, Bonta stopped just short of coming to this obvious conclusion w/his questions to Grijalva. And once APD did 5150 Zack, THEY HAD A DUTY TO PROTECT HIM FROM HIMSELF, b/c that’s what 5150 means! IMHO, police use their 5150 power w/far too little discretion! You don’t label someone then leave them to fend for themselves! That’s why the City will lose this lawsuit or have to settle. And, despite knowing they sent Zack to John George Psychiatric Pavilion last year, NO ONE from APD even bothered to ask about any antidepressant meds he might have been taking, which is key to why he succumbed under otherwise harmless conditions. Nobody dies just b/c they walked into the Bay w/their clothes on. (Dennis Evanovsky did @ the Wade-Out!). This could happen to any of us under the wrong circumstances, unless APD & AFD shape up!!!

  • Denise Lai

    Blanche: AGREED! I was surprised to hear that Zack had prayed overnight on the beach and had been picked up by the APD the morning after; and I had not known that he’d been in and out of institutions and 5150d. Clearly the police had information about Zack that they should have used on Memorial Day to assess what was really happening.

    Rosemary McNally (a brilliant woman) and I conceived The Wade Out and organized it together—it was proven that Zack could have heard anyone from shore with a bullhorn, and that anyone, even 65 year old women could walk out there safely.

    The Report did nothing to determine why APD did not send a negotiator out there, why the AFD and the APD did not collaborate, why the AFD did not make a single mutual aid call, etc., etc.

    At the same time, I was please that Chief Noonan has humility and commitment to doing better while D’Orazi is focused on where he’s spending more money. Spending money on overtime/training and new equipment doesn’t solve a thing; the problem is management and command structure, and protocols/procedures. The AFD fails time and time again, like the house that burned in Bay Farm unnecessarily and never has to be accountable for anything they fail to do because their protocols are so substandard that they allow them to fail and still keep their jobs. It’s incredibly bad city leadership and management that has allowed this.

    The Grijalva report is disturbing at best, so inadequate, incomplete and pedestrian, a cover up actually; but what’s really disturbing is CM Russo’s acceptance of it.

  • Maria Gordanier

    I simply want to express my appreciation for your analysis and insight.
    Except for DeHaan, the city leaders are pathetic. It’s not just the lack of protocols and management, it is the overall attitude. I wouldn’t put an
    animal in their care, oh wait! They aren’t interested in animals either!

    Thank you again, Denise. I watched the meeting after reading your
    post, and you are right-on. Keep up the good work.

    At least a few people are fired up about this.

  • Denise Lai

    Maria: thank you. yes, many of us are finally getting very upset, finally believing the horrible truth that’s been right before our very eyes but which we have been unwilling to acknowledge because, quite honestly, it’s unbelievable, isn’t it?

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