SERIOUS INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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TEXAS DEPARTMENT OF CRIMINAL JUSTICE
STATE JAIL DIVISION
SERIOUS INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
CORRECTIONS CORPORATION OF AMERICA
September 7, 2000
SERIOUS
INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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TEXAS DEPARTMENT OF CRIMINAL JUSTICE
INTER-OFFICE COMMUNICATION
I
TO: Thomas A. Baker DATE: 7
September, 2000
Director, TDCJ-SJD
THRU: Nathaniel Quarterman
Regional Director
State Jail Division
From: John Rupert SUBJECT:
Serious Incident Review
Committee Chair Team Report
Bartlett State Jail
BACKGROUND
A serious incident review of
the Bartlett State Jail was conducted by a team comprised of the following members:
Warden John Rupert (Hutchins SJ), Warden Kenneth Karl (Dominguez SJ), Tim Sanson (SJD-HQ), Major Will Churchill (Glossbrenner
SAFP), Major Stanley Kinney (Lychner SJ), Mr. Jerry
Thompson (Lychner SJ), Ms. Audrey Winkler (Dominguez
SJ), Sgt. Carmen Carpenter (Hutchins SJ), Sgt. Fred Gutierrez (Hutchins SJ) and
Sgt. John A Berry (Glosssbrenner SAFP). The review
was conducted at the request of the Director. TDCJ-SJD, following an offender
escape that occurred on August 27,2000.
SCOPE AND OBJECTIVES
The scope and objective of
the serious incident review of the Bartlett State Jail involved an examination
of the total operation of the unit by functional area. These areas included
Facility Layout, Correctional Training, Staffing, Offender Classification,
Count Procedures, Emergency Procedures, Food Service, Maintenance and Law
Enforcement Relations. The objective of the review was to identify problem
areas that existed which may have, directly or indirectly, led to the incident
on August 27, 2000, and to offer recommendations for corrective action at unit
level. The examination was accomplished, through on-site observations of
functional areas, by reviewers, interviews of staff and offenders, and reviews
of documentation by functional area.
In addition to operational
areas of the unit, the Bartlett State Jail organizational and management
structures were examined to establish what lines of communication and authority
were in place and to ascertain the overall staff attitude of the Bartlett State
Jail.
SERIOUS INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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I
INCIDENT REVIEW
In order to accurately assess
what factors contributed to the incident that occurred on August 27, 2000,
offenders representing all custody levels and numerous staff were interviewed.
Presented herein is a chronological explanation of events that led to the
escape on August 27, 2000.
The subjects of this incident
are:
Offender
Sanders, David Lee, TDCJ# 861517 (White Male, 5'9" 182 lbs.). Offender Sanders sentenced to an
eight-year sentence in The Texas Department of Criminal Justice, for Aggravated
Assault with a Deadly Weapon. Offender Sanders arrived at the Bartlett Unit on
March 24, 1999, underwent the intake and classification process and assigned to
J7 dorm.
Offender James, Kyndall Dwight. TDCJ# 915758. (White Male). Offender James sentenced to a ten-year
sentence in The Texas Department of Criminal Justice, for Aggravate Assault
with Deadly Weapon. Offender James arrived at the Bartlett Unit May 04, 2000,
underwent the make and classification process and assigned to J4 dorm.
On August 27, 2000, at
approximately 04:00 hrs, Offender Sanders and Offender James were assigned to
work the Barden State Jail Food Service Department. Between the hours of 04:00
and 04:51 said offenders exited through the rear door of the food service
department and gained access to the back dock area of the kitchen. From this
area the offenders were able to scale an eight foot fence and enter the inner
compound area. Offenders Sanders and James then proceeded
to the maintenance department where they gained entry through an outer roll up
door. After entry into the maintenance department said offenders then obtained
(2) two 8" linesman pliers, (1) one 8" flat head screwdriver and (1)
one box cutter. The offenders then exited maintenance and proceeded to the
fence on the southwest side of the back gate area. Offenders Sanders and James,
using the linesman pliers cut through the inner perimeter and proceeded to the
outer perimeter fence. Surveillance cameras then revealed offenders Sanders and
James, at 04:51 hrs escape the outer perimeter fence, pause for several seconds
and then disappear into the dark.
UNIT MANAGEMENT
Unit Management has been
active in improving the communication of and perception of the staff. Meetings
are conducted weekly to ensure line staff are able to
communicate with upper administration on a regular basis. Through
out the facility attitudes appear up beat and professional.
SERIOUS
INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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FACILITY LAYOUT
Bartlett State Jail is a
State Jail Division Unit managed and operated by the Corrections Corporation of
America under the Administrative over-sight of Warden Mickey Liles, Bartlett is
a 962 bed facility housing both State Jail Felons and Institutional Division
offenders of all custody levels. Bartlett State Jail is located on 60 acres in
Bartlett, Texas, Williamson County.
CORRECTIONAL TRAINING
The area of Correctional
Training was reviewed, to determine compliance with American Correctional
Association Standards and TDCJ Guidelines, which require a continuous training
program to ensure an adequately trained staff.
Finding: Corrections Corporation of America, "Unit Staff Training Officer" Post Order states the training officer will ensure that the shift, training officer provides continuous training to staff. A review, of the. Bartlett State Jail, training records reveal that only Pre-service and annual In-service training are the only documented training for all staff. Interviews with correctional staff revealed no training, has been conducted in areas of CCTV, Escape Procedures or the Unit Emergency Plan.
Corrective Action: Unit Training Managers will coordinate a Training Schedule that ensures staff will receive continuous training that updates Job Knowledge (i.e. Post orders, emergency response, escape procedures. Use of Force, etc... ). This training is to be documented with length of training, Trainers signature, topic, date, and staff signature. All training records should be retained in employee training record.
STAFFING
The area of staffing at the
Bartlett State Jail was reviewed to ensure compliance with management
requirements and the Unit Staffing Document.
Finding: A review of the Food Service department revealed a shortage of staffing during the time of escape. Current staffing document requires two Food service workers and one correctional officer on first shift. At the time of escape a total of one food service worker and one correctional officer present.
Corrective Action: Ensure staffing levels are adequate
at all times.
Finding: Review of turnout rosters and interviews with employees revealed the position of Closed Circuit Television is not properly staffed at all times. The CCTV post was reassigned prior to the incident on 8-27-00. thus leaving the position vacant at time of incident.
SERIOUS INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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Corrective Action: The CCTV post will be staffed three shifts a day with 7 days of coverage. At no time will staff be removed from post unless properly relieved by trained personnel.
OFFENDER CLASSIFICATION
During this review the
Offender Classification program was reviewed to ensure compliance with TDCJ
operating procedures and State Jail standadrds. This
review revealed the Bartlett State Jail Classification department was operating
within set guidelines during Unit Classification Committees and Housing Schemes
however also revealed the following findings, which may have contributed to the
incident on August 27, 2000:
Finding: Review of Offender Sanders, David Lee, TDCJ# 861517, travel card revealed offender had two (2) prior escape charges from out of state penal institutions. E-mail from Michael Countz, Director of Classification prohibits transfer offenders with escape history to be transferred to State jail facilities.
Corrective Action: State Jail Administrator for Programs and representatives from TDCJ Classification meet and review criteria for offender placement in a State Jail Facility while classified as transfer offender.
Finding: Guidelines to follow when offenders are, inappropriately, classified to a State Jail facility specifically require Unit Classification staff to notify the Bureau of Classification upon arrival. Review of notifications revealed there was no notification that Offender Sanders was, inappropriately, classified.
Corrective Action: Communicate criteria for placement with all classification staff and ensure offenders are reviewed during UCC.
Finding: A review of 361 offender travel cards revealed 6 of 361 were inappropriately classified to a State Jail facility. Of the six-travel card, five met the criteria for prior escape history and one was currently convicted of aggravated sexual assault of a child.
Corrective Action: Review current population for criteria and submit findings to State Jail Division for consideration for transfer.
Finding: Travel cards were reviewed for compliance with A.D. 04.72 of the twenty-five cards reviewed (Janitors), one was found with a prior conviction of sodomy.
Corrective Action: It is recommended that classification review all travel cards to ensure compliance with A.D. 04.72 and reassign offenders not meeting
SERIOUS INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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criteria for support service. A.D. 04.72 is not applicable to State Jail Division or Transfer Offenders but is utilized as a reference in all division as a standard operating practice.
COUNT PROCEDURES
A review of
the Bartlett State Jails count procedures to ensure compliance with TDCJ
Security Memorandums.
Finding: A review Of count sheets and referencing the Unit Building Schedule reveals Shift Supervisors do tot follow the building schedule when performing counts.
Corrective Action: Shift Supervisors will follow the published building schedule while performing operations during their tour of duty. All counts will be performed by established schedule unless circumstances require a special count.
Finding: During the investigation of the escape on August 27, 2000 it was revealed that during the morning count, the shift supervisor was outside the perimeter and a correctional officer was taking the count.
Corrective Action: TDCJ Post Order 07.004 requires Shift supervisors, as part of their duties, will take all counts. Ensure Supervisor is present and actively performing the counting procedures.
EMERGENCY PROCEDURE
A review of
the. Bartlett
State Jail Emergency Procedures was conducted to ensure compliance with TDCJ
policies.
Finding: Review of Emergency procedures reveal emergency plan is not compliant with TDCJ Security Memorandums Volume IV. Escape procedure is insufficient and does not provide detailed plan of action (i.e. no maps, call out checklist, departmental responsibilities).
Corrective Action: Facility administrator will obtain TDCJ Security Memorandums Volume IV, revise current procedures to include detail duties, checklist and maps of area. Ensure procedures are revised and staff trained on an annual basis.
FOOD SERVICE
The Food Service department
was reviewed to determine if any procedures might have directly related to the
incident on August 27, 2000.
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BARTLETT STATE JAIL
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Finding: Review of reports and documents relating to the incident as well as interviews of offenders and staff revealed back doors to kitchen were not properly secured.
Corrective Action: Appropriate action is to be taken to ensure door is capable of securely locking and staff trained to utilize locking mechanisms. (Has been corrected).
Finding Observations of Food Service offender clerks revealed clerks are not under direct supervision of a staff when typing or utilizing the computer.
Corrective Action: Staff shall utilize A.D. 04.72 as guideline for impermissible conduct.
MAINTENANCE DEPARTMENT
Finding: Maintenance department "rolling door" was not properly secured at time of incident. Investigation reveals rolling door able to opened approximately 24" allowing access to shop area.
Corrective Action: Appropriate action is to be taken to ensure door is capable of securely locking and staff are trained to utilize locking mechanisms. (Has been corrected).
LAW ENFORCEMENT RELATIONS
Law Enforcement Agencies
Notification — information compiled by Internal Affairs Division, Region 6
Manager, C. Joe Nesmith, Austin, Texas on August 31, 2000.
Finding: The Bartlett State Jail ESCAPE ACTION PLAN describes notification procedures immediately following the determination that an escape has occurred. Listed under the section entitled "NOTIFICATION" on page 14, is this excerpt:
"...the Control Center operator will verify the notification of the Warden, Chief of Security, and all law enforcement agencies per the notification list in the Control Center."
A review of the notification list in the Control Center disclosed that the Georgetown telephone number for the Department of Public Safety (DPS) was listed; however, no secondary contact number was listed for after hours calls to DPS.
The notification list does not include any telephone numbers of the Internal Affairs Division. even though an investigator has an Office on that unit and a listing of all Region 6 IAD personnel has been furnished to the unit.
SERIOUS
INCIDENT REVIEW TEAM REPORT
BARTLETT STATE JAIL
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An interview with one correctional officer in the Control Center confirmed that a checklist of phone numbers to be called in the event of an escape has been available to officers assigned to that station in the past but the correctional officer was unable to find one in the ESCAPE ACTION PLAN with which she was provided. An interview with the Warden’s secretary also yielded no such checklist in her manual, even though she responded that they were available at one time.
Corrective Action:
1. Provide an emergency, telephone number checklist that can be easily understood by anyone assigned to the Control Center and can be used to notify the proper authorities when such an event occurs.
2. A valuable resource, in addition to the Internal Affairs Division personnel, is the service provided by the Texas Rangers. Sergeant H.D. "Dino" Henderson can be contacted in Georgetown. He has provided his list of phone numbers, which are:
Office 512-930-9433 Home 512
Pager Cell phone
3. Add phone numbers for the Regional Supervisor and Regional Managers of Internal Affair so that notification can be promptly made to all investigative personnel in the region in order to ensure response to unit.
4. The appropriate phone number for the Department of Public Safety is 512-497-4131, which is the dispatch center in Austin. (This phone number was obtained from Corporal John Ramsey, assigned to the Georgetown office.) More resources are available if that number is made a part of the checklist.
Finding: Notification of law enforcement agencies in the area, as well as the Internal Affairs Division, was slightly delayed. The first responders, Barden Police Department officers, are on duty 24 hours a day, seven days a week, and were not notified until 09:40 am. at earliest account. The Chief of Police, Tom Howes, and a Sergeant, Dan Weierman, were interviewed and stated that Sergeant Weierman and a patrolman were on duty. They normally patrol around the unit two times each shift. They are always within ten minutes of the unit and able to respond at any time. They were notified by dispatch around 10:00 a.m. and responded immediately. Because of the lag time in reporting the escape, the officers
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BARTLETT STATE JAIL
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immediately began searching around the town. Other responders, within 20-30 minutes, include one Bell County Sheriff’s deputy, one Granger Police Department Patrolman and two Williamson County Sheriff’s Deputies. The unit log does not reflect which specific agencies were alerted, however, the Department of Public Safety, Texas Rangers, and the Internal Affairs Division are not mentioned in the log as being notified. The only notation about alerting taw enforcement agencies is, "Appropriate phone calls were made to 911, Corporate, and Texas Department of Criminal Justice."
Corrective Action: A suggestion was made by the Bartlett Police Department that the unit purchase two hand held radios for the Warden and perimeter patrol vehicle so that constant contact by radio will exist, unless existing radios are compatible and can have the necessary frequencies installed in them.
Finding: The Bartlett Police Department does not have an established relationship with management officials of the unit. The Department of Public Safety and Texas Rangers do not have an established relationship with the management officials of the unit. The Williamson County Sheriff’s Department does not have an established relationship with the management officials of the unit.
Corrective Action: The management officials of the unit are encouraged to extend themselves into the law enforcement community. The history of the Texas Department of Criminal Justice is rich with relationships between the Agency and local and State law enforcement personnel. Those law enforcement personnel are a valuable asset to the correction’s community.
OBSERVATIONS
Several observations
concerned the team throughout the review, though not findings or deficiencies,
but are submitted for consideration to improve the security practices of the
facility. These observations are as follows:
Observation: The color of offender uniforms, (dark blue) may have contributed to the difficulty in observing the offenders escape.
Reviewing actual taped footage of escape, revealed offenders were only seen as shadows. Comparison of the dark blue, orange and white uniforms revealed blue and orange were not distinguishable however, the best visibility was from the white uniform.
Suggestion: Change all uniforms to a standard
white issue.
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BARTLETT STATE JAIL
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Observation: Food Service back-dock fence area, though used for control and not containment, considered to be ineffective. Height of fence is easily scaled with various items stored in area.
Suggestion: Administration should research the possibilities of raising fence or enclosing area.
Observation: Culverts and drain pipes flowing under perimeter road offer cover and concealment for escaping felons.
Suggestion: Consider screening or placing bars in openings to prevent access without decreasing drainage.
Observation: Water hoses within the compound were left unsecured and unsupervised. These items can easily be used as rope for escape purposes.
Suggestions: Review use of water hoses and offender supervision during the use of hoses.
Observation: Review of turnout procedures of offender workers reveal staff assigned to housing areas are not utilizing roster to verify offender turnout.
Suggestion: Utilize a current "Master Roster"’ to determine ingress and egress of offender housing.
Observation: Walk-through of facility revealed offender traffic not properly supervised on main hallway. Interviews with offender population suggest no supervision except during meal times. Review of staffing documents revealed no corridor officer required.
Suggestion: Require utility officers to supervise hallway at all times. Ensure supervisor presence during turnouts and high traffic times.
SUMMARY
This Serious Incident Review
encompassed all functional areas and identified many procedural and mechanical
deficiencies. Though these deficiencies were found, it was discovered that the
primary factor allowing this incident to escalate to such a serious level was
human error. The supervisor’s decision to remove the CCTV officer from her
assigned position and the Control Center officer’s decision to silence and
disregard the perimeter alarm without verifying the existence or non-existence
of a threat. All Findings and observations in this review are easily
correctable however, the human error will exist and all must strive to ensure
we understand how our actions will affect the outcome.
The review team would like to
express sincere appreciation to the Bartlett State Jail staff for their
cooperation during this review. Bartlett allowed the review team to move freely
through the facility without interruption or delay, staff and offender
population were
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BARTLETT STATE JAIL
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available at all times for interviews and
documentation and records were made available. The Barlett
State Jail Administration proved a true spirit of cooperation and were open to the team’s suggestions. The entire staff of the Bartlett State Jail, from correctional to upper
administration, were willing to seek answers and uncover the complete
picture. The Bartlett State Jail should be recognized for their cooperation and
assistance during this review.
JR/ts