Serious Incident Review - ICC Gang Fight, ID DOC, 2012
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IDAHO DEPARTMENT OF CORRECTION Serious Incident Review (SIR) Report ,:.:). Date: 05/21/12 Type of Incident: Facility/District: -=...:IC:.;:C:.....-._ _ Incident Location: -=--.F-....:.1_ _ _ _ _ _ _ __ On 05/05/12, at 1154, the Idaho Correctional Center had an incident in F pod of their close custody unit involving aD ~ssault with weapons. Security Threat Group members from the Aryan Knights (AK) and Severely Violent Criminals (SVC) hid in a janitor closet during a recreation movement. When the next quadrant of offenders were released into the dayroom the AK and SVC offenders came out of the closet and attacked members of the Youngsters Fucking Society (YFS) with weapons. There were 13 offenders involved in this incident. 11:54 ~~~~~~~~~------------------' IOOC#: '~9::;;:5:.:::2.:::..94~_ _ _ _ _ _...:......_ IOOC#: 55891 ,., . IOOC#: 67575 . IOOC#: 66757 IOOC#: 61348 , (Add additional rows If necessary) Associate #: 1507 Associate #: ·8836 Associate #: . 8786 Associate #: 0581 Associate #: 0273 Associate #: 0173 Associate #: 1142 0179 Associ ate #: Associate #: 1045 6401 Associate #: Associate #: 0465· Associate #: 1154 Ass'ociate #: '. 7583 , Associate #: 1335 1343 Associate #: 3110 Associate #: Associate #: 7592 8871 Associate ~: 6437Associate #: 1272 Associate #: Page 1 of 10 Name: Associate #: Mills, Jacob (Add additional rows If necessary) ' 1264' " ' --..:.=-~------- Others Involved: Name: Name: Name: LeMaster, Carrol Registered Nurse BUrmeister, Michelle Licensed Practical Nurse Segal, Jodi Licensed Practical Nurse (Add additional rows If necessary) 'Wasforc~used? Yes ' ~ No D Did all involved staff members compieted information reports? Yes 0 ' No [ ] There is no report on his actions. Nari)~,ancUp,b. title ,of_the shift commander (correctional facility) or supelYisor (community corrections) at the time' of the incident: ' I Brian Johnson - Unit Manager o Describe the shift commander/supervisor's involvement: The shift commander in this incident was Unit Manager Brian Johnson. In the reports received and during interview~" there was 'no Clear indication during the incident of who was in charge. The shift commander did j,'ot seem to recognize the scope of the incident and his duties. The Shift commander who was in charge .. seemed to be unsure of all oT the weapons, injuries, and offenders being moved through the crime scene quring the incide,nt. After the jnitial pbmbatants were removed from the tier he gave orders to go get the ,rest 'ontie offenders out of their cells for treatment. He was unaware that the offenders were being moved unrestrained and allowed to contaminate items from'the crime scene. The report written by the shift commander stated inmates appeared to have weapons. However, during the panels inter,view with t~e shift,commander stated he knew weapons were involved. " , • •. . . .- . . , . • !. The Shift Qommander did not-feel this incident rose to the level of activating ICS because by the tirne he arr,ived on;s~en~ the incident was alre.adY.9y~r.~sth~ offe_r:ld.~rs wer~. no Ip8ger c;o!lJb.ative, A~ of Op/21/12 'staf(seem to be ..unclear of what emergency procedures they are using: When asked if'they are using IMT qr. I,CS, the panel w~s told, by the shift commanderthey are and have been using ICS. When asked how they are trained on ICS he stated ,iAnnually". However, it is' clear that they are not using the Incident Command, System. , . - , . • ,., • • •••• • •. ' '; ! .,:. • I · . ~ ' . ' ,. If applicable, the name and ,title (if available) of any'medical personnel involved: Dr. Agl~r LeMaster, Carrol Registered Nurse Burmeister, Michelle, Licensed Practical Nurse Jodi Ucensedpi-a'dicai Nurse ' - , Segai: Describe in general, any medical care given: The panel did not receive reports from medical staff in regards to this incident. There was limited information given in reports as to the medical care given. With the information,provided it appe'ars that medica!'staff'noted injuries and stitched up the wounds that warranted 'it. o Appendix E. 1-05.02.01 ;002 ' ' -. ; , '. (Appendix last. updated 8/4/11) Page 2 of 10 What department policies, SOPs, FMs, post orders, living guides, etc. govern the incident? SOP 504.02.01.002 Security Threat Group Management ( \,~) '. SOP 317.02.01:001 Searches: Cell/Living Unit, and Offender SOP 307.02.01.001 Use Of Force SOP 116.02.01.002 Custody of Evidence .SOP 1.05.02.01.001 General Reportingand..Jnvestigations of Major Incidents Idaho Correctional Center·Post Orders - General ICC Post Orders·ICC PO-OO Idaho Correctional Center Post Orders - Close Custody O-E-F ICC PO-100 Memo from Chief Jepson 3/15/10 (OC) ICC Inmate Handbook . . . . Contract CPO 012167 Amendment 5 Contract SUbsection 2.6 Security and Control section (d) W~re.policies, SOPs, FMs, post orders, living guides, etc. followed? SOP 507.02.01.001 Emergency Preparedness was not followed. The shift commander stated that 'Incident'Coinmand System was not followed as he did not think the incident rose to that level because the incident was contained by the time he arrived at the unit several minutes after the initial "Code Blue~ was called. It appears that staff do' not understand when to implement ICS. By not using ICS the resources were dispatchec;l to the ~rong area and other resources were not used efficiently. Staff on the tier did not hav.e 8:.clear understanding. of-whO. was. in,charge'-during the incident. .The shift commander stated that he had contrql'in:the;fqyer of the pod bot could'not say who the group leader or on scene supervisor was on the tier. .', .. II, l.~O I sop 504.02.01.002 Security Threat Group Managementwas not followed. Offenders documented in the .I0o.c, o.f(end~r. $y~ter:T.1, IC.$, ..as. part of.a $.ecurity Threat Group, were hO\Jsed together in quadrants of the:tier.·Qne quad rant. of offenders was just moved onto the tier. These offenders were suspected members o.f the Security Threat Group YFS (Youngsters Fucking Society). Staff stated they knew that · tnem b.ers .of the YF$ group. had safety concerns being housed arour:td memb.ers of t.he Aryan Knights (AK) andJhe·SevereJy Violent. Criminals: ($vq) ... However; .the u.nit manager, knowing .this information, decided to move a group of YFS onto the tier, on the same level, as the AK and SVC. The Unit Man'age'r and some . '9fthe other.. u.l"!it supervisClrs:.w~re,.co.nsulting .susp~cted leaders of STC? groups, i)1 eSl?eflQe.getting their approval before making moves. " . I I ·;1 ~ I ! I j SOP 317.02.01.001 Searches: .Cell/Living Unit, and Offender was not follow.ed. Clothed body searches ' were not conducted on offenderswho were leaving their cells. These should be conducted frequently to , make sure offenders on:the tiers are not carrying contraband SUch as homemade weapons. Although cell : searches·were!shown,as being completed,. a re.view.ofseveral mo.nths of logs showed.no.major.. . .. cohtraband found.i-Basedon'-staWinterviews·a good cell.search·is completed in 15 minutes. 'This is a-very · short· period of time 'for a two person cell. Idaho·Correctional Center Post Orders.- General ICC POst Orders ICC PO,=,OO was not followed. The · officer .did.not .cbe.ck JD's or haveJhe offenders .identify themselves as they were leaving to recreation. The officer·on the tier did not conduct an informal count of the offenders left on the tier after a recreation movement. This would have alerted him to the fact that six offenders were unaccounted for. The officer admits that.he thoughphey were' all out so there was no need to look in the windoWs. Furthermore, the " windows' arerreql!entlyblocked out .by the offenders making seeing into the cell·for accountability· . . . impossible unless stopping·and putting your ·face up to the window while cupping your hands to block out light.from the: tier, This'makesit impossible,for staff.to observe and count living breathing.flesh in that.cell. The frequency of windows being covered can be noted in weekly reports from the contract monitors as well · as when this panel went on the tier there were many windows covered to which offenders were refusing to remove the objects. blocking the light. Offenders have affected an escape in the past in 100C facilities by covering a window to which staff did not check. By not checking or having the offender remove the:it~ms blocking his window they.could not see that he was altering the window in preparation for an escape. A:';~ridix E·.··' :........ :., . '..........;... , ' . '. Pa e 30f·10 .. PP ..... '.' '....., ................. :' .. .;. ' " .' '. g. . .. 105.02'-01.002 . . '. . (Appendix 'Iast u'pdatedS/4/11) . 0:..•.. • :' , I I I II I i _ _ _ _~_ _ _ _ _ _ _ _ _ _ _ _ _ _ __'.__._ ._._ _ _ _ _ J Were olieies, SOPs, FMs, ost orders, livin uides, etc. followed? SOP 307.02.01.001 Use Of Force was not followed. By not using the equipment and tools available the responding officers put themselves in harm's way. Staff failed to recognize -the seriousness of the situation therefore they did not use the tools available for protection such as shields, stab vests, pepperball gun, and restraints that. were in Responding staff also did not obtain effective use of force equipment or protective equipment on their way to the quell incident. Not only did this slow the process of containment but put staff safety in serious jeopardy. It is apparent in the response by the staff on the tier and ERT response that they did not take into account the behaviors and risk factors associated with close custody offenders, therefore they did not escalate their level of response to the level of the incident by considering other lethal or less lethal options as back up. 1 - Ie 9-340(b) The safety equipment that could have been used for this incident is located in , however, staff did not take with them nor w~re they directed to take with them control equipment or protective gear to ,the incident. Had ICS been implemented this gear could have been distributed to staff as they arrived on scene. Based on interviews, staff seemed hesitant to use the use of force equipment available i n . SOP 116.02.01.002 Custody of Evidence was not followed . Once combative offenders were restrained, staff returned to get other offenders out of their cells for medical treatment. While this was taking place other offenders were picking up objects jn the crime scene and carrying them around. Furthermore, the cells in which offenders were fighting were left unsecured once those offenders were removed. The shift commander did declare a crime scene and a log was started however the log is incomplete and' does not · include important/complete information. Clothing items that were collected were placed allin, one bag and they were all wet therefore unusable, by the crime scene detectives. o Staff did do well -in that they took pictures off all offenders involved and included their names, IDOC number, date, time, and who photographed the offenders. This helps staff correctly identify those who were involved in the incident and can be instrumental in the investigative and prosecutorial pr.ocess. This leaves no doubt who was involved as they were photographed immediately after they were removed from the incident. SOP 105.02.01.001 General Reporting and Investigations of Major Incidents. While a 105 was completed by the shift commander and -notification was made, the verbiage in the 105 was inaccurate. The shift commander wrote "The attacking inmates appeared to have weapons ... " even though he had been to the incident scene and witnessed the weapons himself. Memo from Chief Jepson 3/15/10 (OC): The memo that Chief Jepson wrote on 03/15/10, that staff who are certified to use OC will carry it. His failure to deploy OC in response to this incident delayed containment of the offenders involved. . Based on the professional opinions of the SIR board, did the staff respond properly? In our opinion the staff member on the tier initially acted appropriately by using the radio to call in the incident and deploying OC. He then advanced into the group of fighting offenders to deploy more ac. While doing so he assessed the situation and believed that an offender's life was in jeopardy since he was being stabbed by another offender. He pulled the offender doing the stabbing off of the victim. While we would not normally recommend that staff place themselves into the middle of a group of combative offenders, we commend him for his courage during this incident. o The initial responding staff member had appropriate containment equipment but chose not to use it. Had he used the OC and used it in conjunction with the verbal direction he was giving we believe he could have Appendix E 105.02.01.002 (Appendix last updated 8/4/11) Page 4 of 10 , ". ;! j . ,I 0·· Based on the professional opinions of the SIR board , did the staff respond properly? contained the offenders and/or had a faster resolution to the incident. Because responding staff chose not to use the OC he increased the risk to the other staff member and himself on the tier. The ERT team responded quickly to the scene. However, they did not use safety/containment equipment that was .available to them . The other pods were not celled up which could have led .to a more serious incident. More staff were needed in this incident to effectively control the situation. The pod control officer was left alone to do the log book, open doors, answer the radio and phone. This led to an incomplete log of events that transpired during the incident. Again, had ICS been implemented more resources would have been available to accomplish these tasks. Prior to the incident the Unit Manager was allowing the unit to be operated outside of the guidelines of the . post orders. There was minimal accountability for staff or offenders who were not following established rules or procedures. According to staff interviews the unit has been operating for more than a year outside of the establlshed post orders. Contract staff provided a pass down log as evidence, along with the inter.views that the panel conducted with staff, that supports the fact the Unit Manager had directed staff to deviate from post orders in regards to dayroom operations as far ,back as November. When interviewing the Unit Manager she did admit that staff should have been opening the cell doors one at a time. The Unit Manager has also been using STG leadership counsel in regards to moves of STG offenders . During our interview with the Unit Manager she admitted that she talked to a leader of the YFS in regards to making moves. This process was confirmed by the other staff members that we interviewed. She continues to group offenders in her pods by STG affilfation and encourages offenders to group together in "communities". The STG influence on staff is so pronounced that while interviewing staff, staff refer to . offenders crimes as ".solid" or "lame". While interviewing the Unit Manager as well as unit staff we learned that the Unit Manager has also allowed offenders to influence the way rule violations are corrected. The Unit Manager stated when STG offenders tell her that enforcing the rules will make it more difficult for her staff she chooses not to enforce holding the offenders accountable. Her decision to include STG leadership in unit management decisions contributes to STG groups gaining more control and authority in the unit. In our professional opinion the shift commander's response could have been handled more appropriately such as the shift commander did not seem to.recognize the scope of the incident and his duties. The Shift commander who was in charge seemed to be unsure of all of the weapons, injuries, and offenders being . moved through the crime scene during the incident. The report written by the shift commander stated inmates appeared to have weapons. However, during the panels interview with the shift commander stated he knew weapons were involved. . What, if an hin , can be done to reduce the risk of a similar incident in the future? Offender Acc.o untabilityFrequent informal counts completed after each movement or tier rotation. This will allow staff to account for all the offenders as well as be alerted to any offenders in the wrong area. Recreation and DayroomMovements should be completed in a very controlled manner. Offenders should be given firm g.uidelines and instructions from staff during the movement process. Offenders should be made to line up to go to recreation and not allowed to wander the tier. During this process of outside movement the offenders will be accounted for by identification card and numerical counting process. <J Janitor closets should be secured at all times unless directl Appendix E 105.02.01.002 (Appendix last updated 8/4/11) s~2ervised by an officer. The office~ Page 5 of 10 I I I .. II . I :,1 ' II I '1 I ! 'What if anything, can be 'done to reduce the risk of a similar incident in the future? open the door for the offender to get th~ supplies out and then immediately secure the door a'nd reverses this process to return the supplies. Currently offenders are alloweq 5 to 10 minutes with their doors open to gather .property to use during 'dayroomand, leave·the ceiL This shou'ld be changed·to an auditory. announcement .Ietting the offenders · know fhey 'have 5 minutes to prepa~e for ·dayropm .. Cell doors could then be immediat~ly secured: as · offenders leave the'ir:cells; 'one :Celi·~t 'a time. Establishing 'this process would decrease the' amount of time needed to transfer offenders from ·their cells to recreation Cilnd dayroom. This would also prevent them from going 'into areas that are restricted and. increase staffs ability to account for the offenders. Tier Checks. ·Staff·eire·not accounting for living breathing flesh. Proper tier checks and addressing'potential security hazards such as covering windows should· be· part ef·the·tier-·eheek-·pl'eeess·;-.._·····.. ....- .... . .' Searches- . .. ' . . Frequent pat se~rches during .movements and:dayroor:n time wil! allow staff to un'cover cot'ltraqand ~Lich as weapons used 'during .this·incident. Quality.cell searches versus quantity. Staff need to spend significant . time-.in '~Cell to:uncover serious contraband. Two offenders with close c~tody property cannot be . searched properly in 15 minutes. The requirement to do pat searches should be added to their unit post orders,: .: . ':. '.. :; . ". . . '. ' :..;.. .. . . '.. . .. : •• <io.!\ :' iJi : . ,j;::,,' ':.:~~:'.':-" :::.::, .," ', ' Ruie ··Enfotcement.;.·i~·. o ! ' . ,'.: >'~. '."" . ~"' ''' ''''''''':' '," :. ':. I, ; " :'.' '., .... ";' ;.: .... '.:.. . ,... .. .. " . : .:. _...: . l I:' .•......: , .. ::' " ... .' .... ;....... ,:', ,', ; .' ... : :' .'~ ..... , i :.:- ;. .. , ..... ,',:" ", .......... . Enforcir:lg: all"rule~' in~iLiding:ttio~~ ;th~f;n~y: se~~: insignificant -to' st~ff·a:nd·· ~ff~nd~~. e~'~8res"a"s~fe and clean environment and also allows staff. to gauge the attitude of t~e' inmates on 'the tier~ Offenders on the '. tier'displayed: verbal :resistance to' ·comply.ing wi'ijl rule enforcement.·. Supporting·staff in"rule' enforcement and rewarding staff for diligence in 'this area will encourage staff to take ownership of the unit. . E;quipmenf- .: ...... . :' . . . ,". , . . Equipment should be .readily available and used by staff assigned to the pod. For example, us.ing a flashli'ght to see into the cells. Staff should be required by. post order to carry arid use.the necessary· equipment. ' [ocation of .Iess lethal munitions and the comfort level of supervisory staff fo'authorize the use pf such · weapons needs to be evaluated to inci.reas~ their usage and:effectiveness. ' .: . . .,' , ; .• • ' ': ', j , Post.Orde·rs": .. :... ': .. . ....: ... \ ......, . ... , . .: . : .' .. .. . C'.: .. ',: . C· ' .' '. .. ' . .. : .. ". ......... . Post orders need to be followed .and should be reviewed fr.equently to ensure they are 'effective and reflect · de~ired''Practices: Staff should qe held· accountable for signing that they have read the. post 'orders and are following them. · . . .: . '''0 . . ' . on Resu,lt~, fifl.dings, and recommendations the foliowing: . :Comme~dation. o~ disci lina . acti?n: . .' . ' ~.•_... .. . . . . . .. .. . .. Correctlve'actlon should be' conSidered wlth·the'unrtmana er Norma Rodrr uez as man of her deCISions ;. Appendix E" ':~ ". . ". " . .. . . . . .' Page 6 of 10 10~.02.01.002 . ; (A,.ppendix last 'updated 8/4/11) •• '.,. . . : ': .. " • • : ,_ ~ '. .:." '. i .: ' . :. ", • ," : • • . , : ' . '\ ., ... 1 • ••• • 1 • " , •• • ••• ." ~ ., . '. ' .. , ', .. Commendation or discipiinary action: 'and her lack of managing the employees and her unit resulted in an atmosphere that allowed this incident to occur. o , Corrective action should be considered with 'Sgt. Ca~rick for failing' to use Use of Force ~ciuipmerit (OG) .to control the incident. His actions delayed the containment and resolution of this incident . . .staff .should be held accountable for signing post.. orders and for following them. , Unit . hi spite of the fact that Officer Skogsberg's actions may have contributed to this incidenHhe panel members commend him for his courage in taking action to stop the offenders' assault. The, panel would also like to commend Sgt. Sharp for his actions to take control of the incident and directing staff. ' '. . Staffing: Although the unit appeared to have appropriate staffing several of those staff were performing other duties which distracted them from the duties assigned to the post they were filling. Sup~r:yisory, staff who :ar~ filling i'1,offjc~r P9sts need.t~ insu,rejhat ,t~ey focLJ,s ~m tha,t p.o~t and :d,o, n.~t Il?~.ve the area. Staffing of the unit.needs to be, consistent. In revi~~ing the. schedule' it , posted., , appe~red th~t ~taff were do.uble: Policy and SOP: o · The' facility'should'consider"Litilizing'a 66rririia"nd"struCture that models'the IhCident Command System. · $taff.are unsure of what .elTlergency system they are using and when it is appropriate to activate it, and , seem to feel that ICS is appropriate only for large scale emergencies. The'panelrecommend that all staff receive ,more training in the InCident Command System and perform routine simulations to become proficient inthe ICS system. . ....• .,: . " ,' ' , ' Post orders need to be revised to reflect a safe operational system allowing staff time to complete the · required tasks. In reviewing the post orders the panel found that if staff followed what was written they 'would' gain accountability as the .staff would be .controlling,the movement instead of the,offenders,. Operational Issues: The"STG' pop'ulatibh is grouped into" quadrants' in O-E-F 'which increases the STG 'power base. This· . · .: : ' . population should be diversified among quadrants and pods. . , Staff should be enforcing the living guide and unit rules for cell conditions .. • Staff should. be accountable for following the Post Orders and facility memorandums. This incident may haVe been avoided had staff been following the O-E-F 'and General Post Orders. " 1 .' • • ~ .:: • ..' ' .' • • • _. • ' . • '. I. • Pat,'searches'"and unclothed body searches could be completed with more regularity. Pat searches'should be completed of offenders exiting their cells and leaving the unit or going on to the recreation yard. Property brought out of cells should be searched by staff. Offenders returning to the unit or from the recreation yard should be pat searched and accompanying property searched as well. O-E-F and General Post orders could be more specific and use stronger language about the ir:nportance of maintaining' q safe fa.ciJity th~oL!gh pr~per ~earch.es. ' ", ... " , !O Multiple cell searches by multiple staff are listed on a single search summary form, Each'individual cell : Appendix E " : ... ', ', : . . : ; )05.02,01.002 (Appendix last updated 8/4/11) Page '7 of,1 0 i I , I o I / Operational Issues: search should be reported singularly for clarity on contraband found and issues with the cell. j I I I CCA's IMT system seems to create confusion among staff as to who is in charge of the incident and who is managing the immediate resolution by directing the ERT members who respond to the incident. This confusion extends farther when determining whether Qf not to use ICS,CCA inoicates that IMT is similar and compatible with ICS. However, ICS provides clear'understanding and direction as to how to announce the Incident Commander and command structure for the incident. By eliminating the use of a dual system (IMT and ICS), CCA would eliminate the confusion among staff when responding to an incident. D-E-F Post Orders provide the offenders a 5-minute window to exit their cells for dayroom and recreation time. This 5-minute period is to allow offenders to gather any property that they might need during day room hours. Facility operations could be improved by eliminating this 5-minute grace period and instead, annouhce the movement to the dayroomlrecreation 5 minutes before the movement. D-E-F staff indicated that they must keep to their schedule and thus fail to follow post order requirements for direct offender supervision at each cell before the cell door is opened and the offender is allowed to exit the cell and begin the 5-minute egress period. If staff follows the post orders as written, it would take 40 minutes to transition to and from the dayroom for each dayroom period. I i I Staff should complete informal counts of offenders leaving the unit to maintain offender accountability. In this case if the floor officer had counted the offenders left on the tier, he would have realized that 6 offenders were unaccounted for. During and after the 'incident, not all of the offenders were restrained because staff felt that they were not a threat. These offenders were moved and allowed back out of their cells without restraints. All offenders should be restrained in an incident to ensure safety to staff and other offenders. i 0 1 I I , ; !; i .I 'j ../ I ! Either the janitor's closet was left un-secured or unit staff missed a lock that had been tampered with on the janitor's closet during security device inspections. Staff must complete security device inspections carefully and follow the post orders which require the janitor's closets to remain secured. Staff visibility could be improved by adding a window to"the janitor closet door or an expanded metal gate instead of the solid door. Offenders should be required to keep windows clear in order to verify that the window has not been: ,. tampered with. Cell windows could be covered to conceal D-E-F deficiencies and lead to the ability for offenders to escape from the facility. . Window checks to verify that each cell window is secured and in good condition should be completed and documented at regular and frequent intervals to ensure that they are in good condition and provide security as intended. Incident commanders and shift supervisors should follow evidence handling and crime scene protection standard procedures to ensure that evidence is appropriately collected and can be used to prosecute offenders who commit crimes. Staffing in D-E-F was not mair:Jtained at an appropriate level and was inadequate at the time of the incident. Each position identified should be filled and staffed to ensure safety in the unit and adequate emergency response. o . The ERT responded quickly to the incident and began resolution efforts immediately. There was confusion in the response that could have been avoided if staff and taken a few seconds to organize their actions when entering the tier, including ensuring that the crime scene and evidence was preserved. Staff was in a Appendix E 105.02.01.002 (Appendix last updated 8/4/11) Page 8 of 10 ./ , ; I o o erationallssues: .hurry to r~solve theIncident and oyerlpoked eVidence collection and crilTJe 'scene p~eservati.on. . .Staff is reluctant to' use force options available to them and at the adequate level to safely resolve the incident. For instance, this incident involved immediate imminent life-safety concerns, yet no physical force . was'used, arid only OG.was :Used to quell the attack when pther less lethal options were available (pepper ball launcher, munitions.) Some responding staff responded to the incident with OC but chose not use it even though it would have been appropriate to nd wo isolation of the incident. Less-lethal shotguns are Staff failed to complete adequate and proper tier checks by looking in each cell and visually verifying the safety and well-being of the occupants by seeing living, breathing humans. This error directly contributed '· ' . . to the:incident. .. Training: . Staff failed to adequately protect and collect evidence and the crime scene and allowed offenders to tamper.with the evidence and crime scene. The crime scene log was also inadequate. Staff should be tr~jn.ed to have a better unde~tanding in this area. . S~aff" i~ 'not cqn~ist.eotly c.()~duct.i!.lg .P~t searches, which is allowi.ng contr~band ?nq we~po~s Je;> be .passed from qffender to .offender. Cell search logs do not indicate that staff are finding any significant contraQand. Th.e:s.eJactors.contribute..to.a.lack of. safety. and security in D-E-F,· ,:. . ". " . '. , ',: .,' o . St~ff shpuld to Qe traineQ to;cOl1lplete. adequate tier c;:hecks by ch~C?king .on offenders ~nd ~he.co,nditiol1s of the offenc;lers' cells. .' When completing escorts of the combative offenders from the pod, staff failed to .m~intain adequC!te spatial relations~ips betw~en . each escort. ·: .' . ' .' . .. , :.... . . . , . " .. .... . -:'" Staff failed to use leg restraints on the close custody offenders involved which could have allowed them to continue combative behavior. . . SUpervisors:and staff are confused about ICS and when ··and.l1ow·it 'is to be used . . Further. in depth· training of.lCS· is needed ~ ! " . • .. , i::! ~i .~'~nt Issues: Staff respe;>nded .tq :this ·incide,nt witho.l:I.t equipment.that was .available .to them but could have been gain offender compliarice while decreasing the r.isk to staff such as: shields ' "'I'n'tCI"'lr1\/C restraints,·~~pir~tor.s/ga~ mas~.sl a Pt3Pper ball launcher less lethal munitions. . . Less lethal.munitions and _ This I""-'Tlnn rec.ommen9s that an a confusion, the.weapons can systems . o to The panel to store weapons. Also, -to avoid . orange stocks identifying them as less lethal deployrne'nt Staff is. reporti~g for duty without checking out the proper equipment 'needed to complete their dutie's such as' flashlights, or checking out the equipment and not using it. . Tj,~ 'b ~~~'d ~~d" m'~ke' ~f OC ' u~~'~Cb '~t~ff' did 'not seem' as effective ~s oth~'r b~a~ds' ~nd ~akes such as Page 9 of 10 Appendix E. 105 ..0.2 : 01.,.OO~ (App~ndix ," , . .' last updated 8/4/11) . /.' . ' :. . ', " \ ' . 0 , • _ ._ t ' :,' o . . • •. I ~ ui ment Issues: Sabre Red. The panel suggests that ICC management further research this issue. Other; This same type of incident, with offenders hiding in the janitor's closet, happened less than one _year ago. While the panel was told changes were made so this type of incident could not happen again, it appears that staff had reverted back to the same practices that allowed both incidents to occur. Furthermore, the unit manager and unit staff stated the shortcuts were in 'an effort to keep their schedules on time as not to disrupt the offender population. These changes were either approved by the unit manager, who was the same unit manager for both incidents, or she had knowledge that the unit was being operated in this manner and she took no steps to correct the issues. The panel recommends that facility managers address the is~ue of management of the unit. . ' ,Associate . Panel member!~ Lf. ~ Panel .member ' . " ' I _ ' . : ' :: ' " " o J, 0 "fjtutAssociate # 1b~'> Associate # ,' ', .: , , ' '" , . (Add additionaf.,?ws If necessary) " ',,' , Date ,_ , r :, " . . ; , ," ,': ~ '. . " :• • ! . .... . . " o Appendix E 10 105.02.01.002 , (Appendix last updated 8/4/11) P~ge 10 of