December 22, 2004

BOARD OF COUNTY
COMMISSIONERS
WWW.CO.BAY.FL.US

Kevin Watson

eCA Facility Administrator
Bay County Jail/Annex
314 % Harmon Avenue
Panama City, Florida 32401

ee

POST OFFiCE BOX 1 1

PANAMA CITY, FL 3%402

SUBJ: UNUSUAL INCIDENT REVIEW-LABOR DAY HOSTAGE
AND THIRD FLOOR TAKE OVER AT THE BAY COUNTY
JAIL
Dear Kevin:

COMMISSIONERs;
MIKE NELSON
DISTRICr I
GEORGE B. GAINER

I have attached for your and your staff's review my unusual incident
review concerning the hostage and third floor take over at the Bay County
Jail on Labor Day. It includes my findings, required corrective actions and
some recommendations for improvement. Please distribute it to your
entire management team including your Health Care Administrators.

DISTRICT II
WILLIAM T. DOZIER
DiSTRiCT iii
JERRY L. GIRVIN

DISTRICT IV
MIKE THOMAS
DISTRICT V

PAMELA O. BRANGACCIO

COUNTY MANAGER

Please provide me by January 17, 2005 a corrective action plan and time
line for, at a minimum, all of the required corrective actions.

If you have any questions, please contact me at your earliest
convenience. I want to thank you and your staff for your cooperation while
I was re' . g this matter

Rog
. Hagen Ph.D.
Corr ctio al Program Manager/Contract Monitor
Cc: Chief, Emergency Services
County Manager

Attachment

December 21, 2004

BOARD OF COUNlI"Y
COMMISSIONERS

TO:

Pamela D. Brangaceio, County Manager

THROUGH: Robert J. Majka Jr., Chief of Emergency Services

WWW.CO.BAY.FL.US

FROM:

SUBJ;

POST OFFICE BOX 18 t 8
PANAMA CITY, FL 32402

COMMISSIONERS;

MIKE NELSON
DISTRICT I
GEORGE B. GAINER
DISTRICT II
WILLIAM T. DOZIER
DISTRICT III
JERRY L. GIRVIN
DISTRICT IV

MIKE THOMAS
DISTRICT V

PAMELA D. BRANGACCIO
COUNTY MANAGER

Roger E. Hagen. Correctional Program
Monitor

Manager/Cont~
ilI~""\
,..,

UNUSUAL INCIDENT REVIEW-LABOR DAY HOSTAGE
AND THIRD FLOOR TAKE OVER AT THE BAY COUNTY
JAIL

At approximately 2125 hours on September 5, 2004 the Corrections
Corporation of America (CCA) PIO Mary Hughes notified me that four
lockdawn inmates had taken over the' third floor of the jail and were
holding a correctional officer and three nurses hostage. I have conducted
a review 01 this incident to assess level of compliance with the: Florida
Model Jail Standards (FMJS); CCA policies, procedures and instructive
memos; and the terms and conditions of the contract between the County
and CCA to provide Jail operator services. The review included: the CCA
incident report; FDLE investigative report of the September 6, 2004 officer
involved shootings at the Bay County jail; relevant staff and inmate
Interview transcripts provided by the FDtE and BCSO(personal interviews
were not conducted with these individuals); third floor maintenance logs
and other maintenance records; third floor post duty logs before and after
the incident; CCA authorized staffing patterns; third floor post orders both
before and after the incident; appropriate CCA written policies; staff
personnel records; appropriate inmate count sheets; prior segregation
confinement records for the involved inmates; inmate case files; prior
incident reports for the involved inmates; prior third floor security
inspection reports; prior monthlyJweekly safety inspection reports; results
of a follow up door security audit by the manufacturer; discussions with
appropriate management, security and health care staff; and personal
observation during the incident and thereafter.

BACKGROUND
At approximately 1940 hours on September 5, 2004 four adult inmates
(Kevin B. Winslett, Kevin L. Nix, Matthew R. Coffin and James R. Norton)
took over the third floor of the Bay Coonty jail seizing four hostages
(Correctional Officer James C. Hall, Nurse Ann (Amy) M. Hunt, Nurse
Glena L. Baker, and Nurse Kathleen L. Baucum).

All four inmates were housed in either single or double bunked cells in the
ten bed (eight cells designated as C-1 through C-8) segregation/lockdown
housing pod on the third floor of the jail. All of the cells and beds were
occupied. Two of the inmates were awaiting adjUdication of their charges
and two were convicted felons awaiting movement to state prison.
Three of the hostages were employed by CCA with the fourth being a
contract registry nurse assigned to CCA. The officer was a state certified
correctional officer (certified in November 2001) who had been employed
at the jail since June 22, 2004. Previously he had worked as a
correctional officer at Bay CI for CCA (December 10, 2001-Janruary 26,
2004). The two CCA nurses had worked at the jail and/or annex in excess
of one year. The registry nurse had just reported for her first shift of work
at the jail.
Three of the four hostages were released through-out the twelve hour
standoff and negotiations. Ultimately, the Beso SWAT team had to use
lethal force to gain the release of the fourth hostage and to recover control
of the third floor of the jail. The hostage and two of the four inmates were
injured.
The FDLE took the initial investigative lead and focused solely on making
a determination of the appropriateness of the officer involved shootings by
the SCSO. The BCSO is completing their criminal investigation relative to
the acts of inmates and other parties.
CHRONOLOGY OF EVENTS PRIOR TO TAKEOVER

This chronology of events was developed from information in the
interviews between the FDLE and the Beso investigators and Nurse
Baucum (conducted September 9, 2004), Nurse Hunt (conducted
September 10, 2004) and Correctional Officer Hall (conducted November
22, 2004 well after the date the FDLE submitted their investigative report
to the States Attorney for review). The latter intelView was not part of the
FDLE report since it did not focus on any issues relevant to the BeSO use
of force. Personal interviews were not conducted with these individuals so
as not to interfere with the law enforcement investigations being
conducted by the FDLE and the seso.
The chronology ;s not time based, but provides insight into how the
lockdawn inmates were able to takeover the third floor and seize the four
hostages.
»Correctional OffIcer Hall reported to work on the third floor
apprOXimately 1400 hours.

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at

»First medication pass is completed without incident. Nurse Baker left
medication cart in hallway and both Officer Hall and Nurse Baker go into
the housing pod day room. The nurse passed medication through the food
slot in the cell doors.
»Officer Hall allowed Jackdown inmate Nix out of his cell through the day
room and out into the hall because the inmate wanted to talk to him. The
officer said he did this because he thought the inmate had something
important to say to him. The inmate wanted the officer to get him some
pizza.
»According to Officer HaU Inmate NiX, while unrestrained in the half Way,
started messing or playing with the unlocked outside cell door Jock control
box and opened at least one cell door.
j

»Nurse Hunt obselVed Nix in the third floor hallway "popping doors"
when she reported for work at approximately 1800 hours.
»Officer Hall told Inmate Nix to move away from the lock control box and
to return to his cell.
»Officer Hall said the lock indicator lights never worked and was very
vague about what the lights meant relative to the lock position of the
doors. He stated he relied on whether or not the switch was in the closed
or open position to tell door lock status
»Officer Hall said he thought Nix had opened and closed the door of cell
C-5 (Pierce). Officer Hall also stated Inmate Norton (C-1) did not come out
of this cell and that the door only moved a little and stopped. The Officer
believed aU cell doors were in closed position.
»Inmates Winslett and Norton told Officer Hall they wanted to be let out
of their ceUs into the day room for their one hour out of cell time.
»Officer Hall returned to the lock control box opened it and opened three
cell doors (C-1 Norton/Brown C-3 Nix, and C-8 Winslett) letting them into
the day room at the same time.
j

j

»Officer Hall said he has done this on prior occasions and was aware it
was in violation of CCA policy.
»Officer Hall locked the sally port door, hallway door and the lock control
box door while the inmates were in the day room.

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»Assistant Shift Supervisor Pointer arrived on the floor and Officer Hall
yelled for the inmates to go back into their cells before the supervisor sees
them out.
»Officer Hall said that he did not realize when the inmates closed their
cell doors with the switch in the open position the doors would not lock.
»Officer Hall does not remember putting the cell door lock positions back
into the closed position.
»Nurse Baker returned to pass medications and Officer Hall opened the
hall way and sally port doors. Officer Hall said when he opened the lock
control box he did not check the open/closed status of the cell doors.
»The Nurse Baker passed medication into cell C-1 (assigned to Inmates
Norton and Brown) and noticed door slightly open but said she was not
aware of what it meant.
»lnmate Pierce (C-5) did not come to his door for his medication and
Officer Hall returned to the hall way and opened the inmate's cell door so
he could go in and wake him up (inside sally port door, outside hallway
door and rock control box door were open).
»Officer Hall said when he went to wake up Inmate Pierce Inmate Norton
came up behind him and scared him. He said his radio fell from his
pocket when Norton struck and knocked him to one knee. Officer Hall said
he was not knocked unconscious as he previously had reported to law
enforcement.
»Officer Hall said when he stood up Inmate Norton had his radio and that
Inmates Nix, Winslett and Coffin were with him. Inmates Coffin and Norton
also had home made weapons.
»Officer Hall said the inmates cut his shirt by pUlling it from his body just
prior to releasing him during the negotiations.

INCIDENT TIME LINE
Detailed timelines are presented in the CCA incident report and the FDLE
officer involved shootings investigative report. listed below are excerpts
from those timelines to highlight key events relevant to this administrative
review. All times are approximate.

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September 5, 2004
1940»CCA Shift Supervisor Brown discovers inmates loose on the third
floor while making his security rounds, He returned to the staff elevator
and radioed the control room to turn off the elevators to restrict inmate
access to third floor. The notification of CCA management and seso
was initiated.
2000»CCA Facility Administrator notified,
2020»Facility Administrator assumed role of Incident Manager and
trained SCSO negotiators arrived onsite,
2030»CCA SORT teams 'from the jail/annex and Bay CI were notified as
was the Beso SWAT team. CCA Bay CI Warden arrived and eventually
took over as Incident Manager from the jail Facility Administrator.
2102»lnmate demands started

21 03»SORT team arrived
2120»CCA Corporate notified
2125»Contract Monitor notified
2220»Correctional Officer Hall released in exchange for cigarettes and
pizza
2346»AII hostage families notified
September 6, 2004
0006»Sick inmate and Registry Nurse Baker released
0322»CCA Nurse Baucum released
0358»Breakfast food preparation begun
0536»Master security count completed on all floors except the third
0553»One inmate with health issues removed via the stairwell
0800»Gunshots heard and SWAT team moved onto the floor

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0804»lnjured CCA Nurse Hunt removed from floor and transported to
hospital
0812»lnjured inmate removed from floor and transported to hospital
0815»lnjured inmate removed from floor and transported to hospital
0916»CCA 1M team reestablished
0928» Third floor inmate count cleared by physically comparing each
inmate to their quarter card photograph
0929»FDLE secured crime scene and started interviews of Inmates
1046»Health care services reestablished on the first floor
1059»Trustees allowed to return

to work only under direct supervision

1250»Doctor arrived to check medication, schedule and coverage
1740» Third floor partially released by FDLE for cleanup
1900» Third floor cleanup begun

2225» Third floor cleanup reported 80% complete
SeRtember 7 j, 2004
0805»lnventory of lost or damaged commissary items completed
0930»Started releasing jail from lockdown

FINDINGS AND CORRECTIVE ACTIONS OR RECOMMENDATIONS
Violations of both eCA policies and procedures and the Florida Model Jail
Standards were found to exist at the time the incident occurred, These
violations resulted from a correctional officer not complying with written
CCA policies and procedures and a posted instructive memo directing
how the segregationJIockdown unit was to be managed, Listed below are
specific findings and required corrective actions or recommendations for
improvement.
(1) The third floor correctional officer opened the cell. sally port and the
third floor hallway doors at the same time to allow a segregationllockdown
unrestrained inmate access to the outside third floor hallway. There was
even a note on the floor inmate status board that explicitly directed that

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this particular inmate was to always be in full restraint whenever out of the
lockdown pod. This action was in violation of FMJS (11.12) which
requires two certified correctional officers be present when a high risk
inmate is moved in or out of a detention housing unit. CCA policy, which is
compliant with this standard, requires a shift supervisor to be with the floor
officer during such moves.
While the inmate was in the hallway he was allowed access to the pod's
cell door control box and to open and close doors. This was confirmed by
the officer's own interview statements and by those of a nurse who
observed this when she reported to work on the third floor. This is in
violation with FMJS 11.15 which essentially states inmates shall be
prohibited from having control over another inmate.
The floor officer allowed up to at least four inmates access to the day
room at the same time. This was in direct violation with an instructive
policy memo stating procedures for managing the lockdown unit that was
posted at the officer station and on the walVwindow of the lock down unit.
The officer in his own interview statements said he was not sure when the
inmates went back into their cells whether or not he locked their doors. As
many as four cell doors control switches could have been in the open
position, even though the doors were closed, when he and the nurse
entered the pod day room to pass inmate medications just prior to the take
over.

In the officer's initial interview with law enforcement he stated he was
knocked out. In his second interview he recanted this saying he was
pushed/knocked to one knee, thereby being less than truthful with law
enforcement, which is an act highly unacceptable for a state certified
correctional officer.
Finally, in his own interview statements the third floor Correctional Officer
repeatedly acknowledged his acts were in violation of CCA written
policies.
Required Corrective Action: Take appropriate disciplinary action against
the officer for multiple violations of CCA Policies, guidelines and
instructive memos.
(2) The C-1 cell door either could be easily defeated by the inmates in the
cell or was malfunctioning. This was repeatedly validated by officer and
nurse interview statements, discussions with officers and nurses, a post
duty log statement by a correctional officer on August 30, 2004 and on a
maintenance log by another correctional officer on August 22, 2004. On
the day of the incident the maintenance log entry concerning the door
condition remained unclear or uncorrected by the CCA maintenance staff.

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The two inmates in C-1 were well known for cell door "capping" (and act of
placing something like, a tooth paste tube cap, in the door track as the
door closes to prevent the door lock from fUlly engaging). This past
behavior was clearly noted on the floor inmate status board posted at the
officer station to constantly remind officers of the inmates past actions or
behavior patterns.
Officers on prior shifts had successfully managed to work around the e-1
door condition by complying with CCA policies concerning inmate
management on the floor and in the segregationllockdown housing pod.
Required Corrective Action: All security related maintenance issues shall
be corrected within twenty four hours or Jess or the housing area affected
shall be rendered unoccupied until such time it is corrected. If
overcrowding mandates use of the housing area, then extra correctional
officers shall be assigned to the housing area to perform direct
observation and control of the area.

(3) The procedures for managing the segregationllockdown area were
posted as an instructive memo on the walllwindow of the housing pod.
Critical policy elements of that procedure, such as only one cell can be
opened at a time or only one resident (inmate) can be out of a cell at a
time, were not documented in the correctional officers post orders for the
third floor.
Required Corrective Action: Revise the fifth floor (segregation/lockdown
unit has been relocated to this floor from the third floor) post orders (rev.
December 1, 2004) to include appropriate elements of the lockdown
procedures to be utilized by officers when managing inmates in the
segregation/lockdown housing unit.

(4) Monitoring of stafflinmate activity on each -noor is done by the Shift
Supervisors or their assistants moving from floor to floor making
observations from the floor gate or actually entering the floor and checking
the housing pods.
Recommendation: Install video cameras on each floor and place monitors
in the basement Shift Supervisor's office to augment the amount of direct
monitoring of inmate/staff floor activity.
(5) Correctional officer staffing on the third floor the day of the incident
was compliant with CCA policy and FMJS. However, it may not have been
sufficient given the amount of overcrowding in the jail at that time. CCA
policy required the use of Shift Supervisors or other floating utility
correctional officers to deal with high risk inmate movement or other

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special responses. Such back up becomes less readily available as the
number of inmates to be managed in a facility increases. CCA has
recognized this and has added an additional correctional officer on all
floors that house high risk (maximum and some medium security level and
aU segregation/lockdawn) inmates (floors 3 and 6) and not just on the fifth
floor which was the policy at the time of the incident. Further, they have
added one 24..7 security post to the medical area and post a second
officer when sick call is being conducted,
Required Corrective Action: Maintain this level of correctional officer
staffing and evaluate the need for similar correctional officer staffing at the
annex should high risk inmates (male or female) be housed there.
(6) The segregationllockdown unit has been located on the third floor for
many years. That floor also performs three other jail processing functions
in addition to inmate housing (i.e. commissary storage and distribution,
inmate personal property storage and distribution, and provision of inmate
health care services). The latter two processing functions reqUire active
involvement of the floor correctional officer in addition to their performing
their lockdown housing pod and other housing pod duties. CCA has since
relocated the segregationllockdown area to a housing pod on the fifth floor
which is a floor that is only responsible for housing inmates.
Required Corrective Action: Continue to locate the segregationllockdown
unit on a floor that only performs Inmate housing, thereby allowing the
floor officers to totally focus on the inmate housing management functions
and not other jail processing functions.
The officer station should be located on the floor directly adjacent to the
segregationIJockdown housing pod to enhance sight and sound
observation of the unit, Further, ensure the annex continues to prOVide
separate segregationllockdown housing areas with dedicated correctional
officers for those areas.
(7) Floor or post duty logs and maintenance logs are maintained by the
floor correctional officers to document completion of their various duties,
movement on the floor and maintenance issues that need to be
addressed. When reviewing this documentation, for a 2-4 week time
period prior to the incident, it was apparent that managers or supervisors
are either not regularly reVieWing the logs or if they are, they are not
addressing the issues they document. As an example, a broken key and a
missing flashlight were repetitively documented by different shift floor
officers in the third floor post duty log for the entire time frame i reviewed.

9

Required Corrective Action: A member of management should review
these logs and document in the log their review and any actions taken at
least weekly. A supervisor should do the same on a daily basis.
(8) The quality of the documentation in the dUty logs and the inmate
segregation confinement records (to be updated every thirty minutes) was
in many cases lax. As an example, in some cases it was impossible to
determine if and when the inmate was receiving their reqUired out of cen
time or showers.

Recommendation: Conduct refresher training for all appropriate staff on
how activity information is to be documented in the logs/records in a
manner that can be used at some later date to prove something had or
had not occurred. Also, specialized training shOUld be developed for all
officers assigned to the segregationlJockdown unit addressing the unique
reqUirements for managing inmates housed there.

(9) The incident management team was immediately established per the
CCA Emergency Response Procedures and Plan. All internal and external
agency notifications were made per policy. Both the CCA Jail and Bay CI
SORT teams were deployed in a timely manner to support the seso
hostage negotiation and SWAT teams as well as to maintain the security
and operation of the remainder of the jail facility. Jail operations inclUding
feeding and health care delivery were maintained throughout the take over
and thereafter. The third floor was restored for use in less than two days
and full jail operations in a non-Iockdown mode in less than a week.
Recommendation: Continue to conduct incident management team
response exercises and training and expand the scope of the exercises to
include a variety of incident scenarios of this magnitude. Also, consider
large scale incident scenarios that may be weather related such as loss of
total power on a floor or to the entire facility.
(10) The crippling elements of the proverbial "Correctional Code of
Silence" appears to be more pervasive in the jail among the correctional
officers, health care and support staff and their superiors. This was
evidenced when the nurse observed the inmate unrestrained in the third
floor hallway popping doors and she did not immediately notify the Shift
Supervisor. Also most of the staff I had discussions with were concerned
about being identified if they shared issues or concerns with me.
Recommendation: CCA management should issue a strong statement to
all staff stating their position against the dCode of Silence" and that any
acts of retaliation or reprisal will not be tolerated against any staff who
make managers or supervisors, both within or outside their chain of

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command, aware
deficiencies.

of any problems,

staff errors

or performance

I follow-up and address any and all issues CCA personnel share with me.
If they want me not to know their identity, they can leave their issue in
written form in my internal locked mail box on the first floor or verbally on
my voice mail. Relocation of the mail box to an area more accessible to all
staff should be considered.
Documentation supporting this review is on file in my office. If you have
any additional questions or require additional information please contact
me at your earliest convenience. Upon your approval a copy of this review
will be sent to the eCA Facility Administrator with a time line to implement
the required corrective actions.
CC: Ann Cahall

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