BOARD OF INQUIRY REPORT

June 20, 2008, Homicide of
Correctional Officer Jose Rivera
United States Penitentiary
Atwater, California

SUBMITTED BY:

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Date

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INTRODUCTION
Upon the order of the Director of the Bureau of Prisons, a Board
of Inquiry (hereafter Board) was appointed to review the facts
and circumstances surrounding the serious incident at the United
States Penitentiary, Atwater (hereafter USP Atwater) on Friday
June 20, 2008, when Correctional Officer Jose V. Rivera was
assaulted and murdered by two inmates.
The Board was comprised of the following members:
G. Maldonado Jr., Regional Director, South Central Regional
Office (SCRO) (Chair);
Helen J. Marberry, Complex Warden, Federal Correctional
Complex Terre Haute;
Linda R. Thomas, Correctional Services Administrator,
Correctional Programs Division;
Andre Matevousian, Correctional Services Administrator,
Western Regional Office;
Douglas W. Curless, Senior Attorney, Federal Correctional
Institution (FCI) Phoenix;
Ben Wheat, Regional Psychology Services Administrator, SCRO,
and;
Vernon Ledesma, Supervisory Special Agent, Office of Internal
Affairs.
The purpose for the Board was to review the facts and
circumstances surrounding the homicide at USP Atwater on Friday,
June 20, 2008, when Correctional Officer Jose Rivera was
assaulted and murdered by two inmates (SABLAN, Jose Cabrera,
Reg. No. 90470-011 and GUERRERO, James Ninete Leon, Reg. No.
03744-045).
Due to the pending criminal homicide investigation into this
matter, the Board was instructed to coordinate their review with
the Federal Bureau of Investigation (FBI) and the Office of the
United States (U. S.) Attorney for the Eastern District of
California and to focus on matters related to institution
security. The scope of this Board includes a review of the
overall institution security policies and procedures in relation
to this incident.

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The Board traveled on Monday, July 21, 2008, and held an initial
meeting, that evening, at the hotel to introduce themselves and
discuss a plan for conducting the next day’s inquiry and to set
an agenda for the week.
When the Board arrived at USP Atwater on Tuesday, July 22, 2008,
the penitentiary was in lockdown status, so the Board was not
able to observe normal operations of the USP. Staff were
conducting mass shakedowns of all living units and common areas
of the institution and had accomplished this in eight of the 12
living units of the USP.
On Tuesday morning, the Board met with the FBI Special Agent
investigating the case. The Board was given a 90-minute overview
of the case and investigation, including the review of the
security videotapes. The Board then toured USP Atwater,
including Units 5A and 5B, the Special Housing Unit (SHU) and the
SHU annex, Inmate Systems Management (ISM), Receiving and
Discharge (R&D), and a general tour of the compound. The Board
interviewed all, but one staff member (who was on annual leave
and not reachable), who responded to the emergency and who had
relevant information regarding the incident. The Board also
interviewed several staff who were not present, but who wanted to
be heard by the Board. The Board also interviewed all inmates in
Unit 5A. All members of the USP’s Executive Staff and Special
Investigation Agent (SIA) were interviewed. The Board Chair met
with the President of the Local Union.
All members of the Board reviewed the videotape of the incident
in Unit 5A multiple times. The Board also reviewed the videotape
of Unit 5A operations on the day prior to the event.
Additionally, the Board reviewed videotapes of other housing
units and operations throughout the USP, to gain perspective on
operations at the penitentiary. The Board also reviewed numerous
documents regarding staffing, inmate discipline, other inmate
assaults on staff, and security logs.
The Board concluded its on-site investigation and review on
Friday, July 25, 2008. The Board conducted a televideo
conference on Wednesday, August 13, 2008, to discuss proposed
findings and recommendations.
INSTITUTION OVERVIEW
USP Atwater opened in 2000 and began receiving inmates in 2001.
USP Atwater is a hard-to-fill duty station. The penitentiary has
been designated as a bonus post. At the time of the Board,
USP Atwater had a staff complement of 332 of an authorized
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complement of 389. Custody has 189 filled positions of an
authorized 219. Approximately 30% of the staff have less than
three years experience with the Bureau of Prisons (hereafter
BOP). Approximately 80% of the staff have less than 10 years of
BOP experience. On June 19, 2008, the date of inmate Guerrero’s
arrival, SENTRY indicated there were 1,123 inmates housed at
USP Atwater and 113 inmates housed at the Satellite Camp.
THE VICTIM
Correctional Officer Jose V. Rivera was 22 years old at the time
of his death. He was a four-year veteran of the Navy, and
completed two tours of military duty in Iraq. He began his
career with the BOP as a Correctional Officer on August 5, 2007,
and was in his probationary year. He was working as the Unit
Officer in Unit 5A on the day he was murdered. He was in the
process of locking down the unit, to conduct the 3:30 p.m.
official count, when he was attacked and killed by two inmates.
THE ASSAILANTS
Based upon a review of the security tape and interviews with
staff and inmates, the assailant who stabbed the victim with an
ice pick type weapon was inmate Sablan. SENTRY indicates inmate
Sablan is a boarder from the Territory of Guam. He was convicted
and sentenced for Murder, Attempted Murder, and Felony Escape in
Guam on August 15, 1990. Inmate Sablan received a Life Sentence
for Murder, a consecutive 20-year sentence for Attempted Murder,
and a consecutive five year sentence for Felony Escape. He
currently has a U.S. Marshals Service detainer for Felon in
Possession of a Firearm with a 33-month consecutive sentence.
Inmate Sablan had a significant disciplinary history, including
five 100-level incident reports, four 200-level incident reports,
and four 300-level incident reports. Major incident reports
included Assaulting With Serious Injury, Fighting, Possessing a
Dangerous Weapon, Possessing Drugs and Intoxicants. In 1992, at
USP Lompoc, he physically assaulted a female correctional
officer. He had three years of clear disciplinary conduct prior
to the homicide. He was the unit orderly at the time of the
Assault.
Upon review of the security tape and interviews with staff and
inmates, the assailant who chased down the victim, tackled and
held him to the ground, was inmate Guerrero. SENTRY indicates
inmate Guerrero was convicted and sentenced in the U. S. District
Court for the Territory of Guam for Conspiracy to Commit Armed
Bank Robbery. He received a life sentence on July 9, 1998. He
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had been previously convicted in the U. S. District Court for the
Territory of Guam of Deprivation of Rights Under the Color of
Law, 18 U.S.C. § 242. He received a 10-year sentence on May 7,
1992. Inmate Guerrero had a history of assaulting staff,
including several incidents of serious assault and fighting with
inmates.
On August 14, 2008, inmates Sablan and Guerrero were indicted by
a federal grand jury in the Eastern District of California. The
grand jury returned a true bill charging inmates Sablan and
Guerrero with three death penalty eligible charges. Each
defendant was charged with a violation of 18 U.S.C. § 1111(a),
First Degree Murder, 18 U.S.C. §1114(a), First Degree Murder of a
United States Correctional Officer, and 18 U.S.C. § 1118, Murder
by a Federal Prisoner Serving a Life Sentence. The Honorable
Oliver W. Wanger, U.S. District Court for the Eastern District of
California (Fresno), was randomly selected as the trial court
Judge.
FACTUAL BACKGROUND
On June 19, 2008, inmate Guerrero arrived at USP Atwater from
USP Coleman as a 309 disciplinary transfer. He was originally
assigned a cell in Unit 2B by the Unit Manager. During intake
screening inmate Guerrero was interviewed by Special
Investigation Specialist (SIS) technician Ziragosa. Inmate
Guerrero indicated he would not cell with any other inmates on
Unit 2. SIS technician Ziragosa convinced inmate Guerrero to
cell with another Guamainian, inmate Sablan in Unit 5A. On the
evening of June 19, 2008, inmate Guerrero convinced the
Operations Lieutenant he could not be celled with inmate Sablan
because they were both “Alpha” personality types. The Operations
Lieutenant told inmate Guerrero to “find a cell” and inmate
Guerrero found cell #222. His cell assignment was changed for
the third time in less than 24 hours. However, SENTRY still
reflected inmate Guerrero was celled in #213. The rest of the
evening was uneventful.
After reviewing the tapes and interviewing staff and inmates, the
Board found, the morning of June 20, 2008, things in Unit 5A
appeared to be uneventful. At an undetermined time, in the
afternoon, the Asian/Pacific Islanders in Unit 5A began consuming
intoxicants. They continued to drink for an undetermined period
of time prior to the call for the 3:30 p.m. count.
Correctional Officer Rivera had been assigned as the Unit Officer
to housing unit 5A for June 20, 2008. At approximately 3:18 p.m.,
Officer Rivera called count and began to secure the unit in
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anticipation of the 3:30 p.m. count.
At approximately 3:20 p.m. Officer Rivera approached a group of
Asian/Pacific Islanders near cell 116. Officer Rivera engaged
the group in a brief conversation. Inmates Sablan and Guerrero
appear to be intoxicated. The group began to breakup.
The video revealed inmate Guerrero grabbed a plastic chair and
raised it in the air and dropped it to the floor. Inmates
Guerrero and Sablan then left the first floor of the unit and
went up the stairs to the second tier of Unit 5A. Officer Rivera
began to secure the bottom tier of Unit 5A.
Inmate Guerrero began to walk toward the stairwell near the front
door. Inmates DOWAI, Kenneth, Reg. No. 00339-005, and
TO, Conghau, Reg. No. 18722-018, approached inmate Guerrero and
appeared to be talking to him near cell 119. Inmate Sablan is
standing outside cell 115.
Inmate Sablan walked over to inmate Guerrero in front of cell
119. Inmates Guerrero and Sablan began to walk toward the
stairwell and up to cell 223. When they reached cell 223, inmate
Sablan opened cell 223. Inmates Sablan and Guerrero continued to
stand outside the cell with the door open. Inmate Sablan entered
cell 223, followed by inmate Guerrero who entered cell 223 with a
chair in his hand.
At approximately 3:22 p.m., Officer Rivera finished securing the
bottom tier of Unit 5A and began to approach the stairwell to the
second tier. He began securing the top tier beginning with cell
232.
At approximately 3:23 p.m., Officer Rivera reached cell 223 and
began to close the door as inmates Sablan and Guerrero were
standing outside the cell. Inmate Guerrero stepped inside cell
223 as Officer Rivera began to close the door. Inmate Sablan
remained standing outside cell 223.
Inmate Sablan appeared to pull something from his pocket, and in
a stabbing motion struck Officer Rivera in the torso. Inmate
Guerrero rushed from the cell as Officer Rivera runs from inmates
Sablan and Guerrero. Officer Rivera reached the stairwell first
and began to descend to the first floor of the unit.
Inmate Sablan struck Officer Rivera in the shoulder as they ran
down the stairwell. Officer Rivera turned while on the stairwell
and head butted inmate Guerrero in an attempt to defend himself.
Inmate Sablan swung his arm with the weapon in hand attempting to
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strike Officer Rivera.
Officer Rivera reached the bottom of the stairwell and ran in the
direction of cell 108. It appeared Officer Rivera activated his
body alarm at this point of the incident. He was being pursued
by inmates Sablan and Guerrero as they ran into a plastic trash
can.
Officer Rivera was tackled around the legs by inmate Guerrero
near cell 105. He was held to the ground by inmate Guerrero.
Inmate Sablan got on top of Officer Rivera and began to strike
Officer Rivera with the ice pick type weapon.
Inmate Sablan struck Officer Rivera approximately eight times in
the torso until the arrival of the first staff on the scene.
Unit Secretary Drayton entered the unit through the Unit Team
Door. She approached the scene of the struggle. She appeared to
be shouting commands at the inmates.
She was followed into the unit several seconds later by Unit
Manager Bowles. She entered the unit through the Unit Team Door.
As Unit Manager Bowles moved toward the assault, she positioned
herself near a chair. Several staff reported Unit Manager Bowles
was on the radio requesting assistance. She also appeared to be
shouting commands to the inmates. She did not intervene or
render assistance during the assault.
Unit Secretary Drayton closed the gap between herself and the
inmates and Officer Rivera, who continued to struggle. It
appeared she was yelling commands at the assailants. She did not
attempt to physically intervene at that time. A few seconds
later, Unit Secretary Drayton then moved closer to the assault
and attempted to control inmate Sablan’s arm.
At approximately 3:25 p.m., responding staff entered through the
Unit 5A door. Responding staff began removing inmates Sablan and
Guerrero from Officer Rivera. Both inmates were resisting, were
combative, as they continued to assault Officer Rivera.
Inmate Sablan was the first to be removed from Officer Rivera by
responding staff. Inmate Guerrero was next removed from Officer
Rivera’s lower body by the responding staff. Staff began
administering life saving efforts to Officer Rivera. Officer
Rivera was placed on a gurney and rushed to Health Services.
Once in Health Services, BOP staff continued to perform life
saving techniques and an outside ambulance was summoned. Officer
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Rivera was taken to an outside hospital and was pronounced dead
at the hospital. Officer Rivera’s remains were taken into
custody by the Merced County Sheriffs-Coroner’s Office at that
time. The family was notified of the death by the Coroner’s
Office. A postmortem autopsy was scheduled for June 24, 2008.
The Coroner’s Report and Autopsy stated Officer Rivera suffered
28 sharp force injuries. Twenty-one of the injuries were
puncture wounds and the others were superficial slice wounds.
Seven of these injuries were to the head and neck area.
The cause of death was determined to be two puncture wounds to
the left chest which penetrated the heart muscle resulting in
Officer Rivera bleeding to death (“Cause of Death: Puncture
wounds to left chest with resultant cardiac tamponade, left
hemothorax, and left lung atelectasis.”). At the conclusion of
the autopsy the Coroner ruled the manner of death to be homicide.
FINDINGS
Cell Assignments - Inmate Guerrero was transferred to USP Atwater
as a 309 disciplinary transfer. His Disciplinary Segregation
(AD) time is assumed to have expired on June 17, 2008, while in
transit, two days prior to arrival at USP Atwater. SENTRY
records reflect he was never on disciplinary status at his prior
designation. SENTRY only showed him on AD status while in SHU at
his previously designated facility.
Inmate Guerrero was assigned to two different general housing
units within the first 24 hours of arrival at the USP. Cell
assignment was initially made by the Unit Team, then changed by
the Operations Lieutenant. The SENTRY entry for inmate
Guerrero’s cell assignment did not correspond to the cell he was
occupying.
Staff and inmate interviews indicate inmates entering a housing
unit, awaiting a cell assignment, are told to find a cell by
count time, if not, they would be assigned a cell in the SHU.
It should be noted, eight months prior to the homicide, there was
a staff hostage situation in Unit 5A. The inmate hostage takers
claimed cell assignments were being controlled by gangs, not
staff. They took the Unit 5A Officer hostage using homemade
metal ice pick type weapons. After negotiation with the Hostage
Negotiation Team (HNT), the officer was released and the hostage
takers surrendered. The officer received a contusion to the
upper lip and no other major injuries. An After Action Report
was conducted by the Regional Office (After Action Report, Staff
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Hostage, United States Penitentiary Atwater, California, Date of
incident October 31, 2007, (hereafter AAR). The hostage takers
indicated the reason for the hostage taking was a “tax” on cells
imposed by inmate gangs. The issue had been raised with
institution staff and no action had been taken by staff. This
was perceived by inmates as an accepted practice. The AAR team
found the taxing of cells was a contributing factor for the
number of assaults and protective custody cases at USP Atwater.
Count Issues - It appears from a review of the videotape,
Officer Rivera called count and began counting while inmates were
out of their cells and continuously moving about the floor. One
inmate ran past Officer Rivera and just entered his cell prior to
Officer Rivera locking the cell door.
Some testimonial evidence from staff and inmates suggests inmates
are not necessarily in their assigned cells during count. They
are counted in a cell, but not necessarily their designated cell.
Inmate Sablan was not in his assigned cell at the time of the
incident.
Intoxicants - After a review of the videotapes, it appears the
assailants were intoxicated at the time of the homicide. This
was also confirmed by the inmates interviewed, on Unit 5A, who
were interviewed after the incident. Inmate Sablan admitted to
the FBI, he was drunk at the time of the incident and stated he
did not remember what had happened. The two assailants were not
administered Breathalyzer, Blood, or Urinalysis tests after the
incident. However, videotapes were made of inmates Sablan and
Guerrero after they were secured in the visiting room cells, and
the evidence is very clear they were intoxicated.
The medical assessments conducted on the inmates after the
homicide failed to note any slurring of speech or any other signs
of intoxication which were noted in the video reviews of the
inmates.
After interviews with staff and inmates, review of the videotapes
of the incident, review of Unit Logs, and other records, the
Board found intoxicants were extremely easy for inmates to make
and obtain, despite efforts to eliminate the available
ingredients from the Commissary. Intelligence derived from
inmate mail and interviews indicated inmates are “cooking” the
sugar out of soda (possibly by use of stingers) to provide
ingredients for intoxicants.
Intoxicants are easily obtained by the inmate population at
USP Atwater. This is indicated by the large quantities of
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intoxicants discovered by staff and recorded in the Unit
Logbooks. The intoxicants were mainly sold and transported in
empty plastic soda bottles which were sold in the commissary.
After interviews
of the incident,
Board found many
the confiscation
being written.

with staff and inmates, review of the videotapes
review of Unit Logs, and other records, the
times intoxicants would be discovered, logged in
log and disposed without an incident report

After interviews with staff and inmates, review of the videotapes
of the incident, review of Unit Logs, and other records, the
Board found on several occasions intoxicated inmates were locked
in their cells to “sleep it off,” were not taken to the
Lieutenants’ office, and were not written incident reports.
Intoxicants are a 200-level incident report and cannot be
informally resolved by policy.
A further documented example of intoxicated inmates being allowed
to “sleep it off” was discovered. A staff member found an
intoxicated inmate on the unit. The inmate was sent to the
Lieutenants’ Office and was later returned to the unit to “sleep
it off.” The inmate then assaulted the reporting staff member on
the unit. The staff member suffered a broken jaw as a result of
the assault.
In summary, inmates making intoxicants, and intoxicated inmates
are not being held fully accountable under the institution
disciplinary process.
Weapons - An ice pick type weapon was recovered at the scene of
the murder. Weapons appeared to be plentiful at the
penitentiary. At the time the Board left the penitentiary, 175
weapons had been recovered during the mass shakedowns conducted
in eight of the 12 housing units.
Preliminary information indicates the origin of the material used
to make the weapon used to kill Officer Rivera is suspected to be
from the Food Service Department’s dishwasher.
Interviews with staff and inmates indicated if a weapon was
discovered in an inmate’s quarters, there would be no
disciplinary action taken. If an inmate was discovered with a
weapon on his person, he was written an incident report and taken
to SHU.
It should be noted the AAR found the metal in the dishwasher had
been utilized by inmates to fashion weapons for use in the staff
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hostage taking incident. The AAR, recommended the source of the
material used to create these weapons be identified and removed.
Staff Response - At the time of the attack a GS-8 Senior Officer
was acting as the Operations Lieutenant, there was an acting
Captain, and an Associate Warden who had recently arrived at
USP Atwater. They acted in an appropriate manner during the
emergency until the Captain and other members of the Executive
Staff returned to the penitentiary.
As a result of interviews with staff and inmates, review of the
videotapes of the incident, review of Unit Logs, and review of
other records, it was determined there was only one person in the
unit with the key to the front door of Unit 5A at the time of the
attack. That person was the Unit Officer, who was attacked and
killed. Neither of the two staff in the unit had a key to the
unit’s front door. The Compound Officer had to open the unit to
responding staff.
There was a delay entering the Unit 5A front door until the
Compound Officer arrived with a key to the Unit 5A front door.
It appears the body alarm was activated at approximately 3:24 p.m.
The Unit Secretary arrives first coming from the unit offices,
seconds after the body alarm is sounded. She has no key to the
front door of the unit. She approaches the inmates, but does not
initially intervene in the assault. The Unit Manager is the
second person to arrive on the scene, coming from the unit
offices. She arrives several seconds after the Unit Secretary.
She too, does not have a key to the front door. She positions
herself next to a chair, but away from the assault. She does not
intervene in the assault. Outside responding staff arrive at the
unit, but cannot get in. The Compound Officer arrives and uses
his key to open the front door, which allows staff to enter the
unit. This delay to get responding staff into the unit could have
been reduced, had any of the other unit staff had a key to the
front door. It appears from reviewing the tape, Officer Rivera is
stabbed at least 10 times before the first staff member arrives on
the scene. There appear to be at least another seven stabbings
before the mass staff respond to the emergency.
The assailants were secured in good order and video cameras were
obtained and utilized in a timely manner. The assailants were
removed from the scene and placed in the non-contact visiting
cells in the visiting room.
No Breathalyzer or other types of sobriety tests were
administered at the time of the incident. The medical assessment
of the inmates did not contain references to the inmate’s
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intoxication or intoxicated behavior.
No designated staff were available to deploy less than lethal
munitions since no written plan has been developed.
Lockdown of the penitentiary after the incident was accomplished
in an orderly fashion.
FCI Dublin responded to the USP to transport the assailants and
arrived at approximately 9:25 p.m. They were escorted by the
California Highway Patrol. They removed the assailants from
USP Atwater at approximately 10:00 p.m., on the evening of the
homicide.
Additional Crisis Support Team (hereafter CST) responded from the
Regional Office and FCI Dublin, on the night of the homicide, to
assist the Atwater CST in what had occurred that evening.
Thirty-two staff from Victorville and FCI Dublin came to the USP
in order to relieve those staff who wanted to attend the memorial
service for Officer Rivera.
Medical Response - The Board found staff responded quickly and
admirably in rendering life saving aid, transporting Officer
Rivera to Health Services, and giving heroic emergency
assistance. The outside ambulance response was excellent and the
response at the outside hospital was also excellent.
Outside Law Enforcement Response - The Board found excellent
cooperation and assistance were provided by the FBI, U. S.
Attorneys Office for the Eastern District of California, the
California Highway Patrol, the outside medical ambulance company,
the community hospital, the Merced County Sheriff’s Office, and
the Office of the Coroner.
Crisis Support Team Response - Atwater CST did an outstanding job
responding to this tragic incident. The team was activated
within minutes of the event. Those team members who were not
present at the institution were immediately recalled and returned
to the institution. The Executive Assistant also provided
exemplary assistance, as he initially followed Officer Rivera to
the hospital, notified the family of his death, and provided
comfort and support to the family in conjunction with the CST.
Shortly after arriving at the penitentiary, on the evening of
Officer Rivera’s death, the CST Team Leader (Chief Psychologist)
quickly relinquished her leadership responsibilities to the
Warden’s Secretary Michelle Salm. The Chief Psychologist had
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previously made it clear to the Executive Staff at the
penitentiary she did not want to be the Team Leader. It should
be noted, Michelle, who is not the team leader, took charge of
the penitentiary’s CST response. Once the immediate crisis was
over, she continued to direct the activities of the CST to
include assisting Officer Rivera’s family, providing emotional
support to numerous staff, and assisting in the coordination of
the memorial service.
Regional assistance from Chaplain Gabrian (Regional CST
Coordinator) and Dr. Richard Ellis (Regional Psychology Services
Administrator) arrived at the penitentiary within two hours of
the death of Officer Rivera. Chaplain Gabrian recommended the
activation of the CST from FCI Dublin to assist the Atwater CST.
On June 23, 2008, Chaplain Gabrian and the penitentiary Executive
Staff determined they had enough CST resources on-site. Ten days
after the incident CST members from Victorville and Terminal
Island were activated by the Western Region for a brief period of
time.
The seven members of the Atwater CST remained active for 18 days
after the incident. They carried the largest workload for the
CST response. Nine CST members from Dublin, two from
Victorville, and two from Terminal Island assisted in performing
CST activities at various times. On July 8, 2008, the Atwater
CST was debriefed by Chaplain Joe Pryor of the Central Office.
The Warden did not meet with the family until the Monday
following the incident, three days later.
Security Threat Group (STG) Issues - Posted Picture File - The
Posted Picture File Program Statement (P. S.) 5510.11, requires
the Bureau to identify inmates and/or detainees who, because of
prior record, current offense, institutional adjustment, pose a
significant threat to staff or inmate safety.
It was determined inmate Guerrero had previously been in the
inmate Posted Picture File at USP Coleman from 9/00 until 12/07
for his involvement in a hostage situation and an assault on
staff in 1998.
A review of Cardfiles data indicated inmate Guerrero had numerous
reports of assaulting staff and inmates while in the custody of
the Guam Department of Corrections and the BOP.
Based upon inmate Guerrero’s previous history of violence against
staff, he should have been placed in the institutions Posted
Picture File prior to his arrival at USP Atwater.
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A review of Posted Picture Files data indicated inmate Sablan had
five assaults, one with a weapon, on inmates. He previously
assaulted a female staff member in 1992.
It appeared Officer Rivera had not reviewed the Posted Picture
File for six of the ten months he worked at USP Atwater.
Documentation reviewed reflects the signatures of officers in the
Posted Picture File were signed by a single person on several
occasions prior to the homicide.
STG File Maintenance - An audit of USP Atwater files disclosed
inmate Sablan had a “Ghost” file prepared upon his arrival to
USP Atwater. The file remained in the SIS Office without any
action for the entire time he was housed at USP Atwater. A
further inquiry of the entire STG files revealed hundreds of
files were never completed, or if completed, were not loaded in
SENTRY. (A ghost file is a temporary file on an inmate compiled
of all and any information available at the time of admission.
The ghost file is discarded when the original file from the
sending institution is received or it serves as a reminder to
develop a file on the inmate. The number of ghost files
indicates no files were sent from the sending facility nor was a
proper file developed by Atwater staff.)
Searches - As a result of interviews with staff and inmates,
review of the videotapes of the incident, review of Unit Logs,
and review of other records, the Board found routine pat searches
were not being conducted, by staff including unit officers, when
inmates entered or exited their unit. Pat searches appeared to
occur only in front of the dining room and other limited areas on
the day watch.
Although mass searches were conducted, they were not thorough and
only targeted specific items, such as ingredients for making
intoxicants.
As previously indicated in the Weapons section of the report,
several repairs were made to the dishwasher in Food Service to
replace stainless steel rods from the conveyor belt. However,
this area was never identified as a source of weapons material
with appropriate controls to restrict inmates from removing parts
for the purpose of making weapons. This was noted in the AAR. In
the AAR, the Unit Officer in Unit 5A was taken hostage by two
inmates armed with homemade weapons.
SHU - USP Atwater has a SHU which holds approximately 140
inmates. They have also created an “annex” for protective
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custody cases
approximately
toured by the
noted a large
laundry area.

and special situations. The annex was populated at
50% of capacity. Both SHU and the annex were
Board. During the Board’s tour of the SHU, it was
drawing of a nude female was displayed in the SHU

Discussions with staff indicated the SHU was always full, and
a result, many inmates who received disciplinary sanctions of
either were released from DS status early or never spent time
DS. According to SENTRY records, incident reports are not
processed expeditiously, which impacts the crowding levels in
SHU.

as
DS,
in
the

A review of the SHU visiting logs from March 2008 through
June 2008 indicated Department Heads, Unit Team, and Health
Services staff failed to conduct rounds 27.3% of the time. The
Executive Staff failed to conduct rounds 29.1% of the time.
During the three-month cycle reviewed, the Warden only made
rounds five times.
DHO - The DHO was interviewed and indicated a higher than normal
number of incident reports for assault were being expunged as a
result of staff not meeting the time frames of the DHO process
and misplaced DHO packets. The DHO felt the lack of enforcement
of the disciplinary process has led inmates to believe they will
not be held accountable for their actions. This leads to a
dangerous environment for staff and inmates.
A statistical review of SHU hearings from February 2008 through
August 2008 indicate there were 81 incident reports for Code 104
(Possession of a weapon). During the time period reviewed, nine
of these incident reports were expunged for various errors. More
than 10% of these reports were expunged.
Post Orders - Post Orders were reviewed by the Board and were
outdated and had not been reviewed and signed off by staff. The
Post Orders were worded in a vague manner. They were not
comprehensive regarding actions to be taken by first responders.
They were not specific to actions to be taken during emergencies,
shakedowns, or incident reports.
RECOMMENDATIONS
The Board recommends the following:
Cell Assignment - The procedure for inmate cell assignments
should be reviewed. The Case Management Coordinator and Unit
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Team need to review pipeline screening procedures and make
general housing unit cell assignments.
The Special Investigative Agent (SIA) should have input but
should not be assigning cells. The SIA should focus primarily
on which inmates need to go directly to SHU before receiving
an assigned cell in general population.
A previous hostage AAR, indicated inmates were “selling”
cells. The report suggested creating five Admission and
Orientation (A&O) cells per unit to avoid placing an
inappropriate inmate into general population without proper
screening.
Ensure SENTRY records of cell assignments match with Bed Book
assignments.
Count Issues - Procedurally, when an officer announces count,
the floor should be cleared of inmates before the officer
commences to lock cell doors and conduct the official count.
If inmates do not clear the floor and report to their cell,
the Lieutenant’s Office should be notified.
Other available staff from the Unit Team should be visible in
the living area when inmates are secured for count.
Inmates should be counted in their assigned cells per their
SENTRY assignment.
Intoxicants - Further reduce intoxicant ingredients in the
Commissary. Evaluate whether jellies, jams, dates, and soda
in plastic bottles should be eliminated at USPs. Remove milk
bladders from Food Service and replace with carton or small
pouch milk containers.
Increase frequency of pat searches at Food Service, especially
during the evening meal.
Staff should strictly enforce discipline regarding intoxicants
and intoxicated inmates. Incident reports should be written
for each incident involving intoxicants or intoxication.
Medical assessments of inmates should include signs of
intoxication, i.e., slurring of speech, stumbling, inability
to maintain the head.
Weapons - Conduct more research into the type of weapons being
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manufactured, determine how they are being manufactured,
determine what types of materials are being utilized and the
origins of the materials (dishwasher rods evading metal
detectors). Eliminate, remove, or replace such materials.
When specially ordered, dishwasher manufactures should provide
all plastic conveyors for their machine thus eliminating the
availability of metal rods for the manufacture of weapons.
Conduct more pat searches. Random removal of shoes should be
conducted at the metal detectors, as inmates enter the units.
We suggest establishing a minimum number of random pat
searches at all search locations.
Conduct more area searches with an equal emphasis of recovery
of soft contraband, as well as hard contraband.
Staff Response - Unit Team members should be given a key to
the unit front doors. There was a delay for responders coming
from outside the unit due to the only key to the unit front
door being in the possession of the Unit Officer, who was
under attack.
Breathalyzer, and urinalysis tests should be conducted on all
inmates involved in assault cases where intoxication is
suspected.
Consult with the FBI, and if applicable, the U. S. Attorneys
Office to determine if blood, or other tests should be
administered.
Indications of inmate intoxication should be noted in the
medical assessment and work up.
Develop more guidance for First Responders to emergencies.
Perhaps add the following phrase “Do anything possible to stop
aggressive or assaultive behavior.” The emergency response
plans and Post Orders should identify the expectations for
first responders.
The Quick Response Team needs written direction and procedures
for response.
Medical Response - Medical assessments of inmates involved in
assaultive incidents should reflect whether or not the inmate
appears intoxicated due to alcohol or drugs.
CST- The Western Region does not have a formal Regional CST.
P. S. 5500.11, Correctional Services Manual § 603 states each
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region should have a Regional CST. It is recommended the
Western Region formalize the selection of the Regional CST

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with members selected by the Regional Director. Once
constituted, the Regional CST should establish regional
response plans and then be announced to the Wardens in the
Region.
The current Atwater CST consists of seven members. Four of
the members have not attended national CST training. The four
untrained members of the Atwater CST should receive national
CST training, as soon as possible.
A new CST Team Leader should be selected. Given the shortage
of Psychologists at USP Atwater, consideration should be given
to either the Family Support Center Manager or the Chaplain.
Expand the size of the Atwater CST from seven members to eight
or ten members. This provides enough team members, so two CST
team members can be on each shift for at least the first 24
hours of a crisis.
Establish a formal protocol for assisting staff who have been
seriously assaulted by an inmate. The Northeast and South
Central Regions currently have such programs in place and
could share training materials, forms, and procedures with
other Regions.
Activate the Atwater CST when the penitentiary comes off
lockdown. This would help the staff at the institution as
they return to normal operations.
Establish a national protocol for responding to the homicide
of a staff member who died at the hands of an inmate. This is
a very rare and emotionally charged event. It is critically
important for the staff and the Executive Staff at the
institution to know what will be done to support staff in the
aftermath of such a tragic event. The local CST and Executive
Staff, by the nature of the event is directly and personally
impacted. To rely solely on the local CST and Executive Staff
to carry the burden of assisting staff beyond the first 24
hours is detrimental and harmful. It is important to include
an outline of activation and use of Regional CST to augment
the local CST. This allows the local CST to receive
appropriate support for their own emotional needs. The Warden
or Acting Warden should meet with the family immediately after
the death of a staff member.
STG Issues - Posted Picture File - Ensure all staff review and
sign the Posted Picture File.
Make the Posted Picture File available during Annual Refresher
Training, staff recalls, and other mass gatherings of staff.

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Unit Officers must be made familiar with inmates in their unit
who are on the Posted Picture File.
Posted Picture File P. S. 5510.11 does not require the
application of an STG assignment of POSTPIC into SENTRY on
inmates assigned to the Posted Picture File. The STG
assignment of POSTPIC, as well as the development of specific
category identifiers, such as Staff Assault, Escape, etc.,
should be developed. Policy must also identify who is
responsible for entering these assignments into SENTRY.
Furthermore, once an inmate is assigned to the Posted Picture
File, that assignment should not be removed whenever an inmate
is transferred to another facility.
An electronic posted picture system should be developed which
indexes inmates by specific category. Instead of viewing
inmates in alphabetical order, any staff member should be able
to view a specific assignment category, such as housing unit,
work detail, education assignment, to see what inmates in that
assignment are on the Posted Picture File.
File maintenance - Ensure all STG files are completed and
loaded in SENTRY in a timely manner. Do not maintain “Ghost”
files. “Ghost” files suggest SIS files are not always
received from the sending institution. Current policy
provides no specific way to ensure information (SIS packets)
are sent from the sending institution.
SHU - Process incident reports in a timely manner to assist
with the crowding levels in the SHU. Utilize the annex to its
maximum capacity. A position or individual must be designated
to make SENTRY changes in an inmate’s SHU status of either AD
or DS.
DHO - Ensure the disciplinary process is applied effectively
and consistently to the inmate population by ensuring staff
follow the disciplinary process and meet the deadlines imposed
on timeliness by policy. This can be done by an emphasis in
training of staff on incident report writing and the
disciplinary process.
Post Orders - Post Orders should be updated and clearly state
staff responsibilities in conducting a proper count,
conducting searches, and responding to emergencies.
Training - The Board recommends further institutional training
in confrontation avoidance techniques, Posted Picture File,
pat searches and area searches, count procedures, escort
procedures, and inmate communication.

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Additional training should be provided on the discipline
system to all Lieutenants and supervisors on policy criteria
for placing inmates in the SHU. The failure of not placing
inmates in SHU for such infractions, as possession of weapons
in their cell, possession of intoxicants, use of intoxicants
and severe incidents of insolence must be remedied.
***

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