I.

INTRODUCTION

State prisons in Arizona have experienced problems with cell locks for
decades. In 1997, inmates were able to “spin” the lock on a cell at Perryville to
allow inmate Leroy Cropper to leave his cell to stab correctional officer Brent
Lumley to death. State v. Cropper, 68 P.3d 407 (2003). A 2006 video from the
Department of Corrections’ own website demonstrates how inmates at Lewis
Prison can tamper with their cell doors so that they can later open them.
Security Alert and Video August 21, 2006. But the phenomenon was largely
unknown to the public until, on April 24, 2019, Phoenix ABC Channel 15 aired
a story about non-working prison-door locks, accompanied by video bootlegged
from Lewis Prison. Viewers watched, shocked, as inmates streamed from their
cells on December 30, 2018, to attack vastly outnumbered correctional officers.
In light of this video, the Governor’s Office asked the investigators to
provide “an independent, third-party review into matters of security at the
Arizona Department of Corrections” (“ADC”), and specifically to “provide an
assessment of problems related to cell locks at Lewis Prison.” We were asked
to produce a timeline relating to “the ineffectiveness of locks at Lewis Prison”
and to address how long inmates have been able to open supposedly secured
cell doors; what caused the problem; the steps ADC has taken to address the
issue; and what proactive measures the state should take moving forward.

We were also asked to examine documents and view video evidence

relating to assaults on inmates and staff resulting in serious injury that
occurred between January 1, 2018, and April 30, 2019, and then to analyze
ADC’s actions in reviewing these incidents and the actions it took to prevent
them from occurring again. For each incident, we were to ascertain, if possible,
whether ineffective locks contributed to the conditions that gave rise to the
assault. The contract also requires that we “review management decisions
made by agency leadership” concerning accountability for oversight of the
safety and security of the inmates and staff as they related to the
ineffectiveness of locks at Lewis Prison. Finally, we were asked to provide
recommendations for further action.1
Although a contract for services was not signed until June 18, 2019,
we had agreed to undertake the case in May and began work on May 22.
This report sets forth the process we followed and the steps taken to
secure relevant information, provides a timeline of events, and then addresses
the questions posed. It concludes with observations and recommendations for
consideration.

1 On August 9. 2019, just prior to the submission of this report, Charles Ryan announced his
retirement as Director of the Arizona Department of Corrections.
 II. PROCESS

A. Interviews
We formally interviewed the listed 22 people on the dates indicated,
and we talked informally to several others. Only one person, former Lewis
Warden Berry Larson, failed to respond to requests for an interview.

June 10:

• Terry Stewart, former Director of ADC; Director during

design and build of Lewis Prison.
• Charles Ryan, Director, ADC, 2009 - present.
June 12:

• Gabriela Contreras, Correctional Sergeant who released

videos to ABC Ch. 15; assigned to Lewis prison, 2017-2019.
June18:

• Tara Diaz, Southern Region Operations Director; Deputy

Warden at Lewis, 2010-2012.
• Carson McWilliams, Division Director of Prison Operations,
2014-2019.
• Daniel Walker, Major at Lewis Prison; Complex Chief of
Security.
• Shaun Holland, Correctional Administrator I, 12 years at
Lewis Prison in various capacities.
• Ernie Trujillo, Northern Region Operations Director, 2014-
2019.
June 24:

• Donna Hamm, founder and executive director of Middle

Ground Prison Reform.
• James Hamm, Program Director at Middle Ground Prison
Reform.
• Luis Matos, Correctional Captain and Chief of Security at
Morey Unit, 2010-2014. Assigned (as Lt.) to Morey; returned
to Morey Unit as Captain in 2018.
June 25:

• Mike Landry, ADC Facilities Administrator.

• Jake Gable, ADC Planning Budget Research Administrator.

2
 June 26:

• Randy Standridge, Lewis Complex Major, 2016-2019.

July 8:

• Kevin Tynan, ADC Engineering Facilities Project Manager.

• Luis De La O, COIII, Disciplinary Coordinator, Lewis Prison.
July 10:

• Gilbert Orrantia, Director, State of Arizona Department of

Homeland Security; member of State advisory committee
following April 24, 2019, airing of the ADC video.
• Mark Hasz, Correctional Lieutenant, assigned to Morey Unit,
Lewis (currently at Buckley Unit).
• Travis Scott, Deputy Warden at Stiner Unit, Lewis Prison,
2014-16; DW at Morey Unit, Lewis, 2019-present.
• Chris Moody, Warden, ret., Lewis Prison, 2014-2017.
• Darren Sikes, AZCPOA President, COII with ADC.
July 31:

• Waldemar Mehner, FOP President (telephonic).

August 8:

• Charles Ryan, Director, ADC, follow-up interview.

B. Documents Reviewed

We reviewed several categories of documents, some provided by ADC

employees and some provided by others. The following is a partial list.

1. Materials contained on 10 flash drives, including ADC

Department Order Manual, General Post Orders, Administrative
Inspections of Incidents (Jan. 2018 – 2019), Criminal Investigations
2018-2019, GAR Reports, 703 Reports, Incident Command Reports,
Security Device Incident (SDI) Reports, Warden Reports, Significant
Incident Reports, Performance Observations (May 2019 re Larson,
Ramos, etc.), Lewis Prison Inmate Lock Tampering and Cell Door
Malfunction Timeline, emails, media materials, assignment lists,
Incident Actions Plan for Morey Inmate move, work orders, Security
Device Deficiency (SDD) Reports, videos of assaults and inmate
movements, including 11/8/18 Rast Unit fire and 5/10/18 assault on
COII Radke.
3
 2. Materials provided by ADC through requests to General
Counsel Brad Keough (many provided by flash drive and included in
the drives mentioned in #1):
a. Materials relating to ADC budget, including materials
provided by Jake Gable: ADC Capital Improvement Plan, Prison
Facility Locking Systems Requests 2011-2020 (126 pgs.),
legislation relating to Locking Systems Requests, legislation
staffing report.
b. Organizational charts, media materials, Lewis Prison
Unit opening and warden documents; information on inmate
moves; information on “Inmate Assaults on Staff-TOTALS”
statewide, “staff assaults FY05-FY19” by prison unit, prison
staffing documents, average daily inmate populations, information
on Lewis staffing.
c. Information relating to the pinning and padlocking
decisions.
d. Information related to assaults resulting in serious
bodily injury, including video and investigative reports for the
2/27/18 assault on Inmates Mallory and Mattia; 6/6/18
unwitnessed assault on Inmate McCormick (video of area outside
cell); 9/29/18 assault on COII Peralta; 10/5/18 assault on COII
Ballentine; 10/20/18 assault on COII Pasos; 10/29/18 assault on
COIIs Garza and CO Avila; video, investigative report, Inspector
General’s Report; 11/22/18 assault on Sgt. Markowski; 12/30/18
assault on COII Nash. We also reviewed investigative reports for
the 1/9/18 assault on Inmate Bologna; the 3/25/18 assault on
Inmate Johnson; 4/11/18 assault on Inmate Lewis; 6/8/18
unwitnessed assault on Inmate Olvera; 6/27/18 assault on Inmate
Ellis; 8/13/18 assault on Inmate Mirza; 10/13/18 assault on COII
Garcia; 11/11/18 unwitnessed assault on Inmate Bociung;
12/4/18 assault on Inmate Valdez; 12/23/18 assault on Inmate
Espinoza.
3. Materials Provided by Dir. Charles Ryan: CO Vacancy Rate
Charts and staffing reports, CR Diary entries, media reports, part of a
report re ADC initiatives to reduce staff assault (including Strategic
Initiative A3 Project), Information Report 19-L05-00201, -00203,
00207,-00152; 19-L23-001182-01180, and Administrative Inquiry
(Contreras), booklet of Prison Aerials (contains aerials plus maps and
internal pictures of cells, pods, housing units of various custody
levels—Tents, Dormitories, pods, minimum, close custody, old max
custody [cell and pod], new max custody, organizational chart, budget
documents (FY 2020 Building Renewal Plan, FY2021 Capital

4
 Improvement Plan, FY 2021 ADOA Capital Building Renewal Request
Summary, ADC 2017-2019 Appropriations Report, 2010-2020 Capital
Appropriations Summary, budget emails, ADOA FY 2020 Capital
Improvement Plan), ADC Institutional Capacity and Committed
Population Charts.
4. Miscellaneous media clippings.
5. Emails from Tara Diaz re assaults of COIIs Nash and Duran.
6. Letter forwarded by Dianne Post from Keith Nance, #168108.
7. Materials provided through Governor’s Office: Senior Staff
Briefing May 6, 2019.
8. Materials from Martin Bihn relating to the Investigation of
Death of Inmate Andrew McCormick, #228881; redacted AAIU
Investigation and other reports, 311 pages; complaint in Russett v.
State/Ryan, filed 5/9/16 asserting claims against ADC by COs injured
by inmates, several of whom were able to get out of their cells, 57
pages; Order in Russett v. State/Ryan, 17 pages; Order in Russett v.
State/Ryan, 18 pages; investigative report re death of Inmate Miguel A.
Camacho #167996; 5 Inspector General Supplemental Reports;
Information Reports re video footage; Use of Force Report/ICR; SIR; Use
of Force/ICR, etc.; total 88 pages of reports; Scientific Examination
Report plus other reports re Camacho Death, 101 pages; email from
Lance Bevins, 19-year ADC CO who allegedly was injured in 7/12/14
as a result of inmates’ ability to get out of cells.
In addition to the foregoing documents, we viewed aerial photos of Lewis
and other prisons, “pins” and chains, and videos and photos of prison door
locking systems and general inmate movement out of cells.

III. TIMELINE

To place the events that led to this investigation in context, we developed

the timeline below. Although numerous incidents contributed to the problems
Lewis Prison experienced with inmates leaving their cells, the following list of
events includes those most closely related to the subjects of this investigation.

1998

• Lewis Prison opens the Stiner Unit

o 1999: Lewis opens Barchey and Morey Units
o 2000: Lewis opens Buckley and Bachman Units
o 2002: Lewis opens Rast Unit; Rast Max opens in 2014

5
2002

• 2002 Lock Assessment Report for Arizona Prisons

o No recommendation for Lewis Prison Locks

2003

• First mention of inmates accessing doors at Lewis

2006

• Lewis Security Alert and video demonstrating how inmates

can obstruct doors
• FY 2006: Legislature swept 595.5 FTE positions from the
ADC, including 565 authorized Corrections Officer positions,
to provide a salary increase for filled CO positions in FY 2007

2010

• FY 2010: The legislature mandated a general 5 percent FTE

position reduction by February 1, 2010. The result for ADC
was to eliminate 487 positions, including 51 maintenance-
related positions. The positions eliminated were vacant;
ADC funding was not affected.

2012

• 293 CO positions authorized when legislature added 4,000

prison beds

2013

• 103 CO positions authorized as part of a 3-year plan; the

latter years were not funded

2010 to 2014

• Problems noted with doors at Lewis, particularly the slider

doors
o Reports also note that the control panel showed some
cell doors as secure when unsecure and as unsecure
when secure
o Inconsistent reports as to the extent and cause of
problems with the doors

6
2016

• August 21: Security Alert issued re inmates compromising

security of cell doors by obstructing; COs told to make visual
inspections
• Multiple work orders written directing doors to be repaired

2017

• By fall, general agreement that inmates leaving their cells

without permission had become a problem
• August or September: Began discussion of using pins on
doors at Lewis
• September to December: Purchased doors pins, chains, steel
• November: ADC timeline states that Director first learned of
increase in incidents of witness tampering and cell door
malfunctions
o Director authorized use of pins in the Morey, Buckley
and Rast Units

2018

• Pins installed between January and June

o January 22: Began installation on Morey Unit;
completed May 3
o February 12: Began installation on Buckley Unit;
completed June 11
o June 11: Began installation on Rast Unit; completed
June 20
o Within a short time, the inmates, including porters,
would pull the pins, allowing inmates to open “capped”
cells
• March: New administrators assigned to Lewis
• September: Director met with leadership and instructed
they should be more forceful in enforcing inspections
• October: Director made an unannounced visit to Lewis to
inspect the prison and speak with inmates
• By mid-2018, became evident that pinning had not resolved
the UA problem
• November 8
o Fires in the Rast Unit; reports to the Director were
incomplete
• December: New leadership team sent to Lewis
o Instructed to change the culture at Lewis
o Developed QRF command team to assist COIIs

7
 • December 30: COIIs Nash and Duran-Vargas assaulted by
multiple inmates out of their cells

2019

• Installed padlocks on two units of 25 cells each in Morey and

Rast; three in Buckley, January to April. Dates installed:
o Rast: 1/28 and 2/12
o Morey: 1/24 and 1/30
o Buckley: 1/3, 2/13, and 4/23
• Introduced stepdown program
• Sgt. Contreras met with superiors and union leadership to
discuss assault of COII Nash; she provided videos of that
assault and several others, which the union later released to
news media
• April 24: News media released video tapes provided by Sgt.
Contreras
• April 25: Director authorized use of contingency funds for
an additional 825 padlocks for Lewis close custody cells
• April 27: Prison staff directed to file a Significant Incident
Report for all UAs; the SIR would go to the Regional
Operations Director and then to the Director and the
Governor
• April 27-29: Hasps and padlocks installed on all remaining
close custody cells at Morey, Buckley, and Rast Blue
• April 29: Governor established review team
• May 6: Began transfer of all inmates from Morey to other
prisons; completed by May 15

IV. DISCUSSION: SCOPE AND CAUSES

A. Defining the Issue

Having viewed videos of some of the assaults and fires at Lewis Prison
on TV, we thought as we undertook this investigation that there was general
agreement that the locks at Lewis Prison were broken. We soon learned that
was not the case. There was, and still is to some extent, disagreement about
whether the locks are broken such that the doors can’t be reliably secured or
whether the doors are fine, but the inmates manipulate, tamper with, or “cap”
them so that they fail to fully secure. This disagreement helps explain why
certain steps were not timely undertaken to remedy the problem of inmates
leaving their cells without authorization.2

2 Corrections officers call inmates’ leaving their cells without permission or assistance to gain
access to the pods or other cells “unauthorized access,” or, in shorthand, UA.
8
 The first school of thought, held by much of senior management, from
the warden level and perhaps deputy warden level through the Director, is that
the doors are not broken. They are, however, subject to inmate tampering.
Inmates tamper by placing something – magnets, bottle caps, plastic, or
whatever small object they can find – in the door track to prevent the locks on
the slide doors from fully engaging, a process called “capping.” The doors
appear to be closed and may even “click” so they register as “secure” on the
control console, but the locking mechanism has not fully engaged and the
inmates can later shake or manipulate the doors open. Inmates can
accomplish the same end by kicking at, hitting with objects, or otherwise
denting the doorframe so that the door won’t secure.

If it were the case that the doors are secure unless inmates cap them,
then, of course, the doors do not need “fixing,” and they certainly don’t need to
be replaced.3 Instead, the burden falls to the COs to inspect the door frames
more carefully to ensure that inmates have not obstructed them, and then re-
check by shaking each door each time they close a cell door to make sure it is
fully secured. This view is supported by statements from the lock maintenance
personnel who reported to senior management that 70-80 percent of the locks
they were called out to repair weren’t broken; the inmates had simply capped
the doors. Once the obstructions were removed, the doors worked properly.4

The second school of thought, held mostly by those who work in the
trenches and open and close the doors several times daily, is that many of the
doors are actually broken and will not secure. Although the members of this
group recognize that inmates do place objects in the frame to prevent securing,
this group believes that some of the reason placing the objects can be easily
done and affects the doors’ functioning is that the doors are getting old and
have sufficient “give” in them that they can be manipulated. They respond to
the charge that COs are simply failing to adequately check the doors in two
ways: First, they acknowledge that sometimes this may be so, but assert that
lack of time caused by understaffing leaves them unable to give the extra time
that would be required to inspect the frame of each door each time an inmate is
returned to a cell and then to shake the door for a few seconds after it has been
closed. Estimates of the time this would take ranged from 20 seconds to one
minute per door. As a regular part of their work, COs often return 50 inmates
at a time to their cells (two to a cell). If they must spend an extra 20 seconds
at each door of 25 cells, they have just built in an extra eight minutes5 into

3 This is part of management’s explanation for not seeking funds to replace the doors earlier.
4 An inquiring administrator might regard the 20 to 30% of locks the lock repairman reports
as actually being broken as a sufficient percentage of broken locks to raise concerns in a
prison setting.
5 20 seconds times 25 cells = 500 seconds. Divided by 60 seconds per minute, the added 20-

second intervals per pod add 8.33 minutes.

9
that task of returning inmates– which must then be repeated to let the next
pod of inmates out for or return from meals or recreation or programming.
Delays of 16 minutes here and there add up to delays of an hour or more, and
delaying taking inmates for their necessary meals, showers, phone calls,
recreation, visitation, classes and other activities makes the inmates
dissatisfied. One Lieutenant estimated the time necessary to do a careful
lockdown and inspection at one minute per door. Adding one minute per door
increases inmate movement time by 25 minutes per pod for each inmate-pod
movement, a number that would add delays of a couple of hours in a CO’s day.
If a CO finds a problem with a door, additional time is spent writing the
required report and work order. Second, diverting attention away from the
inmates being locked down poses a security risk.

After much discussion and consideration of the positions advocated by

the interviewees and after viewing several videos of the doors in action, we
concluded that the truth lies somewhere in the middle of the opposing views. It
is clear that the inmates do cap and manipulate the doors. Evidence of this
has been presented time and again. Indeed, even ADC’s own website contains
a video made at Lewis Prison in 2006 demonstrating how the doors can be
obstructed, register as “secure” on the control panel, yet be able to be opened.
But it also is clear that some of the locks are just broken, as evidenced by the
many work orders requesting lock repairs that must be serviced or fulfilled by
lock maintenance staff. They simply will not close, lock, and stay locked.
Finally, several COs spoke of the sound and feel of the doors. As doors get
older and start to deteriorate, they become more difficult to close, may stick,
and fully secure less and less often. Lewis Prison was built in the late 1990s.
The doors are now 20 years old. While that is relatively new in the context of
Arizona prisons, the doors get much use, and their proper functioning is
essential to safe, secure prisons.

So despite initial disagreement about whether the doors are broken,

consensus has now been reached that not all doors effectively and reliably
close, lock, and secure the inmates. The inmates’ ability to UA their doors
presents an untenable security risk that must be remedied.

B. Scope of the Inmate UA Problem

We attempted to determine the scope of the problem – that is, the

frequency with which inmates left their cells. But we found that Lewis records
are not sufficiently complete to make an accurate determination possible. One
supervisor with extensive experience in reviewing reports of inmate UAs
estimated that from 50 to 70 percent of such incidents were not reported. Our
review of various reports and then viewing related video appeared to confirm
that observation. For instance, a report from the warden to the North Regional
Operations Director on July 18, 2018, referred to “a number of unwitnessed
10
assaults” that had recently occurred in cells, but reports of numbers of such
assaults could not be found. Certainly COs reported a number of inmate UAs,
but no written reports reflect the large number of UAs described by those with
whom we spoke.

Several explanations exist for the failure to report. Some COs apparently
concluded that filing disciplinary reports for inmates out of their cells was a
waste of time because meaningful inmate discipline was not likely to occur;
others failed to file reports because they did not have time to do so; while still
others may not have wished to incur the inmates’ wrath for strictly adhering to
discipline protocols. Other COs stated that supervisors told them not to file
disciplinary reports or reports for non-locking doors if the inmates returned to
their cells when ordered to do so. Failure to report did not end with the COs.
We found numerous examples of reports by deputy wardens and wardens that
failed to accurately and completely describe an incident entitled to attention
from leadership. The net result of these failures is that obtaining an accurate
picture of the extent of inmate activity is not possible based on the reports
filed.

The failure to report and failure to file complete, detailed reports

involving security devices may derive at least in part from the fact that the COs
do not have access to an electronic reporting method and so record
handwritten entries in their Correctional Logs using Form 105-6. See Arizona
Department of Corrections Department Order Manual, Chapter 700, sec. 1.1.3.
Initial reports following up are often hand-written as well. Information in them
therefore is not available to automatically populate later reports, so time is
wasted – and the possibility of error creeps in – as information is re-written on
later-stage reports. The additional time required to produce reports under
those circumstances makes producing a complete record less likely.

In addition, COs do not communicate with first-and second-line

supervisors by electronic means. When information must be transmitted
quickly, transmission must take place through telephone calls, radio
transmissions, or hand-delivery of written documents. Only the latter provides
a record of the substance of the communication. Particularly in situations in
which conveying information quickly and accurately is important, a secure
messaging or email system would be useful.6

Because of deficiencies in the reports, we were not able to fully document

the scope of the problem.

6 We recognize that security concerns in the prison militate against providing COs personal
devices that are internet enabled, unless there is adequate security.
11
 C. Causes of the Inmate UA Problem

Even taking into account the difficulty with the doors, a situation that
exists to some extent at other prisons, the inmates’ freedom to UA their cells at
Lewis appears dramatically worse than it is elsewhere in the system.7 We
attempted to ascertain why, and concluded that the ability of inmates to leave
their cells without authorization cannot be attributed to any single factor.
Rather, a confluence of factors, some of them existing in the prison system and
magnified at Lewis prison for many years, coalesced to create the current
situation.

1. Status of Locks

When we began this review, we anticipated we would find that the

inmates’ ability to leave allegedly secure cells resulted from failures of
outdated, non-functioning doors and locks. As noted above, however, we
learned that, although the age of the doors and locks and the lack of sufficient
preventative maintenance contributed to the situation Lewis faced, for much of
prison management, the inmates’ ability to manipulate the doors was of greater
concern in 2017 and 2018.

For many years, inmates in Arizona’s prisons have found ways to

defeat the locking mechanism of cell doors. At Lewis, the inmates learned to
“cap” or manipulate their doors. The impact of capping was magnified by the
fact that, for reasons described below, a CO frequently made only a cursory
check and did not remove the item, making unauthorized access possible. The
status of the locks therefore contributed to but does not entirely explain the
ability of the inmates to leave their cells.

2. Staffing Issues

Most of those with whom we spoke identified staff shortages as a major

reason for lack of inmate control. Our examination of staff levels from FY 2005
to the present confirmed that ADC staffing, particularly for the COII position,
has often been substantially below the level ADC considers adequate for safety
and control.

Several legislative actions affected staff levels. The first occurred in FY

2006, when the legislature swept 565 CO positions to fund a pay increase for

7
During the course of interviews, we were told that the prisons at Winslow, Tucson (Cimarron
and Rincon Units), and Yuma also experience lock problems, although not to the extent that
Lewis Prison does. Yuma Prison features the same model of doors used at Lewis but does not
have the same problem with mass inmate exits, perhaps because it has a far lower vacancy
rate for COIIs. Perhaps the most high-profile failure was the 1997 episode from Perryville
Prison reported in State v. Cropper, in which an inmate got out of his cell and killed
Correctional Officer Brent Lumley.
12
the occupied positions. The impact at Lewis Prison was to reduce authorized
CO positions from 1,035 in FY 2005 to 936 in FY 2006, even as the average
daily inmate population increased, and left fewer COs available to oversee more
inmates at Lewis and statewide. (See Attachment 1.)

The next impact on authorized positions occurred in FY 2010, when

the legislature mandated a 5 percent General Fund Full Time Employee (FTE)
reduction across all State agencies. For the prison system, that mandate
resulted in a loss of 487 FTE positions, including 113 supervisory positions
and 51 maintenance positions. Then, in FY 2012, partly in response to adding
4,000 state prison beds, the legislature authorized an additional 293 COs. (See
Attachments 2 and 3.) Finally, during FY 2012 and 2013, additional CO
positions were authorized, leading to an increase at Lewis of CO positions from
861 in FY 2011 to 916 in FY 2014. (See Attachment 1.) At Lewis, both
authorized and filled positions reached their peak in FY 2016, when the prison
had 1,038 authorized and 957 filled CO positions. Id.8 During those years, the
average daily inmate population also increased, from 4,688 in FY 2006 to 5,769
in FY 2016. Id.

Lewis was designed for staffing of 30 COs in each unit, but Warden
Larson reportedly cut staffing to 21. On some days, the units operate with far
fewer. In extreme situations, such as days on which a large number of COs
“call-in” asking to be excused from duty or days with a large number of inmate
medical visits or programming activities or other CO assignments, staffing can
be as sparse as 15 to 16 COs. The shortage of staff poses dangers to the COs
who often have to work without ready back-up, and it predictably led to various
problems. First, as noted in Section IV.A above, the short staffing left less time
for COs to carefully inspect each door frame and shake the door to ensure that
it was secured as they removed inmates or returned them to their cells. Staff
also hesitated to hold inmates accountable because (a) they feared a physical
response from the inmates and lacked sufficient backup from other COs on
units also short-staffed and (b) they did not want to spend time completing the
paperwork required to impose discipline.

Second, the FY 2010 loss of maintenance positions directly reduced

the staff time available to repair doors and nearly eliminated the time available
for preventative maintenance. Those responsible for completing and
supervising maintenance emphasized that the few remaining maintenance staff
simply did not have sufficient time to inspect the doors for flaws or to

8 Although several administrators tied low staffing levels to the reduction in FY 2006, in fact

neither Lewis nor the statewide system ever filled all authorized positions. Vacancy rates vary
considerably, from 2.5 percent statewide in FY 2007 to a projected 19.7 percent in FY 2020,
corresponding with the five hundred and one thousand authorized positions that have
remained vacant each year since 2015. If ADC were able to fill those positions, most of the
staff shortage would be eliminated. See Attachment 2.
13
document the repairs that were made. Several supervisors described the door
crews as losing motivation because they knew they could not complete their
work.

Third, staff shortages negatively affected training new COIIs. The high
turnover resulted in having fewer experienced officers, which meant that less
time was available to train, and the training that was done was performed by
less seasoned officers. The lack of training, in turn, meant that new COIIs
were less able to effectively handle difficult situations with inmates.

The impact of understaffing was, in the view of at least one supervisor,

exacerbated by the decision to move to 12-hour shifts. Eventually, he said,
experienced staff simply burned out and left, making training ever more
difficult to accomplish.

3. Staff Morale
Nearly everyone with whom we spoke, supervisors and COs alike,
agreed that staff shortages eventually affected staff morale and resulted in staff
not completing security checks of cell doors. They suggested that, faced with
too little time to complete their tasks, the COs either gave up or became
complacent. Complacency became a particular problem after pins were
installed in 2018, as some staff relied upon the pins to secure cells and became
less concerned about making certain the inmates had not capped the doors.
Others believed that staff failed to check doors properly either because they
had never been properly trained or because they just became lazy. Others
suggested that, for security reasons, a number of the COs were afraid to
confront inmates, so they chose to allow the inmates to act as they wished.
Whatever the reason for individual officers, the failure of the COs to make sure
the doors were secure and not obstructed resulted in inmates being able to
leave their cells almost at will. Inmates being outside their cells became a daily
occurrence. As this spiral of indifference by COs and bad behavior by inmates
continued, the morale of the COs dropped.

4. Leadership

Many of the issues involving COs could have been corrected or at least
alleviated with better leadership. Several COs and persons in lower
supervisory positions told us of instances in which leadership failed to hold
those whom they supervised accountable for failing to complete their duties.
We heard of supervisors who told COs not to complete required reports or to
obstruct rather than disclose incidents that could be seen as reflecting badly
on those in charge.

We found a general, although not universal, concern that the COs

could not depend upon leadership to support them. We heard criticism about

14
supervisors who spent most of their time in an office rather than being on the
floor, where they could support and help mentor and train the COs – and learn
about what was going on in the pods. Several persons were particularly critical
of the Lewis leadership during 2017 and 2018.

Several members of upper management suggested that the problems

existing at Lewis in 2017 and 2018 are traceable at least in part to the lack of
quality staff and leadership from the time the prison opened. They explained
that, to convince staff to come to Lewis, persons who otherwise would not have
qualified for promotions received them on the basis of only an oral exam. That
view is not shared by all; we also heard that the initial staff included some
seasoned and capable deputy wardens, wardens, and captains. If the failure of
initial leadership had been as extreme as some suggested, we would have
expected problems to have developed sooner than they did. Inmates could
have tampered with the locks by obstructing them at any time. It seems
unlikely that the issues of 2017 can be closely traced to leadership issues in
1998.

The conclusion we heard from some, that leadership and prison

management had completely broken down at Lewis by 2018, may be extreme,
but does reflect the level of frustration we found.

5. Prison Gangs
The consensus of those with whom we spoke was that, although
inmates had been able to UA their cells for many years, doing so did not
become a real problem until late 2017 or 2018. We asked each interviewee
what happened in 2017 to cause a change, and most did not provide an
explanation.9 Some mentioned the lack of leadership, discussed above. One
person noted that, in 2017, participation in prison gangs became noticeably
more prevalent, and communicating with gang members or reaching members
of competing gangs provided motivation for the inmates to leave their cells and
enter others. That situation would have been aggravated by the fact that the
gang unit failed to validate10 any gang members for more than a year, thus
failing to provide the information needed to move suspected gang members to
another unit or complex.

9 As noted elsewhere, some of the interviewees believe that serious problems with locks did
not develop until 2018.
10 Validation is a process for determining whether an inmate is affiliated with a prison gang.

Once an inmate is validated as a gang member, the inmate may be transferred to a different
prison or to a higher security level.
15
 6. Pinning Cells

Ironically, one of the steps ADC took to keep the inmates in their cells
may have actually increased the frequency of UAs. That was the decision to
use pins, or hasps, on the doors in the Lewis close custody units. The pins are
8-inch steel rods attached to chains and welded to the door frame. Once a cell
door was closed, the pin could be inserted through metal brackets that were
also welded to the doors. The pinning procedure was intended as a redundant
security system, not a primary one; the primary system remained the locking
mechanism on the door. But because the pins were in place, COs may have
become complacent about ensuring that the doors were fully secured before
pinning. Interviewees reported that adding the pins angered the inmates, who
responded by having “pod porters,” inmates who were allowed out of their cells
to perform specific functions, remove the pins or by breaking their cell windows
and removing them. So a system intended to remedy UAs may have
exacerbated the problem and have been a cause of the upswing in mass inmate
UAs.

V. EFFORTS TO ADDRESS DOOR AND LOCK

ISSUES AT LEWIS PRISON

After the videos of assaults at Lewis aired, ADC responded to media

questions about why inmates were able to leave their cells and why effective
preventative actions had not been taken by the Department. In its initial
response, the Department indicated that Director Ryan was not aware until
May 2018 that Lewis had experienced a “material increase” in the incidents of
inmate lock tampering and cell door malfunctions. Shortly thereafter, the
Department corrected its statement to indicate that the Director became aware
of inmate tampering and lock malfunctions in November 2017 and immediately
took corrective action.11
Once ADC leaders acknowledged that having prison cell doors that
inmates could “access” or open without authorization posed a safety risk for
staff and inmate safety, they took several steps to mitigate the problem.

11 In its statement, the Department apparently distinguished individual instances of inmate

lock tampering, which the Department recognizes have occurred for decades, from some other
type of material increase “in the incidents of inmate lock tampering and cell door
malfunctions.” The Department may be suggesting that the increase it noted was in cell exits
involving more than one or two inmates. If so, we do not find documentary evidence to support
that distinction, although we recognize that the reports of UAs may not include all instances of
mass exits.
16
 A. Pinning the Doors

The first and most aggressive step the Department took involved
pinning the cell doors at Lewis.12 Pins apparently were authorized in November
2017 and installed between January and June 2018 in the Morey, Buckley,
and Rast Units at Lewis Prison Complex.

During our interviews and review of documents, we examined both

when ADC made the decision to place pins in the Lewis cells and whether ADC
records support the stated justification, that a material increase in incidents
related to the doors and locks occurred in 2017. We examined reports that
should reveal whether a material increase in incidents occurred and spoke with
personnel involved with the decisions of whether and when to pin the doors.

1. Timing of the Decision to Pin Doors

Given the importance of the Department’s decision to pin the doors, we

expected to find detailed information about the reasons for and timing of the
decision. Instead we found limited records that raise questions about both the
timing and justification for the decision to pin.

Although the Lewis records for 2017 do not include frequent

discussions of whether to pin doors, we did find some evidence of discussions
of the pins in the months before the Director says he first learned of UA
problems. In a September 19, 2017, memo, Deputy Warden James Roan
reported to Warden Larson that staff “have been advised during the DW-COII
meeting that a ‘pin’ system will be installed eventually. Until then, emphasis
will be put on the timely submission of work orders and follow-up for
completion.” The timing of this statement is consistent with the memory of
several supervisors at Lewis who recall being sent to the prison complex in
Winslow during the summer of 2017 to learn about installing a pinning system.
These supervisors believed that the move toward pinning was attributable not
to any big increase in UAs, but rather to the fact that the then-current
Northern Region Operations Director (NROD) had used pins previously and
supported that approach. Purchase records show total expenditures of
$9,080.63 for pins, chains and steel between September and December 2017.13
Minutes of a meeting held by Warden Larson on November 2, 2017, state that
Morey will be the first unit to have pins installed, suggesting again that the

12
As explained earlier, see § V.F, pins are 8-inch steel rods attached to chains and welded to
the door frame. Once a cell door is closed, the pin is inserted through metal brackets welded to
the doors.
13 Most of the funds involved, $6,100.00, were authorized by the Director on December 19,

2017.
17
decision to pin had been made before November 2017 and without any mention
of a material increase in UAs.14
2. Motivation for Pinning: Did a “material increase” in Inmate UAs
Occur before November 2017?

ADC attributes the decision to pin the doors to a “material increase” in

inmate UAs. We attempted to verify that assertion.
ADC has adopted a comprehensive set of Department Orders that
direct the filing of a number of reports when staff members note deficiencies in
security devices, which include doors and locks. See Arizona Department of
Corrections: Department Order Manual (Order Manual), Ch. 700, sec. 703.
We reviewed hundreds of pages of those reports, beginning with 2017, in an
attempt to identify any point at which UA incidents materially increased.
While, as noted elsewhere, these reports are not always complete or sufficiently
detailed to be entirely confident of conclusions based on them, the reports
provided us show examples of UAs in 2017 but do not, on the whole, support
the notion that incidents materially increased during the latter part of 2017.
The report most closely related to our inquiry appears to be that
required of the Chief of Security or his or her designee, who must file a monthly
report describing security device deficiencies and the actions taken to repair
those deficiencies. Order Manual, Ch. 700, sec. 1.1.3. Looking first to the
reports for the Morey Unit, the report for February indicates that some cell
doors show unsecure on the control panel even though they are secure, and
reports for the next several months describe problems with slider doors.
Several mentions are made of cell doors that can be opened, with reports of
multiple doors that can be opened in March and June, but only two being
mentioned in July and four in September. Not until the middle of November,
after the Morey staff had been told that pinning would begin in that unit, does
this report list a substantial number of doors that can be opened from the
inside. The November report lists 40 doors that can be opened, with work
order repair dates ranging from November 18 to November 27.15 The December
report indicates that all the cell door deficiencies noted in November had been
repaired.

14 We requested any memoranda or orders from the Director ordering the installation of pins,
but none was provided.
15
The more detailed reports may be related to the finding of the Inspector General Bureau
Audit Unit’s Annual Audit Report for ASPC Lewis, which found that neither the Morey Unit nor
the Stiner Unit could show completion of the required monthly comprehensive security device
inspection by the Chief of Security. See 2017 Annual Audit for ASPC Lewis (August 2017) at
79, 112. In fact, the Audit Report noted, the Deputy Wardens, Associate Deputy Wardens, and
supervisory staff did not submit the required 703 reports to the Warden or Regional Operations
Director on a monthly basis. Audit Report at 3.
18
 The reports for the Rast Unit follow much the same pattern. For
January through April, the main concern expressed about cell doors is that
approximately 16 show unsecure on the control panel when they are actually
secure. Two doors, the report notes in January, can be opened by inmates.
The May report notes one door that can be easily opened but does not show
unsecure; July notes one cell door will not close. For those months, the report
also notes problems with some sliders. By October, the report notes two cell
doors will not secure and seven show unsecure. By November, eight cell doors
can be opened from the inside but show secured. And, by December 20, 2017,
the report notes 13 doors that can be opened from the inside and 16
malfunctioning doors. These reports, while they reveal the ongoing problem
with inmates being able to open their cell doors without authorization, do not
show a material increase in such activities in September through October that
would prompt a decision to pin in November 2017.

But other reports could have been more specific in reporting problems
with cell doors opening. The Order Manual also directs the Warden to submit
a monthly memorandum to the NROD; among other topics, the memorandum
covers observations about security operations, the incident command system,
and staff professional conduct. Order Manual, Ch. 700, sec. 2.3.1. That report
made no mention of cells or locks in January 2017, although three inmates
were assaulted in their cells, and two died. In February, the report notes that
the Stiner run “began to fill with inmates” and that Rast has adopted enhanced
cell procedure to combat inmates who UA their doors. The report does not
report problems with doors or locks from March through May, although two
more inmates died from assaults within their cells and another was found
unresponsive. The June report notes another inmate assaulted in his cell and
reprimands a COII who allowed pod doors to be unsecure with multiple
inmates out. The July report notes that a large group of inmates became
combative and began striking staff members and that another group
simultaneously broke the trap doors on their cells in Stiner Detention. The
August report notes that approximately seven inmates were involved in an
assault on another, who told staff they “popped” his door. The September
report, however, includes nothing relevant to this issue. In October, the
warden notes safety concerns at Morey related to current staffing levels and
reports an ICS called involving the death of Inmate Diaz. In November, the
warden reports that additional staff at Morey has helped morale tremendously
and that there has been a marked decrease in assaults.

We also examined other documents in an attempt to define the reasons

for the decision to install pins at Lewis beginning in January 2018. We
requested and reviewed minutes of meetings held by the respective wardens at
Lewis. The minutes from the Warden’s meeting with COIIs on August 30,
2017, reflect that doors are “constantly breaking” and that Lewis has two
dedicated officers working every day to make repairs. On the same day, in her
meeting with the Lieutenants, the Warden “demonstrated the proposed new

19
door locks for close custody cells.” In her meeting on November 20, 2017, the
warden discussed the upcoming door control job schedule. Although the
minutes demonstrate awareness of the problems with the doors, they do not
help to define that point at which issues involving these security devices
materially increased.
We also requested that the disciplinary coordinator assemble all
Inmate Disciplinary Reports related to assaults, beginning in 2017. If an
inmate UAs his cell, a disciplinary report should be filed. Although we learned
that the COIIs often did not institute disciplinary proceedings, those that were
filed should provide an indication of whether and when UAs increased. Those
incident reports also do not reflect a pattern of increased activity during 2017.
Most of the assaults that resulted in discipline do not involve an inmate leaving
a cell without permission. The number of such incidents ranged from one in
January, August, October, and November to four in May and two in December.

The reports we reviewed show a relatively consistent level of UAs, with

some months experiencing a higher activity level than others. None of the
reports we reviewed provide substantial support for the statement that pins
became necessary in late 2017 because of an increased incidence of inmates
leaving their cells or because of a notable increase in doors malfunctioning. If
pins were indicated by the end of 2017, presumably that same decision would
have been justified earlier in the year.

3. Success of the Pins in Remedying UAs

The decision to use pins did affect the frequency of UAs and staff and
inmate assaults. The effect, unfortunately, was to increase those incidents.
Interviewees reported that adding the pins angered the inmates, who
responded by having “pod porters” remove the pins or by breaking their cell
windows and removing the pins themselves. So a system intended to remedy
UAs may have instead exacerbated the problem.16
Monthly reports from the warden to the NROD clearly reflect the
continued and growing struggle with inmates pulling pins and with failing
doors. See, e.g., Warden to NROD Memoranda, March 2018 (unit doors
constantly failing or being manipulated by inmates; many pins do not engage);
May 2018 (unit doors constantly failing or being manipulated by inmates;
porters continue to unpin; too many cell doors open); June 2018 (inmates still
capping cell doors and intentionally bending pins; porters continue to unpin;
too many inmates left out and unsecured); July 2018 (inmates capping,
manipulating, intentionally bending pins; some doorways out of alignment;

16 The pins were a failure in another significant respect as well. The inmates learned that by
pulling the pin inside the cell and slamming the cell door, they could break the chain, leaving
the inmates with, in essence, an 8-inch metal shank – a dangerous weapon. The work order
documents reflect pins missing from several doors, and time and effort was expended by COs
trying to retrieve them.
20
unwitnessed assaults; staffing level; decreasing performance and increasing
turnover rate); August 2018 (multiple ICSs due to disruptive inmates that
pulled door pins and refused to lock down); September 2018 (inmates continue
to unpin and UA); October 2018 (doors easily opened by inmates; maintenance
issues and manipulating by obstructing; inmates have destroyed much of
secondary pin system; inmate UAs a danger to staff and other inmates);
November 2018 (same concerns as voiced in October; UAs have resulted in
numerous ICSs and a draw on staff resources); December 2018 (cells doors
continue to be a problem; inmates, despite pins, still able to access doors with
impunity; door pins of little value; doors go through various stages of
degradation).

The frequency of assaults against officers and inmates also increased,

particularly in the last half of 2018. During the first six months of 2018, five
incidents involving serious injury occurred at Lewis, with three involving
unwitnessed assaults on inmates and two inmates assaulted outside the cells.
From July through December, four more inmates suffered serious assaults, one
unwitnessed inside a cell. There were also seven incidents of staff assaults
during that time, some involving injury to more than one officer. A video of the
last 2018 incident, involving COII Nash on December 30, 2018, was distributed
by news media in April 2019.
By mid-year, it was clear that pinning had not resolved the UA
problem.
B. Strategic Initiative A3 Project

In January 2019, ADC instituted the A3 Project, which focused on

reducing staff assaults. Although not specifically directed toward resolving
UAs, the A3 project related to an aspect of the problem. It began as a pilot
program at Morey unit and also at Eyman/SMU-I, and ran through March 21,
2019, at which time it was extended for 60 days to gather additional data. The
program required interviews of staff and inmates involved in assaults about the
causes of assaults. The primary reasons proved to be “ineffective
communication and/or approach by both staff and inmates, inmate
opportunity to commit the assault (meaning the victim is whoever is present
when the opportunity to assault a staff member is available to an inmate), the
officer’s attitude and/or the inmate’s mental health score.” The initial 60-day
pilot showed fewer reported assaults on staff and the program resulted in two
ideas that were implemented: (1) security sergeants walked each pod each day
to talk to inmates and document issues to be followed up on, and also to
mentor correctional officers, and (2) ADC adopted programs to resolve inmate
grievances in the early stages of the process.17 We cannot determine the effect

17These responses come from the answer to question 2 on a 4-page questionnaire produced by
Director Ryan at his interview on 6/10/2019. Although the A3 program addresses staff
21
of these two implemented processes on reducing UAs, although in an August 8
interview, Director Ryan expressed the view that there had been several “quick
wins” from making small changes resulting from ideas elicited in listening
programs and the direct-line to the Director, ideas generated as a result of the
A3 Initiative.

C. New Leadership Team at Lewis

In June 2018, Director Ryan and others made an unannounced visit to
Lewis prison. They were dismayed at what they saw – broken windows,
laundry strewn around, dirty cells, clotheslines in cells, and general
unkemptness. By September, it was clear to prison leadership that the pinning
system was failing to secure inmates. These and other observations led the
Director to advise the leadership on September 7 to clean things up within
three months. But the September 29 assault on Officer Peralta, the November
fires at Rast, and other factors, caused the Director to issue an order effective
in January 2019 changing the leadership team at Lewis prison.
This included transferring or demoting the warden (transfer effective in
December 2018), the deputy warden of operations, four deputy wardens and
the Complex Major. Those interviewed generally agreed that the replacement
was appropriate and that the new leadership team, though faced with a
difficult situation, was taking steps to improve cleanliness, morale, and
discipline. The new leadership team has overseen the installation of padlocks
on cells, emphasized getting inmates into programs, and created a five-member
Quick Response Force (QRF) to respond quickly to security incidents involving
assaults, to hold inmates accountable, and to “have the backs” of correctional
officers.

D. Command Meeting
In September 2018, Director Ryan called a senior/command meeting
during which he ordered more random and unannounced visits to Lewis and
directed Division Director of Prison Operations Carson McWilliams and North
Region Operations Director Ernie Trujillo, who were to retire within the year, to
“‘think about replacement leadership’ for themselves.”

E. Significant Incident Reports

In December 2018, Significant Incident Reports became required for all
lock-related issues. These reports go up the chain of command and so are
designed to provide notice to higher-ups.

assaults, not necessarily issues related to inmates being out of their cells, it is included here
because assaults are a primary reason for concern about inmates’ ability to leave their cells.
22
 F. Padlocking the Cells

Effective January 2019, leadership designated two pods of 25 cells

each to be padlocked in each unit (a total of 825 padlocked cells).18 Inmates
who accessed their doors and refused to return to their cells when instructed to
do so were placed in padlocked cells. Once the use of padlocks became known,
there was pushback from visitors, inmates, fire marshals and others, although
the State Fire Marshal and Buckeye Fire Marshal eventually approved
temporary use of the padlocks.19

Prison cell doors are designed to open automatically from a control

center so that several cells can be released or locked at one time. The ability to
quickly open cell doors can become important in the event of a fire or other
emergency. Although pinning precluded release from the control panel, it
nonetheless allowed relatively easy access to cells should inmates need to be
released quickly. Padlocks, however, must be individually unlocked, which
takes time and may challenge the courage of any CO who must enter a burning
unit to unlock inmates’ cells. And as with other locking mechanisms, the
padlocks were subject to inmate tampering. If locks were left on the doors,
inmates could jam the key hole. For that reason, COs were required to
completely remove the padlock and carry it away each time they opened a
padlocked cell. In rare instances, inmates were able to remove padlocks or find
unsecured padlocks, and these could be placed in a sock and used as a
weapon. So while padlocks successfully secured inmates in cells, they were
heavy, time consuming, and not an acceptable long-term solution.

G. Step Down Program

At some point in 2019, supervisors at Lewis instituted a step down
program, which used inmate “leaders” – those who had influence over other
inmates – to help control inmate behavior and keep the peace. These inmate
leaders were rewarded by extra privileges and withholding discipline. These
privileges reportedly made other inmates unhappy. When asked what makes
inmates influential, interviewees told us that it was sometimes personality and
often because of the inmates’ connections, such as gang leadership positions or
affiliation.

This model of inmate-on-inmate discipline did not prove successful.

Although the paper records show that assaults appear to have gone down in
frequency, interviewees told us that the assaults just occurred within the cells
(where there are no video cameras) and weren’t reported and, with increasing

18 The number of padlocked cells has gradually increased, reaching 1,000 cells at Lewis by
May 5, 2019.
19
These responses come from the answer to question 3, pp. 2-3, on a 4-page questionnaire produced by Director
Ryan at his interview on 6/10/2019.
23
frequency, the “discipline” administered by the inmates was physical and
severe.

H. Moving Morey Inmates

Starting on May 6 and ending May 15, 2019, ADC moved 71620
inmates from Morey Unit in order to rehouse inmates who had been in
padlocked cells and others, enhance staffing levels, and begin “installment of a
long-term solution” – that is, to install doors with a new locking system. This
move was recommended by a statewide team formed by the Governor’s office to
help resolve problems at Lewis prison. Shortly before this mass move, starting
in January 2019, 70 “problematic/predatory” inmates from Morey and Stiner
were moved to other institutions and other, more compliant inmates were
brought in to replace them.

I. National Survey of Locking Systems

ADC contacted several jurisdictions, perhaps as many as 47, about
the cell doors and locking systems used in their penal systems to find potential
solutions for Arizona’s cell door problem. It invited representatives from lock
companies to come to Arizona to make presentations about their products.
That has occurred, and finalists are being considered.

J. State Team
Although not a response initiated by ADC, following the airing of the
assault video on Channel 15 in April 2019, the Governor’s office pulled together
a team to help ADC assess the situation at Lewis Prison and offer suggestions
to help guide ADC through the crisis. The team consisted of Nola Barnes
(ADOA), Josiah Brandt (State Fire Marshal), Heston Silbert (Deputy Dir., DPS),
Billy Long (Phoenix Police Supervisor, ret.), and Gilbert Orrantia (Dir. Arizona
Dep’t of Homeland Security). Gilbert Davidson, State COO, also attended many
meetings. The group met daily until June 25, including by phone on the
weekends. By then, “a rhythm had been established” and the group did not
touch base so regularly. This team recommended moving the Morey prisoners,
setting up a communications hotline to field and respond to calls regarding the
locks situation, and daily telephonic meetings for the ADC leadership team to
discuss all problems.

K. Requests for Funds

20 Media reports and some internal reports say ADC re-housed 800 inmates, but ADC records
from that time report moving 716. Although Morey Unit contains housing for 800 inmates,
because 64 beds were already vacant and 20 soon-to-be-released inmates weren’t transferred,
the correct number moved was 716.

24
 Each interviewee was asked how to remedy the inmate “unauthorized
access” issue. Without exception, each mentioned replacing the locking
systems with a system not easily manipulated by inmates, while acknowledging
the need for the resources to accomplish that task. We therefore looked to see
whether ADC had made requests in its annual capital budget submissions to
ADOA for funds to repair the locks.21

1. ADC Budget Process

ADC’s annual operations budget is approximately $1.1 B, much of it
allocated to “security.” But most of that operations budget is attributable to
personnel costs. New capital projects and substantial hardware costs such as
those needed to change the locking system must come from the Capital
Improvement Program (CIP) funding, building renewal funds, or special
appropriations. The capital (vs. operational) budget process for state agencies
requires each agency to submit its capital improvement funding requests to
ADOA, see A.R.S. § 41-793, so ADOA can consider requests from state agencies
as a whole and adjust agencies’ budget requests to reflect ADOA’s prioritization
of statewide capital improvement needs. This process regularly results in
agencies’ requests being reduced from the amounts the agencies originally
sought. With this process in mind, we asked for information on how much
money ADC requested each year to repair or replace locking mechanisms at
Lewis Complex and also for the prison system as a whole, how much ADOA
approved in its Capital Improvement Projects (CIP) requests to the legislature,
and how much the Legislature appropriated in each fiscal year (FY) for lock
repair and replacement.

2. ADC Requests for Funds for Locking Systems

We reviewed budget submissions from 2005-2020 to see whether the

Department of Corrections recognized the need for money to repair locks at
Lewis prison and annually requested capital improvement funds for that
purpose. Review of the DOC Capital Improvement Plans shows that during
this period, ADC annually submitted requests ranging from a low of
$28,808,505 (FY 2016, 2017, and 2018) to a high of $65,210,205 in 2009 to
repair locking systems in the prison system as a whole. In the ten years the
agency has ranked its capital priorities and stated the result of not getting the
funds, ADC each year ranked the priority of its locks capital request as either 1

21
We looked at submissions to ADOA rather than to the Legislature because ADOA may cut
the amount an agency requests before it is submitted to the Legislature and we were interested
in seeing how much ADC had requested, not how much ADOA chose to pass along. There are,
of course, other funding streams that could be accessed to help repair or replace doors. For
example, maintenance personnel such as locksmiths repair locks, but are paid out of ADC’s
operations budget. ADC also earns income from ACI inmate services and labor, and fees raised
by charges on inmate banking, phone calls, visitation, and other services. One budget
specialist speculated that ADOA Risk Management might be able to provide funds.
25
(8 times) or 2 (two times), and scored the “impact of failure” of locks as “life
safety.”

Oddly, however, although ADC leadership recognized the serious issue

with broken locks statewide, the Lewis Complex was included in the budget
requests for capital improvement funds for “Prison Facility Locking Systems
Requests” only in 2011, 2012, and 2013. That is, the Lewis Complex was not
included in the requests for funds for prison locking systems in 2014, 2015,
2016, 2017, 2018, 2019, or 2020. (See Attachment 4.) This is so even though,
by at least 2017-18, assaults and deaths had resulted in part from the ability
of inmates to “access their doors” and leave their cells without having the COs
open the doors for them, and ADC leadership had acknowledged being advised
that inmates’ ability to get out of their cells had become an increasing problem.
Review of ADC’s FY 2005-2020 Locking Systems Requests Summary
shows requests for appropriations for locking systems submitted to ADOA,
DOA’s adjusted CIP request to the legislature, and the legislature’s
appropriations (and ex-appropriations). (See Attachment 5.) The document
shows recognition by ADC of the serious need for funding to repair or replace
locking systems, but a dramatic reduction each year by ADOA from amounts
ADC requested, resulting in lower requests being forwarded to the legislature,
and low levels of funding from the legislature.

For example, ADC’s request to ADOA for capital improvement funds for
locking systems in FY 2005 and again in 2006 is $40.18 M. In 2005, ADOA
recommended $7.9 M and in FY 2006, $8.5 M. The legislature’s appropriation
in each year? $0.

That result is not selective. In 13 of the 16 years represented on

Attachment 5, the legislature appropriated $0 in response to ADC’s CIP
requests for Locking System funding. In 2007 and 2008, when ADC requested
$47.2 and $55 M respectively and the ADOA CIP passed through a request for
$8.5 M, the legislature appropriated $5.2 M, not a bad percentage of the $8.5M
CIP request from ADOA – except that in 2008 and 2009, the legislature ex-
appropriated (that is, took back) $5.2 M, leaving the cumulative funding during
that 4-year period at $5.2, or $1.3 M per year.22 In FY 2018, when ADC
requested $28.8 M and ADOA submitted a CIP request for $7 M for locking
systems, the legislature appropriated $1.45 M. In total, over the FY 2005-2020
period, ADC requested $582.6 M. On ADC’s behalf, ADOA recommended
adjusted CIP requests of $114.1 M, and the legislature appropriated $11.85 M
(minus the 5.2M ex-appropriation, so a total of $6.65). To be clear, although

22 The legislature appropriated $5.2 M in FY 2006 and $5.2 M in 2007 for a “multi-year capital
project” relating to “Replace and Upgrade Cell Doors and Locks; Restore Appropriations Phase
II.” But then in FY 2008 the legislature ex-appropriated $2 M, and in 2009, it ex-appropriated
$3.2 M. That ex-appropriation of funds resulted in DOA cancelling “Unit Security Upgrades” at
ASPC Florence. 2020 ADOA Building System Cap Improvement Plan, p. 14.

26
ADC submitted requests totaling $582 M during the 2005-2020 period, that
amount does not represent locking-system funding needs, but rather
represents an amount inflated by inclusion of amounts resubmitted (because
unfulfilled) over the course of several years. Ironically, in one year (FY 2010),
ADC submitted a $0 request for funds for locking systems repairs, but it
nonetheless received an ADOA CIP recommendation of $5.2. In any event, it
received the typical legislative response: $0.

Since FY 2012, although it still makes requests for new capital funding
through ADOA, ADC has been authorized to receive building renewal funds
directly through dedicated building renewal fund sources. (See A.R.S. § 41-
793.01; 2011 sess. law; ADOA FY 2020 Building System Capital Improvement
Plan p. 4). The amount of building renewal funds for ADC was to be driven by
a formula that should generate approximately $22.3 M annually for capital
renewal projects. But according to interviews at ADC, the legislature has
funded only approximately $5.5 M annually, or just under one-fourth of the
amount ADC should receive under the formula.23
ADOA reports that since ADC began receiving direct funds, “ADC has
completed locking projects at prison complexes across the state at the cost of
$8.81 M and currently has $1,412,29 [sic] in locking projects in its FY 2019
building renewal plan. Estimates for the remaining scope of this funding issue
are currently in the range of $35 million to upgrade or replace locking systems
at all ADC prison complexes.24 ADOA recommends several years of funding
commitment to a phased approach for multi-complex lock and cell door
projects. . . .” (ADOA FY 2020 Building System Capital Improvement Plan, p.
14.) ADOA’s recommended appropriation is $7.0 M. In short, there is some
recognition that money is necessary to help repair or replace the locking
system at the prisons statewide, but the amount necessary for meaningful
repair or replacement has in the past fallen far short of what will be necessary
to remedy the problem.

This snapshot of the budget process shows that, while ADC regularly
requests money for lock system repairs for the statewide prison system, its
message was for years not presented forcefully enough and was not getting
through, either to the ADOA or to the legislature. The picture presented until
mid-2019 is of a somewhat laissez faire attitude by ADC about

23 “The Legislature fully funded the Building System’s building renewal Formula only once in

the last 30 fiscal years (FY 1999),” supporting ADC’s assertion that the formula is not fully
funded. ADOA FY 2020 CIP Report, p. 6.

24 Even if ADC receives only approximately 5.5 M per year from this formula-driven fund, that

sum, over the six years from 2012-2018 would have generated approximately $33 M. Of that,
ADOA reports that $8.81 was spent on locks. ADC does have other serious capital
improvement needs, of course, but given its own ranking of locking systems as #1 or #2 during
these years, it is surprising that a larger share of funds was not devoted to this critical security
need.
27
requesting/demanding money for locks and security and then, if money is
appropriated, actually spending it for that purpose.

On the latter point, we have not been able to determine how much of
the money appropriated was spent on the repair and replacement of locks.
ADC does employ, among their maintenance staff, personnel who repair locks,
and funding for those positions comes through the operations budget. And as
noted above, ADOA reports ADC as having spent $8.81 M on locks projects
from 2012-2018. But we have not been able to trace the money to particular
projects. Nor have we been able to determine why no money was requested for
locks at Lewis prison from 2014-2020. Asked about the absence of requests
for funds to repair locks at Lewis during these years, ADC explained that it
thought that the pinning program it instituted fixed the problem, and so ADC
did not request funds for locks at Lewis. As set forth in the timeline, however,
pinning was not completed until June of 2018, so that reasoning does not
explain the failure to request funds to fix locks at Lewis Prison for 2014, 2015,
2016 and 2017. That absence may be explained by leadership’s belief that the
inmates’ ability to get out of their cells was not attributable to malfunctioning
doors prior to the 2017, but rather was caused by inmate tampering; so
because the doors did not require fixing, there was no reason to request money
for that purpose.
In a follow-up interview on August 8, 2019, Director Ryan noted that
the “locking systems capital budget requests for FY 2011 to FY 2020 were
originally based on the Arrington Watkins Architects statewide locking system
evaluation completed in January 2002. . . . The cell locking systems at the
Lewis Prison Morey, Buckley, and Rast Units were not identified in the 2002
Arrington Watkins evaluation as needing repair. Additionally, the Lewis Prison
did not request repairs for the locking system as part of the annual capital
budget process in years 2014-2020 because the locking systems were
functioning as designed, notwithstanding inmate tampering, which led to the
pinning and eventual padlocking of the doors in 2018 and 2019, at which time
the locking system issues were elevated and included in the agency capital
request process for 2021.”

In its FY 2020 building System Capital Improvements Plan, ADOA does

“recommend[] several years of funding commitment for a phased approach for
multi-complex lock and cell door projects,” but cautions that “[r]eplacement
priorities are subject to change upon further intensive system evaluations.”
While the latter is of course true, the serious life/safety aspect of functioning
doors in a prison should motivate strong commitment to funding this critical
need.

At a June 16, 2019, Joint Committee on Capital Review (JCCR)

presentation, ADC requested $45.9 M for repairs to occur in three phases to fix
the locks, fire alarm and suppression systems, HVAC, and other capital
28
projects. Although lock-related requests are not broken out in the plan, JCCR
gave favorable review for the expenditure of $17.7 M in non-appropriated
funds, of which approximately $16.5 M in Phase 1 is intended to fix 1284 locks
at Lewis Prison; the extra $1.2 M is for repair of fire alarms and fire
suppression systems. ADC and ADOA place the cost of fixing the locking
system at approximately $12-13,000 per door. The full project is expected to
be completed at Lewis in calendar year 2020.25

VI. GRIEVANCES RELATED TO FAULTY LOCKS

Our assignment from the Governor also asked that we determine

whether “any staff or inmates filed grievances regarding the ineffectiveness of
locks at Lewis Prison during this period of time.” Although the time referenced
in the contract for most inquiries is January 1, 2018, to April 30, 2019, we
requested staff to gather grievances going back to 2017. The existence of
frequent grievances by inmates or staff asserting that non-securing doors
placed them in fear for their safety could have provided notice to leadership
that failing doors presented a security risk.

There weren’t many. No inmate grievances were found at Buckley,

Morey, Stiner, Barchey, Bachman, or Eagle Point Units. There was one from
Rast Unit from 2017. In it, an inmate complained that a control room officer
inadvertently opened his cell door, after which he came out of his cell and
wandered around the pod and could have caused trouble. This, he claimed,
jeopardized his own safety and the public’s safety, for which he asked for
installation of a pin on his door – and $10,000 compensation. See case no.
L21-202-017. The grievance was considered, denied, and appealed. On
appeal, the reviewing officer, again denying the claim, noted that the inmate
could have simply remained in his cell, protecting himself and the public from
harm – from himself. Pins were installed on cell doors in Rast in early 2018,
providing the inmate the security relief he sought.
ADC staff located eleven CO grievances involving inmate UAs of their
cells. None, however, grieves the fact that non-working locks place the officers’
safety in jeopardy, an issue one interviewee said was not grievable. Instead, in
most cases reviewed, the officers challenged discipline imposed for failing to
follow guidelines in handling or preventing an incident at the prison, most
involving observing inmates out of cells and failing to order them to lock down.
See, e.g., 2019-0127 (Diaz); 2018-13065 (Markowski); 2018-0911 (Vargas,
Garcia, Ravelo); 2018-1228 (Hawley); 2018-0899 (Wagner); 2018-0497 (Vega).
In each case, there is evidence that one or more inmates were out of their cells
without authorization, but the CO does not grieve the inmates’ ability to get out
and threaten their safety. Rather, they grieve the discipline imposed for failure

25
Note again, however, that the recommendation is to allow ADC to spend non-appropriated
funds. That is, the recommendation does not include new money. ADC is expected to find the
money for Phase 1 in its existing budget.
29
to follow procedures in returning the inmates to their cells or initiate ICS
procedures. Most cases involve fairly minor discipline that would not have
risen to upper management levels. For that reason, none of these grievances
illuminate the subject of this investigation – that is, providing notice to
leadership about the safety threat to COs and inmates posed by the failing
locks.

A few of the staff grievances, those relating to Officers De La Rosa, and

Mischel Wagner, and Sgt. Brian Devous, involved inmate UAs in the sense that
in each, the officer in question forwarded video of incidents that occurred at
Lewis Prison through Facebook or other electronic means.26 In each case the
discipline imposed was rescinded. These reports do not involve staff
complaints about inmate UAs per se.
In short, no useful information was gleaned by examining the
grievances filed by either staff or inmates that would shed light on this inquiry.

VII. ASSAULTS CAUSING SERIOUS INJURY

We also were asked to review assaults on inmates and staff that

occurred between January 1, 2018, and April 30, 2019, and resulted in serious
bodily injury. For those incidents, we were asked to “provide an analysis of the
department’s actions in reviewing the circumstances of each incident and the
actions taken to prevent them from occurring. This includes review of any
criminal and investigative reviews, medical examiner reports, policies and video.”
In addition, we were asked to determine “whether the ineffectiveness of locks
contributed to the conditions that resulted in the assault.”
As a result of our review of ADC records, and with the help of ADC, we
identified 17 assaults that fall within the “serious bodily injury” category
during the relevant time period. All occurred in 2018. They include ten
assaults on inmates by other inmates and seven assaults on corrections
officers, some of which involved more than one officer and one of which
involved a sergeant. We requested and reviewed all criminal and investigative
reviews, medical examiner reports, and policies related to these matters. We
requested and reviewed relevant video recordings related to those incidents for
which video is available and which may have involved the ineffectiveness of
locks.

A. Observations about the Conduct of Investigations

The investigations completed by ADC in each of these instances
followed expected investigative practices. In each instance, the Office of the
Inspector General of the Department of Corrections filed its report. The reports
typically and appropriately include or refer to other investigations, including
those completed by SSU. The investigations involve, and the reports reflect,

26
These cases are filed by employee number.
30
interviews of the victim(s), suspect(s), and witness(es). The reports typically,
although not each time, include a notation as to whether ADC referred the
matter to the Maricopa County Attorney’s Office for consideration for criminal
prosecution. Not surprisingly, in most instances involving inmate on inmate
violence, the victim inmate chose not to request prosecution. In short, nothing
about the conduct of ADC investigations of incidents involving serious bodily
injury appears unusual or inappropriate.

We also compared the assault reports with disciplinary actions. In

most incidents involving injury to a staff officer, discipline was imposed.27 We
found no disciplinary files that imposed discipline for inmate on inmate
violence. We assume this reflects the likelihood that inmates refused to testify
or press charges, so determining the facts would be difficult.
Neither the investigative nor the disciplinary files include suggestions
of actions that ADC can take to prevent future similar occurrences. We would
expect such suggestions to be made in other reports, such as those from the
warden, the chief of security, the NROD. We discuss the actions taken by ADC
in 2018 and 2019 in Section V, above.

B. Ineffective Locks as a Contributing Factor

We were also asked to determine whether the ineffectiveness of locks
at Lewis Prison contributed to the conditions that resulted in assaults causing
serious bodily injury. We note initially that, in reviewing video evidence of the
assaults when that evidence was available, we found most striking the casual
attitude of the inmates who leave their cells, wander the unit, and enter other
cells. The inmates evidence no concern that they are visible on video and they
may be called to account for their actions. The presence of an officer does not
seem to deter this behavior. The videos make very clear the accuracy of the
comments we heard about inmate UAs being an accepted part of prison life at
Lewis.
The incidents reviewed fall into one of three categories. In the first,
effectiveness of the locks seems to have no relationship to the injury-causing
event, often because the incident occurs when inmates are authorized to be out
of their cells for meals or recreation or involves a situation with no indication
that inmates are present without authorization.

27 Inmates Trujillo and Valencia (9/29/18 assault of COII Peralta), Peters and Percy (10/5/18
assault of COII Ballentine); Mendoza (10/13/18 assault of COII Garcia); Garcia, Euceda, and
Rodriguez (10/30/18 assault of COII Pasos); and Luna, Contreras and Zamora (11/22/18
assault of Sgt. Markowski and COII Cardoza) received discipline. Typically, discipline involved
loss of all or some of the inmate’s earned release credits, 30 days loss of privileges and visits,
and 90 to 180 days in Probation Class III. We received no disciplinary files for the assaults on
COIIs Garza and Avila (10/29/18) and COIIs Nash and Duran-Vargas on 12/30/18.
31
 We include in this category Case 2018-10151, in which Inmate Lewis
was stabbed as in ran from the dining hall; 2018-100252, in which Inmate
Olvera was injured in an unwitnessed assault in the common area of House
2C/D; 2018-100275, in which three inmates assaulted Inmate Ellis between
two housing areas; 2018-100431, in which an inmate assaulted COII Garcia
while he was monitoring a metal detector as inmates passed through to lunch;
and 2018-100499, in which Inmate Valdez was injured in Barchey Unit, which
is an open yard. We also would include here 2018-100341, in which Inmate
Mirza was beaten and kicked near a control room by two inmates. The
investigative report does not indicate whether the inmates were outside their
cells without authorization.

The second category covers those assaults for which we cannot tell
whether inmate UAs contributed to the causes of the incidents, although a UA
could have been a contributing factor. These incidents involve inmates who
were assaulted or otherwise injured in a cell or other area not subject to video
surveillance. Although video evidence for some of these incidents shows other
inmates entering or leaving a cell, and one could surmise or guess that an
assault occurred by inmates out of their cells without authorization, the
evidence we saw does not allow us to conclude that the ineffectiveness of locks
contributed to those injuries. We include in this category 2018-100251, in
which Inmate McCormick sustained serious injuries that he attributed to a
seizure and fall. Video evidence shows several inmates outside the cell who did
not enter and others who entered but said they did so only after McCormick
was injured; one inmate said he entered to help McCormick. We cannot
determine whether any of the inmates visible on the video contributed to the
assault or injury. The same concerns surround 2018-100123, in which Inmate
Johnson was found unresponsive and in a puddle of blood in his cell. It is
likely that the assault did involve inmates out of their cells without
authorization, but we cannot reach a definitive conclusion based on the reports
available. Similarly, in 2018-100010, Inmate Bologna’s cellmate found him on
the cell floor with serious multiple injuries to his facial area, after another
inmate, Soriano, allegedly had told the cellmate he had a problem with
Bologna. Video shows Soriano entering the cell, but nothing further can be
seen. Finally, in 2018-100473, Inmate Bociung sustained injuries in an
unwitnessed assault. The inmates who assaulted Bociung found him in a cell
not his own, which suggests that he left his cell and accessed another without
authorization. In addition, another inmate admitted that he went to give
Bociung a “chin-check,” but that it got out of hand. We think it likely that
ineffective locks contributed to this injury, and video shows inmates entering
the cell being visited by Bociung, but the fact that video does not show when
and how the injury occurred results in our placing the incident in this
category.

In a number of incidents involving assaults on officers, ineffective

locks seem clearly related to the injury-causing incident. In case 2018-

32
100407, video shows that Officer Peralta was assaulted after responding to
reports of multiple inmates out of their cells who were refusing to lock down.
The assault in that case would not have occurred if the locks had worked
effectively because multiple inmates would not have been in the pod. In 2018-
100422, UAs also affected the situation that resulted in the assault on Officer
Ballentine. That incident began when Officer Ballentine learned that two
inmates had UA’d their cells and then attempted to move from one cell to
another. Similarly, Officers Garza and Avila, in case 2018-100457, were
injured when an inmate improperly out of his cell came to help two inmates
who were reluctant to enter their cells. In case 2018-100460, Officer Pasos
entered the area in which the assault was committed to lock down inmates who
were out without authorization and who then pulled pins on several other cell
doors. Sergeant Markowski, in case 2018-100484, encountered a situation in
which at least six cell doors were open and at least eight inmates were out of
their cells without authorization. Three of the inmates improperly roaming the
common area assaulted Sgt. Markowski and Officer Contreras. A similar
situation made possible the assault on Officers Nash and Duran-Vargas, who
returned to an area after learning that inmates had UA’d their cells shortly
after the officers had completed a security walk. See case 2018-100514. The
video of that incident, which caused shock when it was broadcast, shows
multiple inmates streaming out of their cells and assaulting the two officers.
One of the assaults on an inmate also appears clearly related to UAs. In case
2018-100080, Inmate Mallory was assaulted in his cell. Unlike most such
assaults, this assault begins with an inmate who is captured by video
punching someone inside the cell, and later the fight spills into the area
outside the cell, where it is clearly captured by video. At least four inmates are
out of their cells and involved in the assault.

Video and written evidence document many more assaults related to

ineffective locks but not resulting in serious injury. We find convincing
evidence that the ineffective locks at Lewis Prison contributed to assaults on
both staff and inmates.

VIII. MANAGEMENT OVERSIGHT AND ACCOUNTABILITY

We were asked to “review management decisions made by agency

leadership [from January 2, 2018, through April 30, 2019] related to the
management and leadership of Lewis prison, to include accountability for
oversight of the safety and security related to the ineffectiveness of locks at
Lewis prison and provide any recommendations for further action that may be
warranted.”

For most of the 16-month review period, Lewis Prison was under the
immediate supervision of a management team headed by Warden Berry Larson.
In December 2018, Director Ryan changed most members of that team by

33
reassigning two team members, including the Warden, and demoting other
officers. Because the warden, deputy warden of operations, and all deputy
wardens except one were replaced, there seems little value in reviewing the
management decisions of this team. Director Ryan has already determined
that it was not performing satisfactorily and has remedied that situation. The
new leadership team headed by Warden Gerald Thompson has been in place
only since approximately January 2019. Those we interviewed expressed the
view that the new leadership team is strong and is working diligently to remedy
the deficiencies in morale, training, cleanliness, discipline, and attention to
detail that contributed to the problems at Lewis. There is guarded optimism
that things are turning around at Lewis, although slowly, and so it seems
premature to attempt to assess the success of a new prison administration
based on just seven months’ work, when it has been asked to clean up a
situation that has been years in the making.

Director Ryan acted decisively and seemingly effectively to remedy

perceived leadership deficiencies at Lewis that may have contributed to the
inmate UA problem. We turn to whether it took ADC leadership too long to
learn of the lock problems at Lewis or to recognize their seriousness and
whether, once the scope and seriousness were known, leaders acted sufficiently
quickly and decisively to remedy the problems.

According to statements from ADC, the top leadership team believed

until fairly recently – and some, including the Director, still believe today – that
the cell door locks at Lewis were not broken, but the inmates could jimmy their
cell doors open if they capped the doors. In 2019, ADC issued this statement
to media: “We firmly dispute the contention that doors do not lock at all.
Officers assigned to work on the locks indoors report to us that the locks are
functional. It’s the inmate tampering that causes them to be able to open their
doors.”28 Some senior leaders expressed that opinion during our interviews in
June 2019. 29 In fact, it appears that by the end of 2017, there were many
doors that could be capped and shaken open, some doors that could be shaken
open whether capped or not, and a few doors that would “pop open” once pins
were removed.
So when did Director Ryan learn that the doors, whether because they
were capped or broken, sometimes failed to secure the inmates in their cells?
In response to media questions, ADC released a statement saying that the

28
Quoted in D. Biscobing, When did AZ DOC know of broken cell locks? ‘Corrected timeline’
released, May 15, 2019 (KNXV ABC 15 News).
29 SROD Tara Diaz, for example, in April 2019 sent around training materials that stated, in

the “Cell Door Summary”: “Inmates in the Morey, Buckley, and Rast Units [at Lewis Prison]
have been able to tamper with their cell doors by inserting objects of various types in the doors
to hinder the locking mechanisms for fully engaging and thereby securing the door. Locks on
the doors function as designed when they are not tampered with. The locks for the cell doors in
these units are not broken[;] they are functional.” (Emphasis added.)
34
director first learned about the scope of the problems at Lewis in May 2018.
Given the Director’s actions and statements to us, that date actually may be
earlier than the date that he fully recognized the scope of the problem. In our
first interview, the Director discussed the video that aired on Channel 15 in
April 2019, which shows a December 30, 2018, assault on two correctional
officers by several inmates who were able to get out of their cells seemingly at
will. Ryan expressed surprise at the number of inmates out of their cells and
the ease with which they got out. He said that although he received an email
on December 30 about that incident, he got no written report advising that the
event involved an assault on officers, and certainly nothing in it had alerted
him to the extent of inmate UAs. He said that the Significant Incident Reports
and the initial Incident Reports that he reviewed were very cursory and gave
little hint of the seriousness of the incident. He therefore did not know, or if he
knew intellectually he did not fully appreciate, the scope of inmates’ ability to
UA cells until he saw the video in April 2019.

During the same interview at which the December 30 video was

discussed, Director Ryan played for us part of the video of the November 8,
2018, fire incident at Lewis’s Rast unit that aired on channels 12 and 15. That
video shows several fires being started by inmates in at least three locations in
one pod at Lewis. It also exposes several inmates out of their cells and COs
standing around, not doing much to put the fires out or secure the inmates.
Ryan said the written reports of that incident were also cursory and
unenlightening. He again became aware of the seriousness of the incident only
when, at someone’s suggestion, he watched the video. He appeared to have
been shocked, when he first watched the video, to see that the event was quite
serious and lasted approximately an hour and a half, and he was frustrated
that leadership sat back and did not act affirmatively and decisively to resolve
the incident.
ADC fairly quickly revised the timeline as to when Director Ryan knew
of the inmate UA situation from late May 2018 to November 2017. Support for
that date can be inferred because someone in leadership, presumably the
Director, ordered the pinning of the doors of the cells at Lewis in
November/December of 2017, a recognition that the locks alone were not
holding. We asked for a copy of the directive ordering installation of the pins,
but never saw one. Interviewees indicated that the impetus came from NROD
Ernie Trujillo, as he had overseen ADC facilities at which pinning was used
effectively. Discussions with Trujillo about pinning cell doors at Lewis seem to
have begun in the summer of 2017. Nonetheless, the decision to pin by
management indicates the understanding, by summer 2017, that the doors
alone were not keeping the inmates in their cells.30

30 In our August 8, 2019, interview, the Director indicated that the decision to pin the Lewis
doors may have come from NROD Ernie Trujillo and District Director Carson McWilliams,
although he would have agreed.
35
 From the statements and documents we reviewed and the interviews we
conducted, we cannot tell when, precisely, the Director came to understand
that some locks would not secure and to appreciate the seriousness of the
problem at Lewis. Whether it was 2018, 2017, or even 2019 (when the Director
expressed surprise at the extent of UAs shown in the videos), all dates seem
late in the game. Overwhelming evidence shows that the inmates had been
getting out of their cells for years. Inmates being able to get out of their cells
without the permission or assistance of the correctional officers is a problem in
the prison setting, a threat to the safety and security of other inmates and the
officers.

Why did the Director of the Department not know earlier? It appears
that he was misled into thinking the locks were fully functional and inmates
UA’d only because the COs were not checking the frames and securing them.
Senior management should have clearly and fully advised the Director
of the nature and extent of the problem and should have taken him to Lewis
earlier so that he could assess the situation and view and randomly test the
doors. A few interviewees indicated that when the leadership team visited
Lewis, they were steered toward doors that had been capped, but otherwise
worked.
This suggestion assumes, of course, that senior managers knew of the
problems, as they should have known. If they did not know, fault lies with
them for not knowing, but also with a leader who continued to rely on the
perhaps not-well-informed senior managers. If senior management knew but
failed to adequately inform the director, then some fault certainly lies with
those senior managers. But managers usually do not rise to senior positions
without knowledge of their jobs, a part of which is to accurately and adequately
advise their superior so that he might make effective decisions on behalf of the
agency. So if they did not fully report to the director, the question is why.

A few interviewees suggested that Director Ryan cultivates a culture in

which employees fear to tell him negative information. While that seems
contrary to a sign in his office soliciting information and input and emails we
reviewed stating that he invites information and even complaints, we
nonetheless heard from more than one interviewee that he surrounds himself
with those who agree with him (“yes men” was the term used), and that some
dare not disagree with him and slant reports to meet his expectations for fear
of discipline or termination. Some anecdotes were shared to support these
assertions. Most others, however, disputed these contentions and said that
Director Ryan welcomes honesty and desires to be fully informed. The truth is
difficult for us to assess from the outside and may, in fact, depend upon the
employee’s relationship with the Director. But regardless how it happened or
whose fault it was, we conclude that the Director, for too long, remained
surprisingly uninformed about the poor functioning of the locks and scope and

36
seriousness of the danger the inmate UA issue that resulted at Lewis posed to
inmates and officers. That is not acceptable.

That belief that the locks were working does, however, explain the
Department’s multi-year failure to request funds to fix the doors at Lewis. The
Director thought they were not broken, at least until late 2017 (to take the
earliest stated date). It does not, however, explain why other decisive actions
were not taken to ensure (a) that COs fully secured the doors, if that was
believed to be the cause of the UAs, and issued disciplinary tickets for any
inmates who got out of their cells, and (b) that mid-level supervisors were on
the floor to actively mentor, assist, and supervise COs. If the failure to secure
doors stemmed from lack of CO time (because of lack of staff), then the
Department should have been aggressively requesting more money for staff and
salaries and aggressively recruiting and training COs. In short, even if the
Director was misled about the functioning of the locks, he bears the
responsibility as the Director of the Department for not being fully informed.
This is certainly so if he was underinformed because his staff feared to reveal to
him the extent of problems. If the Director was adequately informed but
disregarded the information, he bears responsibility for that as well.

We are confident that the Director accepts ultimate responsibility for the
Department’s functioning.

IX. OBSERVATIONS AND RECOMMENDATIONS

Although our primary responsibility in preparing this report was to

impartially find and analyze the facts surrounding problems with doors and
locks at the Lewis Prison, the Governor requested that we also provide
recommendations for further action that may be warranted. We emphasize
here, as we did when we accepted this assignment, that we do not possess
particular expertise in prison management. We recognize that unique security
considerations may affect the ability of ADC to implement changes that could
be made without difficulty in other organizations. Nevertheless, our
conversations with long-time employees of ADC and our review of the many
materials provided us indicate that changes to ADC practices and procedures
could help prevent the type of problems that we reviewed.

Locking System: Since the end of April 2019, the Arizona Department
of Corrections has made a substantial effort to identify an alternative locking
system that will provide safety for inmates and staff at Lewis Prison. We are
confident those efforts will continue. Indeed, we learned at our August 8, 2019
interview with Director Ryan that a system and vendor have been selected.
After ADC completes installation of a new system, procedures for assuring
continued monitoring and maintenance must be developed.

37
 Staffing: Continued attention to staffing the prison at an adequate
level is essential. We regard it as significant that, for at least the last fifteen
years, ADC has not been able to fill the number of CO positions authorized.
The problem does not seem to be as much with attracting and training new
applicants, but rather with retaining them once hired.

Increased salaries are one component of attracting and retaining staff.

Several interviewees commented that staff had not had a pay raise for 13 years
and, while the 10% pay raise recently authorized is nice, the increase is still
low when apportioned over time. They also noted that signing bonuses, shift
differential, and location pay have disappeared or diminished, reducing the
amount that COs can make. Officers are not eligible for some of these
supplements, even where they do still exist, creating the anomaly that a senior
CO can make more than a junior officer. Several interviewees explained to us
that pay in nearby jurisdictions may exceed ADC pay by nearly $10,000 per
year, so once new COs obtain experience at ADC, they try to secure
employment with Maricopa County or Pinal County.

Salaries are an important but not the only factor in attracting and
retaining staff. A number of interviewees cited safety concerns and the lack of
support from leadership, whether perceived or actual – that is, the feeling that
supervisors and administration just don’t have COs’ backs. Corrections
officers often mentioned the positive impact of supervisors appearing on the
yard and taking time to train them. ADC should immediately develop
programs that improve relationships between supervisors and officers. Until
ADC institutes changes that allow the Department not only to hire but also to
retain COs, reaching adequate staffing levels will be a recurring problem.

Budget: An effective budgeting process is essential to obtaining funds

for adequate funding. We encourage ADC to continue to refine its process for
developing a budget with priorities clearly defined.

Training: We understand that ADC has revamped the training

program for corrections officers. Training for all levels of personnel should be
ongoing. As is true for leaders of all large businesses, prison leaders must be
trained in business processes, principles, and administration.

Security Checks: No matter what locking system is used,

unauthorized access is likely to continue unless staff makes required security
checks. Supervisory personnel must accept responsibility for assuring that
required checks are timely and properly completed.

Revise the Reporting System: ADC’s reporting system is complex

and cumbersome. For instance, Post Orders require multiple reports for each
incident that will or may lead to inmate discipline. As another example, ADC
requires separate reports about security device deficiencies from staff, from

38
sergeants, from deputy wardens, from the warden, and from the Chief of
Security. Often, the system does not make use of available technology. We
recommend that the State consider whether and how to revamp and modernize
the ADC reporting system in a way that eliminates redundancy and provides
ready access and links to all documents relevant to a particular incident while
also helping to ensure that the necessary information concerning an event is
transmitted.

Communication: During our interviews, we learned that some COs

had been instructed not to report security incidents or told that information
should be filtered to make a supervisor or unit “look good.” As a result,
incomplete or misleading information occasionally reached upper
administration. ADC has taken steps to emphasize the importance of
communicating accurate information and should continue that emphasis. In
addition, ADC should consider developing an electronic communication system
that permits immediate contact when necessary.
Leadership: Both to increase employee morale and to stay current
with problems developing within the prisons, top leadership should make
frequent unannounced visits to the prisons. Moreover, ADC leaders must
review and adopt modern prison administration techniques.
Funding: All of the mentioned “fixes” require additional financial
resources. So while funding itself was not often mentioned, it is an integral
part of fixing locks, increasing staffing, boosting staff pay, providing additional
staff training, and procuring, installing, and training on a new electronic
communications system.

X. CONCLUSION

Prisons play an important role in Arizona. Those who work there and
those committed there by our justice system deserve a safe and secure
environment. Lewis Prison has a problem with malfunctioning doors and doors
inmates can manipulate to escape cells that are not otherwise secured by pins
or padlocks. We attempted to isolate the causes of the problem so that they
could be prevented or mitigated. We were not able to definitively document the
scope of the problem, but evidence of it appears in videos showing inmates
streaming from cells to attack correctional officers or other inmates and in the
reports of malfunctioning security devices. This cannot be permitted in our
prisons.

Recently secured funding recommendations to replace the door locking

systems at Lewis Prison is a giant stride forward, and the Director expresses
optimism that recently initiated programs at Lewis will assist in redressing
many of the matters addressed in this report. We have made recommendations
– and passed along recommendations from others – to attempt to further
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remedy the causes of the problems that developed at Lewis. For the sake of
our state, the inmates who are committed to our care, and the officers who
serve in Lewis Prison, we must ensure that the Prison is secure.
We were greatly assisted in this project by the courteous and
professional staff of the Department of Corrections. Without exception, each
current employee responded promptly to all requests for interviews,
documents, videos, and other assistance, tasks that took them away from their
already-busy work schedules. We appreciate their cooperation and the
opportunity to work on this project.

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